Cannabis treatment
Treatments for addiction problems have much in common regardless of the substance. A general, stepwise approach is…
① Stabilisation
② Relapse prevention
③ Lifestyle change
④ Harm reduction
What are the effects of cannabis?
The effects of natural cannabis compounds are variable and predictable only in general terms: this is because there are several species of cannabis plant, each plant produces over 100 alkaloids (natural chemicals) which have psychoactive effects, and the mix of these alkaloids depends on the particular growing environment at any time. The most important chemical for recreational use is tetrahydrocannabinol, THC, which may cause drowsiness, relaxation or stress reduction, joviality, increased sensuality and sensory awareness, distortion of time and space, and sleepiness. At higher doses there may be anxiety, panic, confusion or psychotic symptoms. Cannabidiol, CBD, is not psychoactive but it has a balancing, counter-effect to the THC.
Natural cannabis is prepared for consumption in many forms and the effect depends mainly on the concentration of THC and how it is taken. Weed is produced from the dried leaves and flowers of the plant and usually refers to normal strength cannabis, 7%-20% THC, while skunk refers to plants cultivated to produce more THC, 20%-30%, and contain less CBD to counter the THC. Purified extracts such as hashish and vapes can reach 60%-90% THC.
Synthetic cannabinoids commonly known as spice are too potent, 30-100 times normal cannabis, and too unpredictable in their effects for safe use. Adverse consequences include an inability to move, difficulty breathing, palpitations and extreme anxiety, seizures, and psychosis.
There is very little high quality research on treatments for cannabis or synthetic cannabis use.
Stabilisation
Cannabis is readily available, widely used recreationally and to alleviate pain and symptoms of mental health disorders; this makes treatment difficult. Cannabis used regularly accumulates in the body and related problems, notably lethargy and lack of motivation, develop slowly without an obvious impact; this is a challenge.
Abstinence (detoxification)
Cannabis, tetra-hydro cannabinol and cannabidiol, are both eliminated from the blood stream quite quickly. Regular users will have built cannabis stores in fatty tissues and this produces a slow release of cannabis which can be detected in urine for a week or two and cause a low grade withdrawal syndrome.
Cannabis withdrawal is of mild to moderate severity but prolonged. Symptoms include insomnia, tremulousness, anxiety and irritability. While no detoxification medication is generally recommended there is clinical evidence that a fixed reduction of chlordiazepoxide 40mg at the rate 10mg weekly can be helpful - it is important not to extend the reduction period.
Withdrawal from synthetic cannabis is commonly prolonged with craving, anxiety and low mood.
Cannabis in its natural form contains a number of alkaloids that are eliminated at different rates. The two most important are tetra-hydro cannabinol, which causes the usual cannabis effect, and cannabidiol, which has pain killer and anti-convylsant properties.
Cutting down
Cutting down is usually more difficult than simply stopping. Cutting down, if possible guided by a psychologist, requires adherence to some behavioural rules, all of which should be followed.
Checklist for cutting down…
✔︎ low level of cannabis dependence (Leeds Dependence Questionnaire)
✔︎ to be in daily contact with a supportive person
✔︎ agree no-use rules (abstinence in high risk situations and non-consecutive days use)
✔︎ no significant cannabis related health problems
✔︎ an ability to control impulsivity
Relapse prevention
The strong social associations make it difficult for both recreational and dependent users of cannabis to abstain or moderate use. What might trigger further use?
in the short term
underestimating how long it will take to feel good
low grade withdrawal symptoms
too slow a return to positive daily activities
forgetting to practise coping strategies for cannabis smoking friends
in the long term
personal high risk situations
Rating high risk situations is the first task in a relapse prevention programme. Once identified and rated for the degree of temptation and the individual’s belief in their coping ability, new coping strategies can be identified, practised and implemented in real life.
Relapse prevention medication...
There is no convincing evidence to support pharmacotherapies for cannabis abstinence syndromes.
Medications evaluated include: lithium and benzodiazepines.
Lifestyle change
It is only feasible to get on with the challenge of lifestyle change, which may include sorting out mental health issues, once a person has control of their cannabis use. Social treatments are most likely to be effective, for users, their family and friends, and other approaches can be effective provided that they are well structured and well delivered. Contingency management and other behavioural approaches are effective.
Harm reduction
Generic harm reduction measures to improve health and wellbeing are to be applied throughout treatment. A specific harm reduction strategy is giving information and advice on how to avoid cannabis psychosis.
effective interventions…
