Cannabis: evolution of a withdrawal model - 2017 VAADA Conference
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Mal Doreian considers the changing attitudes towards cannabis withdrawal and how to manage it, with particular reference to the emergence of higher THC strains and synthetic products. He presents findings from a ReGen review and their implications for agency practice.
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Cannabis: evolution of a withdrawal model - 2017 VAADA Conference
- 1. Cannabis Evolution of a withdrawal model
- 2. Cannabis: Evolution of a withdrawal model • Dependence inducing? • Cannabis withdrawal? • What does it look like? • How do we deal with it?
- 3. Cannabis: Evolution of a withdrawal model • Organic/ home grown • Hydroponic: indoor grown, nutrients, pesticides • Skunk: selectively bred high potency • Synthetic: THC analogues added to vegetable material
- 7. Cannabis: Evolution of a withdrawal model “Although most people are tolerant to the repeated use of cannabis, there are those who develop a pattern of cannabis dependence, made even more difficult by withdrawal symptoms.“ Psychology Dictionary: What is cannabis dependence?
- 8. Cannabis: Evolution of a withdrawal model Prior to the publication of DSM 5, there was not enough scientific evidence to ascribe these types of effects to withdrawal from the use of marijuana or hashish. However, times have changed, and the APA now officially recognizes the fact that at least some of the people who withdraw from these substances meet the mental health criteria for substance withdrawal. Doctors can now use the cannabis withdrawal diagnosis to identify these people. Psychology Dictionary: What is cannabis dependence?
- 10. Cannabis: Evolution of a withdrawal model DSM 5 292.0 diagnostic criteria: A: Cessation of use that has been heavy and prolonged B: 3 of the following signs and symptoms develop within 1 week of cessation 1. Irritability, anger or aggression 2. Nervousness or anxiety 3. Sleep difficulty 4. Decreased appetite or weight loss 5. Restlessness 6. Decreased mood 7. At least one of the following: abdo pain, shakes, sweating, fever, chills, headache C: Signs, symptoms of Crit B cause significant distress/ impairment in social, occupational or other areas of functioning D: Signs/ symptoms not attributable to other causes.
- 11. Cannabis: Evolution of a withdrawal model Audit of Clinical Practice • Withdrawal • Synthetic v organic • Modified NCPIC Scale • 7/7
- 13. Cannabis: Evolution of a withdrawal model Audit of Clinical Practice • N =28 • Mainly inpatient • 2/3 male • Under 22 • Single substance dependence
- 14. Cannabis: Evolution of a withdrawal model • Audit of Clinical Practice • Linear decrease in symptom severity • Withdrawal lasts longer than 6 days
- 16. Cannabis: Evolution of a withdrawal model Most common symptoms • Loss of appetite • Sleep disturbance • Low mood • Agitation • Cravings • Vivid dreams
- 17. Cannabis: Evolution of a withdrawal model • Pragmatic • Client centred and driven • Staged reduction • Win-win paradox • Motivational
- 18. Cannabis: Evolution of a withdrawal model • Diary • Negotiated reduction • Review • Further reduction • Cessation • Monitoring • Post withdrawal plan
- 19. Diary
- 20. Cannabis: Evolution of a withdrawal model • Monitored: NCPIC Cannabis Withdrawal Scale • Plot severity, progress • Gauge adequacy of medication • Nutrition • Hydration
- 21. Cannabis: Evolution of a withdrawal model Elements • Commitment • Diary • Pragmatic reduction • Frequent review • Cessation • Medication (Turning Point guidelines) • Symptom monitoring • Reinforcement and encouragement • Post withdrawal plan
- 23. Cannabis: Evolution of a withdrawal model • Environment/ lifestyle • Sleep pattern (30/7+) • Dispose of drugs, paraphernalia • Alternatives • Social • Non compatible alternatives
- 24. Cannabis: Evolution of a withdrawal model Summary • As cannabis has evolved so has our understanding of cannabis withdrawal • It’s in the DSM 5 so it must be real • Manifests as a cluster of symptoms of variable type and intensity • No specific medication • Syndrome lasts longer than funded inpatient episode • Lends itself to step up/ down • Non medical techniques successful in aiding clients decrease/ cease use = The power of the diary.
Editor's Notes
- A few decades ago, people there was a lot of doubt as to whether or not you could become dependent on cannabis. And if you couldn’t become dependent, you wouldn’t go through withdrawal. Now it seems we do believe if enough is used for long enough people can become dependent on cannabis, and therefore sudden cessation or dramatic reduction will result in withdrawal. But what does said withdrawal look like, and how do we deal with it and assist people going through it?
- Cannabis aint what it used to be.
- Back in my youth we’d grow a plant among the tomatoes, sew the seeds on September 1 each year. Raise them like they were our children. I don’t know why they’d be in with the tomatoes, they didn’t look like them, but it was accepted that’s where you did it.
- Then things became more sophisticated and growing moved indoors with 24 hr light, constant high nutrition watering, selective breeding and cloning so people could grow multiple higher quality crops all through the year. The selective breeding lead to higher potency strains with names like skunk, great white, Panama red, Columbian Gold etc.
- But, as the law tried to contain what was happening, as inevitably occurs with prohibition, people found a way around it. So we now have synth, where an ever changing array of synthesized THC analogues are absorbed into vegetable matter and sold under names like Blue Lotus and Kronic in Sex Shops and other places. Being analogues they seek to evade the governing laws becauses they don’t contain delta 9 tetrahydrocannabinol, like what I used to grow in the vegie patch. But at least I knew what was in it and what would happen when I smoked it.
- So this statement from the Psychology Dictionary is a good summary of the situation today: “Although most people are tolerant to the repeated use of cannabis, there are those who develop a pattern of cannabis dependence, made even more difficult by withdrawal symptoms.“ We probably all know people who are able to smoke cannabis and still lead highly functional and productive lives. As with most things, there is a spectrum of users, and it’s only those at the extreme end who develop dependence and are at risk of experiencing the discomfort of withdrawal.
- Read statement So the diagnosis is only relatively recent. 14% of people presenting to ReGen for assistance cite cannabis as their primary drug, making it the third most troublesome substance for out clientele.
- So the publication of the DSM 5 has made a difference to how we view problematic cannabis smoking,
- So these are the diagnostic criteria for cannabis withdrawal as seen in the DSM 5. Read them out
- The world of psychoactive drugs is a fluid one, constantly changing and evolving due to a number of pressures. The state of play today is we se people smoking mostly high potency hydroponic cannabis or synthesized cannabinoids. Seeing as we only recently decided cannabis withdraw was a clinical issue worthy of treatment, we had a sitation requiring a fleshing out of the knowledge base. There is not a lot of clinical guidance for the treatment of cannabis withdrawal. We tend to revert back to the default universal withdrawal position of treating uncomfortable withdrawal symptoms with diazepam. The advent of synthetic, and people presenting for assistance to withdraw from Blue Lotus left us in a bit of a quandary. What did we know about it? We decided to try to learn. Our inpatient model is to treat synthetic cannabis withdrawal as we do organic, due to a lack of any real evidence supporting an alternative method. We decided to run a 6 month Audit of Clinical Practice to compare organic withdrawal to synthetic, se what was h same and what wasn’t, what worked and what didn’t and try to learn what to look out for.
- We used this modified 10 day version of the NCPIC Cannabis Withdrawal Scale. Prior to commencing the Audit, we had a strong run of people presenting with issues from Synth. For the next 6 months we got 1. But we did get 28 admissions for organic cannabis withdrawal. So even though we were unable to compare one to the other, we able to look at the data for patterns and see what it showed us.
- The Audit data came mainly from Williams House, our Youth Withdrawal Unit in Coburg. To be included in the study clients had to be single substance dependent. We don’t pretend for 1 moment that this is a formal research project able to stand up to the rigors of more elaborate and better designed studies. We simply collected the withdrawal scales of clients withdrawing from cannabis over a 6 month period to see if we could learn anything.
- What we learned was that significant discomfort existed for this group. It was higher in the initial stages and trailed off in a relatively linear fashion over the next week. As most people left early on day 7, we were only able to collect 6 days of data. It was also evident though, that there were withdrawal symptoms still present when clients are discharged from the unit after completion of their week long funded stay. This would lend itself to a step down model, where non residential services support the client complete the withdrawal on discharge from the inpatient unit.
- This slide is more a statement about my discomfort with the abandonment of the hand drawn in favour of the computer generated, but it also shows the average score (of a possible 190) of clients through their stay. With a gender split above. 62/190 day 1, still 48/190 on discharge, so not a huge decrease.
- There are 19 symptoms listed on the NCPIC. Loss of appetite had the consistently highest score, followed by sleep disturbance, low mood, agitation, cravings and vivid dreams. There were large variations in the symptoms and it was difficult to definte a typical cannabis withdrawal syndrome.
- We used what we learned from the Audit and our experience in dealing with problematic cannabis use over the years to develop a model we used for homebased withdrawal. Homebased withdrawal can have a role for either the complete withdrawal episode, as step up to help the client reduce intake levels to an amount the inpatient withdrawal considers manageable and as step down to complete withdrawal after an inpatient stay. Primarily, the way we deal with it is pragmatic with a pace that is driven by the client and decided upon by the client, usually occurring in staged reduction rather than an abrupt stop, producing a somewhat paradoxical win – win situation for the client and is based on the consept that an increased awareness will motivate the client to change in a snowballing fashion. That probably makes no sense at all, so let me explain.
- The crux of the withdrawal technique is not medication. There is a lack of clear medical guidelines with no specific pharmacotherapy. The unpredictable pattern or collection of symptoms emphasise that another approach is warranted. So we use a diary. We ask the client to keep a diary for the up to a week so we can get a clear picture of the level and pattern of use. The diary is crucial and needs to be accurate. Without it we won’t be able to continue. Once we have the raw data from the diary we use simply maths to move forward. The reality is that if someone is smoking all day every day, they are not getting what they want anyway. They would be so used to the constant effects of cannabis that they will have developed a tolerance and adapted to it, and won’t really be experiencing the high they seek when they use. So, we find out when the client gets up and when they go to sleep, so how many hours they are awake. We divide the total number of bongs or joints by the number or waking hours. Eg: if the client is smoking 100 bongs per day and is awake for 16 hrs, they are smoking 6.25 bongs per hour, or a bit more frequently than every 10 minutes. If we increase the gap between bongs to just 15 minutes, we reduce their intake to 64 per day, a massive decrease. The client still gets to smoke, but learns some level of control that they may not have had before. They save money, smoke less tobacco. A few days later this process is repeated. Increasing the gap to every 20 minutes, drops it to 48 bongs a day. And so it continues. Though the client is praised and encouraged, the next step is taken when they client agrees to it.
- An example of a genuine client diary . Within a week, this client reuced from 13 joints a day to 8 using this technique. They delayed their first smoke to later in the day, put some large gaps between one and the next. The client was proud of what they had done, so proud that they began to realise that they could make significant modifications to their pattern of use. They also began to experience being a little less foggy, got an enhanced effect from what they did use. It became self perpetuating. The client was admitted to the inpatient unit. for cessation.
- With this method went daily visiting or phone monitoring., using the NCPIC scale. This allows us to monitor the progression of the withdrawal, how bad and which symptoms the clientwas experiencing. If they need medication, how they are eating and drinking and strategies such as grazing to help with issues of hydration and nutrition, which we learned from the audit of clinical practice are the most likely
- So the elements fo this model are:
- We still use these tired old Turning Point Prescribing Guidelines, which have been around forever, though updated. We photocopy the cannabis section and give it to th GP.It’s mainly diazepam and symptomatics. Apart from being old, they don’t cover a lot of the drugs we deal with now and are sorely in need of rewriting.
- Other elements to consider are environment and lifestyle. Computer games Nocturnal Smash the bong Something else realistic to do Non smoking people to mix with Start doing things you can’t do if you’re smoking Supportive counselling, SMART Recovery etc.