Clinical Treatment of Cannibas Use Disorders in Adolescents (Part 2) August 10, 2015 San Francisco Medicine Cannabis Use Disorders, Peter Banys, Physician, San Francisco Medicine, Timmen Cermak 0 By Peter Banys, MD, MSc and Timmen Cermak, MD Note: This article was originally published in the July/August 2015 issue of San Francisco Medicine. Motivating Change Adult heavy users usually establish therapeutic contact themselves, often in response to a partner’s pressure, but for adolescents, the parents are more likely to make the initial contact with a clinician. Most heavy marijuana users are not reluctant to discuss their use if their rationales for use are explored rather than attacked. Several common themes run through patients' denial that marijuana can cause problems. Generally speaking, most heavy users will state that they can quit any time they so desire, that marijuana is beneficial for them, that authorities and parents are hypocrites given their own use of alcohol and pills, and that they notice no difference in function when they quit for a few days. “Everyone I know uses weed.” “It can’t be harmful—it’s natural and organic.” “No one ever died from a marijuana overdose.” “It makes me feel better. I feel more aware of things around me.” “It helps me study boring subjects.” “I have a medical marijuana card, and I have a right to treat my mood.” Individual assessment and treatment depends on developing a nonconfrontational therapeutic relationship, beginning with eliciting the patient’s experience with marijuana, often initially presented by the adolescent as entirely positive. Inevitably there have been some personal costs and getting to them will evoke the cognitive dissonance that is needed to drive change. The principles of motivational interviewing respect patients’ ambivalence and encourage them to wrestle with their own positive and negative facts. [See SFMS June 2015 journal edition for practical “Motivational Inteviewing” tips.—Ed.] Withdrawal Medications Among the most common symptoms seen in the first twenty-one days of cannabis withdrawal are anger, irritability, anxiety, restlessness, decreased appetite, sleep difficulties, dream rebound, diverse physical complaints, and depressed mood. And it is well established that daily users will continue to excrete metabolites and test positive for cannabis for a month or more after cessation, although the clinical significance of this has not been established. There is a small amount of research on medications, including oral THC, to reduce symptoms of cannabis withdrawal, and some medications may help in the short term. However, there are no approved meds to reduce craving or to reduce the odds of relapse. N-acetylcysteine (NAC), a research compound that is available over the counter, more than doubled the odds of having negative urine cannabinoid tests as compared with placebo, with benefits detectable within a week of treatment initiation. For cannabis-dependent patients who have discontinued use, gabapentin substantially reduced withdrawal and craving symptoms, reduced sleep and mood disturbances, and improved executive functions within the first week, an important factor in patients’ ability to make effective use of treatment. Other agents being studied include chemicals called FAAH inhibitors, which may reduce withdrawal by inhibiting the breakdown of the body’s own cannabinoids. Future directions include the study of substances called allosteric modulators that interact with cannabinoid receptors to inhibit THC’s rewarding effects. For a review of medications, see www.drugabuse.gov/publications/research-reports/marijuana/available-treatments-marijuana-use-disorders. Conclusions: Since California’s Prop 215 increased the availability of medical marijuana, we have seen a steady increase in marijuana diversion and usage among adolescents. Paradoxically, legalizing marijuana increases opportunities to regulate its distribution and use, thereby protecting our youth. As clinicians who work with young adult and adolescent marijuana addicts, we favor stronger regulation and enhanced public commitment to youth treatment. Both of these measures are essential to improve the clinical management of cannabis use disorders in adolescents. Click here to read part 1 -- Clinical Treatment of Cannabis Use Disorders in Adolescents Peter Banys, MD, MSc, is clinical professor of psychiatry at UCSF. Timmen Cermak, MD, is an addiction psychiatrist in private practice. Both are members of Lt. Governor Gavin Newsom's Blue Ribbon Commission on marijuana law reform. Comments are closed.
