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Cannabis Abuse and Treatment  

Introduction

While cannabis is used in a responsible and moderate fashion by most, that a small but significant number of individuals use the drug in an abusive manner cannot be denied. The espousal of increased freedom carries with it an obligatory responsibility for its consequences. Responding to these individuals' adverse reactions to cannabis is necessary in a society where use of this drug is becoming more common. While physical dependence is of less concern than with other psychoactive agents, psychological dependence and abuse of cannabis does constitute a problem for some individuals.

Cannabis is a minor tranquilizer and mild euphorient. Ingested through smoking, dosage is easily adjusted by the individual. It's efficacy is sufficiently demonstrated by a multibillion dollar international illicit industry. The current price of high quality crude cannabis in the United States exceeds that of gold!

With any drug use population a certain number are bound to suffer untoward consequences from dependence and abuse. Cannabis users are no exception. While difficult to estimate because of its illicit status, some ten percent of 80 million users in the United States may use the drug abusively. (10% is an estimate of problem drinkers.)

Definition

The Diagnostic and Statistical Manual III (DSM-III) defines cannabis dependence (304.3x)

A. Either a pattern of pathological use or impairment in social or occupational functioning due to cannabis use.

Pattern of pathological use: inability to reduce or stop use; repeated efforts to control use with periods of temporary abstinence or restriction of use to certain times of the day; is intoxicated throughout the day; uses cannabis nearly every day for at least one month; has had two or more episodes of Cannabis Delusional Disorder.

Impairment in social or occupational functioning due to cannabis use: e.g., marked loss of interest in activities previously engaged in, loss of friends, absence from work, loss of job or legal difficulties (other than due to a single arrest for possession, purchase or sale of an illegal substance) (And now also for getting fired for a positive urinalysis).

B. Tolerance: need for markedly increased amounts of cannabis to achieve the desired effect or markedly diminished effect with regular use of the same amount.

Clinical Psychopharmacology

Cannabinoids, non nitrogenous water insoluble lipophilic heterocyclic compounds are absorbed by the lungs and intestines, transported by the lipid fractions of the blood to the fatty tissue of the brain. The psychoactive cannabinoid congeners are deactivated and slowly excreted from the kidneys, gall bladder, and intestines. In chronic heavy users THC's are more quickly metabolized.

Absorption and action are route and dose dependent. Smoked or vaporized cannabis is both rapid and efficient as compared with the oral route. Autotitration of dose avoids overdoseage. Adversely, there is irritation of the tracheobronchial tree.

The oral route, while avoiding irritation present the difficulties of deactivation by the liver and slow absorption. Autotitration is more difficult. Overdose is a frequent side effect of impatience.

Sites of action are probably in the thalamocortical area and meningeal vasomotor control centers. There is some supratentorial minimal vagal disinhibition with initial acceleration of heart rate. Cerebral blood flow and metabolism are increased .

The active principle is an effective sedative that decreases emotional reactivity and anxiety. After a brief mild stimulatory phase with slight increase in heart rate, elevation of mood, and flow of thoughts, sedation ensues. Length and intensity of this biphasic sequence are dose dependent. In high dose or extreme sensitivity temporal distortion, agitation, paranoid delusions, disorganized thinking, and visual hallucinations are common in an inexperienced user. A stressful circumstance and inexperience facilitates the occurrence of a "bad trip". This type of reaction is infrequent in the chronic or experienced user.

With moderate use there is relaxation and introspection. There is a subjective release of the pressure of time.

Psychopathology

Abuse/dependence on cannabis is defined by impairment of functioning of the individual from the use of the drug. Cannabis as used excessively chronically causes behavioral changes similar to the use of minor tranquilizers with decreased energy, impairment of attention and concentration with mental dullness.

With the slow inactivation or excretion of THC metabolites, in some, episodic use of cannabis produces an extended hangover. (Not nearly as intense as with a comparable alcohol hangover)

Abuse of cannabis appears to be an effort to excessively suppress reactivity to unpleasant feelings of anxiety, sadness, and anger. Sedative side-effects of impairment of the emotional dimension of interpersonal relations and decrease of mental acuity further diminish the functioning of the abuser. Paranoia may be a presenting feature but this may be alienation and introspective insight.

While the issues of dealing with the aggravating causes are further avoided or the emotional pain suppressed by the use of cannabis, abusive use will likely continue.

These are broad generalizations. Individual psychological makeup, physiologic idiosyncrasy and diverse circumstance determine the wide range of motivations, abilities and problems necessitating intervention of the health professional.

Other Physical Effects

Irritation and injury to the throat, trachea and lungs constitute another and more specific physical hazard. Chronic bronchitis and cough has been reported in cannabis smokers since the Indian Hemp Drugs Commission Report in 1894. Avoiding this source of irritation would reduce vulnerability to respiratory symptoms of chronic cough and upper respiratory infections with the possible development of cancer. The source of irritation in smoked cannabis may be due to a combination of plant components and impurities such as molds, dirt, and other contaminants. Whether from direct irritation or secondary allergic reaction smoked cannabis is undesirable.

Treatment of Cannabis Dependence

Withdrawal and abstinence. Cannabis may be discontinued abruptly. Because the cannabinoids are slowly excreted the withdrawal symptoms are generally mild with some irritability and restlessness that gradually subsides over three to seven days. During this time the person is not impaired and should be constructively involved in other activities to distract from the withdrawal process. Insomnia can be safely managed by encouraging exercise and daytime activities. Increased dreaming is characteristic of the first several days after discontinuing the drug.

Adequate daytime exercise and activity help minimize restlessness of withdrawal from cannabis dependence. There is, of course, wide variation in individual sensitivity and withdrawal symptoms of restlessness and craving for the drug may recur for up to several weeks. The psychological dependence, however, would appear to be of far more importance clinically than any physiologic changes.

Because cannabis is an effective minor tranquilizer its use for decreasing emotional reactivity is substituted for utilizing other coping strategies. Treatment should be geared to the expectations of maintaining a cannabis free state through providing more suitable coping alternatives.

Developing an individual treatment program depends on the needs of the person seeking treatment and the availability of resources. The situation of the victim and capabilities (including that hard-to-define factor of character) significantly affect the outcome. The quality of life in the community is another major determinant of the efficacy of intervention by therapists and maintenance of a drug free lifestyle.

One approach utilizing group support is the Marijuana Anonymous, a twelve step model formed from polysubstance dependent individuals who, after recovering from their alcohol dependence also wanted to become cannabis free.

They felt discounted by the Alcoholics Anonymous groups that facilitated their sobriety: rejected and belittled for their concern. Because cannabis use does not generally cause disinhibited behavior like alcohol intoxication there is not much material for sharing in the "drunkalogs". There are few comparable "war stories".

A common theme for this group of "recovering" cannabis dependent individuals was the guilt and ambivalence over their habit of using cannabis to control anxiety, anger, and depression. Approach-avoidance and emotional alienation characterized group participants' issues in Marijuana Anonymous.

Another adverse consequence was the diminution of emotional reactivity with impairment of interpersonal relationships. This struggle to manage anxiety and depression through self medication with cannabis has the side effect of being ironically "too effective".

The dampening of emotional reactivity also may produce a distancing and alienation that is worsened by impaired attention/concentration.

Family, significant others, and workplace colleagues, aware of this dysfunction, react with sanctions.

Abusive use of drugs- most any drug- is usually manifested by denial that may be facilitated by a user peer group or family. Untoward consequences are usually progressive and not isolated single episodes. Reactions to this dysfunction are highly dependent by the surrounding social system.

Seen contextually, this self medication may be viewed as attempts to cope with anxiety, anger, and depression that become pathologic because of the impairment brought on by the side effects.

The optimal and appropriate therapeutic intervention is to treat the primary condition.

Cannabis misuse as a sole etiology for psychological dysfunction is probably uncommon. Attempts to represent such must be viewed with skepticism and the motivation of the proponent subjected to scrutiny.

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References

American Psychiatric Association (1987) Diagnostic Criteria from Diagnostic and Statistical Manual of Mental Disorders The American Psychiatric Association Washington, DC 337 pp.

Institute of Medicine Committee to Study the Health-Related Effects of Cannabis and its Derivatives (1982) Marijuana and Health National Academy Press, Washington, DC 188 pp.

Mathew, R.J. and Wilson, W.H. (1992) The Effects of Marijuana on Cerebral Blood Flow and Metabolism. Marijuana/Cannabinoids Neurobiology and Neurophysiology Edited by Murphy, L and Bartke, A. CRC Press Boca Raton 591 pp.

Light, A. (1992) Sinead on a Tear San Francisco Chronicle Datebook November 1, p 41-58.

Report of the Indian Hemp Drugs Commission Government Printing House Simla, India 1895 9 volumes 3,698 pp  v 1 p 223

Reynolds, J.R. (1890)Therapeutical Uses and Toxic Effects of Cannabis Indica Lancet, vol 1, March 22, pp 637-638 (reprinted in Marijuana Medical Papers 1839-1972 MediComp Press, Berkeley, CA 465 pp)

Roffman, R.A., et al. (1988) Treatment of Marijuana Dependence: Preliminary Results J. Psychoactive Drugs vol 20 (1) Jan-March p 129-137

"WW." (1890) Letter Toxic Effects of Cannabis Indica Lancet March 15

Yesavage, J.A. et al (1988) Carryover Effects of Marijuana Intoxication on Aircraft Pilot Performance: A Preliminary Report Am. J. of Psychiatry vol 142: p 1325-1329

Zweben, J.E. and O'Connell, K. (1992) Strategies for Breaking Marijuana Dependence J. Psychoactive Drugs vol 24 (2) April-June p 165-171 __________________________ (1988)Strategies for Breaking Marijuana Dependence J. Psychoactive Drugs vol 20 (1) Jan.-March p 121-127.

THM 1992