Special Features Influencing Treatment
Several approaches that are more important to the treatment of cannabis dependence should be employed in addition to the basic, general substance abuse program. Recent studies examining rea-sons for cannabis use have provided information to guide treat-ment strategies. For example, both adolescent and adult cannabis users frequently report that they use cannabis to relax, or as a stress reduction or coping mechanism. This observation suggests that treatment programs should teach healthier and more effec-tive coping mechanisms and cognitive–behavioral strategies for relaxation and stress reduction (Botvin, 2000; Hendin and Haas, 1985; Weiner et al., 1999).
The most salient feature of cannabis abuse or dependence is that it is often comorbid with other Axis I disorders as discussed earlier. Toxicology screening for other drugs of abuse is impera-tive because the most common comorbid Axis I disorders are other types of substance abuse. Even in the absence of an obvious Axis I diagnosis, psychological reasons for cannabis use should be investigated. For example, use of cannabis for relaxation or improving mood may be indicative of efforts to “self-medicate” underlying anxiety or mood disorders (Chen and Kandel, 1998; Latimer et al., 2000). Thus, treatment programs for cannabis de-pendence should include a dual-diagnosis component. Because of the high frequency of comorbidity among cannabis-dependent individuals, diagnosing and treating the underlying disorder or symptomatology may be a necessary condition for the individual to stop using marijuana (Brady et al., 1991; Cantwell et al., 1999; Crits-Christoph and Siqueland, 1996; Johns, 2001; Menezes et al., 1996; Regier et al., 1990; Rounds-Bryant et al., 1999; Simpson, 1981; Simpson et al., 1997; Troisi et al., 1998).
Another treatment situation frequently encountered is that of an individual with a known Axis I disorder that is being exacerbated by cannabis use. Some studies, performed in populations of patients with schizophrenia, have found that cannabis use worsens the course of the illness, whereas others have found that it does not affect the course (Negrete et al., 1986; Treffert, 1978; Cuffel et al., 1993; Linszen et al., 1994). It is a reasonable assumption that at least some patients with Axis I disorders are adversely affected by cannabis use even if they use the drug only occasionally. In such cases, the role of cannabis as an exacerbat-ing factor must be assessed and discussed with the patient. These patients may or may not be suitable for support groups directed primarily at substance abuse because cannabis may represent a relatively minor portion of the patient’s overall clinical picture.
Like alcohol, the most common problem in managing cannabis use disorders is the high rate of relapse due to the wide availability of the drug and the large number of people who are users. Users are therefore tempted to resume use soon after a period of treat-ment when they find themselves in situations where they are sur-rounded by people using the substance. It is often useful for fami-lies and other people important in the patient’s life to get involved in treatment to understand the role that they play in the patient’s substance abuse. Some treaters advocate periodic random urine testing, which is an inexpensive and reliable method of monitor-ing abstinence, because THC remains present for such a long time and can be detected with infrequent testing (Miller et al., 1989).
A difficult treatment situation arises when it is hypothe-sized that the patient is using cannabis to self-medicate a primary Axis I disorder such as depression or an anxiety disorder. In these individuals, abstinence is difficult to achieve because the patient believes that cannabis will alleviate his or her symptoms. Relapse may occur repeatedly until the underlying Axis I disorder is ef-fectively treated (Peralta and Cuesta, 1992; Dixon et al., 1991; Estroff and Gold, 1986; Warner et al., 1994).
Uncomplicated cannabis intoxication rarely comes to clinical at-tention and, if it does, it does not require treatment other than re-assurance, as it is a self-limiting condition. Similarly, as suggested in the previous sections, symptoms of delirium, psychosis, or anx-iety associated with cannabis use typically resolve promptly af-ter the period of acute intoxication is past. Again, no treatment is necessary other than keeping the patient safe and providing reas-surance that symptoms caused by the drug will stop, as these are also self-limiting conditions. If the symptoms continue after more than 24 to 48 hours of abstinence from the drug, the possibility of another Axis I diagnosis must be considered. In such cases, treat-ment should then be directed at the primary Axis I disorder.
In the given treatment decision tree a diagnosis of canna-bis use disorders is presented Figure 37.2.