What are the treatment options for cannabis use disorder?

Treatment for Cannabis Use Disorder

The cornerstone of treatment for cannabis use disorder is counseling focused on achieving marijuana cessation, combined with brief psychosocial interventions modeled on motivational principles, with no FDA-approved pharmacotherapies currently available. 1, 2

Initial Assessment and Intervention

Brief Psychosocial Intervention (First-Line)

• Offer a single session of 5-30 minutes incorporating individualized feedback and advice on reducing or stopping cannabis consumption, with follow-up offered. 1
• This brief intervention should be delivered in non-specialized primary care settings as the initial approach. 1, 2
• Individuals who do not respond to brief interventions should be referred for specialist assessment and more intensive treatment. 1, 2

Evidence-Based Psychotherapy Approaches

When brief intervention is insufficient, the following combination produces the best outcomes:

• Motivational enhancement therapy combined with cognitive behavioral therapy and contingency management represents the most effective psychotherapy approach, though abstinence rates remain modest and decline after treatment ends. 3
• Short-duration psychosocial support modeled on motivational principles should be offered in non-specialized settings first. 1, 2
• Combining evidence-based psychosocial interventions with pharmacology may be necessary for successful long-term management. 1

Withdrawal Management

Supportive Care Approach

• Cannabis withdrawal should be conducted in a supportive environment with no specific medication recommended for treatment of withdrawal itself. 1, 2
• Symptomatic relief for agitation and sleep disturbance can be achieved with appropriate medications during the withdrawal period. 1, 2
• Common withdrawal symptoms include irritability, insomnia, headaches, decreased appetite, restlessness, and sleep difficulties with strange dreams. 1, 4

Critical caveat: The long half-life of THC results in delayed expression of withdrawal symptoms, meaning they may not appear immediately after cessation and can be easily missed or attributed to other causes. 4

Monitoring for Severe Complications

• Less commonly, depression or psychosis can occur during withdrawal; these patients need close monitoring with specialist consultation if available. 1
• If severe psychiatric symptoms develop, the patient requires immediate specialist referral. 1

Pharmacotherapy Options

Current Status

No medications are FDA-approved specifically for cannabis use disorder or withdrawal. 2, 5, 4

However, emerging evidence suggests potential options:

Promising Agents (Off-Label)

• N-acetylcysteine and gabapentin are the two most promising medications as adjunctive interventions to psychosocial treatment, though neither has emerged as clearly efficacious. 3
• Preliminary evidence from small placebo-controlled studies suggests that fatty acid amide hydrolase inhibitors and CBD can reduce cannabis use, but larger studies are necessary. 1

Agents to AVOID

• Dexamphetamine should NOT be offered for treatment of cannabis use disorders. 1, 2
• This is explicitly contraindicated despite its use in other stimulant disorders. 1

Long-Term Management Strategy

For Cannabinoid Hyperemesis Syndrome (If Present)

If the patient presents with cyclic vomiting, nausea, and abdominal pain with chronic cannabis use:

• For long-term management, counseling to achieve marijuana cessation and tricyclic antidepressants (amitriptyline) are the mainstay of therapy. 1
• Start amitriptyline at 25 mg at bedtime, titrating weekly to reach the minimal effective dose of 75-100 mg. 1
• Topical capsaicin (0.1%) cream can be applied with close monitoring of efficacy and adverse effects. 1

Addressing Comorbidities

• Co-management with a psychologist or psychiatrist is helpful for patients with lack of response to standard therapies or extensive psychiatric comorbidity. 1
• Anxiety and depression are very common associated conditions that require concurrent treatment. 1
• Previous treatment history, alcohol dependence, and major depression increase the likelihood of treatment engagement. 6

Treatment Duration and Follow-Up

• At least a 3-month follow-up period is recommended for longitudinal assessment. 1
• Monitor for recidivism, which is high even among patients who initially respond to treatment. 1
• More than 40% of patients with cannabinoid hyperemesis syndrome could stop all treatments over time, but recurrence rates remain substantial. 1

Critical Pitfalls to Avoid

• Do not rely solely on short-term interventions for severe cases—referral to specialized treatment is necessary when brief interventions fail. 2
• Do not underestimate the withdrawal syndrome—despite delayed onset due to THC's long half-life, withdrawal is real and clinically significant. 4
• Do not prescribe dexamphetamine for cannabis use disorder treatment. 1, 2
• Do not ignore comorbid substance use disorders and psychiatric conditions, as these are extremely common and affect treatment outcomes. 5, 6
• Do not assume patients recognize worsening symptoms—specifically ask about development of nausea, vomiting, or abdominal pain during treatment, as paradoxical cannabinoid hyperemesis can occur. 1

Special Populations

Adolescents

• Cannabis use may have deleterious effects on adolescent brain development and well-being. 2
• Early initiation of cannabis use is associated with elevated risk for developing cannabis use disorder and adverse psychosocial events including major depression and suicidal ideation. 2

Harm Reduction in High-Prevalence Communities

• In communities with high prevalence of substance use, facilitate access to information, health care, and entry to drug treatment. 1, 2
• Public prevention and education efforts should be implemented, particularly in jurisdictions where cannabis has been legalized or decriminalized. 2