Assessment and management of cannabis use disorders in primary care
BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c1571 (Published 01 April 2010) Cite this as: BMJ 2010;340:c1571All rapid responses
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I welcome this balanced and informative discourse about cannabis and in particular the consideration given to the relationship between cannabis, pychosis risk and psychosis. However,in my opinion, incipient psychotic illness and psychosis were not sufficiently highlighted as diagnoses to be differentiated from depression and chronic cannabis intoxication, particularly given the high frequency of emotional dysfunction in the presentation of a schizophrenic prodrome or incipient psychosis(1,2)
Prevention of psychosis as a result of early identification is now recognized as a realistic possibility (3,4) and especially relevant in the population of cannabis users whose use may be aggravating their psychosis risk and amongst those who are escalating their cannabis use (to daily use) in a bid to ward off or cope with early symptoms of psychosis (5).
Many risk factors for psychotic illness are probably not readily modifiable (eg genetic risk, in utero exposure, birth trauma), but in contrast, helping individuals in their efforts to reduce their cannabis use is an intervention that can result in successful preventative action.
Differentiating between: co-morbid depression and chronic cannabis use; chronic cannabis use alone; (incipient) psychosis alone or co-morbid (incipient) psychosis and chronic cannabis use is complex, especially given the emotional dysfunction that is so frequently present in incipient psychosis and early psychotic disorders. Early referral to a local early intervention in psychosis team will help with such differentiation, and allowing for options of many relevant beneficial activities including expert monitoring and therapeutic engagement (6), (family and/ or individual) psychological interventions, prescription of omega 3 fatty acids (which are looking increasingly promising in terms of impact and acceptability)(7) and the opportunity for fully informed discussions about the pros and cons of antipsychotic medication (8,9).
The earlier that all this can be done, the greater the likelihood that serious consequences can be averted or at least reduced, such as the psychological trauma of a full-blown psychotic illness, suicide attempts (10) and hospital admission (6)(frequently including detention under the Mental Health Act, 1983) (11).
In the current cold economic climate with cost cutting in the NHS, such opportunities for early preventative interventions are highly recommended as a pragmatic significant cost saving solution to the very real long term cost implications of chronic psychotic illnesses (12) such as schizophrenia complicated by comorbid substance misuse.
1. Hafner, H. Loffler, W. Mauer, K., Hambrecht, M. & an der Heiden. Depression, negative symptoms, social stagnation and social decline in the early course of schizophrenia. Acta Psychiatrica Scandanavica (1999) 100, 105-18.
2. Hafner H. Mauer, K. Trendler, G. et al Schizophrenia and depression: challenging the paradigm of two separate diseases- a controlled study of schizophrenia, depression and health controls. (2005) Schizophrenia Research 77,11-24
3. Prevention of Negative Symptom Psychopathologies in First-Episode Schizophrenia: Two-Year Effects of Reducing the Duration of Untreated Psychosis. Ingrid Melle; Tor K. Larsen; Ulrik Haahr; Svein Friis; Jan O. Johannesen; Stein Opjordsmoen; Bjørn R. Rund; Erik Simonsen; Per Vaglum; Thomas McGlashan. Arch Gen Psychiatry, Jun 2008; 65: 634 - 640.
4. Reducing the Duration of Untreated First-Episode Psychosis: Effects on Clinical PresentationIngrid Melle; Tor K. Larsen; Ulrik Haahr; Svein Friis; Jan Olav Johannessen; Stein Opjordsmoen; Erik Simonsen; Bjørn Rishovd Rund; Per Vaglum; Thomas McGlashan. Arch Gen Psychiatry, Feb 2004; 61: 143 - 150.
5. Association of pre-onset cannabis, alcohol, and tobacco use with age at onset of prodrome and age at onset of psychosis in first-episode patients. Compton MT, Kelley ME, Ramsay CE, Pringle M, Goulding SM, Esterberg ML, Stewart T, Walker EF. American Journal of Psychiatry. 2009 Nov;166(11):1251-7.
6. Early intervention in psychosis service and psychiatric admissions. G.Dodgson, K. Crebbin, E.Mitford, A. Brabban, R. Paxton. The Psychiatrist (2008) 32: 413-416. doi: 10.1192/pb.bp.107.017442.
7. Long-Chain ?-3 Fatty Acids for Indicated Prevention of Psychotic Disorders. A Randomized, Placebo-Controlled Trial G. Paul Amminger; Miriam R. Schäfer; Konstantinos Papageorgiou; Claudia M. Klier; Sue M. Cotton; Susan M. Harrigan; Andrew Mackinnon; Patrick D. McGorry; Gregor E. Berger. Arch Gen Psychiatry. 2010;67(2):146-154
8. Cardiometabolic risk of second-generation antipsychotic medications during first-time use in children and adolescents. Correll CU, Manu P, Olshanskiy V, Napolitano B, Kane JM, Malhotra AK. JAMA. 2009 Oct 28;302(16):1765-73
9. Antipsychotic Drug Treatment for Patients with Schizophrenia: Theoretical Background, Clinical Considerations and Patient Preferences R. Nielsen and J. Nielsen Clinical Medicine: Therapeutics 2009:1 1053–1068.
10. Early Detection of the First Episode of Schizophrenia and Suicidal Behavior Ingrid Melle, Jan Olav Johannesen, Svein Friis, Ulrik Haahr, Inge Joa, Tor K. Larsen, Stein Opjordsmoen, Bjørn R. Rund, Erik Simonsen, Per Vaglum, and Thomas McGlashan.
11.Larsen TK, Melle I, Friis S, Joa I, Johannessen JO, Opjordsmoen S, Simonsen E, Vaglum P, McGlashan TH. One-year effect of changing duration of untreated psychosis in a single catchment area. Br J Psychiatry. 2007;51(suppl):s128-s132
12. McCrone P. Dhanasiri S., Patel A., Knapp, M & Lawton Smith S. (2008) Paying the Price. The cost of mental health care in England 2026. London Kings Fund.
Competing interests: None declared
Competing interests: No competing interests
Thank you for a most helpful guide to assessing and managing a wide
range of Cannabis Use Disorders.[1] This makes the important point that
the youngest users are at the greatest risk of harm, for example a
depressed, pregnant adolescent in local authority care. Long term anxiety
is common among young people who smoke this drug and clinicians are
sometimes surprised by the abrupt emergence of symptoms like panic or
paranoia. Some doctors struggle to engage with school age users and even
find it difficult to distinguish residual intoxication from bloody
mindedness.
The clinical review seems oriented to engagement within a general
practice surgery, and GPs may find excellent advice from the Royal College
of General Practitioners' Adolescent Primary Care Society. However, key
case identification ("the teachable moment" for a young person) is much
more likely to arise within school health services. The "You're Welcome"
skills to build trust between a doctor and a vulnerable teenager are
crucial for success, here.[2] In both England and Scotland [3]
unprecedented levels of emotional distress are now appearing by the age of
15, and so working at establishing trust and reassurance is more important
than ever - before one can even talk about illicit drug use.
Cannabis use crops up in many other community services, from walk-ins
for minor injuries when cycling to Connexions advice for teenagers
struggling with education. In police custody Forensic Medical Examiners
will see it, as will Safeguarding teams (just look for domestic fires or
drowning incidents and 'neglect'). The spectrum of "Youth Taskforce"
services targeting support at troubled, alienated young people all see
this use. But from all the above agencies, referrals for clinical
management are rare: shame on their local Primary Care Trust 'partners'!
So where can we start to improve primary care for young cannabis users?
Most adolescents live with families, and Family Intervention Projects and
Parenting Early Intervention Programmes are steadily spreading.[4]
Appropriate "whole family assessments" should include a clinical
assessment of the actual impact of smoking cannabis on children in the
family, including use by siblings and carers. For that most vulnerable,
pregnant teenager above, looked-after children are promised a Lead
Professional in the Children Act 2004. That local authority employee has a
duty to ensure she registers with a GP, and that GP needs to collaborate
with her Lead Professional - and with her.
[1] Winstock AR, Ford C, Witton J. Assessment and management of
cannabis use disorders in primary care. BMJ 2010; 340: 800-804.
[2] Churchill D. Making health services young people friendly.
British Journal of School Nursing 2010; 5 (2): 93-94.
[3] Caan W. Editorial. Journal of Public Mental Health 2009; 8 (4): 2
-3.
[4] Department for children, schools and families, Department of
Health, National Treatment Agency for Substance Use. Annex A in: Joint
Guidance on Development of Local Protocols between Drug and Alcohol
Treatment Services and Local Safeguarding and Family Services. London:
DCSF, 2009.
Competing interests:
None declared
Competing interests: No competing interests
On how to manage withdrawal the article referes to "table 2" for the
symptoms of withdrawal. If I was a primary care physician looking to spot
this in my patients, not sure I would be any more informed about if and
what cannabis withdrawal was.
Competing interests:
None declared
Competing interests: No competing interests
I think this is a good clinical review done to understand the core
concept of cannabis use and its effects in people especially of younger
generation. I feel that if we nip it in the bud i.e., assess and manage
the symptoms arising out of cannabis use early on, then we will be
preventing much more damage that will occur to the future of the younger
generation. There have been conflicting research evidence about how much
cannabis can affect one's life and also about its ill effects. It has been
reported that cannabis use over a prolonged period can cause psychosis or
psychosis like symptoms. The emphasis should well be on preventing people
from cannabis use and also to educate them about its ill effects. Also, if
it can be done at the primary care level, then it is even better.
Substance misuse services can then cater to more complex and chronic users
of cannabis or other substance use. By intervening at the primary care
level, we should be able to prevent things from getting worse. We should
hopefully be able to improve the quality of life of people and also
brighten the future of our younger generation.
Competing interests:
None declared
Competing interests: No competing interests
Are we concerned with cannabis or cannabis with poly-medication ??
It has been confirmed that most cannabis dependent persons shift to
other drugs erratically on recreational basis as cannabis use has
previously started. Over time, dependent people on cannabis will usually
combine tramadol, carisoprodol, meprobamate, benzodiazepines or even
opiates. In Egypt these drugs are described by teens as “Chemistry drugs”
to describe the use of unnatural substances.
The treatment of such patients require a priori the proper evaluation
of dependence status, to identify inclusion of other drugs by screening
for which other decisions and plan of treatment would be advocated.
Immunoassay techniques do not always satisfy the treating toxicologist and
other more elaborate techniques as thin layer chromatography (or
preferably GC or HPLC) will be needed to respond and complement screening.
Antidepressants would be hazardous if such patients use tramadol as
complementary to cannabis. Enforcing withdrawal for cannabis associated
with undiagnosed associated benzodiazepines dependence would as well
precipitate serious reactions
A common problem facing the physician is the conflict with a society
that considers cannabis a benign habit less toxic than tobacco smoking. In
some classes of the society and in some areas it would be a big shame if
you don’t offer hashish to your invitee in party and engagement or
marriage celebrations.
More astonishing is the pride to have used hashish among adolescents
and young adults in ladies as well as men who consider using hash, a live
fashion and grandiose experience that should not be omitted. Frequent well
-designed campaigns should be organized on regular intervals and over long
periods to eradicate the fixed traditions and attitudes of an expanding
community in favor of cannabis that, in my opinion, is invading the globe
at larger steps than the campaigns supported by most countries.
Competing interests:
Acute poisoning, Dependence, Cannabis
Competing interests: No competing interests