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
Abstain from cannabis with high THC content. High-potency cannabis (> 10% THC) is associated with earlier onset of first-episode psychosis.54,55
Motivational interviewing
Motivational interviewing (MI) is a psychosocial approach that emphasizes a patient’s self-efficacy and an interviewer’s positive feedback to collaboratively address substance use.56 MI can be performed in short, discrete sessions. Such interventions can reduce the average number of days of cannabis use. One large-scale Cochrane review found that cognitive behavioral therapy (CBT), motivational enhancement therapy, or the 2 therapies combined most consistently reduced the frequency of cannabis use reported by patients at early follow-up.57
Address underlying conditions
Some patients use cannabis to self-medicate for pain, insomnia, nausea, and anxiety. Identify these conditions and address them with first-line pharmacologic or psychotherapeutic interventions when possible. This is especially important for conditions in which long-term cannabis use may adversely impact outcomes, such as in posttraumatic stress disorder, anxiety, and mood disorders.58-60 Little evidence exists for the use of cannabis as treatment of any primary psychiatric disorder.61,62 Family physicians who are uncomfortable treating a specific underlying condition can consult specialists in pain management, sleep medicine, psychiatry, and neurology.
Mitigate withdrawal symptoms
Discontinuation of cannabis use may lead to withdrawal symptoms such as waxing and waning irritability, restlessness, sweating, aggression, anxiety, depressed mood, sleep disturbance, or changes in appetite.63,64 These symptoms typically emerge within the first couple days of abstinence and can last up to 28 days.63,64 Although the US Food and Drug Administration has not approved any medications for CUD treatment, and there are no established protocols for detoxification, there is evidence that CBT or medications such as gabapentin or zolpidem can reduce the intensity of withdrawal symptoms.65,66
Refer to an addiction specialist
Consider referring patients with problematic cannabis use to an addiction specialist with expertise in psychopharmacologic and psychotherapeutic approaches to managing substance use.
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