Despite cannabis being the most widely used illicit drug in the Western world,1,2controlled trials for cannabis use disorder have been reported in the literature only in the last 15 years. Although many clinicians continue to conclude that the relatively mild withdrawal syndrome associated with cannabis indicates that dependence is unlikely and treatment is unnecessary, research suggests that a substantial proportion of cannabis users develop cannabis-related problems, including abuse and dependence.2,3-6 Despite these trends, only a minority seek assistance from a health professional,7 however, demand for treatment for cannabis use disorder is increasing internationally.8
There are no randomised control trials (RCTs) of pharmacological interventions for cannabis withdrawal or craving. The results of less methodologically rigorous studies suggest that oral delta 9-tetrahydrocannabinol (THC),9,10 and possibly mirtazapine11 and lithium,12 are promising for cannabis withdrawal, and that rimonobant13 and perhaps buspiron14 show potential in the management of cannabis craving. Buproprion,15nefazodone,16 divalproex,11,17 naltrexone18 and atomoxetine19 appear less promising for cannabis withdrawal or craving. Also, early indications suggest that oral THC is ineffective in the management of cannabis craving.9
A series of RCTs of psychotherapeutic approaches to managing cannabis dependence have been conducted. In general, these suggest that cognitive behavioural therapy (CBT) and motivational enhancement therapy (MET) are the most effective in reducing cannabis use, dependence and related problems.20-22 Social support psychotherapy showed equivalence with CBT in one study.23 Although brief interventions (usually in the form of MET) appear effective, recent studies suggest that extended, combined therapies are associated with slightly better outcomes.21,22 In addition, recent research suggests that adding voucher-based incentives to MET and CBT improves treatment compliance and long-term outcome in both voluntary24-26 and coerced adult clients,27-29 but that voucher-based incentives alone show improvements in compliance and outcome that diminish over time.25
Adolescent and psychiatric populations
Several RCTs suggest that brief interventions which may involve the provision of information (including to parents), MET, and cognitive behavioural skills training are effective in reducing cannabis use and dependence in adolescents.30,31 It also appears that extended therapies, which often incorporate significant family involvement (such as multidimensional family therapy), are effective in reducing cannabis use and dependence in adolescents, but no more so than are brief interventions.32 Contingency management also shows promise in enhancing treatment engagement in adolescents.33
There is one RCT examining effective treatments for comorbid cannabis use and psychotic disorders, which compared treatment as usual to ten sessions of motivational interviewing and cognitive behavioural therapy.34Clinicians recommendations for the management of substance use in the context of severe and persistent mental illness rests with integrated shared care or dual diagnosis services, in which the critical components are staffed interventions, assertive outreach, motivational interventions, counselling, social support interventions, a comprehensive and long-term perspective, and cultural sensitivity and competence.35,36
Although the strongest evidence in the management of cannabis dependence exists for MET and CBT in adults and brief interventions in adolescents, further RCTs are required to clarify the effectiveness of other treatments, particularly pharmacological interventions and those designed for psychiatrically comorbid cannabis users.
- Anthony, J., Warner, L. & Kessler, R. (1994). Comparative epidemiology of dependence on tobacco, alcohol, controlled substance and inhalants: Basic findings from the National Comorbidity Survey.Experimental and Clinical Psychopharmacology 2, 244-268.
- Swift, W., Hall, W. & Teesson, M. (2001). Cannabis use and dependence among Australian adults: Results from the National Survey of Mental Health and Wellbeing. Addiction 96, 737-748.
- Anthony, J.C. & Helzer, J.E. (1991). Syndromes of drug abuse and dependence. In. L.N. Robins & D.A. Regier. (Eds.). Psychiatric disorders in America: The Epidemiological Catchment Area Study, pp. 116-154. New York: The Free Press.
- Bierut, L.J., Dinwiddie, S.H., Begleiter, H., Crowe, R.R., Hesselbrock, V., Nurnberger, J.I. Jr., Porjesz, B., Schuckit, M.A., & Reich, T. (1998). Familial transmission of substance dependence: Alcohol, marijuana, cocaine, and habitual smoking: A report from the Collaborative Study on the Genetics of Alcoholism. Archives of General Psychiatry 55, 982-988.
- Grant, B.F. & Pickering, R. (1998). The relationship between cannabis use and DSM-IV cannabis abuse and dependence: Results from the National Longitudinal Alcohol Epidemiologic Survey. Journal of Substance Abuse 10, 255-264.
- Young, S.E., Corley, R.P., Stallings, M.C., Rhee, S.H., Crowley, T.J., & Hewitt, J.K. (2002). Substance use, abuse and dependence in adolescence: Prevalence, symptom profiles and correlates.Drug and Alcohol Dependence 68, 309-322.
- Copeland, J., Rees, V. & Swift, W. (1999). Health concerns and help-seeking among a sample entering treatment for cannabis dependence. Australian Family Physician 28, 540-541.
- Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (2003).Emergency department trends from the drug abuse warning network, final estimates 1995 2002, DAWN Series: D-24, DHHS Publication No. (SMA) 03-3780. Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies.
- Hart, C., Haney, M., Ward, A., Fischman, M.W., & Foltin, R.W. (2002). Effects of oral THC maintenance on smoked marijuana self-administration. Drug and Alcohol Dependence 67, 301-399.
- Haney, M., Hart, C., Vosburg, S., Nasser, J., Bennett, A., & Zubaran, C., et al. (2004). Marijuana withdrawal in humans: Effects of oral THC or divalproex. Neuropsychopharmacology 29, 158-170.
- Frewen, A., Baillie, A. & Rea, F. (2007, June). The role of mirtazapine in cannabis withdrawal. Paper contributed to the College on Problems of Drug Dependence. Quebec, Canada. Retrieved on September 8, 2008
- Shu-Sen, C., Bowen, R.C., Gu, G.B., Hannesson, D.K., Yu, P.H., & Zhang, X. (2001). Prevention of cannabinoid withdrawal syndrome by lithium: Involvement of oxytocinergic neuronal activity. Journal of Neuroscience 21, 9867-9876.
- Heustis, M.A., Gorelick, D.A., Heishman, S.J., Preston, K.L., Nelson, R.A., & Moolchan, E.T.(2001). Blockade effects of smoked marijuana by the CB1-selective cannabinoid receptor antagonist SR141716. Archives of General Psychiatry 58, 322-328.
- McRae, A.L., Brady, K.T. & Carter, R.E. (2006). Buspirone for treatment of marijuana dependence: A pilot study. American Journal on Addictions 15, 404.
- Haney, M., Ward, A.S., Comer, S.D., Hart, C.L., Foltin, R.W., & Fischman, M.W. (2001). Buproprion SR worsens mood during marijuana withdrawal in humans. Psychopharmacology 155, 171-179.
- Haney, M., Hart, C., Ward, A., & Foltin, R.W. (2003). Nefazodone decreases anxiety during marijuana withdrawal in humans. Psychopharmacology 165, 157-165.
- Levin, F.R., McDowell, D., Evans, S.M., Nunes, E., Akerele, E., & Donovan, S. et al. (2004). Pharmacotherapy for marijuana dependence: A double-blind, placebo-controlled pilot study of divalproex sodium. American Journal on Addictions 13, 21-32.
- Haney, M., Bisaga, A. & Foltin, R.W. (2003). Interaction between naltrexone and oral THC in heavy marijuana smokers. Psychopharmacology 166, 77-85.
- Tirado, C.F., Goldman, M., Kampman, K.M., & O Brien, C.P. (2007, June). Atomoxetine for treatment of marijuana dependence: A report on the efficacy and high incidence of gastrointestinal adverse events in a pilot study. Paper contributed to the College on Problems of Drug Dependence. Quebec, Canada. Retrieved on September 8, 2008
- Stephens, R., Roffman, R. & Curtin, L. (2000). Comparison of extended versus brief treatments for marijuana use. Journal of Consulting and Clinical Psychology 68, 898-908.
- Copeland, J., Swift, W., Roffman, R., & Stephens, R. (2001). A randomised controlled trial of brief interventions for cannabis use disorder. Journal of Substance Abuse Treatment 21, 55-64.
- Babor, T., Carroll, K., Christiansen, K., Donaldson, J., Herrell, J., & Kadden, R. et al. (2004). Brief treatments for cannabis dependence: Findings from a randomised multi-site trial. Journal of Consulting and Clinical Psychology 72, 455-466.
- Stephens, R., Roffman, R. & Simpson, E. (1994). Treating adult marijuana dependence: A test of the relapse prevention model. Journal of Consulting and Clinical Psychology 62, 92-99.
- Budney, A., Higgins, S., Radanovich, K., & Novy, P. (2000). Adding voucher-based incentives to coping skills and motivational enhancement improves outcomes during treatment for marijuana dependence. Journal of Consulting and Clinical Psychology 68, 1051-1061.
- Budney, A.J., Moore, B.A., Rocha, H.L., & Higgins, S.T. (2006). Clinical trial of abstinence-based vouchers and cognitive behavioral therapy for cannabis dependence. Journal of Consulting and Clinical Psychology 74, 307-316.
- Kadden, R.M., Litt, M.D., Kabela-Cormier, E., & Petry, N.M. (2007). Abstinence rates following behavioral treatments for marijuana dependence. Addictive Behaviours 32, 1220-1236.
- Stephens, R.S., Roffman, R.A., Fearer, S.A., Williams, C., & Burke, R.S. (2007). The marijuana check-up: Promoting change in ambivalent marijuana users. Addiction 102, 947-957.
- Sinha, R., Easton, C. & Kemp, K. (2003). Substance abuse treatment characteristics of probation-referred young adults in a community-based outpatient program. American Journal of Drug and Alcohol Abuse 29, 585-597.
- Carroll, K.M., Easton, C.J., Nich, C., Hunkele, K.A., Neavins, T.M., & Sinha, R. et al. (2006). The use of contingency management and motivational/skills-building therapy to treat young adults with marijuana dependence. Journal of Consulting and Clinical Psychology 74, 955-966.
- Martin, G. & Copeland, J. (2008). The adolescent cannabis check-up: Randomised trial of a brief intervention for young cannabis users. Journal of Substance Abuse Treatment 34, 407-414.
- Walker, D.D., Roffman, R.A., Stephens, R.S., Wakana, K., Berghuis, J., & Kim, W. (2006). Motivational enhancement therapy for adolescent marijuana users: A preliminary randomised trial.Journal of Consulting and Clinical Psychology 74, 628-632.
- Dennis, M., Godley, S.H., Diamond, G., Tims, F.M., Babor, T., & Donaldson, J. et al. (2004). The Cannabis Youth Treatment (CYT) study: Main findings from two randomised trials. Journal of Substance Abuse Treatment 27, 197-213.
- Sinha, R., Easton, C., Renee-Aubin, L., & Carroll, K. (2003). Engaging young probation-referred marijuana abusing individuals in treatment: A pilot trial. American Journal on Addictions 12, 314-323.
- Baker, A., Bucci, S., Lewin, T.J., Kay-Lambkin, F., Constable, P.M., & Carr, V.J. (2006). Cognitive-behavioural therapy for substance use disorders in people with psychotic disorders. British Journal of Psychiatry 188, 439-448.
- Drake, R., Essock, S. & Shaner, A. (2001). Implementing dual diagnosis services for clients with severe mental illness. Psychiatric Services 52, 469-476.
- Carey, K., Purnine, D., Maisto, S., Carey, M.P., & Simons, J.S. (2000). Treating substance abuse in the context of severe and persistent mental illness clinician s perspectives. Journal of Substance Abuse Treatment 19, 189-198.