Harbor:Cannabis Abuse: Difference between revisions

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=Treatment Options=
==Cannabis Use Disorder (CUD)==
* N-Acetyl Cysteine (NAC)
** 600 mg PO BID x 3 days, then 1200 mg PO BID x4d, then 1800 mg PO BID for weeks 2-8
* Gabapentin
** day 1: one 300 mg capsule in the evening; day 2: one 300 mg capsule in the morning and evening; day 3: one 300 mg capsule in the morning, at midday, and in the evening; day 4: one 300 mg capsule in the morning and at midday and two 300 mg capsules in the evening. Subjects maintained the 1200 mg/day dose until week 11.
** Can start 300mg TID prn anxiety or standing and titrate to 900mg TID prn anxiety as tolerated if no contraindications like renal insufficiency or falls.
* Naltrexone:  50 mg PO QD X 12w  or  380 mg IM monthly
** Contraindications: Liver Enzymes 5X normal or greater
* Amitriptyline:  25 mg PO qhs x 1 week, 50 mg PO qhs X 1 week, 75-100 mg PO QHS
 
==Cannabis Hyperemesis==
* Haloperidol 0.05-0.1 mg/kg IV/IM
* Droperidol 0.625 mg/kg IV/IM
* Olanzapine for refractory cases - 5mg IV
* Capsaicin cream
* Consider PPI, diphenhydramine, ondansetron, lorazepam 0.025-0.02 mg/kg/dose
 
==Cannabis Withdrawal Syndrome==
* Definition: At least 3 within 1 week of cessation (irritability, nervousness/ anxiety, sleep difficulty, decreased appetite or weight loss, restlessness, depressed mood, somatic sx causing significant discomfort)
** Gabapentin
*** day 1: one 300 mg capsule in the evening; day 2: one 300 mg capsule in the morning and evening; day 3: one 300 mg capsule in the morning, at midday, and in the evening; day 4: one 300 mg capsule in the morning and at midday and two 300 mg capsules in the evening. Subjects maintained the 1200 mg/day dose until week 11.
**Amitriptyline:  Dose 25 mg PO qhs x 1 week, 50 mg PO qhs X 1 week, 75-100 mg PO QHS
*** Potential adjunctive medications: ondansetron, clonidine
 
=Limited Evidence=
* NAC:  Two RCTs have examined NAC for CUD
** A RCT in treatment- seeking adolescents with CUD ages 15–21 (N = 116) examined CM plus NAC 2400 mg/day for 8 weeks. Intent-to-treat analyses showed greater than twofold odds of bioverified cannabis abstinence in the NAC group vs. placebo at study end (odds ratio = 2.4, 95%, CI = 1.1–5.2).
** A similar RCT by the same team with adults with CUD found that '''NAC 2400 mg/day for 12 weeks did not differ from placebo''' in cannabis craving or use.
*** Herbst ED, Pennington DL, Borsari B, Manuel J, Yalch M, Alcid E, Martinez Rivas M, Delacruz J, Rossi N, Garcia B, Wong N, Batki SL. N-acetylcysteine for smoking cessation among dual users of tobacco and cannabis: Protocol and rationale for a randomized controlled trial. Contemp Clin Trials. 2023 Aug;131:107250. doi: 10.1016/j.cct.2023.107250. Epub 2023 Jun 2. PMID: 37271412; PMCID: PMC10847050.
 
* Gabapentin
** Mason BJ, Crean R, Goodell V, Light JM, Quello S, Shadan F, et al. A '''proof-of-concept randomized controlled study''' of gabapentin: effects on cannabis use, withdrawal and executive function deficits in cannabis dependent adults. Neuropsychopharmacol Off Publ Am Coll Neuropsy chopharmacol. 2012;37(7):1689–98
 
* Naltrexone
** Haney M, Ramesh D, Glass A, Pavlicova M, Bedi G, Cooper ZD. Naltrexone Maintenance Decreases Cannabis Self-Administration and Subjective Effects in Daily Cannabis Smokers. Neuropsychopharmacology. 2015 Oct;40(11):2489-98. doi: 10.1038/npp.2015.108. Epub 2015 Apr 16. PMID: 25881117; PMCID: PMC4569951.
** Notzon, D. P., Kelly, M. A., Choi, C. J., Pavlicova, M., Mahony, A. L., Brooks, D. J., Mariani, J. J., & Levin, F. R. (2018). Open-label pilot study of injectable naltrexone for cannabis dependence. The American Journal of Drug and Alcohol Abuse., 44(6), 619–627. https://doi.org/10.1080/00952990.2017.1423321
** Shamabadi A, Arabzadeh Bahri R, Karimi H, Heidari E, Akhondzadeh S. Emerging pharmacotherapy for the treatment of cannabis use disorder. Expert Opin Pharmacother. 2024 Apr;25(6):695-703. doi: 10.1080/14656566.2024.2353638. Epub 2024 May 15. PMID: 38717605.
 
* Amitriptyline
** Sharaf, R., Venkatesan, T., Shah, R. Management of cyclic vomiting syndrome in adults: evidence review. Neurogastroenterol Motil. 2019; 31, e13605
 
=Patient Resources=
* Hotlines
** https://www.samhsa.gov/find-help/national-helpline (#1-800-662-HELP (4357))
** https://marijuana-anonymous.org/ (#1-800-766-6779)
** https://recovered.org/ (#1-800-NCA-CALL (622-2255))
* LA Area (Meetings)
** https://marijuana-anonymous.org/ (online & in person meetings / 12 step program)
* Rehab Centers
** https://muirwoodteen.com/ (Riverside, CA)
** https://bnitreatment.com/tour/ (Calabasas or Agora Hills)
** https://www.lacada.com/residential.php
** https://www.bhs-inc.org/residential-inpatient-treatment
* Other
** https://recovered.org/treatment (different treatment options)
*Text Messages
** Marijuana Resource Center - Partnership to End Addiction
*Skill building
** Marijuana Resource Center - Partnership to End Addiction
* Apps
** Marijuana Anonymous App - Marijuana Anonymous Info, meetings, obtain sponsor
** IamSober- Tracks time sober and give symptom timeline
** SoberGrid- allows linkage of sobriety and social media (eg, sends posts); for fee can get coaching
** Iam- Daily affirmations
** Nomo- journaling

Revision as of 17:09, 18 March 2025

Treatment Options

Cannabis Use Disorder (CUD)

  • N-Acetyl Cysteine (NAC)
    • 600 mg PO BID x 3 days, then 1200 mg PO BID x4d, then 1800 mg PO BID for weeks 2-8
  • Gabapentin
    • day 1: one 300 mg capsule in the evening; day 2: one 300 mg capsule in the morning and evening; day 3: one 300 mg capsule in the morning, at midday, and in the evening; day 4: one 300 mg capsule in the morning and at midday and two 300 mg capsules in the evening. Subjects maintained the 1200 mg/day dose until week 11.
    • Can start 300mg TID prn anxiety or standing and titrate to 900mg TID prn anxiety as tolerated if no contraindications like renal insufficiency or falls.
  • Naltrexone: 50 mg PO QD X 12w or 380 mg IM monthly
    • Contraindications: Liver Enzymes 5X normal or greater
  • Amitriptyline: 25 mg PO qhs x 1 week, 50 mg PO qhs X 1 week, 75-100 mg PO QHS

Cannabis Hyperemesis

  • Haloperidol 0.05-0.1 mg/kg IV/IM
  • Droperidol 0.625 mg/kg IV/IM
  • Olanzapine for refractory cases - 5mg IV
  • Capsaicin cream
  • Consider PPI, diphenhydramine, ondansetron, lorazepam 0.025-0.02 mg/kg/dose

Cannabis Withdrawal Syndrome

  • Definition: At least 3 within 1 week of cessation (irritability, nervousness/ anxiety, sleep difficulty, decreased appetite or weight loss, restlessness, depressed mood, somatic sx causing significant discomfort)
    • Gabapentin
      • day 1: one 300 mg capsule in the evening; day 2: one 300 mg capsule in the morning and evening; day 3: one 300 mg capsule in the morning, at midday, and in the evening; day 4: one 300 mg capsule in the morning and at midday and two 300 mg capsules in the evening. Subjects maintained the 1200 mg/day dose until week 11.
    • Amitriptyline: Dose 25 mg PO qhs x 1 week, 50 mg PO qhs X 1 week, 75-100 mg PO QHS
      • Potential adjunctive medications: ondansetron, clonidine

Limited Evidence

  • NAC: Two RCTs have examined NAC for CUD
    • A RCT in treatment- seeking adolescents with CUD ages 15–21 (N = 116) examined CM plus NAC 2400 mg/day for 8 weeks. Intent-to-treat analyses showed greater than twofold odds of bioverified cannabis abstinence in the NAC group vs. placebo at study end (odds ratio = 2.4, 95%, CI = 1.1–5.2).
    • A similar RCT by the same team with adults with CUD found that NAC 2400 mg/day for 12 weeks did not differ from placebo in cannabis craving or use.
      • Herbst ED, Pennington DL, Borsari B, Manuel J, Yalch M, Alcid E, Martinez Rivas M, Delacruz J, Rossi N, Garcia B, Wong N, Batki SL. N-acetylcysteine for smoking cessation among dual users of tobacco and cannabis: Protocol and rationale for a randomized controlled trial. Contemp Clin Trials. 2023 Aug;131:107250. doi: 10.1016/j.cct.2023.107250. Epub 2023 Jun 2. PMID: 37271412; PMCID: PMC10847050.
  • Gabapentin
    • Mason BJ, Crean R, Goodell V, Light JM, Quello S, Shadan F, et al. A proof-of-concept randomized controlled study of gabapentin: effects on cannabis use, withdrawal and executive function deficits in cannabis dependent adults. Neuropsychopharmacol Off Publ Am Coll Neuropsy chopharmacol. 2012;37(7):1689–98
  • Naltrexone
    • Haney M, Ramesh D, Glass A, Pavlicova M, Bedi G, Cooper ZD. Naltrexone Maintenance Decreases Cannabis Self-Administration and Subjective Effects in Daily Cannabis Smokers. Neuropsychopharmacology. 2015 Oct;40(11):2489-98. doi: 10.1038/npp.2015.108. Epub 2015 Apr 16. PMID: 25881117; PMCID: PMC4569951.
    • Notzon, D. P., Kelly, M. A., Choi, C. J., Pavlicova, M., Mahony, A. L., Brooks, D. J., Mariani, J. J., & Levin, F. R. (2018). Open-label pilot study of injectable naltrexone for cannabis dependence. The American Journal of Drug and Alcohol Abuse., 44(6), 619–627. https://doi.org/10.1080/00952990.2017.1423321
    • Shamabadi A, Arabzadeh Bahri R, Karimi H, Heidari E, Akhondzadeh S. Emerging pharmacotherapy for the treatment of cannabis use disorder. Expert Opin Pharmacother. 2024 Apr;25(6):695-703. doi: 10.1080/14656566.2024.2353638. Epub 2024 May 15. PMID: 38717605.
  • Amitriptyline
    • Sharaf, R., Venkatesan, T., Shah, R. Management of cyclic vomiting syndrome in adults: evidence review. Neurogastroenterol Motil. 2019; 31, e13605

Patient Resources

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