What are the treatment options for marijuana use disorder?

Treatment Options for Marijuana Use Disorder

The most effective treatments for marijuana use disorder include cognitive behavioral therapy (CBT), motivational enhancement therapy (MET), and contingency management, with psychotherapeutic approaches forming the foundation of treatment while pharmacological options remain limited.

Diagnosis and Assessment

• Cannabis use disorder is diagnosed when a patient meets two or more of the eleven DSM-5 criteria:

  • Mild (2-3 criteria)
  • Moderate (4-5 criteria)
  • Severe (6+ criteria) 1

• The CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble) screening tool is recommended by the American Academy of Pediatrics for adolescents, taking less than 2 minutes to administer with good sensitivity and specificity 2

Evidence-Based Psychotherapeutic Interventions

First-Line Treatments

1. Cognitive Behavioral Therapy (CBT)

   • Moderate to large effect (Cohen's d = 0.53-0.9) on cannabis consumption and psychosocial functioning 3
   • Most effective when combined with other techniques 3
   • Evidence level Ia (highest quality evidence) 3

2. Motivational Enhancement Therapy (MET)

   • Effective for patients with or without an initial desire for cannabis abstinence 3
   • Brief interventions with motivational talk therapy show good outcomes 1
   • Evidence level Ia 3

3. Contingency Management

   • Provides tangible rewards for abstinence or treatment adherence
   • Substantial reductions in frequency of marijuana use and associated problems 4
   • Particularly effective when combined with CBT 5

4. Multidimensional Family Therapy (MDFT)

   • Particularly beneficial for younger adolescents who consume large amounts of cannabis and have psychiatric comorbidities 1
   • Addresses family dynamics that may contribute to substance use

Pharmacological Interventions

Currently, no medications have FDA approval specifically for cannabis use disorder 3, but several options show promise:

1. For Managing Withdrawal Symptoms:

   • Cannabinoid receptor antagonists can alleviate withdrawal symptoms (d = 0.223 and 0.481) 3
   • Synthetic THC (dronabinol) may be considered for heavy cannabis users (>1.5 g/day) experiencing moderate to severe withdrawal symptoms 1
   • Starting at lowest available dose and titrating slowly based on symptom response 1
   • Typical treatment duration: 1-2 weeks during acute withdrawal 1

2. Other Pharmacological Options:

   • Gabapentin shows weak effect (d = 0.26) on quantity consumed and abstinence 3
   • Cannabidiol (CBD) may help treat withdrawal symptoms without psychoactive effects, though more research is needed 1
   • Avoid serotonergic antidepressants as they can worsen withdrawal symptoms and increase relapse risk 1

Managing Cannabis Withdrawal Syndrome

Cannabis withdrawal typically begins 24-72 hours after cessation, peaks within the first week, and lasts 1-2 weeks 1:

• Supportive Care:

  • Quiet environment with minimal stimulation
  • Adequate hydration
  • Regular reassurance and monitoring 1

• Symptom-Specific Management:

  • Headaches/pain: Acetaminophen or NSAIDs
  • Anxiety/agitation: Short-term benzodiazepines
  • Sleep disturbance: Sleep hygiene measures, possibly short-term sleep aids 1

• Monitoring for Complications:

  • Depression
  • Psychosis
  • Seek specialist advice if these develop 1

Special Considerations

Cannabinoid Hyperemesis Syndrome (CHS)

• Identified by stereotypical episodic vomiting in patients with >1 year cannabis use, frequency >4 times/week
• Management includes:
  • Complete cannabis cessation for 3-6 months
  • IV fluid rehydration
  • Dopamine receptor antagonists (haloperidol 0.5-2 mg IV/PO every 4-6 hours)
  • Hot showers/baths and topical capsaicin cream 1

Comorbidities

• Treatment is often complicated by comorbid mental health and other substance use disorders 5
• Patients seeking treatment for marijuana dependence exhibit substantial psychosocial and psychiatric problems comparable to those seeking treatment for cocaine dependence 6

Prevention and Harm Reduction

For those who continue to use cannabis, the Lower-Risk Cannabis Use Guidelines recommend 7:

1. Avoid early age initiation (definitely before age 16)
2. Choose low-potency THC or balanced THC-to-CBD ratio products
3. Avoid synthetic cannabinoids
4. Prefer non-smoking methods over combustion
5. Avoid high-frequency (daily or near-daily) use
6. Abstain from cannabis-impaired driving
7. Higher-risk populations should avoid use altogether

Treatment Outcomes and Expectations

• While treatments can substantially reduce cannabis use and related problems, enduring abstinence is not a common outcome 5
• Substantial reductions in frequency of marijuana use and associated problems can be achieved with proper treatment 4
• The American College of Physicians supports comprehensive insurance coverage of evidence-based treatments for cannabis use disorder 2

Pitfalls and Caveats

• Cannabis legalization in some regions may increase CUD prevalence by making more potent products more readily available at lower prices 5
• Patients may be ambivalent and less confident about stopping marijuana use compared to other substances 6
• Increased risk for developing or exacerbating psychiatric disorders, especially with high-THC products 1
• Impaired cognitive function and increased risk of motor vehicle accidents with continued use 1