cannabis related disorder

1. CANNABIS
RELATED
DISORDER
MODERATOR : DR. SAGAR
LAVANIA
PRESENTED BY : DR. RAMASHANKAR MADDESHIYA
S.N. MEDICAL COLLEGE, AGRA
1

2. INTRODUCTION
 Most widely used illegal drug in world.
 Cannabis , more commonly called , marijuana,
refers to the several varieties of Cannabis sativa,
or Indian hemp plant, that contains the
psychoactive drug Delta -9-
tetrahydrocannabinol (THC).
 Other name are grass, pot, weed, tea, mary
Jane, dagga, sinsemilla, herb, reefer, dope,
shunk, boom, gangster, kif.
2

3.  Cannabis –related disorder refers to the
problem associated with the use of substances
derived from this plant.
 It is also known as gate-way drug.
3

4. HISTORY
 It is used in China , India & middle east for
approx 8000 year primarily for its fiber and
secondarily for its medical properties.
 It was introduce to Europe in early 19th
century
by Napoleon’s army returning from Egypt, and
later in the same century to Britain for medical
use by surgeon who served in India.
4

5. PREPARATION OF CANNABIS
 Male and female plants separated.
 Female contain highest concentration of THC.
 Flowering top has highest THC concentration.
MARIJUANA: Prepared from dried flowering tops
and leave of plant.
 THC concentration 0.5- 5%.
HASHISH ( Hash or charas): consist of dried
cannabis resin.
 Light brown to almost black color.
 THC concentration 5-8%.
5

6. HASH OIL: it obtained by extracting THC from
Hasish or Marijuana in oil.
 Clear pale yellow / green
to brown black colour.
 THC concentration 15-30%.
GANJA: Buds and flowering
top of female plant.
BHANG: Cut and dried large
leaves & stem of plants. 6

7. METHOD OF USE
INHALATION: cannabis is typically
smoked as marijuana in hand role
cigarettes or JOINTS.
 WATER PIPE or BONG is use to
deliver bolus dose.
 Hashish may smoke in joints or
pipe with or without tobacco.
 Hash oil is extremely potent, a few drop is applied
on cigarette or joint.
7

8. ORAL ROUTE:
By eating hashish baked in brownies or cookies.
INDIA: in India bhang, ganja is a common
form , that is use frequently at various
occasions like (Holi, Shivratri ) in which use
like milk based drink called THANDAI or
typically smoked (ganja / charas) in CHILAM
or mixed with tobacco of cigarettes.
MANOKA a dry slightly sweetish preparation
consisting of bhang paste.
8

9. EPIDEMOLOGY
MAJOR DRUGS OF ABUSE IN INDIA
Drug Type NHS (current
prevalence, %)
DAMS (% among
treatment seekers)
Cannabis 3.0% 11.6%
Source : National Survey,
2004
NHS: National household survey
DAMS: Drug abuse monitoring system 9

10. Annual Prevalence (%) of cannabis abuse among those 15 years and
older
India (NHS, 2001 past month use)-
3.0
Canada- 7.4.
Russian Federation-0.9 Sri Lanka ( 1999)-1.4
Australia (1998)-17.9 Pakistan (1998)- 1.2
Bangladesh- 3.2. Nepal (1996)-2.8.
Source : National Survey, 2004
Region NHS DAMS
North- East Manipur ………
North ……….. Uttar Pradesh
East Bihar Bihar
Regional variation of Cannabis abuse in India (high use regions)
10

11. NEUROPHARMACOLOGY
 Primary constituent is ∆9-THC.
 ∆9-THC is rapidly converted to is active form
11- hydroxy ∆9-THC.
 THC and its metabolite are highly fat soluble.
 There are two type of cannabinoid receptor
CB1 and CB2.
 CB1 found primarily in brain and mediate
psychological effect and behavioral effect of
THC.
 CB2 associated with immune system and
modulate inflammatory responses.
 CB1 & CB2 belong to G protein couple
receptor.
11

12. PROBLEM RELATED TO CANNABIS USE
 In ICD-10 cannabis is considered in F12.
 But in ICD -10 the same diagnostic criteria
are use for all substances, whereas in DSM-5
separate diagnostic criteria are present for
individual substances.
12

13. CANNABIS DEPENDENCE:
The compulsive need to use the drug , coupled
with problems associated with chronic drug
use.
13

14. DIAGNOSTIC CRITERIA FOR CANNABIS DEPENDENCE
DISORDER (DSM -5)
At least 2 of following, occurring within 12 month
period:
1.Cannabis is often taken in larger amounts or over a
longer period than was intended.
2.There is a persistent desire or unsuccessful efforts to
cut down or control cannabis use.
3.A great deal of time is spent in activities necessary to
obtain cannabis, use cannabis, or recover from its
effects.
4.Craving, or a strong desire or urge to use cannabis.
5.Recurrent cannabis use resulting in a failure to fulfil
major role obligations at work , school, or home. 14

15. 6.Continued cannabis use despite having persistent or
recurrent social or interpersonal problems caused or
exacerbated by the effects of cannabis.
7.Important social, occupational activities are given up
or reduced because of cannabis use.
8.Recurrent cannabis use in situations in which it is
physically hazardous.
9.Cannabis use is continued despite knowledge of
having a persistent or recurrent physical or
psychological problem that is likely to have been
caused or exacerbated by cannabis. 15

16. CANNABIS INTOXICATION
 Most young people use cannabis in order to
experience a “high,” characterized by feelings
of mild euphoria, relaxation and perceptual
alterations, including time distortion, and the
intensification of ordinary experiences, such
as eating, watching films, listening to music,
and engaging in sex.
 When used in a social setting, the high may be
accompanied by infectious laughter,
talkativeness, and increased sociability.
16

17.  Cognitive changes include impaired short-term
memory and attention that make it easy for
the user to become lost in pleasant reverie and
difficult to sustain goal-directed mental
activity.
 Motor skills, reaction time, motor
coordination, and many forms of skilled
psychomotor activity are impaired while the
user is intoxicated, increasing the risks of
accidents if users drive an automobile.
17

18. CANNABIS INTOXICATED DELIRIUM
 The delirium associated with cannabis
intoxication is characterized by marked
impairment on cognition and performance
tasks.
 Even modest dose of cannabis impair memory,
reaction time, perception , motor coordination,
and attention. High doses that also impair
users, levels of conciousness have marked
effect on cognitive measures .
18

19. CANNABIS AND SCHIZOPHRENIA
 There is consistent clinical and
epidemiological evidence that cannabis use
can precipitate schizophrenia in vulnerable
individuals or exacerbate its symptoms in
those who have already developed the
disorder.
 Various study found dose–response
relationships between frequency of cannabis
use, early age of onset, and the risk of
developing psychotic disorders.
19

20. CANNABIS-INDUCED ANXIETY DISORDER
 Some user report increase anxiety, panic, a
fear of going mad, and depression after using
cannabis.
 Mostly feel by new user.
 The appearance of anxiety symptoms is
correlated with the dose.
 Most frequent adverse reaction to the
moderate use of smoked cannabis.
20

21. CANNABIS WITHDRAWAL
 Cessation of the use in daily cannabis user
results in withdrawal symptom.
 Appear within 24 hours , most marked within
10 days and may persist up to 28 days.
21

22.  Irritability, anger, or aggression.
 Nervousness or anxiety.
 Sleep difficulty (e.g., insomnia, disturbing
dreams).
 Decreased appetite or weight loss.
 Restlessness.
 Depressed mood.
 Physical symptoms causing significant
discomfort: abdominal pain, shakiness/tremors,
sweating, fever, chills, or headache.
 Fatigue ,yawing, difficulty in concentration etc..
22

23. CANNABIS INDUCED PSYCHOTIC
DISORDER
 It is rare.
 Transient paranoid ideation is more common.
 Florid psychosis is common in country in
which some person have long term assess to
cannabis of high potency.
 Rarely “bad-trip’’ experience which is often
associated with hallucination intoxication.
23

24.  “HEMP INSANITY’’ term given by Dhunjibhoy
for cannabis psychosis in 1930.
 Characterised by
• Acute schizophreniform disorder
• Disorientation
• Confusion
o good prognosis.
24

25. COGNITIVE IMPAIRMENT
 Long term use of cannabis may produce subtle
form of cognitive impairment in higher
cognitive functions of memory attention &
organization of complex formation.
 Longer the period of heavy cannabis use, the
more pronounced the cognitive impairment.
UNPECIFIED CANNABIS RELATED DISORDER
Like mania , hypomania, sleep disorder, sexual
dysfunction
25

26. FLASH BACKS:
Users experiencing symptoms of cannabis
intoxication that occur day or week after they
last use cannabis.
AMOTIVATIONAL SYNDROME:
 Associated with long term heavy use.
 Characterised by a person’s unwillingness to
persist in a task- be it a school, at work , or in
any sitting that require prolong attention.
26

27. EFFECT OF CANNABINOID USE
Respiratory system:
 It impair the functioning of large airway and
causes symptoms of chronic bronchitis such
as coughing, sputum, and wheezing.
 Increases the risks of respiratory cancer.
Pregnency :
Cannabis use during pregnancy produces
babies with smaller birth weights, perhaps as
a consequence of shorter gestation.
 Infant show behavioral & developmental effect
when expose during first few month after birth
27

28. INVESTIGATION
 Urine test can usually identified metabolite of
cannabinoids, 11-hydroxy Δ-9 THC .
 Because they are fat soluble, remain in body
for extended period.
 Individual who are chronic users of
cannabinoids may show +ve urine test for 2-4
week after using.
 It can also detect in head hair , pubic hair,
urine, sweat, saliva and blood of users.
28

29. TREATMENT SETTING*
 PHARMACOLOGICAL ASPECTS
 PSYCHOSOCIAL ASPECTS
 * SORCE: Basu D, Dalal PK. Clinical practice guideline for the assessment and management of
substance use disorder; indian psychiatric society 2014; 1:271-285.
29

30. PHARMACOLOGICAL ASPECTS:
CANNABIS INTOXICATION:
 Usually mild, self limiting, mostly does not
need pharmacological intervention.
 T/t needed in severe distressing anxiety or
psychotic symptom induced by intoxication.
 Anti psychotic (preferably atypical) for
psychosis.
 Benzodiazepine in acute anxiety state.
 Propanolol has little effect.
 Duration not longer than one day.
30

31. CANNABIS WITHDRAWAL
 Benzodiazepines are most commonly
prescribe medication.
 Dronabinol (cannabis receptor agonist) ,
synthetic THC (20-60 mg/day) for 7-10 days
depending on duration of withdrawal
symptom.
 Beclofen (40 mg/day) or Lofexidine (α2 agonist
,2.4 mg/day) are another alternative. But not
much effective.
31

32.  CANNABIS DEPENDENCE
 No medication has been shown broadly
effective for this , nor any approved by any
regulatory authority.
 Buspiron (up to 60 mg/ day) for 12 week is 1st
choice.
 Fluoxetine (20-40 mg/day) is another
alternative.
 Other drug like Dronabinol, mood stabilizer
tried but not much effective.
32

33.  Emerging evidence of Baclofen(40-60 mg/day)
another reasonable T/t option.
 Rimonabent ( CB1 receptor antagonist) are
marketed as appetite suppressant but
withdraw due to its psychiatric side effect
(specially sucidality).
33

34. PSYCHOSOCIAL ASPECT:
 Motivational enhancement therapy (MET).
 Cognitive behavior therapy (CBT).
 Contingency management (CM).
 Family and system intervention.
 Combined psychosocial treatment.
34

35. MOTIVATIONAL ENHANCEMENT
THERAPY (MET).
 Designed to help resolve ambivalence about
quitting and strengthen motivation to change.
 Technique include, exploration of pores and
cones of drug use, rolling with resistance,
making goal plan etc .
 Duration 1-4 session.
 45-90 minute individual session.
35

36. COGNITIVE BEHAVIOR THERAPY (CBT).
 45-60 minute group or individual counseling
session.
 Focus on coping skill relevant to quitting
marijuana and other related problem that might
interface with good outcome.
• Development of self management plan to avoid or
cope with drug use triggers
• Drug refusal skill
• Problem solving skill
• Role playing
• Interactive exercise
 6-14 session.
36

37. CONTINGENCY MANAGEMENT (CM)
(ABSTINENCE REINFORCEMENT THERAPY)
 Central feature is systemic application of
reinforcing or punishing consequence in order to
achieve therapeutic goals.
 Positive reinforcement to:
• Increase abstinence from drug use
• Facilitate other therapeutic changes
• Include retention in T/t
• Attendance at therapy session
• Compliance with medication regimens.
37

38. FAMILY AND SYSTEM INTERVENTION.
 There is reciprocal relation between family
functioning and substance use.
 According to family system theory substance
abuse increase during period in which ,
patients away from his family, family conflict
( like marital problem), use of substance by
other family member etc.
 MULTIDIMENTIONAL FAMILY THERAPY is
applied that approach to resolve this issues.
38

39. COMBINED PSYCHOSOCIAL
TREATMENT
 MET + CBT
 MET + CBT + CM
 MET + CBT + FSN (family support network)
 According to cannabis youth treatment
study(CTY) all are equally effictive.*
* Diamond G, Godley SH, Liddle HA. Five output treatment modeles for aldolesent marijuana
use: a description of the cannabis youth treatment intervention. Addiction 2002;97:70-83.
39

40. CANNABIS AND NDPS ACT
Substance Small quantity Commercial quantity
Ganja 1 kg 20 kg
Charas 100 g 1 kg
Quantity Punishment
Small quantity Imprisonment up to 1 yr OR fine of
10000/- OR both
Greater than Small quantity but
Less than Commercial quantity
Imprisonment up to 10 yr with fine
up to 1 lakh
Commercial quantity Imprisonment shall not be less
than 10 yr. max extend up to 20 yr
+ fine not less than 1 lakh
On repeat offence one & half time the punishment for offence.
40

41. THERAPUTIC EFFECT OF
CANNABINOIDS
Primarily to relieve symptoms rather than to
cure .
Analgesia:
 Modest analgesic effects on acute
postoperative and chronic pain including
neuropathic pain.
 Sativex , an oral spray consisting of natural
cannabis extract for the T/t of cancer pain.
Nausea and vomiting:
Previously it was use to control over nausea
induced by cisplatin( anti cancer drug). 41

42. Wasting syndrome and appetite stimulation in
HIV/AIDS:
THC stimulates appetite and
assists in weight gain in HIV/
AIDS patients in short-term trials.
Muscle spasticity:
Epilepsy:
Epidiolex ,containing cannabidiol was granted
orphan drug status for the T/t of certain rare,
intracable type of epilepsy in children.
Glaucoma:
It reduce IOP by 25 percent, but the effect lasts
only 3 to 4 hours. 42

43. …Thank
you 43