State of the art treatments for cannabis dependence.

The treatment of cannabis dependence can be viewed as a cup half empty or half full. On the one hand, few people who might benefit from treatment actually receive it. Among those who undergo treatment in randomized trials, long-term abstinence is achieved by fewer than 20%. Moderate use goals have been associated with decreases in consequences, but the differential impact of such goals on the long-term course of cannabis dependence is unknown. Optimal duration of treatment is unclear, and certain populations, particularly patients with co-occurring disorders, have not been studied adequately. Twelve-step programs are low cost, effective for other substance use disorders, and readily available in most regions of the world. However, their role and efficacy in cannabis dependence has not been examined. Finally, effective pharmacologic treatments are under development, but none have yet been firmly established. On the other hand, psychotherapeutic strategies used to treat other substance use disorders can be effective for cannabis dependence. A recent meta-analysis of psychosocial interventions for illicit substance use disorders found that treatments for cannabis dependence had comparatively larger effect sizes than treatments for other substance use disorders. Combination therapies have proven most effective, particularly those that begin with a motivational intervention, utilize incentives to enhance the commitment to change, and teach behavioral and cognitive copings skills to prevent relapse. Among adolescents, family engagement and collaboration with community stakeholders adds substantial value. Although only 9% of cannabis users develop cannabis dependence, the volume of people who smoke cannabis ensures that the total number of people in need of help is larger than the capacity of substance abuse specialty services. Thus, although efforts to refine and improve the efficacy of treatment interventions continue, innovations that increase the availability and accessibility of treatment are also needed. Computer- and phone-based interventions, social media, and brief interventions that can be implemented in primary care settings are areas that may hold promise for reaching at-risk populations. Adolescents and persons with co-occurring mental illness are at particularly high risk of cannabis dependence, and may suffer disproportionately from cannabis’s adverse effects. As in the treatment of other substance use disorders, there is a need for a continuing care model with long-term follow-up that extends past the periods typically evaluated in treatment studies. Additionally, there is a need for further investigation of genetic underpinnings and endophenotypes underlying cannabis dependence to identify neurobiological mechanisms for targeted intervention. One benefit of the societal focus on cannabis has been a prominent increase in research covering everything from the basic science to public health impact of cannabis. Over the next decade, physicians who provide treatment for individuals with cannabis dependence are likely to see their armamentarium of effective interventions expand, to the ultimate betterment of patients, their families, and society at large.