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.
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
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Indica Lancet March 15
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THM 1992
