MARIJUANA AND CANNABIS DEPENDENCE - SYMPTOMS, AND TREATMENT - Written by Dean Gustar, Relapse Prevention Specialist

Cannabis use disorder

Since the 1990s there has been a lot of change in cannabis potency. New methods of indoor cultivation allowed for easy growing of herbal cannabis. A shift began. It became simpler and easier to grow marijuana than to take the risks of importing it. The growers became very adept and were able to achieve higher THC levels in herbal cannabis.

As the THC content increased, problems began to emerge. The strains of high potency cannabis now dominate the market. Many observers feel this is strongly linked to prohibition. Producers want to have the strongest product, and the cannabis users have few alternatives. The high potency cannabis led to increased risk of developing a range of adverse effects, including medical and psychiatric issues. There is clear evidence that shows a direct link between this increased potency and an increase in people with cannabis dependence.

It is estimated that around 10% of marijuana users will develop a dependence. The identification of this disorder mirrors closely the other substance disorders in terms of diagnosis and symptoms. The criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) are as follows:

A problematic pattern of cannabis use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

1. Cannabis is often taken in larger amounts or over a longer period than was intended.

2. There is a persistent desire or unsuccessful efforts to cut down or control cannabis use.

3. A great deal of time is spent in activities necessary to obtain cannabis, use cannabis, or recover from its effects.

4. Craving, or a strong desire or urge to use cannabis.

5. Recurrent cannabis use resulting in a failure to fulfil major role obligations at work, school, or home.

6. Continued cannabis use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of cannabis.

7. Important social, occupational, or recreational activities are given up or reduced because of cannabis use.

8. Recurrent cannabis use in situations in which it is physically hazardous.

9. Cannabis use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by cannabis.

10. Tolerance, as defined by either of the following:

    1. A need for markedly increased amounts of cannabis to achieve intoxication or desired effect.

    2. A markedly diminished effect with continued use of the same amount of cannabis.

11. Withdrawal, as manifested by either of the following:

    1. The characteristic withdrawal syndrome for cannabis (refer to DSM-5 for further details).

    2. Cannabis (or a closely related substance) is taken to relieve or avoid withdrawal symptoms.

The severity of the disorder is linked to the number of symptoms present. 2-3 would be classed as a mild cannabis use disorder, 4-5 as moderate and the presence of six or more symptoms would be a severe cannabis disorder.

Prevalence and progression

Cannabis dependence is most prevalent amongst 18-25 year olds, with the majority being male (approximately 60%). This age group are likely to be either living at home, or closely connected with their families and there are a range of indicators that may have been noticed. The progression follows a similar path to other substances. It usually begins with smoking cannabis with friends as a fun and social activity. Then, they may start cannabis smoking on their own, maybe throughout the day. Other areas of life begin to suffer. The impact becomes more pronounced as the people around the person of concern start to become aware.

Symptoms – what will be observed and noticed

We would expect to see some clear indicators of the adverse effects of cannabis, including short-term and long-term effects. These are some of the things to watch out for:

• Loss of motivation and drive

• Poor short-term memory

• Isolation from family and friends

• Drop-off in performance at school or work

• Evidence of psychotic symptoms

• Mood swings and periods of depression

If you have observed some of these warning signs or symptoms then it is a good idea to discuss your concerns and build your own understanding of whether there is a real cause for worry.

How to talk about cannabis dependence

As previously noted, marijuana use is more prevalent in the 18-25 age group. If it is clear that effects of cannabis are impacting on several areas of a person's life then a conversation should take place. How this happens is very important. Here's a few ideas to support that conversation.

Educate yourself....

First of all, it is important that you come from a place of (at least some) knowledge. If you are not sharp and well informed then you can end up losing credibility. Here is a recent example observed by the author:

A concerned parent started the talk by saying that he was concerned about his son's drug use, and that he did not want illicit drug use taking place in the family home.He was also concerned that cannabis might lead to a mental illness.

So, on the surface this may seem pretty reasonable. The parent was, however, immediately challenged about the consumption of alcohol at home, and that alcohol is a drug. That scientific research has shown that alcohol was a far more dangerous drug than the cannabis plant. Also that cannabis is well documented as having a medical use, sometimes even for people suffering with a mental illness. Why is it okay for him to smoke tobacco which is far more harmful than cannabis smoke and cannabis products.

So be prepared. Do your research. Do not take a moral stance – this is not about right or wrong. Read up on the most recent cannabis research and available evidence. Think about what it is you have the problem with. Is it the cannabis or is it the consequences? And if it is the consequences, then which ones?

Timing is very important

Timing is important for all persons involved. Don't go looking for an in-depth, positive conversation when your emotions are rattled. Tell the person you want to sit down and speak to them. Ask them when would be a good time. Have an adult conversation at a time that suits you both. If, during the conversation, difficult emotions get triggered then take a break.

Listen and learn

Listen to them. Do not judge. Try to ask some open questions to find out what purpose the marijuana use is serving. Express your concerns in a non-judgemental manner. Try and encourage them to help you understand their motivation for smoking cannabis, and see if they have any worries or concerns. Learning why they are smoking will give you a lot of insight into potential underlying issues.

No lectures please

Don't fall into a lecturing trap. This won't get anywhere. It's best to gently encourage them to open up. Ask them if it's okay to share what you have been observing.It will also help to see if they have any concerns – do they feel they get enough support at home or school or work. Talk from your heart, and agree on some clear rules about behaviour and expectations.

Treating cannabis dependency

When a person decides that they want to address their cannabis use disorder there are several different approaches to support them. The initial phase of support would include a withdrawal from cannabis. Because it is not a highly physically addictive substance like alcohol or opiates, this can usually be managed in an outpatient setting, with minimal medical oversight. Some of the withdrawal symptoms can, on some occasions, be very uncomfortable. If this is the case some medications may support the person.

Withdrawal symptoms may include things like restlessness, irritability, anxiety, poor sleep or even insomnia. Prolonged and/or heavy cannabis use is more likely to lead to withdrawal symptoms. Likely they will last around two weeks, peaking in intensity after one week. In some circumstances, residential treatment would be worth considering. Withdrawal can be managed in a comfortable manner, and a programme of supportive psychological therapies can be implemented.

Evidence-based Psychotherapy

There are several psychotherapeutic approaches that have good evidence in helping people with cannabis use disorders. They can work well individually or in combination. Three important approaches are:

Cognitive-Behavioural Therapy (CBT)

CBT is a practical approach to help identify problems and develop strategies and skills to address those problems. With cannabis use disorder, this would include work on preventing a relapse, or coping in case of a relapse. The client is encouraged to learn about how their thoughts and behaviours are linked. New skills will be learned and awareness is developed.

It can also be applied to any underlying issues that may have been part of the overall problem. For example, if a person felt they needed to smoke cannabis to fit in, or if they needed an escape from the pressure of life.

Often, education is important in the approach. The work is generally very structured. The client is encouraged to break problems down to help them manage life issues more effectively, and develop autonomy and agency.

Motivational-Enhancement Therapy (MET)

MET is a person-centred approach that focuses on improving a person's motivation for change. Cannabis has a negative impact on motivation, so this intervention can realign them with their values, and address areas of resistance to change.

The person is encouraged to improve awareness of problems, and develop a clear understanding of how they can identify solutions and make positive actions to change. As with CBT, it has a goal of improving self-efficacy and self-belief, so the person can take charge of their lives.

Contingency Management (CM)

CM is an approach that uses operant conditioning as a driver for change. In simple terms, operant conditioning is a system that offers reward for change. It has good research to show effectiveness. A simple example could be a reward for an agreed improvement in school attendance.

Other interventions

As part of the treatment it would also be helpful to consider some of the following interventions:

• Full medical assessment – this will help to identify any potential health consequences or any existing underlying health consequences and treat them accordingly

• Psychiatric assessment – it is important to know if there are any psychiatric conditions that are present. These might be pre-existing or as a consequence of the use of cannabis

• Life Coaching – a programme of coaching can help to regain motivation for education or work. It will help to identify goals and plan steps to improve performance in a way that is in line with overall life goals

• Nutrition & Lifestyle counselling – this will support the overall health and well-being of a person, and increase self-worth and self-esteem

Medical cannabis

Medical marijuana use is now fairly accepted across the world for a variety of different conditions. It can still be extremely difficult to get a prescription because of some of the legal intricacies involved for doctors to prescribe. There are many high quality studies that show the benefits and efficacy of medical cannabis. Though some physicians are very reluctant to prescribe cannabis, as the research base grows, hopefully it will be more accepted as a safe remedy for many people with certain conditions.

Some of the conditions that can be supported through cannabis include:

• Multiple sclerosis

• Chronic pain

• Neuropathic pain

• Glaucoma

• Epilepsy

• Abdominal pain

• Post-traumatic stress disorder

• Effects of chemotherapy such as nausea and vomiting

There are many other conditions where cannabis and its active ingredients may provide an alternative to more traditional prescription drugs. More is being learned about the medicinal value of the cannabis plant every year. Watch out for a further blog post that will examine medical cannabis in more detail.

How The Kusnacht Practice treats cannabis dependency

At The Kusnacht Practice we have developed our programme for the treatment of cannabis addiction based on effective evidence-based interventions, alongside our experience and expertise of working with clients who have cannabis and other substance use disorders. We believe in having a person-centred approach to our work. We understand that the relationship with the client can help form the foundation to recovery. We work with the client in establishing goals, treatment plans and boundaries, each step of the way.

The first steps of the programme will be with our dedicated Medical and Psychiatric Teams who will work to ensure that all current and potential medical issues, and any existing mental health issues are diagnosed and addressed. They will plan an appropriate detox regime and setting - ensuring the safety of the client and managing withdrawal symptoms.

It is important for families and loved ones to know that there is no quick fix. Often, residential treatment is one of the early phases of a much longer continuum of care. We will work with our clients and their families to establish an aftercare programme to help maintain the gains made in treatment, and to navigate the potential ups and downs on the recovery journey.

The Kusnacht Practice is renowned for its absolute, dedicated attention and precision, honesty, and transparency in a warm and empathetic environment for all. With the pure waters of Switzerland’s Lake Zurich lapping on its nearby shores and among nature and clean air, the treatment centre offers a holistic, 360-degree, mind, body and soul rebalancing and restoration. Its state-of-the-art facility combines Swiss standards of excellence, luxury and cutting-edge, innovative technology with world-renowned medical expertise, compassion, and sensitivity. Each patient is treated uniquely and privately in their own sumptuous, five-star residence and provided with the highest standards of professionalism, care, and discretion.

We have successfully treated many individuals who have encountered difficulties with their marijuana use. We will provide a safe, kind, and friendly environment where discretion and privacy are key. And our tranquil location and luxurious surroundings will help you relax and focus on your well-being in a place where we can concentrate on nothing more than improving your health and supporting you onto a path of recovery.

Our experienced team of experts and professionals will seek to scratch beneath the surface to identify the roots of your issues. We wish to give you back control of your life and to learn coping strategies for a more content future - for you and your loved ones. Our treatment plans are unique and absolutely personalised, but simply opening up about your problem to a discreet professional is a big first step – alongside other therapies, naturally. We will organise everything for you with no detail overlooked.

Written by Dean Gustar