Is your patient’s cannabis use problematic?
Individuals who do not meet DSM-5 criteria for cannabis use disorder may still have problematic use. The screening tool and 5 interventions detailed here can help.
PRACTICE RECOMMENDATIONS
› Address underlying conditions for which patients use recreational cannabis to manage symptoms. B
› Consider discrete, in-office sessions of motivational interviewing and referral for cognitive behavioral therapy for patients with problematic cannabis use. B
› Provide counseling around harm reduction for all patients—especially those with problematic cannabis use. C
› Consider referral to an addiction specialist for patients with cannabis use disorder or other problematic cannabis use. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Guidelines for screening and evaluation
All primary care patients should be screened for problematic cannabis use, but especially teenagers, young adults, pregnant women, and patients with a mental health or substance use history. A variation of the single question used to screen for alcohol use disorder can be applied to cannabis use.23 We recommend asking the initial question, “Over the past month, how many days a week on average have you used cannabis and products that contain THC?” Although some guidelines emphasize frequency of cannabis use when identifying problematic consumption,24,25 duration of behavior and content of THC are also important indicators.19 Inquire about cannabis consumption over 1 month to differentiate sporadic use from longstanding persistent use.
Explore what types of cannabis the patient is ingesting and whether the patient uses cannabis heavily (4 or more times a week on average). Also determine the method of ingestion (eg, eating, vaping, smoking), THC-content (%, if known), and estimated weight of daily cannabis use in grams (TABLE 326). Although patients may not always be able to provide accurate answers, you can gain a sense of the quantity and forms of cannabis a patient is ingesting to inform future conversations on risk and harm reduction.27
Assess a patient’s risk for harm
Cannabis use has the potential to cause immediate harm (linked to a single event of problematic cannabis use) and long-term harm (linked to a recurring pattern of problematic consumption). Cannabis can be especially harmful for patients with the following medical comorbidities or psychosocial factors, and should be avoided.
Cardiovascular disease. Cannabis is associated with an elevated risk for acute coronary syndrome and cardiovascular disease.28 Long-term cannabis use is linked to increased frequency of anginal events, development of cardiac arrhythmias, peripheral arteritis, coronary vasospasms, and problems with platelet aggregation.29,30 Strongly caution against cannabis use with patients who have a history of cardiovascular disease, orthostatic hypotension, tachyarrhythmia, or hypertension.
Pulmonary disease. Patients with pulmonary disease such as asthma may find cannabis helpful as a short-term bronchodilator.31 However, for patients with underlying pulmonary disease who also smoke cigarettes, strongly discourage the smoking of cannabis or hashish, as that may worsen asthma symptoms,32 increase risk of chronic bronchitis,33 and increase cough, sputum production, and wheezing.31 There is currently insufficient evidence to suggest a positive association between cannabis use and the development of chronic obstructive pulmonary disease.34
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