For a 36‑year‑old female with heavy weekly vaping of high‑potency THC (≈1 g of 87% THC) used for emotional regulation, who has relational obsessive‑compulsive disorder, attention‑deficit/hyperactivity disorder, dysthymia, mild‑moderate L5‑S1 disc herniation, and is taking spironolactone, topical ketoconazole 2%, fluoxetine 30 mg daily, quetiapine 50 mg at bedtime, and methylphenidate (Ritalin) 0.5 mg twice daily, what additional assessment questions are needed to clarify cannabis use disorder severity and what management recommendations are appropriate?

Assessment and Management of Heavy High-Potency Cannabis Use in a Patient with Psychiatric Comorbidities

This patient meets criteria for cannabis use disorder and requires immediate intervention with structured brief motivational counseling, psychiatric medication optimization, and specialist referral—continued high-potency THC vaping at this level (approximately 870 mg THC weekly) places her at severe risk for irreversible neurotoxicity, worsening psychiatric symptoms, and cardiovascular events. 1, 2

Critical Additional Assessment Questions

Cannabis Use Disorder Severity

• Quantify tolerance and withdrawal: Ask specifically about needing more cannabis to achieve the same effect, and whether she experiences irritability, anxiety, insomnia, decreased appetite, restlessness, or abdominal pain within 24-72 hours of reducing use 3
• Assess functional impairment: Document specific examples of how cannabis affects her work performance in healthcare, relationships, and daily responsibilities—this distinguishes problematic use from lower-risk patterns 4
• Screen for cannabinoid hyperemesis syndrome: Ask about any episodes of cyclical vomiting (≥3 times yearly), compulsive hot-water bathing for symptom relief, or abdominal pain during active use 3

Psychiatric Symptom Trajectory

• Temporal relationship: Determine whether her relational OCD, dysthymia, and ADHD symptoms worsen during periods of heavy use versus abstinence—cannabis exacerbates existing psychiatric disorders in vulnerable individuals 1, 2
• Psychotic symptoms: Screen for paranoia, memory impairment, or disorganized thinking, as 87% THC concentration is associated with psychotic symptoms even in previously stable patients 1, 5
• Suicidal ideation: Cannabis use increases risk for depression and suicidal behavior, particularly with early-onset use 2

Medication Interactions and Efficacy

• Fluoxetine and quetiapine response: Ask whether she perceives these medications as effective—cannabis may be masking inadequate psychiatric treatment 6
• Methylphenidate dose verification: The listed dose of "ritilin 0.5 mg BID" appears incorrect (typical ADHD dosing is 5-20 mg BID); clarify actual dosing, as subtherapeutic ADHD treatment may drive cannabis use for self-medication 6

Cardiovascular and Respiratory Risk

• Cardiovascular symptoms: Screen for palpitations, chest pain, or orthostatic dizziness—high-potency cannabis causes tachycardia, arrhythmias, and myocardial ischemia 1
• Respiratory symptoms: Ask about chronic cough, sputum production, or dyspnea, as vaping high-potency concentrates carries unique pulmonary risks 1

Driving and Safety

• Motor vehicle operation: Document whether she drives to/from work or while using cannabis—users have more than twice the accident risk of non-users 3

Evidence-Based Management Recommendations

Immediate Interventions

Deliver structured brief motivational counseling (5-30 minutes) with individualized feedback on her specific health risks during this visit. 3 This single-session intervention improves cessation outcomes and should incorporate these elements:

• Present her specific risk profile: 870 mg THC weekly at 87% potency places her in the highest-risk category for neurotoxicity, cardiovascular events, and cannabis use disorder progression 1, 5
• Frame abstinence as the goal: Partial reduction or switching to edibles does not improve outcomes—complete cessation is required 3
• Address her belief that "nothing else provides" relief: Explain that chronic high-potency cannabis causes downregulation of CB1 receptors and dopamine dysregulation, creating a neurochemical dependency that falsely appears irreplaceable 3, 2

Psychiatric Medication Optimization

Urgently coordinate with her psychiatrist (do not wait for the next "few months" appointment) to:

• Verify and optimize ADHD treatment: Inadequate methylphenidate dosing is a common driver of cannabis self-medication in ADHD patients 6
• Reassess fluoxetine 30 mg daily: This dose may be subtherapeutic for her dysthymia and relational OCD, particularly given cannabis-induced exacerbation of depressive symptoms 1, 2
• Consider quetiapine adjustment: At 50 mg nightly, this is a subtherapeutic dose for mood stabilization and may only provide sedation 6

Specialist Referral (Mandatory)

Refer immediately to addiction medicine or addiction psychiatry for co-management. 3, 4 This patient meets criteria for specialist referral based on:

• Severe cannabis use disorder (daily high-potency use, multiple failed quit attempts, functional impairment) 3
• Co-occurring psychiatric disorders (relational OCD, dysthymia, ADHD) 3, 6
• Lack of response to prior interventions (therapy, 12-step programs) 4

Pharmacotherapy for Cannabis Use Disorder

If withdrawal symptoms emerge during cessation attempts, the specialist may consider:

• Loperamide for gastrointestinal symptoms (diarrhea, abdominal cramping) that occur during withdrawal 3
• Avoid opioids entirely—they worsen nausea, carry addiction risk, and do not address cannabis withdrawal pathophysiology 3
• Cannabinoid agonist substitution (nabilone or nabiximols) may be appropriate for severe withdrawal in select cases, though this requires specialist supervision 3

Monitoring for Cannabinoid Hyperemesis Syndrome

If she develops cyclical vomiting episodes:

• Acute management: Lorazepam 0.5-2 mg every 4-6 hours is first-line; haloperidol or droperidol second-line 3
• Definitive cure: Requires ≥6 months continuous abstinence 3
• Prophylaxis: Amitriptyline 25 mg at bedtime, titrated weekly by 25 mg to 75-100 mg maintenance dose 3

Harm Reduction Counseling (If Abstinence Not Immediately Achievable)

While abstinence remains the goal, provide these interim safety measures:

• Cardiovascular precautions: Avoid cannabis before/during physical exertion; seek immediate care for chest pain or palpitations 1
• Driving prohibition: Do not drive within 4-6 hours of use 3
• Avoid combining with tobacco: Combined use causes greater tachycardia and vasoconstriction than either alone 1

Critical Prognostic Information to Discuss

Neurotoxicity Risk

High-potency daily cannabis use causes measurable, potentially irreversible brain damage through glutamate excitotoxicity, particularly affecting:

• Executive function (decision-making, impulse control) 2
• Verbal learning and memory 2
• Prefrontal cortex connectivity 2

Cognitive recovery requires ≥6 months of continuous abstinence, and deficits persisting beyond 6 months suggest permanent impairment. 1

Psychiatric Deterioration

• Cannabis worsens her existing conditions: OCD symptoms, dysthymia, and ADHD are all exacerbated by chronic high-potency use 1, 2, 7
• Psychosis risk: 87% THC concentration significantly elevates risk for psychotic symptoms, even in patients without prior psychosis 1, 5
• Dependency: Approximately 10% of chronic users develop cannabis use disorder; her pattern of daily high-potency use places her at much higher risk 1

Withdrawal Timeline

Prepare her for withdrawal symptoms:

• Onset: 24-72 hours after last use 3
• Peak: Days 2-6 3
• Duration: 1-2 weeks for acute phase; cravings may persist months 3
• Symptoms: Irritability, anxiety, insomnia, decreased appetite, restlessness, abdominal pain 3

Common Pitfalls to Avoid

• Do not accept her rationalization that cannabis is her only option—this belief reflects neurochemical dependency and inadequate psychiatric treatment, not therapeutic necessity 3, 2
• Do not delay specialist referral—her multiple failed quit attempts and daily high-potency use require addiction medicine expertise 3, 4
• Do not prescribe opioids for any pain complaints—they worsen cannabis-related symptoms and carry high addiction risk in this population 3
• Do not overlook medication optimization—subtherapeutic psychiatric treatment is a major driver of continued cannabis use 6