CANNABIS RELATED

DISORDERS

PRESENTOR : N PRIYANKA( FIRST YEAR PG)

MENTOR : DR.MAITHRI (SENIOR RESIDENT)
Plan of presentation
1. Introduction
2. Preparations of Cannabis
3. Epidemiology
4. Neuropharmacology
5. Clinical Features
6. Cannabis Intoxication
7. Cannabis Withdrawl
8. Cannabis Use and Related Disorders
9. Comorbidity
10. Medical Uses
11. Treatment and Rehabilitation
12. references
INTRODUCTION
• Cannabis is the most widely used illegal drug in the world.

• Cannabis, a plant that grows wildly in India, remains the

most commonly used illicit substance in the country as well.

• The recent national survey suggests that there are more than
30 million cannabis users in India, and many of them have
cannabis use disorders

• Over the past 40 years, cannabis use has become a standard

part of youth culture in most developed societies, with first
use now occurring in the mid-to-late teens.
• In the United States, there is a movement
to legalize cannabis at the state level,
with some states allowing the use of
cannabis for medical purposes only and
others for recreational use.

• It has been used in China, India, and the

Middle East for approximately 8,000
years, primarily for its fibers and
secondarily for its medicinal properties.

• Cannabis sativa, or the Indian hemp

plant, is the source of number of
products known collectively as cannabis
• The plant occurs in male and female forms.

• The female plant contains the highest

concentrations of cannabinoids.

• The term Cannabinoids refers to the various

compounds obtained from the cannabis plant
that have psychoactive properties.

• Synthetic cannabinoids refers to various

compounds which are synthesized in
laboratories(not obtained from cannabis plant)
with similar properties of cannabinoids.
 PREPARATIONS OF CANNABIS
• Three preparation most commonly used in India are:-

 BHANG- cut and dried large leaves and stem of the plant, typically
eaten after mixing with in food and beverages.
 GANJA BUDS and FLOWERING TOPS OF FEMALE PLANT
 CHARAS(Hashish)- most potent forms of cannabis come from the
flowering tops of the plants or from the dried, black-brown,
resinous exudate from the leaves, called hashish or hash.
• Delta-9-tetrahydrocannbinol(delta 9 THC), the primary psychoactive compound in
cannabis is a highly lipophilic molecule that readily crosses the BBB and acts through
cannabinoid receptor which mediates its psychological and behavioral effects.

• Concentration of THC range from 0.5% to 3% in Bhang, 3-5% in Ganja and 5-8% in
Charas.

• The cannabis plant is usually cut, dried, chopped, and rolled into cigarettes (commonly
called “joints”).

• The common names for cannabis are marijuana, grass, pot, weed, tea, and Mary
Jane, although there are many other names.

• The potency of marijuana preparations has increased in recent years because of

improved agricultural techniques used in cultivation so that plants may contain up to 15
or 20 percent THC.
EPIDEMIOLOGY
• Most widely used illegal drug in United States, with an estimated 24 million users
aged 12 and older in 2016 (approximately 9 percent of the population).

• Prevalence and Recent Trends The Monitoring the Future survey of adolescents in
school indicates that 36 % of twelfth graders used marijuana in the past year, which
is slightly lower than the most recent peak in the 1990s (39 percent in 1997).

• In 2018, prevalence of marijuana use was 28% in tenth graders (compared to 35

percent in 1997) and 11 % in eighth-graders (compared to 18 percent in 1997).

• Demographic Correlates Rates of cannabis use in the user’s lifetime, the past year,
and the past week are consistently higher among males than females, as are daily use
and long- term daily use.
• African American students have lower rates of use in all grades than white or
Hispanic students.
• About 2.8% of Indians aged 10-75years are current users of any cannabis
product and 0.66% of Indians need help with their cannabis use( i.e. use
cannabis in a dependent or harmful pattern).
Neuropharmacology
• Cannabis plant contains more than 400 chemicals, of which about 60 are
chemically related to Δ9-THC.
• In humans, Δ9-THC rapidly converts to 11- hydroxy-Δ9-THC, the metabolite
that is active in the CNS.
• The cannabinoid receptor, a member of the G-protein–linked family of
receptors, is linked to the inhibitory G protein (Gi), which inhibits adenylyl
cyclase.
• The highest concentrations of the cannabinoid receptor are in basal ganglia,
hippocampus, and cerebellum, with lower concentrations in the cerebral
cortex.
• The brainstem lacks this receptor, explaining the drug’s minimal effects on
respiratory and cardiac functions.
• It is not clear whether the cannabinoids stimulate the so-called reward centers
of the brain, such as the dopaminergic neurons of the VTA.

• Tolerance to cannabis does develop, however, as does psychological

dependence.

• Withdrawal symptoms in humans are limited to modest increases in irritability,

restlessness, insomnia, and anorexia and mild nausea; all these symptoms
appear only when a person abruptly stops taking high doses of cannabis.

• Smoking cannabis- the euphoric effects appear within minutes, peak -30
minutes, and last 2 to 4 hours.

• Some motor and cognitive effects last 5 to 12 hours.

• Oral cannabis is also frequent, usually as an additive in baked goods, such as
brownies and cakes.

• It requires about two to three times as much oral cannabis to be as potent as

smoked cannabis.

• Many variables affect the psychoactive properties of cannabis, including the

potency of the cannabis used, the route of administration, the smoking
technique, the effects of pyrolysis on the cannabinoid content, the dose, the
setting, and the user’s experience, expectations, and unique biologic
vulnerability to the effects of cannabinoids.
CLINICAL FEATURES
• Most young people use cannabis to experience a “high” characterized by
feelings of mild euphoria, relaxation, and perceptual alterations.

• Cognitive changes include impaired short-term memory and attention that

makes it easy for the user to become lost in pleasant reverie and have difficulty
sustaining goal-directed mental activity.

• Motor skills, reaction time, motor coordination, and many forms of skilled
psychomotor activity are impaired while the user is intoxicated.
Physical Effects of Cannabis Use
• Common:-
• Dilation of the conjunctival blood vessels (red eyes)
• Mild tachycardia
• Increased appetite
• Dry mouth
• Orthostatic hypotension (higher doses)

• Heavy chronic use:-

• Chronic respiratory disease
• Lung cancer
• Cerebral atrophy
• Seizure susceptibility
• Chromosomal damage
• Birth defects
• Impaired immune reactivity
• Alterations in testosterone concentrations
• Dysregulation of menstrual cycles
ICD 10 ICD 11 DSM 5
F12.5 - Mental and 6C41.6 Cannabis-induced Cannabis-induced
behavioral disorders due psychotic disorder psychotic disorder
to use of cannabinoids
with Psychotic Disorder
CANNABIS INTOXICATION
• Heightens users sensitivities to external stimuli and subjectively slows the appreciation
of time.

• In high doses, users may experience depersonalization and derealization.

• Cannabis use impairs motor skills, and this effect remains after the euphoriant effects
have resolved.

• For 8 to 12 hours after using cannabis, users’ impaired motor skills interfere with the
operation of motor vehicles and other heavy machinery.

• Cannabis intoxication can markedly impair cognition and performance.

• Even modest doses of cannabis impair memory, reaction time, perception,
motor coordination, and attention.

• High doses that also impair users’ levels of consciousness have marked effects
on cognitive measures.
CANNABIS WITHDRAWL
• Cessation of use in daily cannabis users results in withdrawal symptoms
within 1 to 2 weeks of cessation.
• Symptoms:
• Irritability
• Cannabis cravingsRestlessness
• Headache
• Chills
• Stomach pain
• Sweating
• TremorsNervousness
• Anxiety
• Insomnia
• Disturbed or vivid dreaming
• Decreased appetite
• Weight loss
• Depressed mood
CANNABIS USE DISORDER
• People who use cannabis daily for weeks to months are most likely to develop
a cannabis use disorder.

• The risk of developing cannabis use disorder is around one in ten for anyone
who uses cannabis.

• The earlier the age of first use, the more often cannabis has been used, and the
longer it is used, the higher the risk of developing the disorder.
CANNABIS INDUCED PSYCHOTIC DISORDER
• Cannabis-induced psychotic disorder- a genuine psychotic process, is rare; transient
paranoid ideation, however, is common.

• Florid psychosis is somewhat commonplace in countries in which some persons have

long-term access to high potency cannabis.

• The psychotic episodes are sometimes called “hemp insanity.”

• Cannabis use rarely causes the “bad-trip” experience we associate with hallucinogen
intoxication.

• When cannabis-induced psychotic disorder does occur, the affected person is likely to
have a preexisting personality disorder.
CANNABIS INDUCED ANXIETY DISORDER
• Cannabis-induced anxiety disorder is common during acute intoxication,
which in many persons, induces short-lived anxiety states often provoked by
paranoid thoughts.

• In such circumstances, ill-defined and disorganized fears may induce a panic

attack.

• Anxiety symptoms are the most common adverse effect of moderate cannabis
use and correlate with the dose taken.

• Inexperienced users are much more likely to experience anxiety symptoms

than are experienced users.
UNSPECIFIED CANNABIS-RELATED DISORDERS
• DSM-5 includes this for cannabis disorders that do not fit into the other
diagnoses.

• Examples could be episodes of depressive or hypomanic symptoms, although

these symptoms may suggest long-term cannabis use.

• When sleep disorder or sexual dysfunction symptoms are related to cannabis

use, they almost always resolve within days or a week after cessation.

• Flashbacks- Persons have experienced sensations related to cannabis

intoxication after the short-term effects of the substance have disappeared.
Cognitive Impairment-
• The long-term use of cannabis may produce subtle forms of cognitive impairment
in the higher cognitive functions of memory, attention, and organization and the
integration of complex information.
• The longer the period of heavy cannabis use, the more pronounced the cognitive
impairment.
• Nonetheless, because the impairments in performance are subtle, it remains to be
determined how significant they are for everyday functioning.
Amotivational Syndrome:-
• Traditionally, a person’s unwillingness to persist in a task—be it at school, at
work, or in any setting that requires prolonged attention or tenacity—
characterizes the syndrome, which is associated with long-term heavy use
• People with the syndrome become apathetic and anergic, may gain weight, or
appear slothful.
 CIPD Cannabis Intoxication

In CIPD the hallucinations and/or Psychotic symptoms in Cannabis

delusions are the focus of the Intoxication are more mild and self-
clinical presentation and are limited and are not even required to
severe enough to warrant clinical make that diagnosis.
attention/treatment

Hallucinations in CIPD are In Cannabis Intoxication the

experienced without insight. hallucinations when present are
experienced with insight intact.

CIPD can last for days and even Cannabis Intoxication will necessarily
weeks after cannabis exposure resolve within 24 hours
Cannabis and Schizophrenia
• Three hypotheses outline the potential relationship between
cannabis and schizophrenia in contemporary literature:
1) Cannabis can trigger schizophrenia in an individual who would not
have developed the illness if they had not been exposed to the
drug.
2) Individuals with a predisposition to schizophrenia use cannabis to
mitigate the prodromal symptoms of schizophrenia, referred to as
reverse causation.
3) Common cause suggests that other factors are responsible for the
relationship such as childhood trauma or genetics for example.
• A specific example of genetic involvement in the
cannabis/schizophrenia association can be seen in the COMT gene.
• The COMT gene codes for the enzyme catechol-O-
methyltransferase which is important in the breakdown of
dopamine, particularly in the prefrontal cortex.
• Dysregulation of dopamine has long been considered a crucial part
of the pathophysiology of schizophrenia and a great deal of research
has been done to investigate the link between COMT
polymorphisms and schizophrenia, particularly with respect to
negative symptoms and cognition.
COMORBIDITY
• Cannabis is often referred to as a “gateway drug” - cannabis users are at high
risk for other substance use disorders.

• Also, cannabis use may be comorbid with depression, anxiety, conduct

disorder, and suicidality.
Medical Use of Marijuana
• Marijuana- used as a medicinal herb for centuries, and cannabis was listed in
the US Pharmacopeia until the end of the 19th century as a remedy for anxiety,
depression, and GI disorders, among others.

• Cannabis is currently a controlled substance, and the Drug Enforcement Agency

(DEA) does not recognize any medical use for the substance.

• Patients and doctors have used the drug, sometimes illegally, to treat a variety of
disorders, including nausea secondary to chemotherapy, HIV- associated weight
loss, multiple sclerosis (MS) chronic pain, epilepsy, and glaucoma.

• As of 2020, 15 states have legalized the recreational and medicinal use of

marijuana, along with the District of Columbia, and several US territories.
• Dronabinol-synthetic form of THC, has been approved by the US Food and
Drug Administration (FDA) for the treatment of anorexia-associated weight loss
in HIV and nausea and vomiting associated with chemotherapy.

• Dronabinol is also under investigation for the treatment of obstructive sleep

apnea.

• Nabilone-a synthetic cannabinoid, has been approved for the treatment of

nausea and vomiting associated with chemotherapy.

• In 2013, cannabidiol was granted orphan drug status for the treatment of certain
rare, intractable types of epilepsy in children.

• Nabiximols-oral spray consisting of natural cannabis extracts, is currently being

investigated for the treatment of cancer pain.
SCREENING TOOLS
• CRAFFT and ASSIST help in detecting substance use (including cannabis and
related problems in primary and general medical care settings).
TREATMENT SETTING
• Owing to the transitory and self-limiting nature of most cannabis use disorders,
outpatient treatment is sufficient for most patients.

• Inpatient treatment is warranted for those who develop:-

• Severe anxiety or paranoia with cannabis intoxication

• Cannabis induced psychosis that is unmanageable in the outpatient setting

• Serious comorbid psychiatric disorders (like Schizophrenia)which merits

hospital admission

• Comorbid substance use disorder with an independent indication for

inpatient treatment
General Assessment
• Clinical history: Form, relative potency and the amount of the cannabis
consumed, route of administration, duration and frequency of intake, last intake,
history of previous adverse reactions.

• Determination of the diagnosis of cannabis use disorders: based on the nature

and severity of presenting complaints (cannabis intoxication/ withdrawal) .

• Assessment for co-morbid substance use disorders/psychiatric disorders/general

medical or neurological conditions.

• Laboratory tests: urine qualitative immunoassay for the presence of

cannabinoids in urine; not diagnostic of any disorders but indicates recent use of
cannabis(upto 4 weeks).
Treatment of Cannabis Intoxication
• Symptoms are mostly transient, mild and self-limiting
• Reassurance and supportive care are usually sufficient
• Pharmacological treatment is necessary in patients with:
• Severe and distressing anxiety symptoms
• Unmanageable and disruptive psychotic symptoms
• Suggested’ treatment: Benzodiazepine (preferably short acting) and
antipsychotics (preferably second generation) are drugs of choice
forsymptomatic relief
• ‘Might be considered’ treatment: Propranolol 60-120 mg/day
• Duration of treatment: 1-2 days.
Treatment of Cannabis Withdrawal Syndrome
• Symptoms are mostly transient, mild and self-limiting Reassurance and
supportive care are usually sufficient.

• Pharmacological treatment is necessary in patients with severe and distressing

withdrawal symptoms.

• ’Suggested’ treatment: Benzodiazepines, based on clinical experience.

• ’Might be considered’ treatment: Dronabinol (20-60 mg/day), Baclofen

40mg/day.

• Duration of treatment: around 7 days

Treatment of Cannabis Dependence
• Maintaining complete abstinence is the goal of treatment.

• Psychosocial interventions are the mainstay of treatment.

• Evidence for drug treatment is still preliminary.

• Pharmacological treatment:
1. Should ideally be used in combination with psychosocial interventions
2. Suggested’ treatment: Buspirone (up to 60 mg/day)
3. ’Might be considered’ treatment: Baclofen (40-60 mg/day), Fluoxetine(20-
40 mg/day), N-acetyl-cysteine (1200 mg/day), Entacapone (200 mg/day)
• Duration of treatment: 3-12 months
Psychosocial Interventions
• Motivation enhancement therapy (MET)
• Cognitive behavioral therapy (CBT
• Combined MET & CBT
• Contingency management (CM) in conjunction with either MET/CBT
• Family Systems therapy
• Number of sessions for psychosocial intervention: 2-14 depending on the type
and setting of psychosocial intervention
• Frequency of sessions: once in a week to once in 2 weeks
• Either individual or group sessions
Motivation Enhancement Therapy (MET)
i. Non-directive
ii. Resolve ambivalence for quitting
cannabis and strengthen the motivation
to change
iii.Individual session duration:45-60
minutes session
iv. Number of sessions: 1-4 sessions
v. Tested across various age groups and
treatment settings
Cognitive Behavior Therapy (CBT)
i. Teaching of coping skills to quit
cannabis
ii. Problem solving skill training
iii.Life style management
iv. Conducted through interactive
exercises, practical assignments and
role playing
v. Individual session duration:45-60
minutes
vi.Number of sessions: 6-14
vii.Has synergistic effect when
combined with MET
Contingency management (CM)
I. Reinforcing or punishing consequences in order to achieve therapeutic goal

II. Primarily aims at abstinence reinforcement

III.Also intends to facilitate retention in treatment, adherence to medications or

therapy sessions

IV.Reinforcement is mostly through payment of token vouchers

V. Should always be used in conjunction with other forms of psychosocial

intervention
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