ADDICTIONS
Cannabis-Related Disorders
Cannabis Use Disorder
Cannabis use disorder refers to a problematic pattern of cannabis use that leads to clinically significant impairment or distress.
It manifests itself as some of the following within a 12-month period:
Cannabis is often taken in larger amounts or over a longer period than was intended.
A persistent desire or unsuccessful efforts to cut down or control cannabis use are observed.
Lots of time is spent in activities necessary to obtain cannabis, use cannabis or recover from its effects
Craving/a strong desire or urge to use cannabis
Recurrent cannabis use is observed, resulting in a failure to fulfill major role obligations in various important settings (e.g home, school, work).
Continued cannabis use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of cannabis
Important social, occupational, or recreational activities are given up or reduced because of cannabis use
Recurrent cannabis use in situations in which it is physically hazardous
Cannabis use is continued despite knowledge of having a persistent or recurrent physical and physiological problem that is likely to have been caused or exacerbated by cannabis.
Tolerance, as defined by either of the following:
A need for markedly increased amounts of cannabis to achieve intoxication or desired effect
Markedly diminished effect with continued use of the same amount of cannabis
Withdrawal, as manifested by either of the following:
The characteristic withdrawal syndrome for cannabis (refer to Criteria A and B of the criteria set for cannabis withdrawal)
Cannabis (or a closely related substance) is taken to relieve or avoid withdrawal symptoms
Cannabis Intoxication
The following have to be observed in order to qualify for a diagnosis of cannabis intoxication:
Recent use of cannabis
Clinically significant problematic behavioral or psychological changes (e.g impaired motor coordination, euphoria, anxiety, sensation of slowed time, impaired judgment, social withdrawal) that developed during, or shortly after, cannabis use
2 (or more) of the following signs or symptoms developing within 2 hours of cannabis use:
Conjunctival injection
Increased appetite
Dry mouth
Tachycardia (heart rate that is too fast)
Cannabis Withdrawal
To be diagnosed with cannabis withdrawal, the following criteria must be present:
Cessation of cannabis use that has been heavy and prolonged (i.e. usually daily or almost daily use over a period of at least a few months)
Three (or more) of the following signs and symptoms develop within approximately 1 week after cessation:
Irritability, anger, or aggression
Nervousness or anxiety
Sleep difficulty (e.g. insomnia, disturbing dreams)
Decreased appetite or weight loss
Restlessness
Depressed mood
At least one of the following physical symptoms, causing significant discomfort: abdominal pain, shakiness/tremors, sweating, fever, chills or headache
Causes, Risk Factors and Comorbidities
There are numerous reasons why people consume marijuana, with reasons differing across different age groups and life stages. Children and adolescents from certain societies/countries might choose to consume cannabis because it is more easily accessible than other drugs – in fact, cannabis is known as a “gateway drug” to other heavier substances. Other reasons include a desire to look “cool” among one’s peers. College students and young adults most commonly cite experimentation and/or enjoyment as a reason for cannabis consumption. There are also individuals who use cannabis to relax or cope with stress, with this associated with depression, anxiety and PTSD.
However, what increases the risk of one developing cannabis use disorder? There are various factors that come into play, such as one’s temperament, the environment one grew up in/is currently in and genetics. Individuals with a history of conduct disorder in childhood/adolescence and antisocial personality disorder tend to be at a higher risk of developing cannabis use disorder. In addition, as some individuals use cannabis to cope with stress, individuals with internalizing disorders (e.g depression, anxiety) are also at a higher risk of developing cannabis disorder.
The environment that one grew up in/is currently in also contributes to the risk of developing cannabis use disorder. Unstable or abusive family situations, cannabis usage among immediate family members and a family history of substance use disorder heightens the risk of one developing cannabis disorder. In some cultures, cannabis might be relatively easy to obtain, therefore increasing the risk of developing cannabis use disorder. Tobacco smoking is also associated with a higher risk of developing cannabis use disorder. Lastly, genetics also influence the development of cannabis use disorders, with heritable factors contributing between 30% to 80% of the total variance in risk of cannabis use disorders.
Consequences of Cannabis Use
The consequences of cannabis use are rather widespread, with it affecting numerous aspects of life. Frequent cannabis use can negatively affect behavioral functioning, hence adversely impacting optimal performance at work/school. Cannabis use is also associated with impairments in several aspects of cognitive function, notably on short-term memory, planning, decision-making and response speed. Cannabis use is also associated with increased risk-taking and impulsivity.
It is also common for family and social functioning to be adversely affected. Arguments with spouses or parents over the use of cannabis in the home, or its use in the presence of children, can adversely impact family functioning (trust issues, strained relationships over time, etc.). Long-term cannabis use is also associated with less ideal educational and career outcomes. Among adolescents, early initiation of heavy cannabis use is associated with lower income, lower college degree completion, unemployment and the use of other drugs.
Prognosis
The prognosis of cannabis use disorder is rather mixed, with the likelihood of continuing cannabis abuse varying from person to person. However, what’s currently known are that these factors play a role in affecting a client’s prognosis: risk appetite, withdrawal, the experiencing of stressful situations etc. Impulsive individuals are more likely to experiment with substances and might continue using cannabis. Factors such as enjoyment, habit and activity enhancement, and altered perceptions/perspectives are associated with heavier cannabis use as well.
Therapy
Psychotherapy is recommended for those who have cannabis use disorder, with cognitive-behavioural therapy (CBT), motivational enhancement therapy and contingency management being some of the more commonly used therapeutic modalities. Support groups and family therapy are also good complements to therapy, with the latter used more commonly when working with adolescents.
CBT for individuals with cannabis use disorder is aimed at achieving the following: one being relapse prevention, and the other being to identify and change beliefs and behaviours that maintains or trigger cannabis use behaviour. The latter also includes working on identifying external and environmental triggers that contribute to problematic cannabis use. CBT for cannabis use disorder has been associated with various positive outcomes, such as reduced frequency of cannabis use and a subsequent decrease in cannabis-related problems.
Widely used in addressing substance use disorders and other related behaviours, motivational enhancement therapies are primarily aimed at increasing the client’s motivation for change. To achieve this, the clinician establishes rapport and commitment language for the client and attempts to start conversations about change as well. This therapeutic modality is suitable for those who did not voluntarily seek help (e.g court-referred clients), as well as those who are contemplating change, but are not quite ready to move into the action phase.
Contingency management is also commonly used in addressing cannabis use disorder. With it being reinforcement-based, it seeks to promote decreases in substance use by providing explicit positive reinforcement (e.g providing tangible rewards). This approach is helpful in improving/maintaining abstinence or therapy compliance.
Family therapy can be useful in managing cannabis use disorder, with it being more commonly used for teenage clients. Family therapy programs are designed to breakdown distrust and guilt by giving everyone a chance to be heard. This is useful in helping family members understand themselves and one another and resolve conflicts in a healthy way. One example of family therapy is multidimensional family therapy (MDFT). MDFT is focused on engaging the family, establishing goals, focusing on key adolescent and family themes (e.g communication, trust/mistrust) and preparing the adolescent with some skills for the future while incorporating substance use into the therapeutic approach. Support groups are available as well, with the National Addictions Management Services (NAMS) holding weekly support group sessions for individuals suffering from drug and alcohol use problems (BRIDGE).
Supporting a Loved One Struggling with Cannabis Use Disorder
It is no easy feat to support a loved one struggling with cannabis use disorder – as much as we would like to support them, it is inevitable that there are times where things might be challenging, from approaching them about therapy to supporting them throughout therapy. It is not easy to broach the topic of going for therapy to them, but here’s what you can do to make it more manageable: focus on the issue at hand (e.g. “I am concerned about your cannabis use.”) instead of labelling or criticizing them (e.g. “You are a drug addict!”). Not only does this appear non-judgmental, it also shows them that you care and are there to support them. Express your concern and offer your help – this will show your willingness to support them, such that they will feel less alone in the journey of recovery.
During the recovery process, be patient with them and their progress. Depending on the situation, some individuals might have consumed cannabis for a long period of time, resulting in chronic cannabis use. It can take a long time for the behaviors and patterns associated with addiction to really change. Recovery might be a long process, and there are times where relapses might occur, or they become frustrated amid therapy. While these might be disheartening, it might be helpful to keep this in mind - relapses are a normal part of recovery, especially when it’s a long process. Steps can also be taken to prevent relapses during therapy.
However, don’t go through it alone! There are support groups for caregivers/families of individuals with cannabis use disorder - NAMS holds weekly support group sessions for caregivers and family members (BRIDGE Family). They act as a safe, non-judgmental space where family members can learn, discuss and cope with an addiction unfolding in their midst. It is also helpful in alleviating feelings isolation and doubt, and family members get the skills they need to better handle the interpersonal problems they’re facing.