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Cannabis Abuse and Treatment
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.)
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.
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
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.
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
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.
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
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.
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