Kevin P. Hill, MD
Director, Division of Addiction Psychiatry, Beth Israel Deaconess Medical Center, and assistant professor of psychiatry at Harvard Medical School.
Dr. Hill has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
CATR: So, what do you feel is the big-picture challenge of treating heavy cannabis users?
Dr. Hill: A big challenge is helping heavy users understand that cannabis use disorder is a real thing. It is hard for people to appreciate the risks that are associated with heavy use when they hear about the medical benefits and the recreational aspects of cannabis. There is also a relationship with dose and an increased likelihood of adverse effects with increased dose, which is important because of today’s higher potency levels and concentrates. Unfortunately, there also are no FDA-approved medications for cannabis use disorder or cannabis withdrawal.
CATR: You mention potency, and we’ve been reading how stronger levels of tetrahydrocannabinol (THC), the chemical compound that causes the high, can create severe withdrawal syndrome. Can you tell us more?
Dr. Hill: Daily use of potent cannabis is going to produce the most severe withdrawal symptoms. The potency of cannabis has skyrocketed in the last several years. THC potency today is about 12.9%, whereas in the 1960s, 70s, and 80s, THC content in cannabis was 3%–4% (ElSohly MA, Biol Psychiatry 2016;79(7):613–619). Concentrates, where people distill the plant down into very pure forms of cannabis, are another issue relative to withdrawal symptoms. With concentrates, THC potency levels can exceed 90%. Although there isn’t a lot of scientific evidence to support a dose-response curve, it seems—at least anecdotally—that increased doses or increased potency of cannabis leads to more severe withdrawal symptoms, or increased incidence of other adverse effects.
CATR: Let’s assume that I’m a heavy user. I’m not sure that I really want to stop cold turkey, even with a medication. As psychiatrists, what do we say and how do we deal with this type of patient?
Dr. Hill: Well, most people who come to my office with cannabis use disorder are being pushed in by their schools, their employers, their spouses, or their families. Oftentimes, it takes a lot of motivational interviewing to get them to understand that they need to make a change in their cannabis use. That often involves talking about things that they value that are in jeopardy, or that they’ve already lost. So, if people get to a point where they are willing to make a significant reduction, we will start with medications. But there also must be an understanding that it’s still going to be difficult for them to totally abstain. That gets to the issue of how, perhaps, it’s better for some of these patients to use quantitative urine testing, which tells you how much of a specific substance is present in a patient’s urine specimen. This gives us a tool that allows us to better track patients’ progress in reducing their use.
CATR: In terms of just talking patients through the process, do you have them quantitate the amount of use, and then give them a tapering schedule of cannabis to get down? What seems to work the best?
Dr. Hill: I don’t have a quantitative amount I suggest. I tell them to try avoiding using cannabis, and then we will start the medication if warranted. If they are taking a medication, people can dramatically reduce their use. The question becomes, is that sustainable? People who aren’t going to do well will manage a few days or even a week of reduced use, and then their use will creep back up, even while they are on the medicine. Some people can sustain it. If we have the medicine, and the patient is ready to do it, then we do it and try to use as little cannabis as possible. But I don’t talk about a taper schedule. Also keep in mind that cannabis use at the level of cannabis use disorder does not occur in a vacuum. There are often other issues that require attention, psychosocial stressors, pain, or psychiatric disorders like depression, anxiety, or ADHD. I often get referrals from other doctors when they discover that daily cannabis use may be contributing to the ineffectiveness of an antidepressant or a stimulant that they are prescribing.
CATR: You mentioned medications. So, what would you recommend for a pharmacological approach, either as part of managing cannabis withdrawal syndrome or as actual treatment?
Dr. Hill: Unfortunately, there are no FDA-approved medications now for cannabis use disorder, but there are other things that you can try. You can try an agonist approach. Dronabinol and nabilone are FDA-approved cannabinoids, and were shown in trials at Johns Hopkins to lessen withdrawal symptoms (Vandrey R et al, Drug Alcohol Depend 2013;128(1–2):64–70). Any practitioner can prescribe both cannabinoids, but chances are that they won’t be covered by insurance, and the drugs are expensive. Also, I think we need more evidence through studies that cannabinoids are truly effective as pharmacotherapy for cannabis use disorder. In terms of off-label medications, gabapentin had a very positive trial (Mason BJ et al, Neuropsychopharmacology 2012;37(7):1689–1698). In that study, administering 1,200 mg of gabapentin showed reductions in cannabis withdrawal symptoms.
CATR: What about N-acetylcysteine as an option for treating cannabis use disorder? We’ve heard there have been some positive studies here.
Dr. Hill: A study on N-acetylcysteine (Gray KM, Am J Psych 2012;169(8):805–812) showed reduction in cannabis use among adolescents. However, that finding in adolescents wasn’t replicated in adults, according to another study that just came out in Drug and Alcohol Dependence. But, from my perspective, if somebody has a therapist and the person’s other psychiatric disorders are being adequately addressed, then I am apt to try either N-acetylcysteine or gabapentin, largely because the side effect profiles are relatively favorable.
CATR: If we try gabapentin or N-acetylcysteine, what would you recommend around dosing?
Dr. Hill: For gabapentin, 1,200 mg daily. For N-acetylcysteine, 1,200 mg twice a day. One 300 mg capsule in the morning and at midday, and two 300 mg capsules in the evening. N-acetylcysteine can be purchased over the counter.
CATR: Where do you start when helping patients deal with cannabis withdrawal syndrome?
Dr. Hill: I begin with the most important strategy, which is education. So many people are distorting the evidence about cannabis—for example, people who are trying to get you to vote one way or another on the legalization issue. We need to make patients aware that, if they are using heavily and stop using, it is likely that they will experience a physical withdrawal syndrome. In reality—and even though there are people who think that smoking cannabis is not as addictive as smoking (tobacco) cigarettes—there are studies that show a similarity between cannabis withdrawal syndrome and nicotine withdrawal (Vandrey RG et al, Am J Addict 2005;14(1):54–63).
CATR: What’s the best way to specifically approach that education piece?
Dr. Hill: Preparing patients for the fact that they are going to have a challenge with a withdrawal syndrome is the best initial strategy that you can take. If they are prepared for cannabis withdrawal, they are less likely to use cannabis to alleviate those symptoms. As we know from opioid use disorder and nicotine withdrawal, those types of symptoms often are the triggers that get people to continue to use. So, in my initial evaluations of patients, I always explain what they may experience during withdrawal. Being aware they may experience severe withdrawal symptoms puts them in a better position to be able to avoid relapse. When they leave my office, and then attempt to quit or reduce their cannabis use, they are not going to be surprised about the level of discomfort that they may encounter.
CATR: What should we specifically tell our patients to expect with withdrawal?
Dr. Hill: Let them know first about what they may experience, including the potential for irritability, anxiety, difficulty sleeping, decreased appetite, restlessness, and depressed mood. Then let them know that—while they won’t likely experience all these symptoms—their discomfort will take place in the first day or so, and generally peak between days 2 and 6. But overall, research is showing that cannabis withdrawal symptoms can last, on average, 4 to 14 days. According to the DSM-5, cannabis withdrawal syndrome involves having at least 3 of those 7 symptoms I mentioned.
CATR: So, after educating the patient on withdrawal syndrome, it’s time to offer further treatment. How should we proceed from here?
Dr. Hill: The second and third strategies are similar to what we use for other psychiatric disorders—namely, behavioral interventions and pharmacotherapies. With cannabis use disorder, or cannabis withdrawal, it should be any type of psychotherapy that you feel comfortable using. For me, it’s generally cognitive behavioral therapy (CBT), and also self-help groups, such as Marijuana Anonymous (www.marijuana-anonymous.org).
CATR: Can you tell us more about your approach using CBT, and how we should put that into practice?
Dr. Hill: I’ve used CBT for years for smoking cessation and cannabis use withdrawal. We’ve done a few small research studies using a manualized version of CBT to help people stop. But what I think it boils down to for cannabis use is that people are using it in specific everyday situations. It’s important to recognize that using first thing in the morning—“wake and bake”—is different than using to relax after work, which in turn is different than using before bedtime as a sleep aid. So, consider using a CBT approach for each of those particular moments. When you are talking about treating people, who often are using cannabis multiple times a day for years, it takes a lot of hard work to be able to chip away and help them. CBT definitely can work for these patients.
CATR: When we think of CBT, we often think of having automatic thoughts that lead patients to respond emotionally. So can you tell us more about how we should approach it, using your first example of patients needing to use cannabis first thing in the morning?
Dr. Hill: Sure. When abstaining after regularly using first thing in the morning, patients are more likely to encounter physical withdrawal symptoms, just like somebody needing that first (tobacco) cigarette of the day. So as part of CBT, you ask them, “Have there been times when you haven’t had cannabis first thing in the morning?” And invariably, they say yes. That helps them understand that it’s not an automatic response to use cannabis first thing in the morning, and that’s where you start with therapy. Obviously, you want to try to help them manage the anxiety that they may have, or manage the withdrawal symptoms. But it’s important to first reinforce the idea that they don’t absolutely have to smoke cannabis first thing in the morning.
CATR: What are some other challenges you’ve seen while treating heavy cannabis users with CBT, or another therapy?
Dr. Hill: When people are using cannabis 7 days a week, 3–5 times a day, you need to understand that, while you can help them significantly reduce their use, reduction might never reach zero. While this emphasizes a harm reduction approach, I try to help patients achieve at least limited periods of abstinence. Sometimes they slowly taper their use, perhaps by eliminating their use at one key point in the day—right when they get home from work, for example. Also, one of the challenges when treating cannabis patients over a longer period is that a qualitative urine drug screen—which only tells you if a substance is present in a patient’s urine specimen, and not how much—might not provide useful information. If somebody was using 30 or 40 times a week, and has gone down to just using a few times over a weekend, obviously that person will always be positive on a urine drug screen. This is why, with some patients, I recommend using quantitative urine testing, which tells you how much of a specific substance is present in a patient’s urine.
CATR: As part of therapy, are there additional resources or forms of treatment we should be telling our patients about?
Dr. Hill: Marijuana Anonymous, like Alcoholics Anonymous, is excellent. There are live as well as online meetings, and I think it’s very useful for people to meet with others who are knowledgeable about cannabis and have also been through this process. So, I think using some type of psychotherapy to address the underpinnings of their cannabis use, and then supplementing that with self-help is a great start.
CATR: Is there anything else you’d like to mention?
Dr. Hill: Maybe a good place to wrap up is with what I’ll call one of my soapbox pieces. One reason there are no FDA-approved cannabinoids is because cannabis remains on Schedule I of the Drug Enforcement Administration’s Controlled Substance Act, which categorizes it as a substance with no currently accepted medical use and with a high potential for abuse. It certainly can be addictive, but it is hard at this point to make the case that there are no medical uses for cannabis. Because of that, it’s really difficult to secure funding and to get the licenses you need to do trials and research. Since we have more people than ever before using cannabis, and the number of people with cannabis use disorder is increasing, it’s imperative that we have effective treatment strategies. We need to figure out ways to remove barriers to study, and removing cannabis from Schedule I would be a start.