Management of Cannabis Use Disorder

Introduction to Cannabis Use Disorder

Cannabis use disorder should be diagnosed when a patient meets two or more of the eleven DSM-5 criteria, with severity classified as mild (2-3 criteria), moderate (4-5 criteria), or severe (6+ criteria), as recommended by the American Psychiatric Association 1
Tolerance and withdrawal alone (without other criteria) should not be considered diagnostic of cannabis use disorder when cannabis is used appropriately under medical supervision, as noted by the American Psychiatric Association 1

The American Medical Association recommends a combination of cognitive behavioral therapy (CBT) and motivational enhancement therapy (MET) for the management of cannabis use disorder, as this approach has demonstrated the greatest efficacy in reducing cannabis use and associated problems 2
Combined CBT and MET delivers the strongest outcomes for reducing cannabis use, and provides training in behavioral self-control skills, targeting cognitive, affective, and environmental risks for substance use 2
The addition of contingency management to CBT/MET is particularly effective in enhancing treatment outcomes, and can include voucher-based incentives 2
Evidence-based treatments can substantially reduce cannabis use and cannabis-related problems, with successful outcomes for CUD being as likely as for chronic diseases such as diabetes, hypertension, and asthma 3

The FDA has not approved any medications specifically for the treatment of cannabis use disorder, although several medications show limited promise 3
The American College of Physicians recommends monitoring patients closely for sedation, obtundation, and myocardial ischemia, especially when using cannabis or cannabis-related products 4

CHS can be identified by stereotypical episodic vomiting in a patient with cannabis use for >1 year, cannabis use frequency >4 times per week, relief from hot showers/baths, and resolution of symptoms after cannabis cessation 5, 6
Emergency department differential diagnosis should include life-threatening conditions such as acute abdomen, bowel obstruction, mesenteric ischemia, pancreatitis, and myocardial infarction in patients presenting with cyclic vomiting 6
First-line interventions for CHS include:
Second-line options include:
A multifaceted approach with cannabis cessation as the cornerstone of treatment, supplemented by medications for symptomatic relief during acute episodes, is strongly supported by recent evidence 6
Ondansetron may provide some benefit in controlling nausea in patients with CHS, while avoiding opioids is crucial due to the risk of worsening nausea and high addiction potential 6

A supportive environment, including a quiet setting with minimal stimulation, adequate hydration, regular reassurance, and monitoring, is recommended for managing cannabis withdrawal, with close monitoring required for complications such as depression or psychosis 9
Providing a quiet, supportive environment, ensuring adequate hydration, and managing specific symptoms with appropriate medications, such as acetaminophen or NSAIDs for headaches and pain, and benzodiazepines for anxiety and agitation, can help alleviate symptoms 10, 9

Patients should be cautioned about driving or operating machinery until the effects of cannabis completely resolve, and should never drive within at least 6 hours of cannabis use to minimize the risk of impaired driving ability, as recommended by the American College of Physicians and the Journal of Clinical Oncology 4, 11
Potential interactions with warfarin, buprenorfina, and tacrolimus should be closely monitored due to the high risk of adverse effects, as warned by the American Society of Clinical Oncology 11
The American Academy of Child and Adolescent Psychiatry recommends avoiding the combination of cannabis oil with sertraline due to the risk of developing serotonin syndrome and other drug interactions, or to apply it with caution under specialist supervision 12
The American Psychiatric Association warns of increased risk for developing depressive disorders, exacerbation of existing psychiatric disorders, anxiety, panic attacks, psychotic symptoms, and suicidal ideation, especially with high-THC products 11

Intervention	Description
Complete cannabis cessation	For at least 3-6 months [5]
First-line interventions	IV fluid rehydration, dopamine receptor antagonists (e.g., haloperidol 0.5-2 mg IV or PO every 4-6 hours) [5, 7, 8], hot showers/baths, and topical capsaicin cream [5]
Second-line options	Serotonin receptor antagonists, benzodiazepines (e.g., lorazepam 0.5-2 mg PO/SL/IV every 6 hours) [7, 8], olanzapine (5-10 mg PO daily) [7], and corticosteroids [5]