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Ghasemian-Yadegari J, Adineh A, Mohammadi H, Davari S, Veisani Y, Ghaneialvar H, Aidy A, Abbasi N, Karimi E. Attenuation of cannabis withdrawal symptoms by Prosopis farcta extract, its luteolin and melatonin in mice: Involvement of brain-derived neurotrophic factor and dopamine. Cell Biochem Funct 2024; 42:e3980. [PMID: 38491827 DOI: 10.1002/cbf.3980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 02/20/2024] [Accepted: 03/03/2024] [Indexed: 03/18/2024]
Abstract
The aim of this study was the identification of luteolin in Prosopis farcta extract (PFE) and melatonin to evaluate its effect on THC withdrawal syndrome in mice. Luteolin was identified by high-performance liquid chromatography (HPCL). Signs of toxicity of mice in PFE and luteolin were monitored for LD50 calculation. The behavioral symptoms of THC withdrawal (stereotypies, ambulation, and inactivity time) induced by the rimonabant challenge were illustrated in THC-dependent mice receiving PFE, luteolin, and melatonin. The expression of mature BDNF (mBDNF) was evaluated by Western blot analysis. The dopamine concentrations were measured using HPLC. PFE and luteolin LD50 were 650 and 220 mg/kg, respectively. PFE (300 mg/kg), all doses of luteolin, and melatonin increased significantly the mBDNF expression and decreased the dopamine concentration. The findings suggest that PFE, luteolin, and melatonin are mighty in reducing the signs of THC withdrawal. It seems these effects were due to a decrease in dopamine concentration level and an increase in mBDNF protein expression in mice brains.
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Affiliation(s)
- Javad Ghasemian-Yadegari
- Department of Pharmacognosy, School of Pharmacy, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Ahmad Adineh
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Hamidreza Mohammadi
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Shima Davari
- Department of Pharmacognosy, School of Pharmacy, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Yousef Veisani
- Research Center for Psychosocial Injuries, Ilam University of Medical Sciences, Ilam, Iran
| | - Hori Ghaneialvar
- Biotechnology and Medicinal Plants Research Center, Ilam University of Medical Sciences, Ilam, Iran
| | - Ali Aidy
- Biotechnology and Medicinal Plants Research Center, Ilam University of Medical Sciences, Ilam, Iran
| | - Naser Abbasi
- Biotechnology and Medicinal Plants Research Center, Ilam University of Medical Sciences, Ilam, Iran
- Department of Pharmacology, Medical School, Ilam University of Medical Sciences, Ilam, Iran
| | - Elahe Karimi
- Biotechnology and Medicinal Plants Research Center, Ilam University of Medical Sciences, Ilam, Iran
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Piscura MK, Henderson-Redmond AN, Barnes RC, Mitra S, Guindon J, Morgan DJ. Mechanisms of cannabinoid tolerance. Biochem Pharmacol 2023; 214:115665. [PMID: 37348821 PMCID: PMC10528043 DOI: 10.1016/j.bcp.2023.115665] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 06/09/2023] [Accepted: 06/13/2023] [Indexed: 06/24/2023]
Abstract
Cannabis has been used recreationally and medically for centuries, yet research into understanding the mechanisms of its therapeutic effects has only recently garnered more attention. There is evidence to support the use of cannabinoids for the treatment of chronic pain, muscle spasticity, nausea and vomiting due to chemotherapy, improving weight gain in HIV-related cachexia, emesis, sleep disorders, managing symptoms in Tourette syndrome, and patient-reported muscle spasticity from multiple sclerosis. However, tolerance and the risk for cannabis use disorder are two significant disadvantages for cannabinoid-based therapies in humans. Recent work has revealed prominent sex differences in the acute response and tolerance to cannabinoids in both humans and animal models. This review will discuss evidence demonstrating cannabinoid tolerance in rodents, non-human primates, and humans and our current understanding of the neuroadaptations occurring at the cannabinoid type 1 receptor (CB1R) that are responsible tolerance. CB1R expression is downregulated in tolerant animals and humans while there is strong evidence of CB1R desensitization in cannabinoid tolerant rodent models. Throughout the review, critical knowledge gaps are indicated and discussed, such as the lack of a neuroimaging probe to assess CB1R desensitization in humans. The review discusses the intracellular signaling pathways that are responsible for mediating CB1R desensitization and downregulation including the action of G protein-coupled receptor kinases, β-arrestin2 recruitment, c-Jun N-terminal kinases, protein kinase A, and the intracellular trafficking of CB1R. Finally, the review discusses approaches to reduce cannabinoid tolerance in humans based on our current understanding of the neuroadaptations and mechanisms responsible for this process.
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Affiliation(s)
- Mary K Piscura
- Department of Biomedical Sciences, Marshall University, Huntington, WV 25755, USA; Department of Biomedical Sciences, Edward Via College of Osteopathic Medicine, Auburn, AL 36832, USA
| | | | - Robert C Barnes
- Department of Pharmacology and Neuroscience, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
| | - Swarup Mitra
- Department of Biomedical Sciences, Marshall University, Huntington, WV 25755, USA
| | - Josée Guindon
- Department of Pharmacology and Neuroscience, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
| | - Daniel J Morgan
- Department of Biomedical Sciences, Marshall University, Huntington, WV 25755, USA.
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3
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Wang J, Deane FP, Kelly PJ, Robinson L. A narrative review of outcome measures used in drug and alcohol inpatient withdrawal treatment research. Drug Alcohol Rev 2023; 42:415-426. [PMID: 36633552 PMCID: PMC10108086 DOI: 10.1111/dar.13591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 11/20/2022] [Accepted: 11/28/2022] [Indexed: 01/13/2023]
Abstract
ISSUES Assessing drug and alcohol inpatient withdrawal treatment programs is important, as these represent a first step of treatment among people with alcohol and drug problems. However, there are many ways of measuring outcomes making it difficult for service providers to decide which domains and methods to use. This narrative review aims to clarify frequencies of the domains and methods used to assess withdrawal treatment outcomes. APPROACH We reviewed published studies that examined outcomes of inpatient drug and alcohol withdrawal treatment. The types of outcome measures used and the frequency of use were summarised. KEY FINDINGS The review showed that assessment of withdrawal treatment outcomes goes beyond traditional abstinence measures. Outcomes mainly focus on biological and psychological outcomes, with social outcomes rarely measured. Even within outcome domains (e.g., cravings), there were many assessment methods. IMPLICATIONS The review provides service providers with an outline of common outcome domains and measures. Given the importance of social functioning to recovery from alcohol and drug problems, greater emphasis on such measures is desirable. Future research could develop greater consensus on outcome measures for use in withdrawal management services to facilitate clarity around factors associated with treatment success. CONCLUSION Outcome assessment in withdrawal treatment goes beyond abstinence to include holistic measurement of biological, psychological and some social outcomes; but more work needs to be done to cohere the different assessment methods and broaden the scope to include social functioning.
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Affiliation(s)
- Jing Wang
- School of Psychology, University of Wollongong, Wollongong, Australia
- Illawarra Health and Medical Research Institute, Wollongong, Australia
| | - Frank P Deane
- School of Psychology, University of Wollongong, Wollongong, Australia
- Illawarra Health and Medical Research Institute, Wollongong, Australia
| | - Peter J Kelly
- School of Psychology, University of Wollongong, Wollongong, Australia
- Illawarra Health and Medical Research Institute, Wollongong, Australia
| | - Laura Robinson
- School of Psychology, University of Wollongong, Wollongong, Australia
- Illawarra Health and Medical Research Institute, Wollongong, Australia
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Connor JP, Stjepanović D, Budney AJ, Le Foll B, Hall WD. Clinical management of cannabis withdrawal. Addiction 2022; 117:2075-2095. [PMID: 34791767 PMCID: PMC9110555 DOI: 10.1111/add.15743] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 10/27/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND AIMS Cannabis withdrawal is a well-characterized phenomenon that occurs in approximately half of regular and dependent cannabis users after abrupt cessation or significant reductions in cannabis products that contain Δ9 -tetrahydrocannabinol (THC). This review describes the diagnosis, prevalence, course and management of cannabis withdrawal and highlights opportunities for future clinical research. METHODS Narrative review of literature. RESULTS Symptom onset typically occurs 24-48 hours after cessation and most symptoms generally peak at days 2-6, with some symptoms lasting up to 3 weeks or more in heavy cannabis users. The most common features of cannabis withdrawal are anxiety, irritability, anger or aggression, disturbed sleep/dreaming, depressed mood and loss of appetite. Less common physical symptoms include chills, headaches, physical tension, sweating and stomach pain. Despite limited empirical evidence, supportive counselling and psychoeducation are the first-line approaches in the management of cannabis withdrawal. There are no medications currently approved specifically for medically assisted withdrawal (MAW). Medications have been used to manage short-term symptoms (e.g. anxiety, sleep, nausea). A number of promising pharmacological agents have been examined in controlled trials, but these have been underpowered and positive findings not reliably replicated. Some (e.g. cannabis agonists) are used 'off-label' in clinical practice. Inpatient admission for MAW may be clinically indicated for patients who have significant comorbid mental health disorders and polysubstance use to avoid severe complications. CONCLUSIONS The clinical significance of cannabis withdrawal is that its symptoms may precipitate relapse to cannabis use. Complicated withdrawal may occur in people with concurrent mental health and polysubstance use.
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Affiliation(s)
- Jason P. Connor
- National Centre for Youth Substance Use ResearchThe University of QueenslandSt LuciaQLDAustralia,Discipline of Psychiatry, Faculty of MedicineThe University of QueenslandHerstonQLDAustralia
| | - Daniel Stjepanović
- National Centre for Youth Substance Use ResearchThe University of QueenslandSt LuciaQLDAustralia
| | - Alan J. Budney
- Center for Technology and Behavioral HealthGeisel School of Medicine at DartmouthLebanonNHUSA
| | - Bernard Le Foll
- Translational Addiction Research Laboratory, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental HealthUniversity of TorontoONCanada,Departments of Family and Community Medicine, Psychiatry, Pharmacology and ToxicologyUniversity of TorontoONCanada
| | - Wayne D. Hall
- National Centre for Youth Substance Use ResearchThe University of QueenslandSt LuciaQLDAustralia,Queensland Alliance for Environmental Health SciencesThe University of QueenslandWoolloongabbaQLDAustralia
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Bahji A, Meyyappan AC, Hawken ER, Tibbo PG. Pharmacotherapies for cannabis use disorder: A systematic review and network meta-analysis. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 97:103295. [PMID: 34062288 DOI: 10.1016/j.drugpo.2021.103295] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 04/28/2021] [Accepted: 04/30/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE This study aimed to determine the efficacy and acceptability of pharmacotherapies for cannabis use disorder (CUD). METHODS We conducted a systematic review and frequentist network meta-analysis, searching five electronic databases for randomized placebo-controlled trials of individuals diagnosed with CUD receiving pharmacotherapy with or without concomitant psychotherapy. Primary outcomes were the reduction in cannabis use and retention in treatment. Secondary outcomes were adverse events, discontinuation due to adverse events, total abstinence, withdrawal symptoms, cravings, and CUD severity. We applied a frequentist, random-effects Network Meta-Analysis model to pool effect sizes across trials using standardized mean differences (SMD, g) and rate ratios (RR) with their 95% confidence intervals. RESULTS We identified a total of 24 trials (n=1912, 74.9% male, mean age 30.2 years). Nabilone (d=-4.47 [-8.15; -0.79]), topiramate (d=-3.80 [-7.06; -0.54]), and fatty-acid amyl hydroxylase inhibitors (d=-2.30 [-4.75; 0.15]) reduced cannabis use relative to placebo. Dronabinol improved retention in treatment (RR=1.27 [1.02; 1.57]), while topiramate worsened treatment retention (RR=0.62 [0.42; 0.91]). Gabapentin reduced cannabis cravings (d=-2.42 [-3.53; -1.32], while vilazodone worsened craving severity (d=1.69 [0.71; 2.66]. Buspirone (RR=1.14 [1.00; 1.29]), venlafaxine (RR=1.78 [1.40; 2.26]), and topiramate (RR=9.10 [1.27; 65.11]) caused more adverse events, while topiramate caused more dropouts due to adverse events. CONCLUSIONS Based on this review, some medications appeared to show promise for treating individual aspects of CUD. However, there is a lack of robust evidence to support any particular pharmacological treatment. There is a need for additional studies to expand the evidence base for CUD pharmacotherapy. While medication strategies may become an integral component for CUD treatment one day, psychosocial interventions should remain the first line given the limitations in the available evidence.
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Affiliation(s)
- Anees Bahji
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada.
| | - Arthi Chinna Meyyappan
- Department of Psychiatry, Queen's University, Kingston, ON, Canada; Centre for Neurosciences, Queen's University, Kingston, ON, Canada; Providence Care Hospital, Kingston, ON, Canada
| | - Emily R Hawken
- Department of Psychiatry, Queen's University, Kingston, ON, Canada; Centre for Neurosciences, Queen's University, Kingston, ON, Canada; Providence Care Hospital, Kingston, ON, Canada
| | - Philip G Tibbo
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada; Nova Scotia Early Psychosis Program, Halifax, NS, Canada
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6
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Gabapentin attenuates somatic signs of precipitated THC withdrawal in mice. Neuropharmacology 2021; 190:108554. [PMID: 33845073 DOI: 10.1016/j.neuropharm.2021.108554] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 03/23/2021] [Accepted: 03/30/2021] [Indexed: 11/21/2022]
Abstract
Cannabis is the most frequently used federally illicit substance in the United States. However, there are currently no FDA-approved pharmacotherapies to mitigate the withdrawal symptoms associated with cessation in heavy users. A promising, readily available, non-cannabinoid therapy are the gabapentinoids. Although currently approved for epilepsy and neuropathic pain, gabapentinoids are increasingly used for their "off-label" efficacy in treating various psychiatric conditions and substance abuse. Gabapentin (GBP) synergizes with cannabinoid agonism in neuropathic pain models, substitutes for Δ9-tetrahydrocannabinol (THC) in drug discrimination procedures, and reduced withdrawal symptoms in an outpatient clinical trial. However, there are limited data on the biological plausibility of the therapeutic action of gabapentinoids in cannabinoid withdrawal in preclinical models. The purpose of the current study was to determine the efficacy of GBP on attenuating THC withdrawal in mice, using an array of tests targeting withdrawal-induced and withdrawal-suppressed behaviors. Separate cohorts of male and female mice were administered THC (10 mg/kg, s.c.) or vehicle for 5.5 days, and withdrawal was precipitated by the CB1 antagonist rimonabant (2 or 3 mg/kg, i.p.) on the sixth day. GBP (≥10 mg/kg) reduced somatic signs of withdrawal (i.e., paw tremors and head twitches), but had no effect in locomotor activity or conditioned place preference. GBP (50 mg/kg) also restored withdrawal-suppressed responding on a progressive ratio reinforcement schedule. However, GBP (50 mg/kg) had no effect in withdrawal-suppressed marble burying or tail suspension struggling and did not normalize the stress response induced by THC withdrawal, as indicated by plasma corticosterone. These data suggest gabapentin may be effective at treating cannabinoid withdrawal symptoms including somatic and affective symptoms but may act independently of endocrine stress activation.
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7
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Mariani JJ, Pavlicova M, Jean Choi C, Basaraba C, Carpenter KM, Mahony AL, Brooks DJ, Bisaga A, Naqvi N, Nunes EV, Levin FR. Quetiapine treatment for cannabis use disorder. Drug Alcohol Depend 2021; 218:108366. [PMID: 33153828 DOI: 10.1016/j.drugalcdep.2020.108366] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 08/31/2020] [Accepted: 10/09/2020] [Indexed: 10/23/2022]
Abstract
BACKROUND Pharmacotherapy for cannabis use disorder (CUD) is an important unmet public health need. METHODS In a 12-week randomized double-blind placebo-controlled trial, the efficacy of quetiapine (300 mg nightly) for the treatment of CUD was tested in 130 outpatients. Weekly cannabis use was categorized into three groups: heavy use (5-7 days), moderate use (2-4 days) and light use (0-1 days). RESULTS At baseline both groups were considered heavy users (using days per week: median = 7.0; interquartile range (IQR): 6.5-7.0; daily dollar value: median = $121.4; IQR: 73.8-206.3). The week-by-treatment interaction was marginally significant (χ2(2) = 5.56, P = .06). With each week, the odds of moderate compared to heavy use significantly increased in the quetiapine group (OR=1.17, P < .0001), but not significantly in the placebo group (OR=1.05, P = .16). The odds of light versus heavy use did not significantly differ over time (P = .12). Treatment was also associated with reduced cannabis withdrawal symptoms by 10.4% each week (95% CI: 8.9-11.8). No serious adverse events occurred during the study and no evidence of development of a movement disorder was detected. Adverse effects were not significantly different between the quetiapine and placebo treatment arms. CONCLUSIONS The use of quetiapine to treat CUD was associated with an increased likelihood of heavy frequency use transitioning to moderate use, but not light use. The clinical significance of reductions in cannabis use, short of abstinence warrants further study.
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Affiliation(s)
- John J Mariani
- New York State Psychiatric Institute, Division on Substance Use Disorders, 1051 Riverside Drive, New York, NY, 10032, USA; Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, 630 West 168th Street, New York, NY, 10032, USA.
| | - Martina Pavlicova
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, 630 West 168th Street, New York, NY, 10032, USA
| | - C Jean Choi
- New York State Psychiatric Institute, Division of Mental Health Data Science, 1051 Riverside Drive, New York, NY, 10032, USA
| | - Cale Basaraba
- New York State Psychiatric Institute, Division of Mental Health Data Science, 1051 Riverside Drive, New York, NY, 10032, USA
| | - Kenneth M Carpenter
- New York State Psychiatric Institute, Division on Substance Use Disorders, 1051 Riverside Drive, New York, NY, 10032, USA; Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, 630 West 168th Street, New York, NY, 10032, USA
| | - Amy L Mahony
- New York State Psychiatric Institute, Division on Substance Use Disorders, 1051 Riverside Drive, New York, NY, 10032, USA
| | - Daniel J Brooks
- New York State Psychiatric Institute, Division on Substance Use Disorders, 1051 Riverside Drive, New York, NY, 10032, USA
| | - Adam Bisaga
- New York State Psychiatric Institute, Division on Substance Use Disorders, 1051 Riverside Drive, New York, NY, 10032, USA; Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, 630 West 168th Street, New York, NY, 10032, USA
| | - Nasir Naqvi
- New York State Psychiatric Institute, Division on Substance Use Disorders, 1051 Riverside Drive, New York, NY, 10032, USA; Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, 630 West 168th Street, New York, NY, 10032, USA
| | - Edward V Nunes
- New York State Psychiatric Institute, Division on Substance Use Disorders, 1051 Riverside Drive, New York, NY, 10032, USA; Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, 630 West 168th Street, New York, NY, 10032, USA
| | - Frances R Levin
- New York State Psychiatric Institute, Division on Substance Use Disorders, 1051 Riverside Drive, New York, NY, 10032, USA; Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, 630 West 168th Street, New York, NY, 10032, USA
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8
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Loflin MJE, Kiluk BD, Huestis MA, Aklin WM, Budney AJ, Carroll KM, D'Souza DC, Dworkin RH, Gray KM, Hasin DS, Lee DC, Le Foll B, Levin FR, Lile JA, Mason BJ, McRae-Clark AL, Montoya I, Peters EN, Ramey T, Turk DC, Vandrey R, Weiss RD, Strain EC. The state of clinical outcome assessments for cannabis use disorder clinical trials: A review and research agenda. Drug Alcohol Depend 2020; 212:107993. [PMID: 32360455 PMCID: PMC7293929 DOI: 10.1016/j.drugalcdep.2020.107993] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 03/17/2020] [Accepted: 03/19/2020] [Indexed: 11/17/2022]
Abstract
There is considerable variability in the use of outcome measures in clinical trials for cannabis use disorder (CUD), and a lack of consensus regarding optimal outcomes may have hindered development and approval of new pharmacotherapies. The goal of this paper is to summarize an evaluation of assessment measures and clinical endpoints for CUD clinical trials, and propose a research agenda and priorities to improve CUD clinical outcome assessments. The primary recommendation is that sustained abstinence from cannabis should not be considered the primary outcome for all CUD clinical trials as it has multiple limitations. However, there are multiple challenges to the development of a reliable and valid indicator of cannabis reduction, including the lack of a standard unit of measure for the various forms of cannabis and products and the limitations of currently available biological and self-report assessments. Development of a core toolkit of assessments is needed to both allow flexibility for study design, while facilitating interpretation of outcomes across trials. Four primary agenda items for future research are identified to expedite development of improved clinical outcome assessments for this toolkit: (1) determine whether minimally invasive biologic assays could identify an acute level of cannabis use associated with psychomotor impairment or other cannabis-related harms; (2) create an indicator of quantity of cannabis use that is consistent across product types; (3) examine the presence of cannabis-specific functional outcomes; and (4) identify an optimal duration to assess changes in CUD diagnostic criteria.
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Affiliation(s)
- Mallory J E Loflin
- University of California San Diego, School of Medicine, 9500 Gilman Dr, La Jolla, CA 92093, United States; San Diego Veterans Affairs Healthcare System, 3350 La Jolla Village Dr, San Diego, CA 92161, United States
| | - Brian D Kiluk
- Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510, United States.
| | - Marilyn A Huestis
- The Lambert Center for the Study of Medicinal Cannabis and Hemp, Thomas Jefferson University, 4201 Henry Ave, Philadelphia, PA 19144, United States
| | - Will M Aklin
- NIH/NIDA Division of Therapeutics and Medical Consequences of Drug Abuse, 10 Center Dr, Bethesda, MD 20814, United States
| | - Alan J Budney
- Geisel School of Medicine at Dartmouth, 1 Rope Ferry Rd, Hanover, NH 03755, United States
| | - Kathleen M Carroll
- Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510, United States
| | - Deepak Cyril D'Souza
- Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510, United States
| | - Robert H Dworkin
- University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Rochester, NY 14642, United States
| | - Kevin M Gray
- Medical University of South Carolina, 67 President St, MSC861, Charleston, SC 29425, United States
| | - Deborah S Hasin
- Columbia University Medical Center, 722 W. 168(th) St, New York, NY 10027, United States
| | - Dustin C Lee
- Johns Hopkins University School of Medicine, 733 N Broadway, Baltimore, MD 21205, United States
| | - Bernard Le Foll
- Centre for Addiction and Mental Health and University of Toronto, 33 Russell St, Toronto, ON, M5S 2S1, Canada
| | - Frances R Levin
- New York State Psychiatric Institute, Columbia University Medical Center, 1051 Riverside Dr, New York, NY 10032, United States
| | - Joshua A Lile
- University of Kentucky College of Medicine, 800 Rose Street MN 150, Lexington, KY 40506, United States
| | - Barbara J Mason
- The Scripps Research Institute, 10550 N Torrey Pines Rd, La Jolla, CA 92037, United States
| | - Aimee L McRae-Clark
- Medical University of South Carolina, 67 President St, MSC861, Charleston, SC 29425, United States
| | - Ivan Montoya
- NIH/NIDA Division of Therapeutics and Medical Consequences of Drug Abuse, 10 Center Dr, Bethesda, MD 20814, United States
| | - Erica N Peters
- Battelle Memorial Institute, 6115 Falls Rd #200, Baltimore, MD 21209, United States
| | - Tatiana Ramey
- NIH/NIDA Division of Therapeutics and Medical Consequences of Drug Abuse, 10 Center Dr, Bethesda, MD 20814, United States
| | - Dennis C Turk
- University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195, United States
| | - Ryan Vandrey
- Johns Hopkins University School of Medicine, 733 N Broadway, Baltimore, MD 21205, United States
| | - Roger D Weiss
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, United States; McLean Hospital, 115 Mill St, Belmont, MA 02478, United States
| | - Eric C Strain
- Johns Hopkins University School of Medicine, 733 N Broadway, Baltimore, MD 21205, United States
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9
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Kondo KK, Morasco BJ, Nugent SM, Ayers CK, O'Neil ME, Freeman M, Kansagara D. Pharmacotherapy for the Treatment of Cannabis Use Disorder: A Systematic Review. Ann Intern Med 2020; 172:398-412. [PMID: 32120384 DOI: 10.7326/m19-1105] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Cannabis use disorder (CUD) is a growing concern, and evidence-based data are needed to inform treatment options. PURPOSE To review the benefits and risks of pharmacotherapies for the treatment of CUD. DATA SOURCES MEDLINE, PsycINFO, Cochrane Database of Systematic Reviews, and clinical trial registries from inception through September 2019. STUDY SELECTION Pharmacotherapy trials of adults or adolescents with CUD that targeted cannabis abstinence or reduction, treatment retention, withdrawal symptoms, and other outcomes. DATA EXTRACTION Data were abstracted by 1 investigator and confirmed by a second. Study quality was dually assessed, and strength of evidence (SOE) was determined by consensus according to standard criteria. DATA SYNTHESIS Across 26 trials, the evidence was largely insufficient. Low-strength evidence was found that selective serotonin reuptake inhibitors (SSRIs) do not reduce cannabis use or improve treatment retention. Low- to moderate-strength evidence was found that buspirone does not improve outcomes and that cannabinoids do not increase abstinence rates (moderate SOE), reduce cannabis use (low SOE), or increase treatment retention (low SOE). Across all drug studies, no consistent evidence of increased harm was found. LIMITATIONS Few methodologically rigorous trials have been done. Existing trials are hampered by small sample sizes, high attrition rates, and heterogeneity of concurrent interventions and outcomes assessment. CONCLUSION Although data on pharmacologic interventions for CUD are scarce, evidence exists that several drug classes, including cannabinoids and SSRIs, are ineffective. Because of increasing access to and use of cannabis in the general population, along with a high prevalence of CUD among current cannabis users, an urgent need exists for more research to identify effective pharmacologic treatments. PRIMARY FUNDING SOURCE U.S. Department of Veterans Affairs. (PROSPERO: CRD42018108064).
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Affiliation(s)
- Karli K Kondo
- Veterans Affairs Portland Health Care System and Oregon Health & Science University, Portland, Oregon (K.K.K., B.J.M., S.M.N., M.E.O., D.K.)
| | - Benjamin J Morasco
- Veterans Affairs Portland Health Care System and Oregon Health & Science University, Portland, Oregon (K.K.K., B.J.M., S.M.N., M.E.O., D.K.)
| | - Shannon M Nugent
- Veterans Affairs Portland Health Care System and Oregon Health & Science University, Portland, Oregon (K.K.K., B.J.M., S.M.N., M.E.O., D.K.)
| | - Chelsea K Ayers
- Veterans Affairs Portland Health Care System, Portland, Oregon (C.K.A., M.F.)
| | - Maya E O'Neil
- Veterans Affairs Portland Health Care System and Oregon Health & Science University, Portland, Oregon (K.K.K., B.J.M., S.M.N., M.E.O., D.K.)
| | - Michele Freeman
- Veterans Affairs Portland Health Care System, Portland, Oregon (C.K.A., M.F.)
| | - Devan Kansagara
- Veterans Affairs Portland Health Care System and Oregon Health & Science University, Portland, Oregon (K.K.K., B.J.M., S.M.N., M.E.O., D.K.)
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Nielsen S, Sabioni P, Gowing L, Le Foll B. Pharmacotherapies for Cannabis Use Disorders: Clinical Challenges and Promising Therapeutic Agents. Handb Exp Pharmacol 2020; 258:355-372. [PMID: 31375922 DOI: 10.1007/164_2019_258] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
This chapter reviews pharmacotherapies that have been trialled for cannabis dependence, identifying those that warrant further research and those of little or uncertain value. A diverse range of medicines have been tested, representing a broad range of pharmacological strategies. These include tetrahydrocannabinol preparations, various types of antidepressant, anxiolytics, a glutamatergic modulator and the neuropeptide oxytocin. Cannabinoid agonists warrant further research. For the FAAH inhibitor PF-04457845, oxytocin, varenicline and gabapentin, although there is a signal to indicate further research is warranted, these medications do not yet have sufficient evidence to support clinical use, and larger, longer-term trials are needed in representative treatment-seeking populations. Special populations that warrant consideration are those with cannabis dependence and concurrent mental health conditions and those that develop dependence through therapeutic use.
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Affiliation(s)
- Suzanne Nielsen
- Monash Addiction Research Centre, Monash University, Peninsula Campus, Frankston, VIC, Australia
| | - Pamela Sabioni
- Translational Addiction Research Laboratory, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Linda Gowing
- Discipline of Pharmacology, University of Adelaide, Adelaide, SA, Australia
| | - Bernard Le Foll
- Translational Addiction Research Laboratory, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada.
- Acute Care Program, Centre for Addiction and Mental Health, Toronto, ON, Canada.
- Departments of Family and Community Medicine, Pharmacology and Toxicology, Psychiatry, Institute of Medical Science, University of Toronto, Toronto, ON, Canada.
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada.
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Lithium Preparations in Psychiatry, Addiction Medicine and Neurology. Part II. Biochemical Mechanisms of Its Action. ACTA BIOMEDICA SCIENTIFICA 2019. [DOI: 10.29413/abs.2019-4.2.13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Lithium is the first and the lightest in the series of alkali metals, to which, in addition to lithium, two very biologically important elements – sodium and potassium, as well as trace elements rubidium and cesium, belong. Despite its formal affiliation to the group of alkali metals, lithium, like many other chemical elements of the «atypical» second period of the periodic table (for example, boron), is more similar in its chemical properties not to its counterparts in the group, but to its «diagonal brother» – magnesium. As we will show in this article, the diagonal chemical similarity between lithium and magnesium is of great importance for understanding the mechanisms of its intracellular biochemical action. At the same time, the intragroup chemical similarity of lithium with sodium and potassium is more important for understanding the mechanisms of its absorption, its distribution in the body and its excretion. Despite the 70 years that have passed since John Cade’s discovery of the antimanic effect of lithium, the mechanisms of its therapeutic action are still not completely understood. In the end, it turns out that the mechanism of the therapeutic action of lithium is extremely complex, multicomponent, unique and not imitable. Certain aspects of the mechanism of its action may be compatible with the mechanisms of action of other mood stabilizers, or with the mechanisms of action of so-called «lithium-mimetics», such as ebselen. However, no other drug to date failed to fully reproduce the biochemical effect of lithium on the body.
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Abstract
BACKGROUND Globally, cannabis use is prevalent and widespread. There are currently no pharmacotherapies approved for treatment of cannabis use disorders.This is an update of a Cochrane Review first published in the Cochrane Library in Issue 12, 2014. OBJECTIVES To assess 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. SEARCH METHODS We updated our searches of the following databases to March 2018: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO and Web of Science. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs involving the use of medications to treat cannabis withdrawal or to promote cessation or reduction of cannabis use, or both, in comparison with other medications, placebo or no medication (supportive care) in people diagnosed as cannabis dependent or who were likely to be dependent. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included 21 RCTs involving 1755 participants: 18 studies recruited adults (mean age 22 to 41 years); three studies targeted young people (mean age 20 years). Most (75%) participants were male. The studies were at low risk of performance, detection and selective outcome reporting bias. One study was at risk of selection bias, and three studies were at risk of attrition bias.All studies involved comparison of active medication and placebo. The medications were diverse, as were the outcomes reported, which limited the extent of analysis.Abstinence at end of treatment was no more likely with Δ9-tetrahydrocannabinol (THC) preparations than with placebo (risk ratio (RR) 0.98, 95% confidence interval (CI) 0.64 to 1.52; 305 participants; 3 studies; moderate-quality evidence). For selective serotonin reuptake inhibitor (SSRI) antidepressants, mixed action antidepressants, anticonvulsants and mood stabilisers, buspirone and N-acetylcysteine, there was no difference in the likelihood of abstinence at end of treatment compared to placebo (low- to very low-quality evidence).There was qualitative evidence of reduced intensity of withdrawal symptoms with THC preparations compared to placebo. For other pharmacotherapies, this outcome was either not examined, or no significant differences was reported.Adverse effects were no more likely with THC preparations (RR 1.02, 95% CI 0.89 to 1.17; 318 participants; 3 studies) or N-acetylcysteine (RR 0.94, 95% CI 0.71 to 1.23; 418 participants; 2 studies) compared to placebo (moderate-quality evidence). For SSRI antidepressants, mixed action antidepressants, buspirone and N-acetylcysteine, there was no difference in adverse effects compared to placebo (low- to very low-quality evidence).There was no difference in the likelihood of withdrawal from treatment due to adverse effects with THC preparations, SSRIs antidepressants, mixed action antidepressants, anticonvulsants and mood stabilisers, buspirone and N-acetylcysteine compared to placebo (low- to very low-quality evidence).There was no difference in the likelihood of treatment completion with THC preparations, SSRI antidepressants, mixed action antidepressants and buspirone compared to placebo (low- to very low-quality evidence) or with N-acetylcysteine compared to placebo (RR 1.06, 95% CI 0.93 to 1.21; 418 participants; 2 studies; moderate-quality evidence). Anticonvulsants and mood stabilisers appeared to reduce the likelihood of treatment completion (RR 0.66, 95% CI 0.47 to 0.92; 141 participants; 3 studies; low-quality evidence).Available evidence on gabapentin (anticonvulsant), oxytocin (neuropeptide) and atomoxetine was insufficient for estimates of effectiveness. AUTHORS' CONCLUSIONS There is incomplete evidence for all of the pharmacotherapies investigated, and for many outcomes the quality of the evidence was low or very low. Findings indicate that SSRI 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, THC preparations should be considered still experimental, with some positive effects on withdrawal symptoms and craving. The evidence base for the anticonvulsant gabapentin, oxytocin, and N-acetylcysteine is weak, but these medications are also worth further investigation.
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Affiliation(s)
- Suzanne Nielsen
- Monash UniversityMonash Addiction Research CentrePeninsula CampusMcMahons RoadFrankstonVICAustralia3199
| | - Linda Gowing
- University of AdelaideDiscipline of PharmacologyFrome RoadAdelaideSouth AustraliaAustralia5005
| | - Pamela Sabioni
- Centre for Addiction and Mental Health; University of TorontoTranslational Addiction Research Laboratory33 Russell StreetTorontoONCanada
| | - Bernard Le Foll
- Centre for Addiction and Mental Health; University of TorontoTranslational Addiction Research Laboratory33 Russell StreetTorontoONCanada
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Lee DC, Schlienz NJ, Peters EN, Dworkin RH, Turk DC, Strain EC, Vandrey R. Systematic review of outcome domains and measures used in psychosocial and pharmacological treatment trials for cannabis use disorder. Drug Alcohol Depend 2019; 194:500-517. [PMID: 30530238 PMCID: PMC7038155 DOI: 10.1016/j.drugalcdep.2018.10.020] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 10/09/2018] [Accepted: 10/13/2018] [Indexed: 01/21/2023]
Abstract
Cannabis use disorder (CUD) is prevalent and demand for treatment is increasing, yet few individuals engage in formal treatment and the efficacy of established interventions for CUD is modest. Existing clinical trials evaluating psychosocial and pharmacological treatments for CUD have incorporated a wide variety of measures for assessing cannabis use outcomes, including abstinence, self-reported frequency and quantity used, withdrawal, use/dependence severity, and other psychosocial outcomes. The heterogeneity of measures and outcomes has limited quantitative analyses of the comparative effectiveness of existing interventions. The purpose of this systematic review is to: 1) identify and characterize approaches for measuring cannabis use in existing CUD intervention trials, including abstinence, frequency and quantity of use, and 2) summarize measures used to assess treatment efficacy in other outcome domains (e.g., cannabis use severity, psychosocial functioning, cannabis withdrawal), and provide a platform for future research to evaluate which outcome measures are most likely to reflect treatment efficacy and clinically significant improvement in other outcome domains.
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Affiliation(s)
- Dustin C Lee
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Nicolas J Schlienz
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Erica N Peters
- Battelle Public Health Center for Tobacco Research, Battelle Memorial Institute, Baltimore, MD, USA
| | - Robert H Dworkin
- Department of Anesthesiology, School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA
| | - Dennis C Turk
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Eric C Strain
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Ryan Vandrey
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Zhand N, Milin R. What do we know about the pharmacotheraputic management of insomnia in cannabis withdrawal: A systematic review. Am J Addict 2018; 27:453-464. [PMID: 30113101 DOI: 10.1111/ajad.12783] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 06/04/2018] [Accepted: 07/22/2018] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Sleep disturbance is one of the hallmarks of cannabis withdrawal. Studies have indicated that treatment of this key symptom may facilitate abstinence. In the present paper we aim to provide a systematic review of the extant literature on pharmacological management of sleep disturbance associated with cannabis withdrawal. METHOD We conducted a systematic literature search across five electronic databases including PubMed, Psycinfo, MEDLINE, Cochrane review and Embase. Human studies using a pharmacological treatment for sleep disturbances associated with cannabis withdrawal were included. Review articles, case-series, open trials, posters, and editorials were excluded. RESULTS Seventeen publications, involving 562 participants, were included in this review. Major limitations involved small sample size, high dropout rate, methodological limitations, and heterogeneity of participants. Most of the studies were at high risk of bias, further downgrading the level of evidence. A meta-analysis was not performed due to lack of quantitative data, marked heterogeneity and low quality of the included studies. CONCLUSION There is not sufficient evidence for any of the reviewed treatment options. Methodological limitations in a majority of the studies rendered their findings preliminary. Of the twelve investigated pharmacological agents, Gabapentin, Lofexidine, Mirtazapine, Quetiapine, and Zolpidem showed some primary benefits for treatment of sleep difficulties associated with cannabis withdrawal; however, future prospective studies are required to confirm such results. SCIENTIFIC SIGNIFICANCE This review examines the current evidence for potential pharmacological options for treatment of cannabis withdrawal and associated sleep disturbance. It furthers our knowledge and provides groundwork for future research. (Am J Addict 2018;27:453-464).
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Affiliation(s)
- Naista Zhand
- Department of Psychiatry, University of Ottawa, Ontario, Canada
| | - Robert Milin
- Department of Psychiatry, University of Ottawa, Ontario, Canada.,Head, Division of Addiction and Mental Health, Department of Psychiatry, University of Ottawa, Ontario, Canada
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Mouhamed Y, Vishnyakov A, Qorri B, Sambi M, Frank SMS, Nowierski C, Lamba A, Bhatti U, Szewczuk MR. Therapeutic potential of medicinal marijuana: an educational primer for health care professionals. Drug Healthc Patient Saf 2018; 10:45-66. [PMID: 29928146 PMCID: PMC6001746 DOI: 10.2147/dhps.s158592] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
With the proposed Canadian July 2018 legalization of marijuana through the Cannabis Act, a thorough critical analysis of the current trials on the efficacy of medicinal marijuana (MM) as a treatment option is necessary. This review is particularly important for primary care physicians whose patients may be interested in using MM as an alternative therapy. In response to increased interest in MM, Health Canada released a document in 2013 for general practitioners (GPs) as an educational tool on the efficacy of MM in treating some chronic and acute conditions. Although additional studies have filled in some of the gaps since the release of the Health Canada document, conflicting and inconclusive results continue to pose a challenge for physicians. This review aims to supplement the Health Canada document by providing physicians with a critical yet concise update on the recent advancements made regarding the efficacy of MM as a potential therapeutic option. An update to the literature of 2013 is important given the upcoming changes in legislation on the use of marijuana. Also, we briefly highlight the current recommendations provided by Canadian medical colleges on the parameters that need to be considered prior to authorizing MM use, routes of administration as well as a general overview of the endocannabinoid system as it pertains to cannabis. Lastly, we outline the appropriate medical conditions for which the authorization of MM may present as a practical alternative option in improving patient outcomes as well as individual considerations of which GPs should be mindful. The purpose of this paper is to offer physicians an educational tool that provides a necessary, evidence-based analysis of the therapeutic potential of MM and to ensure physicians are making decisions on the therapeutic use of MM in good faith.
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Affiliation(s)
- Yara Mouhamed
- Graduate Diploma & Professional Master in Medical Sciences, School of Medicine, Queen’s University, Kingston, ON, Canada
| | - Andrey Vishnyakov
- Graduate Diploma & Professional Master in Medical Sciences, School of Medicine, Queen’s University, Kingston, ON, Canada
| | - Bessi Qorri
- Department of Biomedical and Molecular Sciences, Queen’s University, Kingston, ON, Canada
| | - Manpreet Sambi
- Department of Biomedical and Molecular Sciences, Queen’s University, Kingston, ON, Canada
| | - SM Signy Frank
- Graduate Diploma & Professional Master in Medical Sciences, School of Medicine, Queen’s University, Kingston, ON, Canada
| | - Catherine Nowierski
- Graduate Diploma & Professional Master in Medical Sciences, School of Medicine, Queen’s University, Kingston, ON, Canada
| | - Anmol Lamba
- Graduate Diploma & Professional Master in Medical Sciences, School of Medicine, Queen’s University, Kingston, ON, Canada
| | - Umrao Bhatti
- Graduate Diploma & Professional Master in Medical Sciences, School of Medicine, Queen’s University, Kingston, ON, Canada
| | - Myron R Szewczuk
- Department of Biomedical and Molecular Sciences, Queen’s University, Kingston, ON, Canada
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16
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The Current State of Pharmacological Treatments for Cannabis Use Disorder and Withdrawal. Neuropsychopharmacology 2018; 43:173-194. [PMID: 28875989 PMCID: PMC5719115 DOI: 10.1038/npp.2017.212] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 08/31/2017] [Accepted: 08/31/2017] [Indexed: 02/07/2023]
Abstract
Cannabis use disorder (CUD) commonly occurs and carries a notable economic and functional burden at both individual and societal levels. While there are no clearly efficacious medication treatments for CUD, 20 years of committed and high-quality research in the human laboratory and clinical settings have resulted in medications with demonstrated effectiveness in the treatment of cannabis withdrawal, the ability to reduce cannabis use, and results that point to promising future work. The current state of pharmacology research for CUD highlights the need to consider particular characteristics of patients, such as gender, impulsivity, and severity of cannabis use, when selecting a medication in the off-label treatment of CUD or cannabis withdrawal. As a field, the body of work also exposes some areas in need of improvement in study design, selection of outcome measures, interpretation of results, and the overall process of evaluating candidate medications. Coming to a consensus as a field and addressing these gaps in future research will likely lend itself to further advances in improving the lives of patients with CUD.
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Sherman BJ, McRae-Clark AL. Treatment of Cannabis Use Disorder: Current Science and Future Outlook. Pharmacotherapy 2017; 36:511-35. [PMID: 27027272 DOI: 10.1002/phar.1747] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Cannabis is the most commonly used illicit substance in the United States. Rates of cannabis use and cannabis use disorder (CUD) have increased in the past decade, paralleling changes in the legal and political climate favoring legalization. Almost 20 million people 12 years or older report past-month cannabis use, and 8 million report daily or near-daily use. Concurrently, the perception that cannabis use poses a significant risk of negative consequences has decreased. Contrary to this perception, heavy cannabis use is associated with cognitive impairment, increased risk for psychotic disorders and other mental health problems, lower education attainment, and unemployment. Clinical trials of various treatments for CUD have likewise increased, focusing primarily on psychotherapy treatments, specifically motivational enhancement therapy, cognitive behavioral therapy, and contingency management. Their findings suggest that a combination of these three modalities produces the best abstinence outcomes, although abstinence rates remain modest and decline after treatment. More recently, pharmacotherapy trials have been conducted as adjunctive interventions to psychosocial treatment. N-acetylcysteine and gabapentin are two of the most promising medications, although no pharmacologic treatment has emerged as clearly efficacious. In this review, we provide a detailed summary of clinical trials that evaluated psychotherapy and pharmacotherapy for treating CUD and discuss emerging areas of clinical research and cannabis-specific barriers to treatment.
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Affiliation(s)
- Brian J Sherman
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina
| | - Aimee L McRae-Clark
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina
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Nikolaou K, Kapoukranidou D, Ndungu S, Floros G, Kovatsi L. Severity of Withdrawal Symptoms, Plasma Oxytocin Levels, and Treatment Outcome in Heroin Users Undergoing Acute Withdrawal. J Psychoactive Drugs 2017; 49:233-241. [PMID: 28443705 DOI: 10.1080/02791072.2017.1312644] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Pre-clinical studies show that, following chronic opioid exposure, oxytocin neurons exhibit over-excitation upon withdrawal, causing an increase in oxytocin brain and plasma levels. Relevant clinical data on humans are scarce. This study investigates the opioid withdrawal stress effect on oxytocin plasma levels in humans. We evaluated 57 male chronic heroin users in a residential detoxification program. We determined plasma oxytocin levels by ELISA and measured the stress effects of withdrawal using the COWS scale for opioid withdrawal, the VAS scale for craving, and the Hamilton scales for anxiety and depression on the second day of admission. Out of the 57 patients enrolled in the study, 27 completed the 21-day program, while the remaining 30 dropped out prior to completion. Plasma oxytocin levels were significantly higher in those individuals who dropped out than in those who completed the program. Participants who dropped out at some stage scored higher in the COWS, VAS-Craving, and Hamilton-anxiety scales, indicating a higher stress and explaining the higher oxytocin levels. In addition, plasma oxytocin levels correlated positively with the scores achieved in the COWS and Hamilton-anxiety scales. Higher withdrawal stress levels are associated with higher plasma oxytocin levels and early treatment discharge.
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Affiliation(s)
- Kakia Nikolaou
- a Consultant Psychiatrist, Head of the Addictions Department IANOS , Papanikolaou General Hospital of Thessaloniki-Psychiatric Hospital of Thessaloniki , Thessaloniki , Greece
| | - Dorothea Kapoukranidou
- b Associate Professor, Department of Physiology, School of Medicine , Aristotle University of Thessaloniki , Thessaloniki , Greece
| | - Samuel Ndungu
- c Emeritus Professor, Laboratory of Forensic Medicine and Toxicology, School of Medicine , Aristotle University of Thessaloniki , Thessaloniki , Greece
| | - Georgios Floros
- d Scientific Associate, Second Department of Psychiatry, School of Medicine , Aristotle University of Thessaloniki , Thessaloniki , Greece
| | - Leda Kovatsi
- e Assistant Professor, Laboratory of Forensic Medicine and Toxicology, School of Medicine , Aristotle University of Thessaloniki , Thessaloniki , Greece
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Walther L, Gantner A, Heinz A, Majić T. Evidence-based Treatment Options in Cannabis Dependency. DEUTSCHES ARZTEBLATT INTERNATIONAL 2016; 113:653-659. [PMID: 27776623 PMCID: PMC5098026 DOI: 10.3238/arztebl.2016.0653] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Revised: 01/10/2016] [Accepted: 05/03/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Now that the consumption of natural and synthetic cannabinoids is becoming more widespread, the specific treatment of cannabis-related disturbances is an increasingly important matter. There are many therapeutic options, and it is not always clear which ones are evidence-based and appropriate for use in a given clinical situation. METHODS This review is based on reports of pertinent randomized and controlled trials (RCTs) that were retrieved by a selective search in the PubMed and Cochrane databases. RESULTS Cognitive behavior therapy (CBT) combined with other techniques has been found to have a moderate to large effect (Cohen's d = 0.53-0.9) on the amount of cannabis consumed as well as on the level of psychosocial functioning or the dependence syndrome. Systemic multidimensional family therapy (MDFT) has been found beneficial for younger adolescents who consume large amounts of cannabis and have psychiatric comorbidities. Short-term interventions with motivational talk therapy have been found effective for patients with or without an initial desire to achieve cannabis abstinence. All of these psychotherapeutic interventions are effective at evidence level Ia. The administration of gabapentin had a weak effect (d = 0.26) on the quantity consumed and on abstinence (evidence level Ib). Withdrawal symptoms can be alleviated with cannabinoid-receptor antagonists (d = 0.223 and 0.481) (evidence level Ib). On the other hand, there is evidence that serotonergic antidepressants can worsen withdrawal manifestations and increase the likelihood of relapse. CONCLUSION Psychotherapeutic techniques remain the foundation of treatment for cannabis dependence. No drug has yet been approved for the treatment of cannabis dependence because of the lack of scientific evidence. The rates of abstinence that are currently achieved, even with psychotherapy, are still only moderate. Further clinical studies are needed for the evaluation of combinations of various treatments that can meet the needs of individual patients.
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Affiliation(s)
- Lisa Walther
- Department of Psychiatry and Psychotherapy Charité-Universitätsmedizin Berlin, Campus Mitte, Therapieladen e. V., Berlin, Department of Psychiatry and Psychotherapy, Charité-Universitätsmedizin Berlin, Charité Campus Mitte at St. Hedwig Hospital, Charité Campus Mitte
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Brzozowska N, Li KM, Wang XS, Booth J, Stuart J, McGregor IS, Arnold JC. ABC transporters P-gp and Bcrp do not limit the brain uptake of the novel antipsychotic and anticonvulsant drug cannabidiol in mice. PeerJ 2016; 4:e2081. [PMID: 27257556 PMCID: PMC4888295 DOI: 10.7717/peerj.2081] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 05/03/2016] [Indexed: 12/14/2022] Open
Abstract
Cannabidiol (CBD) is currently being investigated as a novel therapeutic for the treatment of CNS disorders like schizophrenia and epilepsy. ABC transporters such as P-glycoprotein (P-gp) and breast cancer resistance protein (Bcrp) mediate pharmacoresistance in these disorders. P-gp and Bcrp are expressed at the blood brain barrier (BBB) and reduce the brain uptake of substrate drugs including various antipsychotics and anticonvulsants. It is therefore important to assess whether CBD is prone to treatment resistance mediated by P-gp and Bcrp. Moreover, it has become common practice in the drug development of CNS agents to screen against ABC transporters to help isolate lead compounds with optimal pharmacokinetic properties. The current study aimed to assess whether P-gp and Bcrp impacts the brain transport of CBD by comparing CBD tissue concentrations in wild-type (WT) mice versus mice devoid of ABC transporter genes. P-gp knockout (Abcb1a/b (-∕-)), Bcrp knockout (Abcg2 (-∕-)), combined P-gp/Bcrp knockout (Abcb1a/b (-∕-) Abcg2 (-∕-)) and WT mice were injected with CBD, before brain and plasma samples were collected at various time-points. CBD results were compared with the positive control risperidone and 9-hydroxy risperidone, antipsychotic drugs that are established ABC transporter substrates. Brain and plasma concentrations of CBD were not greater in P-gp, Bcrp or P-gp/Bcrp knockout mice than WT mice. In comparison, the brain/plasma concentration ratios of risperidone and 9-hydroxy risperidone were profoundly higher in P-gp knockout mice than WT mice. These results suggest that CBD is not a substrate of P-gp or Bcrp and may be free from the complication of reduced brain uptake by these transporters. Such findings provide favorable evidence for the therapeutic development of CBD in the treatment of various CNS disorders.
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Affiliation(s)
- Natalia Brzozowska
- Discipline of Pharmacology, School of Medical Science, University of Sydney , Sydney, NSW , Australia
| | - Kong M Li
- Discipline of Pharmacology, School of Medical Science, University of Sydney , Sydney, NSW , Australia
| | - Xiao Suo Wang
- Bosch Mass Spectrometry Facility, Bosch Institute, Sydney Medical School, University of Sydney , Sydney, NSW , Australia
| | - Jessica Booth
- Psychopharmacology Laboratory, School of Psychology, Faculty of Science, University of Sydney , Sydney, NSW , Australia
| | - Jordyn Stuart
- The Lambert Initiative of Cannabinoid Therapeutics, The Brain and Mind Centre, University of Sydney, Sydney, NSW, Australia; Psychopharmacology Laboratory, School of Psychology, Faculty of Science, University of Sydney, Sydney, NSW, Australia
| | - Iain S McGregor
- The Lambert Initiative of Cannabinoid Therapeutics, The Brain and Mind Centre, University of Sydney, Sydney, NSW, Australia; Psychopharmacology Laboratory, School of Psychology, Faculty of Science, University of Sydney, Sydney, NSW, Australia
| | - Jonathon C Arnold
- Discipline of Pharmacology, School of Medical Science, University of Sydney, Sydney, NSW, Australia; The Lambert Initiative of Cannabinoid Therapeutics, The Brain and Mind Centre, University of Sydney, Sydney, NSW, Australia
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Copeland J, Pokorski I. Progress toward pharmacotherapies for cannabis-use disorder: an evidence-based review. Subst Abuse Rehabil 2016; 7:41-53. [PMID: 27217809 PMCID: PMC4862355 DOI: 10.2147/sar.s89857] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Cannabis is the most widely used and variably regulated drug in the world, with increasing trends of use being reported in the US, Australia, Asia, and Africa. Evidence has shown a decrease in the age of commencement of cannabis use in some developed countries and a prolongation of risk of initiation to cannabis use beyond adolescence among more recent users. Cannabis use is associated with numerous health risks and long-term morbidity, as well as risk of developing cannabis-use disorders. Cannabis users infrequently seek professional treatment, and normally do so after a decade of use. Cannabis-use disorders are currently treated using a selection of psychosocial interventions. Severity of withdrawal is a factor that increases the risk of relapse, and is the target of pharmacotherapy studies. Currently, there is no approved pharmacotherapy for cannabis-use disorders. A number of approaches have been examined, and trials are continuing to find a safe and effective medication with little abuse liability.
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Affiliation(s)
- Jan Copeland
- UNSW Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Izabella Pokorski
- UNSW Medicine, University of New South Wales, Sydney, NSW, Australia
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Angarita GA, Emadi N, Hodges S, Morgan PT. Sleep abnormalities associated with alcohol, cannabis, cocaine, and opiate use: a comprehensive review. Addict Sci Clin Pract 2016; 11:9. [PMID: 27117064 PMCID: PMC4845302 DOI: 10.1186/s13722-016-0056-7] [Citation(s) in RCA: 192] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 04/08/2016] [Indexed: 01/27/2023] Open
Abstract
Sleep abnormalities are associated with acute and chronic use of addictive substances. Although sleep complaints associated with use and abstinence from addictive substances are widely recognized, familiarity with the underlying sleep abnormalities is often lacking, despite evidence that these sleep abnormalities may be recalcitrant and impede good outcomes. Substantial research has now characterized the abnormalities associated with acute and chronic use of alcohol, cannabis, cocaine, and opiates. This review summarizes this research and discusses the clinical implications of sleep abnormalities in the treatment of substance use disorders.
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Affiliation(s)
- Gustavo A Angarita
- Yale University Department of Psychiatry, Connecticut Mental Health Center, 34 Park Street, New Haven, CT, 06519, USA
| | - Nazli Emadi
- Yale University Department of Psychiatry, Connecticut Mental Health Center, 34 Park Street, New Haven, CT, 06519, USA
| | - Sarah Hodges
- Yale University Department of Psychiatry, Connecticut Mental Health Center, 34 Park Street, New Haven, CT, 06519, USA
| | - Peter T Morgan
- Yale University Department of Psychiatry, Connecticut Mental Health Center, 34 Park Street, New Haven, CT, 06519, USA.
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Panlilio LV, Justinova Z, Trigo JM, Le Foll B. Screening Medications for the Treatment of Cannabis Use Disorder. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2016; 126:87-120. [PMID: 27055612 DOI: 10.1016/bs.irn.2016.02.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Cannabis use has been increasingly accepted legally and in public opinion. However, cannabis has the potential to produce adverse physical and mental health effects, and cannabis use disorder (CUD) occurs in a substantial percentage of both occasional and daily cannabis users. Many people have difficulty discontinuing use despite receiving treatment. Therefore, it would be beneficial to develop safe and effective medications for treating CUD. To achieve this, methods have been developed for screening and evaluating potential medications using animal models and controlled experimental protocols in human volunteers. In this chapter, we describe: (1) animal models available for assessing the effect of potential medications on specific aspects of CUD, (2) the main findings obtained so far with these animal models, (3) the approaches used to assess potential medications in humans in laboratory experiments and clinical trials, and (4) the effectiveness of several potential pharmacotherapies on particular aspects of CUD modeled in these human studies.
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Affiliation(s)
- L V Panlilio
- Preclinical Pharmacology Section, Behavioral Neuroscience Research Branch, NIDA, NIH, DHHS, Baltimore, MD, United States
| | - Z Justinova
- Preclinical Pharmacology Section, Behavioral Neuroscience Research Branch, NIDA, NIH, DHHS, Baltimore, MD, United States
| | - J M Trigo
- Translational Addiction Research Laboratory, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
| | - B Le Foll
- Translational Addiction Research Laboratory, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada; Addiction Medicine Service, Ambulatory Care and Structured Treatments, Centre for Addiction and Mental Health, Toronto, ON, Canada; Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada.
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24
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Allsop DJ, Bartlett DJ, Johnston J, Helliwell D, Winstock A, McGregor IS, Lintzeris N. The Effects of Lithium Carbonate Supplemented with Nitrazepam on Sleep Disturbance during Cannabis Abstinence. J Clin Sleep Med 2015; 11:1153-62. [PMID: 26285109 DOI: 10.5664/jcsm.5090] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 04/30/2015] [Indexed: 01/08/2023]
Abstract
STUDY OBJECTIVE Sleep disturbance is a hallmark feature of cannabis withdrawal. In this study we explored the effects of lithium treatment supplemented with nitrazepam on objective and subjective measures of sleep quality during inpatient cannabis withdrawal. METHODS Treatment-seeking cannabis-dependent adults (n = 38) were admitted for 8 days to an inpatient withdrawal unit and randomized to either oral lithium (500 mg) or placebo, twice daily in a double-blind RCT. Restricted nitrazepam (10 mg) was available on demand (in response to poor sleep) on any 3 of the 7 nights. Dependent outcome measures for analysis included repeated daily objective actigraphy and subjective sleep measures throughout the 8 day detox, subjective cannabis withdrawal ratings, and detoxification completion rates. RESULTS Based on actigraphy, lithium resulted in less fragmented sleep compared to placebo (p = 0.04), but no other objective measures were improved by lithium. Of the subjective measures, only nightmares were suppressed by lithium (p = 0.04). Lithium did not have a significant impact on the use of nitrazepam. Sleep bout length (p < 0.0001), sleep efficiency (p < 0.0001), and sleep fragmentation (p = 0.05) were improved on nights in which nitrazepam was used. In contrast, only night sweats improved with nitrazepam from the subjective measures (p = 0.04). A Cox regression with daily repeated measures of sleep efficiency averaged across all people in the study a predictor suggests that a one-unit increase in sleep efficiency (the ratio of total sleep time to the total time in bed expressed as a percentage) resulted in a 14.6% increase in retention in treatment (p = 0.008, Exp(B) = 0.854, 95% CI = 0.759-0.960). None of the other sleep measures, nor use of lithium or nitrazepam were significantly associated with retention in treatment. CONCLUSIONS Lithium seems to have only limited efficacy on sleep disturbance in cannabis withdrawal. However the nitrazepam improved several actigraphy measures of sleep disturbance, warranting further investigation. Discord between objective and subjective sleep indices suggest caution in evaluating treatment interventions with self-report sleep data only.
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Affiliation(s)
- David J Allsop
- School of Psychology, University of Sydney, Sydney, NSW, Australia.,Discipline of Addiction Medicine, Central Clinical School, University of Sydney, NSW Australia.,The Langton Centre, Drug and Alcohol Services, South Eastern Sydney Local Health District, Surry Hills, NSW, Australia
| | - Delwyn J Bartlett
- Woolcock Institute of Medical Research &University of Sydney, NSW, Australia
| | - Jennifer Johnston
- University Centre for Rural Health, University of Sydney, Lismore, NSW, Australia
| | | | | | - Iain S McGregor
- School of Psychology, University of Sydney, Sydney, NSW, Australia
| | - Nicholas Lintzeris
- Discipline of Addiction Medicine, Central Clinical School, University of Sydney, NSW Australia.,The Langton Centre, Drug and Alcohol Services, South Eastern Sydney Local Health District, Surry Hills, NSW, Australia
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Abstract
Some of the earliest reports of the effects of cannabis consumption on humans were related to endocrine system changes. In this review, the effects of cannabinoids and the role of the CB1 cannabinoid receptor in the regulation of the following endocrine systems are discussed: the hypothalamic-pituitary-gonadal axis, prolactin and oxytocin, thyroid hormone and growth hormone, and the hypothalamic-pituitary-adrenal axis. Preclinical and human study results are presented.
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Affiliation(s)
- Cecilia J Hillard
- Neuroscience Research Center and Department of Pharmacology and Toxicology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA.
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