#9 A Joint Conversation: Cannabis Use Disorder with Dr. Deepika Slawek

September 1, 2022 | By Shawn Cohen

Partner with your patients to address cannabis use disorder. Learn how to talk through someone’s motivations for cannabis use, treat cannabis withdrawal, address cannabis use disorder, and the eternal importance of harm reduction in cannabis use. Dr. Deepika Slawek @DeepikaSlawekMD (Einstein Medicine Bio) joins us on this can’t miss episode!

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Credits

• Producer, Writer, Show Notes, Infographic, Cover Art: Shawn Cohen MD
• Hosts: Carolyn Chan, MD and Shawn Cohen MD
• Reviewer: Era Kryzhanovskaya, MD
• Showrunner: Carolyn Chan, MD
• Technical Production: Castos
• Guest: Dr. Deepika Slawek

Production Partner: ACAAM

CME Partner: VCU Health CE

Show Segments

• Intro, disclaimer, guest bio  0:30
• Guest one-liner 3:45
• Case from Kashlak 6:40
• Taking a history 9:40
• Discussing Cannabis Use Disorder 12:03
• Rolling with resistance 15:25
• Harm Reduction counseling 17:40
• Benefits of a regulated cannabis supply 25:02
• Cannabis withdrawal 31:20
• Treatment for Cannabis Use Disorder : 37:50
• Outro 46:00

Cannabis Use Disorder Pearls

1. We should encourage and create space for an open and honest conversation about cannabis use with patients!
2. Addressing why someone uses cannabis and the benefits of use for them can help begin a conversation about the role the substance plays in their life and informs us about what underlying issues/medical conditions we can help them address.
3. Cannabis use disorder exists, and there are known long-term risks of cannabis use that often depend on the route of use (i.e., smoking, vaporizing, eating)
4. Cannabis withdrawal symptoms include decreased appetite, anxiety, depression, insomnia, restlessness, and weight loss.
5. Treatment of cannabis withdrawal is generally supportive, using anxiolytics and sleep aids.
6. Psychosocial interventions remain 1st-line for the treatment of cannabis use disorder.
7. Harm reduction should always be the foundation of our treatment, focusing on becoming more comfortable and discussing safer ways of using cannabis.

Getting Blunt About Cannabis Use Disorder

Taking a History

Centering the conversation on why people are using cannabis (i.e., anxiety) is a way to open the door to explore more about the use. As discussed in the stimulant use disorder episode (episode 5), we’re barking up the wrong tree if we don’t address the reasons and positive aspects of someone’s cannabis use when first speaking with them. You can ask why they use it, what they expect from it, and what happens. This also allows you to address and possibly treat the underlying reason they’re using cannabis while gaining their trust.

An essential step in obtaining history is quantifying the amount someone uses and how they use it. Don’t be afraid to let the expert (the patient) teach you – a joint can mean different things to different people in geographic regions, so learn from their experience. Dr. Slawek suggests asking, “if you’re saying you use it when you’re anxious, how many days a week is that? How many of the last 30 days have you used cannabis? How does cannabis use fit into your life?” For an excellent systematic guide to quantifying, see box 5 of this publication (Slawek 2022).

After working toward establishing rapport and addressing the positives and underlying motivations for cannabis use, you can start to talk more about their relationship with cannabis and any negative aspects of it. Cannabis use disorder, like all substance use disorders, is formally diagnosed using the DSM-V criteria (Westreich, 2021). However, getting the information required to make the diagnosis doesn’t need to be a checklist. This can be easier if you have a relationship with the person already AND if you’re using patient-centered questions to hear more about their use: you can ask how their loved ones or family feels about their use, what they don’t like about cannabis, have they ever tried cutting back and what happened when they did, and have they had to buy more each week to have the desired effect. This information can become the basis of motivational interviewing to help build internal motivation to make a change based on their goals, such as cutting back or stopping use. It’s important to remember that this is a long process and likely won’t happen in one single visit but over a week, months, or years as you develop trust and a longitudinal relationship with the patient. Keeping the patient’s health at the center of the conversation–affirming their strengths, goals, and steps they’ve personally taken to focus on their well-being–is key to a richer discussion and patient-provider relationship. 

Risks of chronic use

Before jumping right into speaking about the risks of cannabis use, ask permission to share information about cannabis. Overall risks can be thought about in two buckets – risk of cannabis use impacting your life (cannabis use disorder) and risks of cannabis use impacting your health.

First, you can share that 8-10% of people who use cannabis will go on to develop a cannabis use disorder (Lopez-Quintero 2011).

The health risks of cannabis use are associated with the method of use so this can be a great way to open the door to a harm reduction conversation. Get into the nitty gritty and then use that information to have a directed conversation about risks and how to reduce them.

• How do they use it (vape, smoke, vs eaten)? Smoking cannabis comes with the risk of bronchitis and chronic cough related to inhalation of hot smoke (Tetrault 2007, Ghasemiesfe 2018)
• Do they mix in any products?  Inquire why or what that mixed in substance does for them. Is it for the sensation from using tobacco or to bulk up their product (i.e. make what they have last longer as cannabis is expensive)? Mixing in tobacco comes with additional risks associated with tobacco (see our upcoming episode on tobacco use disorder).
• What papers do they use to roll the cannabis? Cigar papers are made of tobacco leaf so this adds in the risks associated with tobacco use
• Do they have a regulated supply or access cannabis through the unregulated (illicit) market? Unregulated cannabis, like any unregulated substance, comes with the risk of contaminants (Dryburgh 2018).

The risk of cannabis itself is generally centered on mental health. Cannabis use in young adult years is associated with an increased risk of the development of schizophrenia (Hjorthøj 2021) and use in adolescence is associated with development of depression and suicidality (Gobbi, 2019)  Since THC content of cannabis products has been increasing (Chandra 2019), it’s particularly relevant that higher THC doses have been associated with a more negative mood. (Childs 2017)

While often discussed, cannabis hyperemesis syndrome was until recently poorly defined and is uncommon.. The definition requires generally discrete episodes of vomiting with current heavy cannabis use although the definition of chronic heavy use remains vague (Perisetti 2020). Per Dr Slawek, you can consider it in people who use cannabis regularly (at least 4 days/week) for 1 year and it often improves with prolonged cessation.

Harm Reduction

Now that you know how a patient uses cannabis, you can easily transition into discussing safer use methods. 

If they mix in tobacco with their cannabis (and you’ve discussed the reasons for this), strategize ways to reduce this approach or completely stop mixing in tobacco based on why they are mixing it in. This can include not using tobacco for bulking up their product and using papers that don’t have tobacco leaf.

When considering methods of use, edibles/tinctures are safer than vaporizing, which is safer than smoking (combusted cannabis). It’s essential to have the upfront conversation that the rapidity of onset and thus the sensation of edibles is significantly different (slower).

Regulated cannabis is always safer than unregulated (which can be contaminated with cocaine, K2 & spice, tar, pesticides, and/or heavy metals per Dr. Slawek). Still, the regulated market is not a reality for all. Nineteen states and Washington DC have legalized recreational cannabis, while 38 states have legalized medical cannabis (NORML). In states with medical cannabis laws, certification for those with state-specific indications can allow your patient to access a safe, regulated supply. Medical cannabis indications are state-specific, so get to know your state! (procon.org) 

While cannabis use disorder is not a state-specific indication for medical cannabis certification, in Dr. Slawek’s expert opinion accessing a regulated medical supply of cannabis is a harm reduction strategy. If a patient has cannabis use disorder and an indication for medical cannabis certification, consider certifying your patient for cannabis so they can access a safe, regulated supply as a harm reduction strategy. Once your patient can access medical cannabis, you can be prescriptive about how the cannabis is used as well: safer formulations, lower THC dosing.

We must acknowledge the disparate impact of the criminalization of cannabis on minoritized communities and people (ACLU). These same communities have unequal access to medical cannabis (Curbsiders #338 LIVE! Medical Cannabis: Is it still dope?). While there isn’t data that certifying for medical cannabis decreases the risk of criminalization, it’s worth considering.

Cannabis Withdrawal

As with all substances, a good framework to think about cannabis withdrawal is that symptoms are the opposite of intoxication. The main symptoms of withdrawal are increased anxiety, agitation, irritability, insomnia, restlessness, depressed mood, decreased appetite, and weight loss (Panilio, 2015). While the DSM-V also lists sweating, chills, fevers, and tremors as part of the cannabis withdrawal syndrome, Dr. Slawek sees those less frequently. While cannabis withdrawal is not life-threatening, it can be extremely uncomfortable, and a motivator for returning to use, so addressing it is ESSENTIAL. Symptoms can last weeks (Bonnet, 2017)

Treatment is symptomatic as there aren’t any FDA-approved medications specifically for cannabis withdrawal. Consider using anxiolytics such as a short course of gabapentin (Mason 2012), or hydroxyzine for worsening anxiety. For insomnia, there is limited data for medications though some experts note they support brief courses of zolpidem. (Zhand 2018)

If they’re using tobacco with their cannabis as described above, it’s also critical to address tobacco use. Using nicotine replacement therapy can help manage any symptoms from nicotine withdrawal that may also contribute. 

Dr. Slawek highlights that talking through how they reduce their use can be helpful. Abruptly stopping will almost certainly lead to withdrawal symptoms. Although there is no clear guidance, if their reduction/cessation seems too abrupt or their symptoms are intolerable, recommend slowing down their taper.

Treatment of Cannabis Use Disorder

Psychosocial treatment is the gold standard!

The most robust data for treatment of cannabis use disorders is with psychosocial interventions, specifically Cognitive Behavioral Therapy (CBT) and Motivational Enhancement Therapy (MET) (Gates 2016), to explore the narratives patients are working with regarding their use, utilize strength-based thinking, and address how the patient thinks cannabis affects their life and how to promote healthier strategies. Contingency management, a form of treatment in which prizes are given (usually picking out prizes out of a fishbowl) when specific goals are met (Carroll, 2006), has been studied as an adjunct with other psychosocial treatments and medications. 

While you can integrate elements of these psychosocial interventions into your practice, complete psychosocial treatment requires referral to a mental health professional, so know your local (in-person and virtual) resources. 

Medications

The evidence for medications to treat cannabis use disorder is generally lacking. 

In young adult patients (15-21yo), there is supportive data for N-acetyl-cysteine (NAC) 1,200mg twice daily in reducing cannabis use when used with contingency management (Gray 2012). A similar trial in adults did not find any improvement with N-acetyl-cysteine, so its evidence-based use is limited to young adults (Gray 2017). NAC is available only as an over-the-counter supplement, not as a prescription.

Data for other medications is generally limited (e.g. topiramate, nabilone, dronabinol) and more research is needed.

Links

1. Crackdown (podcast)- AMAZING podcast led by activists telling stories about people who use drugs and their resilience despite a system that is often actively hostile against them.

Goal

Listeners will develop a framework to discuss cannabis use, diagnose and treat cannabis use disorder and integrate harm reduction into the management.

Learning objectives

After listening to this episode listeners will…  

1. Be able to diagnose an individual with cannabis use disorder. 
2. Be able to identify cannabis withdrawal based on the DSM-5 criteria.
3. Develop a treatment plan to manage cannabis withdrawal symptoms Discuss evidence-based treatments for cannabis use disorder.
4. Discuss harm reduction strategies surrounding cannabis use. 

Disclosures

Dr. Slawek reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Cohen SM, Slawek D, Kryzhanovskaya E,  Chan, CA. “#9 Getting Blunt About Cannabis Use Disorder”. The Curbsiders Addiction Medicine Podcast. http://thecurbsiders.com/episode-list September 9, 2022.