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Feingold D, Tzur Bitan D, Ferri M, Hoch E. Predictors of effective therapy among individuals with Cannabis Use Disorder: a review of the literature. Eur Arch Psychiatry Clin Neurosci 2024:10.1007/s00406-024-01781-4. [PMID: 38493284 DOI: 10.1007/s00406-024-01781-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 02/16/2024] [Indexed: 03/18/2024]
Abstract
Treatment demand for Cannabis Use Disorder (CUD) has increased in the past decade in almost all European countries, and CUD is currently the most common reason for first-time drug-related treatment admission in the European Union. Even though several therapeutic approaches have been shown to benefit individuals with CUD, there is a lack of knowledge regarding factors associated with effective therapy and the underlying mechanisms of change among individuals with CUD presenting for treatment. The aim of the present paper was to review current knowledge on factors that have been shown to contribute to positive outcomes in CUD treatment. A scoping methodology was used, focusing on empirically evaluated studies that used defined, cannabis-related outcome measures. In eligible studies, factors of investigation were categorized as either 'mediators', i.e., treatment-related factors associated with the processes or mechanisms through which patients benefit from therapy, or 'moderators' which are patient-related characteristics that predict his/her odds to benefit from treatment or patient-related (i.e., moderators). Factors categorized as mediators were then classified 'specific factors' if they were related to a certain technique or treatment modality or 'common factors' if they were assessed beyond treatment modalities. Findings suggest that in CUD treatment, specific mediators include treatment duration, addressing motivation to change, acquiring coping skills, enhancing self-efficacy, and integrating several therapeutic components. Common mediators include therapeutic alliance, empathy, expectations and cultural adaptation. Moderators in CUD treatment include sex, ethnicity, age-related factors and comorbid disorders.
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Affiliation(s)
- Daniel Feingold
- Psychology Department, Achva Academic College, Achva, Israel.
| | - Dana Tzur Bitan
- Department of Community Mental Health, University of Haifa, Haifa, Israel
- Shalvata Mental Health Center, Hod Hasharon, Israel
| | | | - Eva Hoch
- Department of Psychiatry, Ludwig-Maximilians-University, Munich, Germany
- IFT Institut für Therapieforschung, Centre of Health and Addiction Research, Munich, Germany
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2
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Keen L, Turner AD, Harris T, George L, Crump J. Differences in internalizing symptoms between those with and without Cannabis Use Disorder among HBCU undergraduate students. J Am Coll Health 2023; 71:2390-2397. [PMID: 36108170 PMCID: PMC10014475 DOI: 10.1080/07448481.2021.1970560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 08/04/2021] [Accepted: 08/16/2021] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To determine the differences in internalizing symptoms between those who met criteria for Cannabis Use Disorder (CUD) and those who did not in young adults attending a Historically Black College or University (HBCU). PARTICIPANTS The sample included 619 undergraduate students, with 110 (18%) who met criteria for CUD. METHODS Participants completed an online survey, which included demographic, anxious and depressive symptomatology, and substance use assessment. RESULTS Those who met CUD criteria reported more depressive symptoms (M = 22.83 ± 10.74) and anxiety symptoms (M = 45.70 ± 12.82) than their non-CUD counterparts (M = 19.17 ± 10.58; M = 40.57 ± 14.11, respectively). CONCLUSION Differences between those who met criteria for CUD and those who did not are consistent with previous literature and may aid in characterizing internalizing behaviors in HBCU students with CUD. Future research should examine the subgroups that may cycle through withdrawal symptoms, despite not having severe CUD. This subgroup may be at higher risk for psychopathology than their severe counterparts.
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Affiliation(s)
- Larry Keen
- Department of Psychology, Virginia State University
| | - Arlener D. Turner
- Department of Psychiatry and Behavioral Sciences, University of Miami
| | - Toni Harris
- Department of Psychology, Virginia State University
| | | | - Jonae Crump
- Department of Psychology, Virginia State University
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3
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Macatee RJ, Preston TJ, Afshar K, Blaine SK, Schermitzler B. Temporal stability of neurophysiological drug cue reactivity before and after acute stress in cannabis users: A test of incentive sensitization. Drug Alcohol Depend 2023; 247:109862. [PMID: 37062250 DOI: 10.1016/j.drugalcdep.2023.109862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 03/02/2023] [Accepted: 03/21/2023] [Indexed: 04/18/2023]
Abstract
BACKGROUND Given increasing rates of Cannabis Use Disorder (CUD), objective measures are needed that can reliably index risk and track cannabis use progression. Based on incentive sensitization models, neurophysiological reactivity to cannabis cues, measured with the electroencephalography-recorded late positive potential (LPP), may be a candidate biomarker. To serve as such, the cannabis cue-elicited LPP must demonstrate adequate retest reliability and sensitivity to cannabis use change. Moreover, incentive sensitization theory suggests that state-level contextual variables, such as acute stress, can impact drug cue reactivity. Therefore, the present study evaluated the three-month retest reliability of the cannabis cue-elicited LPP, recorded before and after a laboratory stress induction, as well as its sensitivity to cannabis use change. METHOD Cannabis and neutral cue-elicited LPPs were measured in 102 adults reporting frequent cannabis use (86 % with current CUD) before and after an acute stress induction at two lab visits three-months apart. Physiological and subjective stress reactivity were also measured. RESULTS Manipulation checks confirmed expected cannabis cue and acute stress effects. Cannabis cue-elicited LPP amplitudes showed significant three-month retest reliability of poor-to-fair through moderate-to-good size. Change in cannabis use frequency significantly predicted change in cannabis cue-elicited LPP amplitudes, particularly at post-stress. CONCLUSION Consistent with incentive sensitization models of addiction, the cannabis cue-elicited LPP demonstrated trait-like, moderate three-month stability and responsivity to change in cannabis use behavior. Greater predictive validity of the post-stress LPP may arise through kindling effects of acute stress on incentive salience-related neural activity, which should be explored in future studies.
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Affiliation(s)
- Richard J Macatee
- Auburn University, Department of Psychological Sciences, 226 Thach Hall, Auburn, AL 36849, USA..
| | - Thomas J Preston
- Auburn University, Department of Psychological Sciences, 226 Thach Hall, Auburn, AL 36849, USA
| | - Kaveh Afshar
- Auburn University, Department of Psychological Sciences, 226 Thach Hall, Auburn, AL 36849, USA
| | - Sara K Blaine
- Auburn University, Department of Psychological Sciences, 226 Thach Hall, Auburn, AL 36849, USA
| | - Brandon Schermitzler
- Auburn University, Department of Psychological Sciences, 226 Thach Hall, Auburn, AL 36849, USA
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4
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Lake S, Cooper ZD. Understanding Cannabis Use Disorder Diagnoses in the U.S. Veterans Health Administration in the Era of Legalization. Am J Psychiatry 2022; 179:702-704. [PMID: 36181332 DOI: 10.1176/appi.ajp.20220675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Stephanie Lake
- UCLA Center for Cannabis and Cannabinoids, Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles (Lake, Cooper); Department of Psychiatry (Lake, Cooper) and Department of Anesthesiology and Perioperative Medicine (Cooper), David Geffen School of Medicine, University of California, Los Angeles
| | - Ziva D Cooper
- UCLA Center for Cannabis and Cannabinoids, Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles (Lake, Cooper); Department of Psychiatry (Lake, Cooper) and Department of Anesthesiology and Perioperative Medicine (Cooper), David Geffen School of Medicine, University of California, Los Angeles
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5
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Hasin DS, Saxon AJ, Malte C, Olfson M, Keyes KM, Gradus JL, Cerdá M, Maynard CC, Keyhani S, Martins SS, Fink DS, Livne O, Mannes Z, Wall MM. Trends in Cannabis Use Disorder Diagnoses in the U.S. Veterans Health Administration, 2005-2019. Am J Psychiatry 2022; 179:748-757. [PMID: 35899381 PMCID: PMC9529770 DOI: 10.1176/appi.ajp.22010034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE In the United States, adult cannabis use has increased over time, but less information is available on time trends in cannabis use disorder. The authors used Veterans Health Administration (VHA) data to examine change over time in cannabis use disorder diagnoses among veterans, an important population subgroup, and whether such trends differ by age group (<35 years, 35-64 years, ≥65 years), sex, or race/ethnicity. METHODS VHA electronic health records from 2005 to 2019 (range of Ns per year, 4,403,027-5,797,240) were used to identify the percentage of VHA patients seen each year with a cannabis use disorder diagnosis (ICD-9-CM, January 1, 2005-September 30, 2015; ICD-10-CM, October 1, 2015-December 31, 2019). Trends in cannabis use disorder diagnoses were examined by age and by race/ethnicity and sex within age groups. Given the transition in ICD coding, differences in trends were tested within two periods: 2005-2014 (ICD-9-CM) and 2016-2019 (ICD-10-CM). RESULTS In 2005, the percentages of VHA patients diagnosed with cannabis use disorder in the <35, 35-64, and ≥65 year age groups were 1.70%, 1.59%, and 0.03%, respectively; by 2019, the percentages had increased to 4.84%, 2.86%, and 0.74%, respectively. Although the prevalence of cannabis use disorder was consistently higher among males than females, between 2016 and 2019, the prevalence increased more among females than males in the <35 year group. Black patients had a consistently higher prevalence of cannabis use disorder than other racial/ethnic groups, and increases were greater among Black than White patients in the <35 year group in both periods. CONCLUSIONS Since 2005, diagnoses of cannabis use disorder have increased substantially among VHA patients, as they have in the general population and other patient populations. Possible explanations warranting investigation include decreasing perception of risk, changing laws, increasing cannabis potency, stressors related to growing socioeconomic inequality, and use of cannabis to self-treat pain. Clinicians and the public should be educated about the increases in cannabis use disorder in general in the United States, including among patients treated at the VHA.
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Affiliation(s)
| | - Andrew J. Saxon
- VA Puget Sound Health Care System and University of Washington
| | | | - Mark Olfson
- Columbia University and New York State Psychiatric Institute
| | | | | | | | | | - Salomeh Keyhani
- San Francisco VA Health System and University of California at San Francisco
| | | | | | | | | | - Melanie M. Wall
- Columbia University and New York State Psychiatric Institute
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Browne KC, Stohl M, Bohnert KM, Saxon AJ, Fink DS, Olfson M, Cerda M, Sherman S, Gradus JL, Martins SS, Hasin DS. Prevalence and Correlates of Cannabis Use and Cannabis Use Disorder Among U.S. Veterans: Results From the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III). Am J Psychiatry 2022; 179:26-35. [PMID: 34407625 PMCID: PMC8724447 DOI: 10.1176/appi.ajp.2021.20081202] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE The authors sought to estimate the prevalence of past-12-month and lifetime cannabis use and cannabis use disorder among U.S. veterans; to describe demographic, substance use disorder, and psychiatric disorder correlates of nonmedical cannabis use and cannabis use disorder; and to explore differences in cannabis use and cannabis use disorder prevalence among veterans in states with and without medical marijuana laws. METHODS Participants were 3,119 respondents in the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III) who identified as U.S. veterans. Weighted prevalences were calculated. Logistic regression analyses tested associations of nonmedical cannabis use and cannabis use disorder with demographic and clinical correlates and examined whether prevalence differed by state legalization status. RESULTS The prevalences of any past-12-month cannabis use and cannabis use disorder were 7.3% and 1.8%, respectively. Lifetime prevalences were 32.5% and 5.7%, respectively. Past-12-month and lifetime cannabis use disorder prevalence estimates among nonmedical cannabis users were 24.4% and 17.4%, respectively. Sociodemographic correlates of nonmedical cannabis use and use disorder included younger age, male gender, being unmarried, lower income, and residing in a state with medical marijuana laws. Nonmedical cannabis use and use disorder were associated with most psychiatric and substance use disorders examined. CONCLUSIONS Among veterans, the odds of nonmedical cannabis use and use disorder were elevated among vulnerable subgroups, including those with lower income or psychiatric disorders and among survey participants residing in states with medical marijuana laws. The study findings highlight the need for clinical attention (e.g., screening, assessment) and ongoing monitoring among veterans in the context of increasing legalization of cannabis.
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Affiliation(s)
- Kendall C. Browne
- Center of Excellence in Substance Addiction Treatment and Education, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA,Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Healthcare System, Seattle, WA,Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA
| | - Malki Stohl
- New York State Psychiatric Institute, New York, NY
| | - Kipling M. Bohnert
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI,VA Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI 48109, USA
| | - Andrew J. Saxon
- Center of Excellence in Substance Addiction Treatment and Education, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA,Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA
| | - David S. Fink
- New York State Psychiatric Institute, New York, NY,Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY
| | - Mark Olfson
- New York State Psychiatric Institute, New York, NY,Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY,Department of Psychiatry, Columbia University Medical Center, New York, NY
| | - Magdalena Cerda
- Department of Population Health, New York University, New York, NY
| | - Scott Sherman
- Department of Population Health, New York University, New York, NY
| | | | - Silvia S. Martins
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY
| | - Deborah S. Hasin
- New York State Psychiatric Institute, New York, NY,Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY,Department of Psychiatry, Columbia University Medical Center, New York, NY
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7
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Akbari M, Bahadori MH, Mohammadkhani S, Kolubinski DC, Nikčević AV, Spada MM. A discriminant analysis model of psychosocial predictors of problematic Internet use and cannabis use disorder in university students. Addict Behav Rep 2021; 14:100354. [PMID: 34141856 PMCID: PMC8186557 DOI: 10.1016/j.abrep.2021.100354] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 05/08/2021] [Accepted: 05/20/2021] [Indexed: 12/13/2022] Open
Abstract
Researchers have found similarities and differences between behavioral and drug addictions. The present study was designed to explore which of a series of psychosocial predictors of addictive behaviors could differentiate problematic Internet use (PIU) and Cannabis Use Disorder (CUD) in a sample of University students. A total of 144 participants (76 males, mean age = 23.03 years ± 2.83) were separated into three groups: those presenting with PIU (18 females, Mean age = 22.27 years), those presenting with CUD (22 female, Mean age = 22.73 years), and a control group (28 female, Mean age = 24.04 years). Participants completed the Internet Abusive Use Questionnaire (IAUQ), the Severity of Dependence Scale (SDS), the Multidimensional Scale of Perceived Social Support (MSPSS), the Barratt Impulsiveness Scale-11 (BIS-11), the Multidimensional Distress Tolerance Scale (MDTS), the Emotion Regulation Questionnaire (ERQ), the Metacognitions Questionnaire-30 (MCQ-30), and the Repetitive Thinking Questionnaire-10 (RTQ-10). The classification analysis results showed that 68.8% of the control group, 70.8% of the PIU group, and 81.3% of the CUD group were correctly classified in their respective groups. In addition, the results of the discriminant function analysis showed that there was a significant difference between members of the PIU and CUD groups in the degree of family support (0.45), significant other (0.33), tolerance of physical discomfort (0.30), reappraisal (0.42), and cognitive confidence (0.35). The findings provide evidence that specific psychosocial predictors can discriminate PIU from CUD.
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Affiliation(s)
- Mehdi Akbari
- Department of Clinical Psychology, Faculty of Psychology and Education,
Kharazmi University, Tehran, Iran
| | - Mohammad Hossein Bahadori
- Department of Clinical Psychology, Faculty of Psychology and Education,
Kharazmi University, Tehran, Iran
| | - Shahram Mohammadkhani
- Department of Clinical Psychology, Faculty of Psychology and Education,
Kharazmi University, Tehran, Iran
| | - Daniel C. Kolubinski
- Division of Psychology, School of Applied Sciences, London South Bank
University, London, UK
| | - Ana V. Nikčević
- Department of Psychology, School of Law, Social and Behavioural Sciences,
Kingston University, Kingston-upon- Thames, UK
| | - Marcantonio M. Spada
- Division of Psychology, School of Applied Sciences, London South Bank
University, London, UK
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8
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Kayser RR, Senter MS, Tobet R, Raskin M, Patel S, Simpson HB. Patterns of Cannabis Use Among Individuals with Obsessive-Compulsive Disorder: Results from an Internet Survey. J Obsessive Compuls Relat Disord 2021; 30:100664. [PMID: 34336561 PMCID: PMC8323783 DOI: 10.1016/j.jocrd.2021.100664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Americans increasingly use cannabis, including those with psychiatric disorders. Yet little is known about cannabis use among individuals with obsessive-compulsive disorder (OCD). Thus, we conducted the first survey of cannabis users with OCD. METHODS Adults with OCD (i.e., prior professional diagnosis and/or score above the cutoff on a validated scale) who reported using cannabis were recruited from internet sources to complete a survey querying demographic information, medical/psychiatric history, cannabis use patterns, and perceived cannabis effects. RESULTS Of 1096 survey completers, 601 met inclusion criteria. Inhalation/cannabis flower were the most common method/formulation participants endorsed; most identified using high-potency cannabis products; 42% met criteria for cannabis use disorder. Nearly 90% self-reported using cannabis medicinally, 33.8% had a physician's recommendation, and 29% used specifically to manage OCD symptoms. Most participants reported cannabis improved obsessions/compulsions; those with increased obsession severity perceived less benefit. Finally, most participants were not receiving evidence-based OCD treatment, and the odds of receiving treatment decreased with increased cannabis use. CONCLUSIONS In this survey, participants with OCD reported both subjective benefits and harms from cannabis use. Future research should clarify the risks and benefits of cannabis use to those with OCD and develop treatment models to better support this population.
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Affiliation(s)
- Reilly R Kayser
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
- Research Foundation for Mental Hygiene, New York State Psychiatric Institute, New York, NY
| | - Meredith S Senter
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Rebecca Tobet
- University of Connecticut School of Medicine, Farmington, CT
| | - Marissa Raskin
- Institute for Neuroscience, University of Texas at Austin, Austin, TX
| | - Sapana Patel
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
- Research Foundation for Mental Hygiene, New York State Psychiatric Institute, New York, NY
| | - H Blair Simpson
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
- Research Foundation for Mental Hygiene, New York State Psychiatric Institute, New York, NY
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9
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Martin EL, McRae-Clark AL. Evidence for the Endocannabinoid System as a Therapeutic Target in the Treatment of Cannabis Use Disorder. Curr Addict Rep 2020; 7:545-52. [PMID: 33816054 DOI: 10.1007/s40429-020-00342-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Purpose of Review Cannabis use disorder (CUD) is highly prevalent. Psychotherapy alone is not adequately effective, with few individuals achieving abstinence. Pharmacotherapeutic supplementation may improve efficacy, and the endocannabinoid system presents a target specifically dysregulated by heavy cannabis use. This review compiles current literature evaluating endocannabinoid modulation as a treatment strategy for CUD, with implications for future research. Recent Findings Cannabinoid receptor agonists have been found to reduce cannabis withdrawal symptoms without a notable effect on relapse, and antagonists can produce severe psychiatric symptoms. Fatty acid amide hydrolase inhibitors and cannabidiol demonstrate the most promising efficacy in treating CUD thus far, but research with these compounds is still preliminary. Summary Components of the endocannabinoid system may serve as unique treatment targets with differential efficacy for the treatment of cannabis use disorder as a whole. Further research is needed exploring novel methods for targeting endocannabinoid dysfunction in CUD.
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Blair RJR, Bajaj S, Sherer N, Bashford-Largo J, Zhang R, Aloi J, Hammond C, Lukoff J, Schwartz A, Elowsky J, Tyler P, Filbey FM, Dobbertin M, Blair KS. Alcohol Use Disorder and Cannabis Use Disorder Symptomatology in Adolescents and Aggression: Associations With Recruitment of Neural Regions Implicated in Retaliation. Biol Psychiatry Cogn Neurosci Neuroimaging 2020; 6:536-544. [PMID: 33712378 DOI: 10.1016/j.bpsc.2020.11.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 11/18/2020] [Accepted: 11/22/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Alcohol and cannabis are commonly used by adolescents in the United States. Both alcohol use disorder (AUD) and cannabis use disorder (CUD) have been associated with an increased risk of aggression. One form of aggression seen during retaliation is reactive aggression to social provocation. This study investigated the association between AUD and CUD symptom severity and recruitment of neural regions implicated in retaliation. METHODS In this study, 102 youths aged 13-18 years (67 male; 84 in residential care) completed self-report measures of aggression-related constructs and participated in a retaliation task during functional magnetic resonance imaging to investigate the association between relative severity of AUD/CUD and atypical recruitment of regions implicated in retaliation. RESULTS AUD Identification Test scores were positively associated with irritability and reactive aggression scores. CUD Identification Test scores were positively associated with callous-unemotional traits and both proactive and reactive aggression scores. In functional magnetic resonance imaging analyses, only AUD Identification Test (not CUD Identification Test) scores were associated with an exaggerated recruitment of regions implicated in retaliation (dorsomedial frontal, anterior insula cortices, caudate, and, to a lesser extent, periaqueductal gray). CONCLUSIONS These data suggest that relative severity of AUD is associated with a disinhibited, exaggerated retaliation response that relates to an increased risk for reactive aggression. Similar findings were not related to severity of CUD.
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Affiliation(s)
- R James R Blair
- Center for Neurobehavioral Research, Boys Town National Research Hospital, Boys Town, Nebraska.
| | - Sahil Bajaj
- Center for Neurobehavioral Research, Boys Town National Research Hospital, Boys Town, Nebraska
| | - Noah Sherer
- Department of Biological Sciences, Fordham University, New York City, New York
| | - Johannah Bashford-Largo
- Center for Neurobehavioral Research, Boys Town National Research Hospital, Boys Town, Nebraska
| | - Ru Zhang
- Center for Neurobehavioral Research, Boys Town National Research Hospital, Boys Town, Nebraska
| | - Joseph Aloi
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana
| | - Chris Hammond
- Department of Psychiatry, Johns Hopkins University, Baltimore, Maryland
| | - Jennie Lukoff
- Center for Neurobehavioral Research, Boys Town National Research Hospital, Boys Town, Nebraska
| | - Amanda Schwartz
- Center for Neurobehavioral Research, Boys Town National Research Hospital, Boys Town, Nebraska
| | - Jaimie Elowsky
- Center for Neurobehavioral Research, Boys Town National Research Hospital, Boys Town, Nebraska
| | - Patrick Tyler
- Child and Family Translational Research Center, Boys Town National Research Hospital, Boys Town, Nebraska
| | - Francesca M Filbey
- Center for BrainHealth, School of Behavioral and Brain Sciences, University of Texas at Dallas, Dallas, Texas
| | - Matthew Dobbertin
- Center for Neurobehavioral Research, Boys Town National Research Hospital, Boys Town, Nebraska
| | - Karina S Blair
- Center for Neurobehavioral Research, Boys Town National Research Hospital, Boys Town, Nebraska
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11
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Hasin DS, Shmulewitz D, Cerdá M, Keyes KM, Olfson M, Sarvet AL, Wall MM. U.S. Adults With Pain, a Group Increasingly Vulnerable to Nonmedical Cannabis Use and Cannabis Use Disorder: 2001-2002 and 2012-2013. Am J Psychiatry 2020; 177:611-618. [PMID: 31964162 PMCID: PMC7332392 DOI: 10.1176/appi.ajp.2019.19030284] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Given changes in U.S. marijuana laws, attitudes, and use patterns, individuals with pain may be an emerging group at risk for nonmedical cannabis use and cannabis use disorder. The authors examined differences in the prevalence of nonmedical cannabis use and cannabis use disorder among U.S. adults with and without pain, as well as whether these differences widened over time. METHODS Data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC, 2001-2002; N=43,093) and NESARC-III (2012-2013; N=36,309) were analyzed using logistic regression. Risk differences of past-year nonmedical cannabis use, frequent (at least three times a week) nonmedical use, and DSM-IV cannabis use disorder were estimated for groups with and without moderate to severe pain, and these risk differences were tested for change over time. RESULTS Any nonmedical cannabis use was more prevalent in respondents with than without pain (2001-2002: 5.15% compared with 3.74%; 2012-2013: 12.42% compared with 9.02%), a risk difference significantly greater in the 2012-2013 data than in the 2001-2002 data. The prevalence of frequent nonmedical cannabis use did not differ by pain status in the 2001-2002 survey, but was significantly more prevalent in those with than without pain in the 2012-2013 survey (5.03% compared with 3.45%). Cannabis use disorder was more prevalent in respondents with than without pain (2001-2002: 1.77% compared with 1.35%; 2012-2013: 4.18% compared with 2.74%), a significantly greater risk difference in the data from 2012-2013 than from 2001-2002. CONCLUSIONS The results suggest that adults with pain are a group increasingly vulnerable to adverse cannabis use outcomes, warranting clinical and public health attention to this risk. Psychiatrists and other health care providers treating patients with pain should monitor such patients for signs and symptoms of cannabis use disorder.
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Affiliation(s)
- Deborah S. Hasin
- NewYork State Psychiatric Institute, NewYork; Department of Psychiatry, Columbia University Medical Center, New York; Department of Epidemiology, Columbia University Mailman School of Public Health, New York
| | - Dvora Shmulewitz
- NewYork State Psychiatric Institute, New York; Department of Psychiatry, Columbia University Medical Center, New York; Department of Epidemiology, Columbia University Mailman School of Public Health, New York
| | - Magdalena Cerdá
- Columbia University Mailman School of Public Health, New York; Department of Population Health, New York University, New York
| | - Katherine M. Keyes
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York
| | - Mark Olfson
- NewYork State Psychiatric Institute, New York; Department of Psychiatry, Columbia University Medical Center, New York, Department of Epidemiology
| | - Aaron L. Sarvet
- Department of Epidemiology, Harvard University School of Public Health, Boston
| | - Melanie M. Wall
- NewYork State Psychiatric Institute, New York; Department of Psychiatry, Columbia University Medical Center, New York; Department of Biostatistics
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Moss HB, Ge S, Trager E, Saavedra M, Yau M, Ijeaku I, Deas D. Risk for Substance Use Disorders in young adulthood: Associations with developmental experiences of homelessness, foster care, and adverse childhood experiences. Compr Psychiatry 2020; 100:152175. [PMID: 32345436 DOI: 10.1016/j.comppsych.2020.152175] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 04/03/2020] [Accepted: 04/09/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Multiple developmental risk factors for Substance Use Disorders (SUDs) during young adulthood have been identified. In this investigation, we examined the impact of homelessness, foster care, and adverse childhood experiences (ACEs) prior to 12th grade on the development of three common SUDs during young adulthood-Alcohol Use Disorder (AUD), Tobacco Use Disorder (TUD) and Cannabis Use Disorder (CUD). Our hypothesis was that while both homelessness and ACEs are significant risk factors for young adult SUDs, foster care involvement might convey protection. METHODS Using nationally representative data from the National Longitudinal Study of Adolescent to Adult Health, measures of ACEs were derived from the CDC-Kaiser ACE study, and DSM-V SUD diagnoses were derived from items originally based on DSM-IV. SUD diagnoses were binned into "mild", "moderate", and "severe" groupings. Survey-based logistic models were used to estimate risks of SUDs while controlling for demographics. RESULTS The results suggest that the experience of homelessness prior to 12th grade in addition to ACEs were significantly associated with the development in young adulthood of the most severe forms of AUD and TUD and all severity levels of CUD. Foster care was not associated with either risk or protection from SUDs. CONCLUSIONS The experience of homelessness during development may be viewed as another detrimental ACE that is a risk factor for the most common SUDs in young adulthood. Given the magnitude of the current epidemic of homelessness in the U.S., these results should raise substantial concern.
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Affiliation(s)
- Howard B Moss
- University of California at Riverside School of Medicine, United States of America.
| | - Shaokui Ge
- University of California at Riverside School of Medicine, United States of America
| | - Evan Trager
- Stanford University School of Medicine, United States of America
| | - Madeline Saavedra
- University of California at Riverside School of Medicine, United States of America
| | - Margaret Yau
- University of California at Riverside School of Medicine, United States of America
| | - Ijeoma Ijeaku
- University of California at Riverside School of Medicine, United States of America
| | - Deborah Deas
- University of California at Riverside School of Medicine, United States of America
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Affiliation(s)
- Kathleen T Brady
- Department of Psychiatry, Medical University of South Carolina, Charleston
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14
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Abstract
Since antiquity, Cannabis has provoked enormous intrigue for its potential medicinal properties as well as for its unique pharmacological effects. The elucidation of its major cannabinoid constituents, Δ9-tetrahydrocannabinol (THC) and cannabidiol (CBD), led to the synthesis of new cannabinoids (termed synthetic cannabinoids) to understand the mechanisms underlying the pharmacology of Cannabis. These pharmacological tools were instrumental in the ultimate discovery of the endogenous cannabinoid system, which consists of CB1 and CB2 cannabinoid receptors and endogenously produced ligands (endocannabinoids), which bind and activate both cannabinoid receptors. CB1 receptors mediate the cannabimimetic effects of THC and are highly expressed on presynaptic neurons in the nervous system, where they modulate neurotransmitter release. In contrast, CB2 receptors are primarily expressed on immune cells. The endocannabinoids are tightly regulated by biosynthetic and hydrolytic enzymes. Accordingly, the endocannabinoid system plays a modulatory role in many physiological processes, thereby generating many promising therapeutic targets. An unintended consequence of this research was the emergence of synthetic cannabinoids sold for human consumption to circumvent federal laws banning Cannabis use. Here, we describe research that led to the discovery of the endogenous cannabinoid system and show how knowledge of this system benefitted as well as unintentionally harmed human health.
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Affiliation(s)
- Lesley D Schurman
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, USA
| | - Dai Lu
- Rangel College of Pharmacy, Health Science Center, Texas A&M University, Kingsville, TX, USA
| | - Debra A Kendall
- Department of Pharmaceutical Sciences, University of Connecticut, Storrs, CT, USA
| | - Allyn C Howlett
- Department of Physiology and Pharmacology and Center for Research on Substance Use and Addiction, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Aron H Lichtman
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, USA.
- Department of Medicinal Chemistry, Virginia Commonwealth University, Richmond, VA, USA.
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Stevens JE, Steinley D, McDowell YE, Boness CL, Trull TJ, Martin CS, Sher KJ. Toward more efficient diagnostic criteria sets and rules: The use of optimization approaches in addiction science. Addict Behav 2019; 94:57-64. [PMID: 30777336 PMCID: PMC6544486 DOI: 10.1016/j.addbeh.2019.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 01/24/2019] [Accepted: 02/04/2019] [Indexed: 11/26/2022]
Abstract
Psychiatric diagnostic systems, such as The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), use expert consensus to determine diagnostic criteria sets and rules (DCSRs), rather than exploiting empirical techniques to arrive at optimal solutions (OS). Our project utilizes complete enumeration (i.e., generating all possible subsets of item combinations A and B with all possible thresholds, T) to evaluate all possible DCSRs given a set of relevant diagnostic data. This method yields the entire population distribution of diagnostic classifications (i.e., diagnosis of the disorder versus no diagnosis) produced by a set of dichotomous predictors (i.e., diagnostic criteria). Once unique sets are enumerated, optimization on some predefined correlate or predictor will maximally separate diagnostic groups on one or more, disorder-specific "outcome" criteria. We used this approach to illustrate how to create a common Substance Use Disorder (SUD) DCSR that is applicable to multiple substances. We demonstrate the utility of this approach with respect to alcohol use disorder and Cannabis Use Disorder (CUD) using DSM-5 criteria as input variables. The optimal SUD solution with a moderate or above severity grading included four criteria (i.e. 1) having a strong urge or craving for the substance (CR), 2) failure to fulfill major role obligations at work school or home (FF), 3) continued use of the substance despite social or interpersonal problems caused by the substance use (SI) and 4) physically hazardous use (HU)) with a diagnostic threshold of two. The derived DCSR was validated with known correlates of SUD and performed as well as DSM-5. Our findings illustrate the value of using an empirical approach to what is typically a subjective process of choosing criteria and algorithms that is prone to bias. The optimization of diagnostic criteria can reduce criteria set sizes, resulting in decreased research, clinician, and patient burden.
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Affiliation(s)
- Jordan E Stevens
- Department of Psychological Science, University of Missouri, United States.
| | - Douglas Steinley
- Department of Psychological Science, University of Missouri, United States
| | - Yoanna E McDowell
- Department of Psychological Science, University of Missouri, United States
| | - Cassandra L Boness
- Department of Psychological Science, University of Missouri, United States
| | - Timothy J Trull
- Department of Psychological Science, University of Missouri, United States
| | | | - Kenneth J Sher
- Department of Psychological Science, University of Missouri, United States
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Aloi J, Blair KS, Crum KI, Meffert H, White SF, Tyler PM, Thornton LC, Mobley AM, Killanin AD, Adams KO, Filbey F, Pope K, Blair RJR. Adolescents show differential dysfunctions related to Alcohol and Cannabis Use Disorder severity in emotion and executive attention neuro-circuitries. Neuroimage Clin 2018; 19:782-792. [PMID: 29988822 PMCID: PMC6031867 DOI: 10.1016/j.nicl.2018.06.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 04/27/2018] [Accepted: 06/04/2018] [Indexed: 11/20/2022]
Abstract
Alcohol and cannabis are two substances that are commonly abused by adolescents in the United States and which, when abused, are associated with negative medical and psychiatric outcomes across the lifespan. These negative psychiatric outcomes may reflect the detrimental impact of substance abuse on neural systems mediating emotion processing and executive attention. However, work indicative of this has mostly been conducted either in animal models or adults with Alcohol and/or Cannabis Use Disorder (AUD/CUD). Little work has been conducted in adolescent patients. In this study, we used the Affective Stroop task to examine the relationship in 82 adolescents between AUD and/or CUD symptom severity and the functional integrity of neural systems mediating emotional processing and executive attention. We found that AUD symptom severity was positively related to amygdala responsiveness to emotional stimuli and negatively related to responsiveness within regions implicated in executive attention and response control (i.e., dorsolateral prefrontal cortex, anterior cingulate cortex, precuneus) as a function of task performance. In contrast, CUD symptom severity was unrelated to amygdala responsiveness but positively related to responsiveness within regions including precuneus, posterior cingulate cortex, and inferior parietal lobule as a function of task performance. These data suggest differential impacts of alcohol and cannabis abuse on the adolescent brain. Alcohol and cannabis are the most widely abused substances by adolescents. AUDIT scores are related to amygdala hyperactivity to emotional stimuli. AUDIT scores are related to hypoactivity in executive attention neuro-circuitry. CUDIT scores are related to hyperactivity in executive attention neuro-circuitry.
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Affiliation(s)
- Joseph Aloi
- Center for Neurobehavioral Research, Boys Town National Research Hospital, Boys Town, NE, United States; Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE, United States.
| | - Karina S Blair
- Center for Neurobehavioral Research, Boys Town National Research Hospital, Boys Town, NE, United States
| | - Kathleen I Crum
- Center for Neurobehavioral Research, Boys Town National Research Hospital, Boys Town, NE, United States
| | - Harma Meffert
- Center for Neurobehavioral Research, Boys Town National Research Hospital, Boys Town, NE, United States
| | - Stuart F White
- Center for Neurobehavioral Research, Boys Town National Research Hospital, Boys Town, NE, United States
| | - Patrick M Tyler
- Center for Neurobehavioral Research, Boys Town National Research Hospital, Boys Town, NE, United States
| | - Laura C Thornton
- Center for Neurobehavioral Research, Boys Town National Research Hospital, Boys Town, NE, United States
| | - Alita M Mobley
- Center for Neurobehavioral Research, Boys Town National Research Hospital, Boys Town, NE, United States
| | - Abraham D Killanin
- Center for Neurobehavioral Research, Boys Town National Research Hospital, Boys Town, NE, United States
| | - Kathryn O Adams
- Center for Neurobehavioral Research, Boys Town National Research Hospital, Boys Town, NE, United States
| | - Francesca Filbey
- Center for BrainHealth, School of Behavioral and Brain Sciences, University of Texas at Dallas, Dallas, TX, United States
| | - Kayla Pope
- Center for Neurobehavioral Research, Boys Town National Research Hospital, Boys Town, NE, United States; Department of Psychiatry, University of Nebraska Medical Center, Omaha, NE, United States; Department of Psychiatry, Creighton University, Omaha, NE, United States
| | - R James R Blair
- Center for Neurobehavioral Research, Boys Town National Research Hospital, Boys Town, NE, United States
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Metrik J, Gunn RL, Jackson KM, Sokolovsky AW, Borsari B. Daily Patterns of Marijuana and Alcohol Co-Use Among Individuals with Alcohol and Cannabis Use Disorders. Alcohol Clin Exp Res 2018; 42:1096-1104. [PMID: 29656401 PMCID: PMC5984172 DOI: 10.1111/acer.13639] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 04/04/2018] [Indexed: 01/20/2023]
Abstract
BACKGROUND The study aims were to examine daily associations between marijuana and alcohol use and the extent to which the association differs as a function of cannabis use disorder (CUD) and/or alcohol use disorder (AUD) diagnosis. METHODS Timeline Followback interview data was collected in a study of veterans (N = 127) recruited from a Veterans Affairs hospital who reported at least 1 day of co-use of marijuana and alcohol in the past 180 days (22,860 observations). Participants reported 40% marijuana use days, 28% drinking days, with 37% meeting DSM-5 criteria for CUD, 40% for AUD, and 15% for both. Use of marijuana on a given day was used to predict a 3-level gender-adjusted drinking variable (heavy: ≥5 (men)/4 (women) drinks; moderate: 1 to 4/3 drinks; or none: 0 drinks). A categorical 4-level variable (no diagnosis, AUD, CUD, or both) was tested as a moderator of the marijuana-alcohol relationship. RESULTS Multilevel modeling analyses demonstrated that participants were more likely to drink heavily compared to moderately (OR = 2.34) and moderately compared to not drinking (OR = 1.61) on marijuana use days relative to nonuse days. On marijuana use days, those with AUD and those with AUD + CUD were more likely to drink heavily (OR = 1.91; OR = 2.51, respectively), but those with CUD were less likely to drink heavily (OR = 0.32) compared to moderately, nonsignificant differences between any versus moderate drinking in interaction models. CONCLUSIONS Heavy drinking occurs on days when marijuana is also used. This association is particularly evident in individuals diagnosed with both AUD and CUD and AUDs alone but not in those with only CUDs. Findings suggest that alcohol interventions may need to specifically address marijuana use as a risk factor for heavy drinking and AUD.
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Affiliation(s)
- Jane Metrik
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, Providence, RI, 02903, USA
- Providence VA Medical Center, Providence, RI, 02908, USA
| | - Rachel L. Gunn
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, Providence, RI, 02903, USA
| | - Kristina M. Jackson
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, Providence, RI, 02903, USA
| | - Alexander W. Sokolovsky
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, Providence, RI, 02903, USA
| | - Brian Borsari
- San Francisco VA Health Care System, San Francisco, CA, 94121, USA
- Department of Psychiatry, University of California – San Francisco, San Francisco, CA, 94103, USA
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Abstract
Purpose of review The present review will provide an overview of the neurobiology, epidemiology, clinical impact, and treatment of cannabis use disorder (CUD) in mood disorders. Recent findings Patients with mood disorders including major depressive disorder (MDD) and bipolar disorder (BD) have higher rates of cannabis use, and CUD compared to the general population. Reasons for this association are not clear, nor are the putative therapeutic effects of cannabis use, or its components delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD), in these illnesses. The evidence surrounding treatments for patients with this comorbidity is lacking, with more support for psychotherapeutic treatments compared with pharmacological treatments. Summary Cannabis use may be associated mood disorders, but more research is needed to increase our understanding of the mechanisms for this association, and to develop more effective treatments for this comorbidity.
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Abstract
Purpose of the Review Cannabis is the most commonly used illicit substance worldwide. In recent decades, highly concentrated products have flooded the market, and prevalence rates have increased. Gender differences exist in cannabis use, as men have higher prevalence of both cannabis use and cannabis use disorder (CUD), while women progress more rapidly from first use to CUD. This paper reviews findings from preclinical and human studies examining the sex-specific neurobiological underpinnings of cannabis use and CUD, and associations with psychiatric symptoms. Recent Findings Sex differences exist in the endocannabinoid system, in cannabis exposure effects on brain structure and function, and in the co-occurrence of cannabis use with symptoms of anxiety, depression and schizophrenia. In female cannabis users, anxiety symptoms correlate with larger amygdala volume and social anxiety disorder symptoms correlate with CUD symptoms. Female cannabis users are reported to be especially vulnerable to earlier onset of schizophrenia, and mixed trends emerge in the correlation of depressive symptoms with cannabis exposure in females and males. Summary As prevalence of cannabis use may continue to increase given the shifting policy landscape regarding marijuana laws, understanding the neurobiological mechanisms of cannabis exposure in females and males is key. Examining these mechanisms may help inform future research on sex-specific pharmacological and behavioral interventions for women and men with high-risk cannabis use, comorbid psychiatric disease, and CUD.
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Abstract
PURPOSE OF REVIEW This report provides an updated overview of pre-clinical and clinical research on the etiology and biological substrates of the cannabis withdrawal syndrome. RECENT FINDINGS Long-term cannabis use is associated with downregulation of type-1 cannabinoid receptors (CB1). Reduced CB1 receptor density is related to increased withdrawal during early abstinence, and the reduction in CB1 receptor density reverses with extended abstinence. Females have been shown to have increased rate and severity of a subset of cannabis withdrawal symptoms compared with men. SUMMARY Recent studies have extended knowledge of the biological processes and individual difference variables that influence cannabis withdrawal. However, caveats include small sample sizes in clinical studies, participant samples that are predominantly male, and limited examinations of endocannabinoids, enzymes that degrade endocannabinoids, negative allosteric modulators, and other neurobiological systems that may directly impact cannabis withdrawal symptom expression.
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Affiliation(s)
- Nicolas J. Schlienz
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21224
| | - Alan J. Budney
- Department of Psychiatry, Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth, Lebanon, NH 03766
| | - Dustin C. Lee
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21224
| | - Ryan Vandrey
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21224
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