What is the recommended treatment approach for a patient with cannabis use disorder?

Treatment of Cannabis Use Disorder

Brief psychosocial interventions combining motivational enhancement therapy (MET) with cognitive-behavioral therapy (CBT) are the first-line treatment for cannabis use disorder, delivered over 5-30 minutes initially or extended to multiple sessions for those with ongoing problems. 1

Initial Treatment Approach

Brief 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 is appropriate for initial management in non-specialized settings 1
• Patients who do not respond to brief interventions should be referred for specialist assessment 1

Structured Psychosocial Treatment (For Non-Responders)

• Short-duration psychosocial support modeled on motivational principles should be offered in non-specialized settings for those requiring more intensive intervention 1
• The combination of MET plus CBT is the most consistently supported evidence-based approach, particularly when delivered over more than 4 sessions 2
• Cognitive-behavioral therapy targets cognitive, affective, and environmental factors maintaining dependence through coping skills training, functional analysis of use patterns, and addressing social/family/occupational reinforcements 3, 2
• Motivational enhancement therapy is particularly effective for patients ambivalent about cessation 4

Enhancing Treatment Effectiveness

Contingency Management

• Adding contingency management (CM) with voucher-based incentives for cannabis-negative urines significantly improves outcomes when combined with MET and CBT 1, 5, 2
• Five out of six studies support abstinence-based incentives to enhance treatment effect on cannabis use frequency 2
• The addition of CM to standard MET-CBT improves treatment results, though individualized assessment and treatment programs (IATP) may not require CM augmentation 5

Treatment Intensity

• High-intensity interventions (more than 4 sessions delivered over longer than 1 month) produce consistently better outcomes compared to low-intensity interventions, particularly for cannabis use frequency and severity of dependence 2
• Approximately 7 sessions over 12 weeks is typical, though range varies from 1-14 sessions over 1-56 weeks 2

Family and Social Support Integration

• Actively incorporate family members into treatment through couples/family therapy and mutual help groups 4
• Family members should engage with appropriate mutual help groups to address their own responses to the substance use disorder 4
• Failing to address family dynamics and social support systems negatively impacts treatment outcomes 4

Pharmacotherapy

No medications are currently approved or recommended specifically for cannabis use disorder. 1, 3, 4

• Unlike alcohol or opioid use disorders, no pharmacotherapy has demonstrated consistent efficacy for cannabis dependence 3
• Symptomatic medication may be used during withdrawal for agitation or sleep disturbance, but no specific medication is recommended for cannabis withdrawal management 1
• Preliminary evidence suggests fatty acid amide hydrolase inhibitors and CBD may reduce cannabis use, but larger studies are necessary before clinical recommendation 1

Withdrawal Management

• Cannabis withdrawal is best undertaken in a supportive environment without specific pharmacological intervention 1
• Relief of withdrawal symptoms (agitation, sleep disturbance) may be achieved with symptomatic medication for the duration of the withdrawal syndrome 1
• Less commonly, depression or psychosis can occur during withdrawal, requiring close monitoring and specialist consultation if available 1

Expected Outcomes and Follow-Up

• Approximately 70% of intervention participants complete treatment as intended 2
• Those receiving psychosocial intervention use cannabis on fewer days (mean difference 5.67 days) compared to inactive control 2
• Abstinence rates are relatively low overall, with approximately 25% of participants abstinent at final follow-up, comparable to treatments for other substance use disorders 2
• Post-treatment self-efficacy for abstinence is the most robust predictor of long-term abstinence 5, 6

Treatment Duration and Monitoring

• Effects are most pronounced at early follow-up (median 4 months), with interventions showing moderate-quality evidence for reduced cannabis use frequency and severity of dependence 2
• No particular intervention was consistently effective at 9-month follow-up or later, highlighting the chronic nature of cannabis use disorder 2
• Regular follow-up and reevaluation are essential throughout the treatment course 4

Comorbidity Considerations

• Screen for anxiety disorders, depression, bipolar disorder, PTSD, and personality disorders, which are more common in patients with substance use disorders 4
• For patients with comorbid anxiety disorders and more severe baseline cannabis use, integrated cannabis and anxiety reduction treatment (ICART) may be more efficacious than MET-CBT alone 7
• Intimate partner violence is common and requires specific assessment 4

Common Pitfalls

• Avoid opioids during acute management due to worsening of nausea and high addiction risk 1
• Relying solely on pharmacotherapy without behavioral interventions significantly reduces treatment effectiveness 4
• Using confrontational rather than motivational communication can worsen treatment engagement 4
• Many patients remain uncertain about the role of cannabis use in their symptoms, attributing problems to food, alcohol, stress, or other gastrointestinal disorders 1
• Recidivism is high—more than 40% of patients may stop treatment over time, and many continue using e-cigarette or vaping products after initial hospitalization 1

Harm Reduction

• Harm reduction can be a valid intermediate goal for patients with cannabis dependence 3
• Educate patients that resuming use of cannabis products might result in recurrence of symptoms, particularly in cases of cannabinoid hyperemesis syndrome 1