Cannabis treatment?

Treatments for addiction problems have much in common regardless of the substance. A general, stepwise approach is…

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.

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.

Watch this slide show by Dr Duncan Raistrick to learn more about harms and harm reduction…

Duncan Raistrick is a Consultant Addiction Psychiatrist