COMMENTARY

Treating Cannabis Dependence? Put Away Your Prescription Pad

Peter Yellowlees, MBBS, MD

Disclosures

April 16, 2019

This transcript has been edited for clarity.

This is the Medscape Psychiatry Minute. I'm Dr Peter Yellowlees.

Globally, cannabis use is prevalent and widespread. There are currently no pharmacotherapies approved for treatment of cannabis use disorders, but should we be using medication-assisted treatments with these patients?

To answer this question, a team of investigators[1] from Monash University in Australia used standard Cochrane methods to perform a review assessing the effectiveness and safety of pharmacotherapies as compared with each other, placebo, or no pharmacotherapy (supportive care) for reducing symptoms of cannabis withdrawal and promoting cessation or reduction of cannabis use. They included 21 randomized controlled trials (1755 participants; 75% male) comparing active medication and placebo.

The authors concluded that there was incomplete and low-quality evidence for all of the pharmacotherapies investigated. They found that selective serotonin reuptake inhibitor antidepressants, mixed-action antidepressants, bupropion, buspirone, and atomoxetine are probably of little value in the treatment of cannabis dependence. Given the limited evidence of efficacy, they thought that THC preparations should be considered still experimental, although they had some positive effects on withdrawal symptoms and craving. The evidence base for gabapentin, oxytocin, and N-acetylcysteine was weak, but these medications were thought to be worthy of further investigation.

So why is this review important? The key message, if you are treating patients with cannabis use disorder, is to put away your prescription pads. Motivational enhancement therapy and cognitive-behavioral therapy are still the therapies of choice for these patients, and the long half-life of cannabis makes medications unnecessary to cover withdrawal. The current role for medications is to treat patients who have other diagnoses, such as major depression or an anxiety disorder. The only potentially useful medications not reviewed in this paper, and where more research is needed, are naltrexone, which has a few positive anecdotal reports supporting its use in cannabis use disorder, and acamprosate, where even these limited reports do not yet exist.

Thank you for listening to this Medscape Psychiatry Minute. Do continue to enjoy your practice.

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