Treatments for cannabis use disorder

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Treatments for cannabis use disorder

By: Sarena Hayer MD, MA, MSc; Madeline A. Hedges; Jamie O. Lo MD, MCR

Background

Cannabis use disorder (CUD) is defined as a pattern of continued use despite clinically significant impairment or distress.1 Among US adults reporting past-year cannabis use, anywhere from 9 to 31% are estimated to have CUD, depending on the survey methods.2,3 Although cannabis use has increased by nearly 18% over the past decade,4 few individuals receive treatment for CUD.5

 Psychotherapeutic Interventions

Psychotherapeutic treatments for CUD are the most well-studied, and evidence supports some approaches.

 Cognitive-behavioral Therapy (CBT)

The goal of CBT is to teach individuals how to identify the circumstances and triggers that promote cannabis use, develop coping skills to prevent return to use, and pursue alternative behaviors.3

  • Several randomized controlled trials (RCTs) examining the role of CBT in the treatment of CUD have found reductions in cannabis use and fewer cannabis-related issues compared to control groups. However, the proportions of participants who remained abstinent at one-year follow-up were consistently low, ranging from 14-22%.6-8 The studied CBT interventions ranged from 1 to 14 weekly or biweekly sessions, either private or group.

 Motivational Enhancement Therapy (MET)

The role of MET is to enhance motivation by providing nonjudgmental, patient-centered feedback and engage participants in goal setting, as well as discussing and resolving ambivalence.6

  • An RCT of 188 participants found that MET treatment was associated with fewer dependence symptoms and less cannabis use at 1 year follow-up.9
  • MET has been shown to have similar efficacy to CBT.6 Overall, treatment with MET may involve fewer resources as the interventions that have been studied are usually brief, involving 1 to 2 individualized sessions with a therapist.

 Contingency Management (CM)

CM is only used as an adjunctive behavioral-based treatment. It uses operant conditioning to target and encourage certain behaviors, such as abstinence, through negative urine drug screens.12

  • Two RCTs demonstrated an association between reinforcement-based treatment and longer periods of abstinence from cannabis use during treatment.12,13
  • When combined with CBT and MET, CM promotes abstinence over the duration of treatment with sustained durability effects.13,14
  • CM alone is a brief intervention usually consisting of 15-minute sessions or presenting for a urine drug screen twice weekly over a period of 2 to 3 months. In studies examining CM in combination with other interventions, treatment was more involved and included weekly, 1-hour sessions for up to 14 weeks.

 Combined Approaches       

Several studies have explored the efficacy of treatment strategies that integrate both CBT and MET, as well as contingency management.

  • An RCT of 450 participants receiving either 2 sessions of MET, 9 sessions of MET plus CBT and case management, or neither found that both intervention groups had decreased cannabis use and fewer consequences associated with use. The 9-session group had more significant reductions in these outcomes, but it is unclear whether this difference is attributed to the duration of treatment or the use of a combined approach.10
  • Combinations of MET and CBT have been shown to reduce cannabis use in adolescents.11

 Other Interventions

Few studies have been conducted on the use of other psychotherapies such as relapse prevention, multidimensional family therapy, mindfulness meditation, drug counseling, and social support. There is  little existing evidence that these interventions affect treatment outcomes.5,15

Pharmacotherapy

To date, there are no pharmacotherapies that are routinely used for the treatment of CUD, none are FDA-approved for this purpose, and existing data on all medication classes is incomplete, with few methodologically rigorous trials.16-18

  • The use of antidepressants and anti-anxiety medications such as escitalopram, nefazodone, bupropion, and buspirone have little benefit for the treatment of CUD or associated withdrawal symptoms.19-21
  • Serotonin-norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine have been associated with reduced abstinence and increased cannabis use.16
  • The use of cannabinoids such as dronabinol and nabiximols may mitigate some symptoms of withdrawal and craving, however use should be considered experimental.18,22,23
  • Evidence for N-acetylcysteine and anticonvulsants such as gabapentin is mixed and necessitates additional investigation.24,25 Topiramate is associated with reduced treatment retention and increased rates of treatment dropout due to adverse effects.16
  • Other medication classes that have been explored with insufficient evidence include antipsychotics such as quetiapine, mood stabilizers, and hormones (oxytocin and progesterone).17

Clinical Considerations

  • CUD is associated with adverse outcomes, including increased odds of developing other substance use disorders as well as disturbances to mood, sleep, and appetite.17,26
  • As cannabis use increases, it is important to universally screen for cannabis use and then routinely for CUD when appropriate. Although screening tools for CUD are not as widely studied as those for other substance use disorders, there are several assessment tools available to providers, including the Cannabis Use Disorder Identification Test Short-Form (CUDIT-SF).27
  • When considering treatment for CUD, it is important to set shared goals with patients; these treatment goals may appropriately range from decreasing cannabis use to complete abstinence. As such, if CM is also utilized, negative urine drug screens may not be the best outcome measure.
  • Treatment options for patients may vary depending on access, therefore it is important to note that any psychosocial intervention for the treatment of CUD has been found to result in less cannabis use than controls.15

 The Bottom Line

Psychotherapeutic treatment remains first line for the treatment of CUD in adults and adolescents. Although the optimal duration and combination of treatments is unknown, existing evidence suggests that the most consistently supported intervention for CUD is a combined approach of CBT, MET, and potentially abstinence-based incentives.15 The ability to treat patients with psychotherapeutic interventions for CUD is dependent upon the availability of mental health professionals trained in treatment of addiction. If access to treatment is an issue, any psychosocial treatment available is preferable to no treatment. No pharmacological agent has been found to be clinically effective for CUD. Further longer-term and methodologically rigorous trials of promising pharmacotherapies are needed in order to conclusively determine their efficacy.

Suggested Citation: Hayer S, Hedges M, Lo J. Treatments for cannabis use disorder. The Systematically Testing the Evidence on Marijuana (STEM) Project. October 2022. https://www.cannabisevidence.org/clinician-resources/clinician-briefs/treatments-for-cannabis-use-disorder.

Author Affiliations: Division of Maternal Fetal Medicine, Oregon Health & Science University, Portland, OR, USA

Acknowledgments: Thank you to Kevin Gray, MD and Marcela Smid, MD, MS, MA for critically reviewing this document.

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Citations

  1. American Pyschiatric Association. Diagnostic and statistical manual of mental disorders. 5th Edition. Arlington, VA: American Psychiatric Pr; 2013.
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  3. Substance Abuse and Mental Health Services Administration. Substance Abuse and Mental Health Data Archive, Public-use Data Analysis System (PDAS): NSDUH years 2002 through 2019. https://pdas.samhsa.gov/#/.
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  26. U.S. Department of Veterans Affairs. Cannabis Provider Education Packet. Washington, DC: Evidence Synthesis Program, Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs. Updated February 2020.https://www.hsrd.research.va.gov/publications/esp/Cannabis-Provider-Education-Packet.pdf.
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