Cannabis Use Disorder: Implications and Best Practices by Cameron Duncan, DNP, MS, APRN, FNP-C, PMHNP-BC; Kendra Butler, BSN, RN; and Laurielyn Loa, BSN, RN

Mental Health Matters

Cannabis use disorder: Implications and best practices By Cameron Duncan, DNP, MS, APRN, FNP-C, PMHNP-BC; Kendra Butler, BSN, RN; and Laurielyn Loa, BSN, RN

Cannabis is the most commonly specifi c factors, such as age of fi rst receptors, such as c annabinoid misused illicit substance in the use as well as amount and fre- receptor type 1 (CB1). C B1 exists US.1,2 The National Survey on quency of use, are associated with a throughout the brain, although it Drug Use and Health found that person developing CUD.6 is mainly found in the frontal cor- cannabis use disorder (CUD) is a Pregnant women are also sig- tex, basal ganglia, and cerebellum; prevalent problem in the country, nifi cantly affected by cannabis use: these receptors are also found in requiring accurate and timely roughly 111,000 (4.7%) had used other parts of the body, from the diagnosis as well as effective cannabis in the previous month spinal cord and gastrointestinal therapeutic management.2 Accord- in 2018, with an estimated 35,000 tract to the reproductive organs.9 ing to the National Academies of (1.5%) admitting to its use every A second receptor, cannabinoid Sciences, Engineering, and Medi- day or nearly every day.7 Accord- receptor type 2 (CB2), is con- cine, this condition is associated ing to a retrospective cohort study sidered the peripheral cannabi- with a higher risk for other of more than 12 million births noid receptor, and is principally substance use and mental health conducted from 1999 through 2013, expressed in the body’s immune disorders.3 incidence of cannabis abuse or cells.9 THC works primarily as a dependence rose from 3.22 in 1,000 partial agonist of CB1, infl uencing ■ Prevalence and epidemiology births in 1999 to 8.55 in 1,000 births pain, digestion, appetite enhance- Recent research indicates the in 2013.8 Pregnant women report- ment, emotions, and processes prevalence of CUD is increasing. ing cannabis use were also more that are mediated through the In 2015, nearly 4% of the global likely to experience adverse peri- endocannabinoid system. Con- population used cannabis, with natal conditions, such as preterm versely, CBD is the major non- 8% of teenagers in the US report- rupture of membranes and intra- psychoactive phytocannabinoid ing having engaged in cannabis uterine fetal demise.8 The Substance component in cannabis.9 use; 9% of users become addicted, Abuse and Mental Health Services THC. Among the major can- with nearly 20% beginning Administration (SAMHSA) lists nabinoids, THC is regarded as the marijuana use in adolescence.1,4 other negative outcomes, including most psychoactive component According to the National Institute fetal growth restriction, preterm when considering behavioral on Alcohol Abuse and Alcoholism, birth, and neurologic development effects.9 It is proposed that the nearly 6 million adults experience concerns that may result in cogni- interaction of THC with the endo- CUD within any given year. In tive abnormalities.7 cannabinoid system is responsible addition, 6.3% meet the diagnostic for the way in which the physiologic criteria for the disorder at some ■ Pharmacokinetics effects of cannabis are primarily point in their lives.5 Cannabis is derived from a can- mediated.10 THC is the main mol- Cannabis is often used as a nabis plant (Cannabis sativa). ecule behind the reinforcing prop- form of self-medication for mental Although more than 100 dif- erties of marijuana (for example, health conditions, such as depres- ferent cannabinoids can be dependence), although the specifi c sion, anxiety, and posttraumatic isolated from this plant, the pathophysiologic mechanisms of stress disorder and is among the primary psychoactive compound cannabis are yet unclear.1 top four psychoactive substances is delta9-tetrahydrocannabinol CBD. CBD produces pharma- used in the US.1,6 The risk for (THC).9 The physiologic effects of cologic effects without any signifi - developing dependence among cannabinoids are due to interac- cant activity on CB1 and CB2 cannabis users is roughly 1 in 10; tions with specifi c cannabinoid receptors, meaning it does not

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Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved. Mental Health Matters produce euphoria or intoxication.11 not limited to: larger amounts or psychological changes; these Therapeutic potential for CBD is of cannabis use than intended; may include impaired motor tied to its antiepileptic, anxiolytic, continual desire to reduce/control coordination, euphoria, anxiety, antipsychotic, anti-infl ammatory, use; cravings; continued substance sensation of slowed time, impaired and neuroprotective effects.11 As it use despite persistent social prob- judgment, and social withdrawal, is generally tolerated, recent lems; compromised engagement which develop during, or soon research indicates that CBD may be in activities (social, occupational, after, cannabis use.15 The patient a promising candidate for pharma- or recreational); tolerance; and may also experience cannabis with- cotherapy of psychostimulant withdrawal.14 drawal especially when undergoing substance use disorders.12 More When assessing a patient pre- detoxifi cation. This occurs if the research is needed into CBD’s senting with symptoms of CUD, patient has a history of prolonged potential health benefi ts. the advanced practice registered cannabis use but has recently nurse (APRN) must take a thor- stopped.15 Some symptoms associ- ■ Complications ough medical and mental health ated with cannabis withdrawal Heavy or chronic cannabis users history; this includes any history include irritability or aggression, are more likely to report a reduced of substance use or family history nervousness or anxiety, sleeping quality of life, including decreased of abuse. All physical and psycho- diffi culties, decreased appetite, satisfaction and achievement logical symptoms should be iden- restlessness, depressed mood, and/ compared with nonusers.13 Long- tifi ed. It is important to monitor or symptoms of physical discom- term use can cause disruptions in psychological symptoms, identify- fort.15 These usually present 1 week not only neurologic and mental, ing whether they are associated after cannabis cessation. A person but also physiologic and social with withdrawal or an undiag- undergoing detoxifi cation may health.13 Cannabis use has been nosed primary mental health ill- experience withdrawal, and APRNs associated with altered brain ness. The patient should be asked need to recommend or coordinate development and cognitive how long these symptoms have medical supervision to effectively impairment, which may lead to been occurring, if they have wors- manage presenting symptoms. lower IQ and poor educational ened over time, as well as if any outcomes; in adolescent users, this actions alleviate them. Cannabis- ■ Comorbidities increases the likelihood of drop- focused questions should also Associations have been found ping out of school.13 be asked, such as when they fi rst between CUDs and other sub- started using cannabis, its amount stance and mental health disor- ■ Assessment and diagnosis and frequency, the route (that is, ders, including alcohol use The American Psychiatric Asso- inhalation through smoking, oral disorders, nicotine disorders, ciation’s Diagnostic and Statistical ingestion through edible products, mood disorders, anxiety disorders, Manual of Mental Disorders and the like), as well as when they personality disorders, and post- (DSM-5) explains that CUD is last used the substance. The APRN traumatic stress disorder; canna- the continued use of cannabis must determine if the patient will bis use and psychosis have also regardless of impairment in need to undergo detoxifi cation been linked, as cannabis users are psychological, physical, or social and whether medical supervision found to have higher rates of posi- functioning.14 CUD includes is necessary. tive psychotic symptoms than pathologic patterns classifi ed nonusers.13 According to the under impaired control, social ■ Cannabis intoxication and SAMHSA, individuals with CUD impairment, risky behavior, or cannabis withdrawal are more likely to have alcohol physiologic adaptation.1 Phases within CUD include canna- and/or tobacco use disorders These patterns of impairment bis intoxication and cannabis with- (over 50%), with nearly 75% of or distress must be manifested drawal. In cannabis intoxication, individuals reporting problematic by specifi c symptoms within a the patient must have recently used use of a secondary or tertiary 12-month time frame for diag- cannabis, resulting in clinically substance (for example, alcohol, nosis of CUD, including but signifi cant problematic behavioral cocaine, methamphetamine, or www.tnpj.com The Nurse Practitioner • March 2021 13

opiates).15 According to a recent ■ Management and treatment may also be considered for the study on the association between The aim of CUD management treatment of anxious and depres- CUD and those with alcohol use should be to improve the indi- sive symptoms. Sedative hypnotics disorder (AUD), cannabis users vidual’s overall function.1 Patel such as zolpidem may be effective who meet criteria for AUD and and Marwaha recommend to help treat sleep disturbances.23 CUD diagnoses are at a greater increased access to mental health Off-label use of other medications, risk for problem drinking on days services, such as psychological including trazodone and mir- when they also use cannabis. This counseling to modify behavior. tazapine, may be benefi cial for the level of heavy drinking is linked CUD may require consultations treatment of insomnia. In addition, with long-term persistent alcohol for behavioral health, neurology, gabapentin has proven to be useful problems.16 Therefore, it is or pain management. in decreasing cannabis use and important to identify any sub- As with any population, patient withdrawal symptoms.22 stance-use-related comorbidities education is essential. According to Nonpharmacologic interven- in patients presenting with CUD. the National Institutes of Health, tions. According to the National There are also comorbidities public education associated with Institute on Drug Abuse, pre- related to psychological condi- the effects of cannabis use is vital vention and treatment of CUD tions. Individuals with a current to address public opinions regard- is vital, especially with ongo- or previous CUD diagnosis have ing the safety and dangers of this ing changes in the substance’s higher rates of concurrent mental substance.20 APRNs must inform legal status at the state level.20 disorders, with major depressive patients that cannabis use can Treatments primarily focus on disorder, anxiety disorders, and result in potentially irreversible nonpharmacologic behavioral personality disorders being cognitive impairments and can be therapies, with emphasis placed common.15 In adolescents, around harmful in pregnancy.8 APRNs on patient education and at-home 33% of those with CUD have should provide supportive treat- management. Psychotherapeutic internalizing disorders, and over ment for patients who must treatments are the most widely 50% have externalizing disor- undergo detoxifi cation, as cannabis studied, demonstrating effective- ders.15 While internalizing disor- intoxication most often does not ness in reducing frequency and ders include behaviors that are require medical management and quantity of use. Unfortunately, focused inward, such as anxiety, resolves on its own.8 abstinence rates for patients depression, social withdrawal, and Pharmacologic interventions. decrease after ceasing treatment.23 fearfulness, externalizing disorders There are no medications that This type of CUD treatment has are comprised of behaviors that are FDA-approved to treat CUD. primarily focused on cognitive- are directed outward toward However, prescription medica- behavioral therapy (CBT), moti- others, including aggression, tions can be benefi cial to alleviate vational enhancement therapy bullying, hyperactivity, and specifi c symptoms of withdrawal. (MET), and contingency manage- delinquency.17 There is strong Alpha-2-adrenergic agonists or ment (CM), and the evidence sug- evidence suggesting that cannabis beta-blockers may be useful in gests a combination of the three use and mental illness co-occur, the treatment of tachycardia, and treatment modalities produces the with cross-sectional data indicat- benzodiazepines may help alleviate best outcomes.23 These therapeu- ing an increased prevalence of episodic panic attacks or general- tic modalities can be administered cannabis use among individuals ized anxiety.1,21 However, APRNs by APRNs with specialty train- with mental illness and an should use caution with prescribing ing including psychiatric mental increased prevalence of mental any addictive substances such as health NPs and psychiatric mental illness among cannabis users.18 A benzodiazepines for the treatment health clinical nurse specialists. study found that CUD was of anxiety. Rather, the off-label use CBT helps patients recognize signifi cantly associated with of fi rst-generation antihistamines the negative repercussions psychotic, depressive, and anxiety such as hydroxyzine may help with associated with cannabis use, symptoms in late adolescence and anxiety and restlessness.1,22 Selec- developing relapse prevention and young adulthood.19 tive serotonin reuptake inhibitors coping skills while engaging in

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11. Bridgeman MB, Abazia DT. Medicinal alternative prosocial behaviors.23 and cannabis-related problems cannabis: history, pharmacology, and implications for the acute care setting. P T. Self-monitoring, cost-benefi t (such as medical, legal, social, 2017;42(3):180-188. analysis, cognitive restructuring, family relations, employment, 12. Calpe-López C, García-Pardo MP, Aguilar MA. Cannabidiol treatment might promote resilience 24 role playing, and modeling are and support). to cocaine and methamphetamine use disorders: a review of possible mechanisms. Molecules. some of the methods employed 2019;24(14):2583. in CBT. This therapy improves ■ Conclusion 13. Hasin DS. US epidemiology of cannabis use and self-effi cacy, with patients more CUD is a serious mental illness, associated problems. Neuropsychopharmacology. 2018;43(1):195-212. likely to effectively use the skills in which can lead to severe physical, 14. American Psychiatric Association. Diagnostic the future.23 MET is based on psychological, and social conse- and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2013. motivational interviewing (MI) quences without appropriate 15. Substance Abuse and Mental Health Services principles, with the aim of assessment and treatment. Further Administration. Facing addiction in America: the Surgeon General’s report on alcohol, drugs, improving a patient’s inspiration research is needed to understand and health. 2016. www.ncbi.nlm.nih.gov/books/ to change by offering nonjudg- the full effects, including poten- NBK424850/. 16. Metrik J, Gunn RL, Jackson KM, Sokolovsky mental feedback, exploring and tially effective pharmacologic AW, Borsari B. Daily patterns of marijuana and resolving uncertainty, and collab- treatments. However, medications alcohol co-use among individuals with alcohol and cannabis use disorders. Alcohol Clin Exp Res. orative goal setting.23 An empa- serve an important role in treating 2018;42(6):1,096-1,104. thetic, nonargumentative comorbid diagnoses and with- 17. Willner CJ, Gatzke-Kopp LM, Bray BC. The dynamics of internalizing and externalizing approach is used to elicit “change drawal symptoms of CUD comorbidity across the early school years. Dev talk” that predicts subsequent Psychopathol. 2016;28(4pt1):1,033-1,052. 23 REFERENCES 18. Lev-Ran S, Feingold D. Cannabis use and its as- behavior change. sociation to mental illness: a focus on mood and There are treatments that 1. Patel J, M arwaha R. Cannabis use disorder. anxiety disorders. In: Preedy VR, ed. Handbook StatPearls. 2019. www.ncbi.nlm.nih.gov/books/ of Cannabis and Related Pathologies. Cambridge, integrate both CBT and MET, NBK538131. MA: Academic Press; 2017. employing the unique strengths of 2. Azofeifa A, Mattson ME, Schauer G, McAfee 19. Leadbeater BJ, Ames ME, Linden-Carmichael T, Grant A, Lyerla R. National estimates of AN. Age-varying effects of cannabis use each by using a mixed treatment marijuana use and related indicators – National frequency and disorder on symptoms of psy- Survey on Drug Use and Health, United chosis, depression and anxiety in adolescents approach. CM may also be offered States, 2002-2014. MMWR Surveill Summ. and adults. Addiction. 2019;114(2):278-293. 2016;65(11):1-28. in addition to psychotherapy. It is 20. National Institute of Health. Marijuana. 2016. 3. The Health Effects of Cannabis and Cannabinoids: www.drugabuse.gov/drug-topics/marijuana. based on operant conditioning of The Current State of Evidence and Recommenda- 21. Copeland J, Pokorski I. Progress toward tions for Research. Washington, DC: The National a target behavior, such as a nega- pharmacotherapies for cannabis-use disorder: Academies Press; 2017. tive urine drug screen. CM is most an evidence-based review. Subst Abuse Rehabil. 4. Peacock A, Leung J, Larney S, et al. Global statis- 2016;7:41-53. tics on alcohol, tobacco and illicit drug use: 2017 effective with frequent reinforce- 22. Brezing CA, Levin FR. The current state of status report. Addiction. 2018;113(10):1,905- pharmacological treatments for cannabis use ment opportunities where rein- 1,926. disorder and withdrawal. Neuropsychopharma- forcers directly follow the target 5. National Institute of Health. Marijuana use cology. 2018;43(1):173-194. disorder is common and often untreated. 2016. behavior, as well as high-perceived www.nih.gov/news-events/news-releases/mari- 23. Sherman BJ, McRae-Clark AL. Treatment of juana-use-disorder-common-often-untreated. cannabis use disorder: current science and reinforcer value and intensifying future outlook. Pharmacotherapy. 2016;36(5): 6. Sadock BJ, Sadock VA, Ruiz P. Synopsis of Psy- 511-535. reinforcement schedule (where chiatry. Philadelphia, PA: Wolters Kluwer; 2015. 24. Gates PJ, Sabioni P, Copeland J, Le Foll B, it is reset after failure to meet the 7. Substance Abuse and Mental Health Services Gowing L. Psychosocial interventions for can- standards).23 According to Gates Administration. Key substance use and mental nabis use disorder. Cochrane Database Syst Rev. health indicators in the United States: results 2016;2016(5):CD005336. and colleagues, the most effective from the 2018 National Survey on Drug Use and Health. 2018. www.samhsa.gov/data/sites/ therapies were those with more default/fi les/cbhsq-reports/NSDUHNational- Cameron Duncan is the chief executive offi cer than four sessions of high-inten- FindingsReport2018/NSDUHNationalFinding- and an APRN at Duncan Family Healthcare PLLC, sReport2018.pdf. Reno, Nev., and assistant professor at the University sity interventions delivered over 8. Petrangelo A, Czuzoj-Shulman N, Balayla J, of Nevada, Reno, Nev. more than 1 month, especially Abenhaim HA. Cannabis abuse or dependence during pregnancy: a population-based cohort Kendra Butler is an RN at the University of MET combined with CBT. With study on 12 million births. J Obstet Gynaecol California, Los Angeles, Calif. this combination therapy, patients Can. 2019;41(5):623-630. 9. Bruni N, Della Pepa C, Oliaro-Bosso S, Pessione Laurielyn Loa is a case manager at United Healthcare, reported a reduction in the E, Gastaldi D, Dosio F. Cannabinoid delivery Las Vegas, Nev. systems for pain and infl ammation treatment. number of days of cannabis use, Molecules. 2018;23(10):2,478. the amount of cannabis smoked 10. Singh A, Saluja S, Kumar A, et al. Cardio- The authors have disclosed no fi nancial relationships related to this article. per day, symptoms of dependence vascular complications of marijuana and related substances: a review. Cardiol Ther. including withdrawal symptoms, 2018;7(1):45-59. DOI-10.1097/01.NPR.0000733712.67456.43