Harbor:Cannabis Abuse

Treatment Options

Cannabis Use Disorder (CUD)

  • N-Acetyl Cysteine (NAC)
    • 600 mg PO BID x 3 days, then 1200 mg PO BID x4d, then 1800 mg PO BID for weeks 2-8
  • Gabapentin
    • day 1: one 300 mg capsule in the evening; day 2: one 300 mg capsule in the morning and evening; day 3: one 300 mg capsule in the morning, at midday, and in the evening; day 4: one 300 mg capsule in the morning and at midday and two 300 mg capsules in the evening. Subjects maintained the 1200 mg/day dose until week 11.
    • Can start 300mg TID prn anxiety or standing and titrate to 900mg TID prn anxiety as tolerated if no contraindications like renal insufficiency or falls.
  • Naltrexone: 50 mg PO QD X 12w or 380 mg IM monthly
    • Contraindications: Liver Enzymes 5X normal or greater
  • Amitriptyline: 25 mg PO qhs x 1 week, 50 mg PO qhs X 1 week, 75-100 mg PO QHS

Cannabis Hyperemesis

  • Haloperidol 0.05-0.1 mg/kg IV/IM
  • Droperidol 0.625 mg/kg IV/IM
  • Olanzapine for refractory cases - 5mg IM
  • Capsaicin cream
  • Consider PPI, diphenhydramine, ondansetron, lorazepam 0.025-0.02 mg/kg/dose

Cannabis Withdrawal Syndrome

  • Definition: At least 3 within 1 week of cessation (irritability, nervousness/ anxiety, sleep difficulty, decreased appetite or weight loss, restlessness, depressed mood, somatic sx causing significant discomfort)
    • Gabapentin
      • day 1: one 300 mg capsule in the evening; day 2: one 300 mg capsule in the morning and evening; day 3: one 300 mg capsule in the morning, at midday, and in the evening; day 4: one 300 mg capsule in the morning and at midday and two 300 mg capsules in the evening. Subjects maintained the 1200 mg/day dose until week 11.
    • Amitriptyline: Dose 25 mg PO qhs x 1 week, 50 mg PO qhs X 1 week, 75-100 mg PO QHS
      • Potential adjunctive medications: ondansetron, clonidine

Limited Evidence

  • NAC: Two RCTs have examined NAC for CUD
    • A RCT in treatment- seeking adolescents with CUD ages 15–21 (N = 116) examined CM plus NAC 2400 mg/day for 8 weeks. Intent-to-treat analyses showed greater than twofold odds of bioverified cannabis abstinence in the NAC group vs. placebo at study end (odds ratio = 2.4, 95%, CI = 1.1–5.2).
    • A similar RCT by the same team with adults with CUD found that NAC 2400 mg/day for 12 weeks did not differ from placebo in cannabis craving or use.
      • Herbst ED, Pennington DL, Borsari B, Manuel J, Yalch M, Alcid E, Martinez Rivas M, Delacruz J, Rossi N, Garcia B, Wong N, Batki SL. N-acetylcysteine for smoking cessation among dual users of tobacco and cannabis: Protocol and rationale for a randomized controlled trial. Contemp Clin Trials. 2023 Aug;131:107250. doi: 10.1016/j.cct.2023.107250. Epub 2023 Jun 2. PMID: 37271412; PMCID: PMC10847050.
  • Gabapentin
    • Mason BJ, Crean R, Goodell V, Light JM, Quello S, Shadan F, et al. A proof-of-concept randomized controlled study of gabapentin: effects on cannabis use, withdrawal and executive function deficits in cannabis dependent adults. Neuropsychopharmacol Off Publ Am Coll Neuropsy chopharmacol. 2012;37(7):1689–98
  • Naltrexone
    • Haney M, Ramesh D, Glass A, Pavlicova M, Bedi G, Cooper ZD. Naltrexone Maintenance Decreases Cannabis Self-Administration and Subjective Effects in Daily Cannabis Smokers. Neuropsychopharmacology. 2015 Oct;40(11):2489-98. doi: 10.1038/npp.2015.108. Epub 2015 Apr 16. PMID: 25881117; PMCID: PMC4569951.
    • Notzon, D. P., Kelly, M. A., Choi, C. J., Pavlicova, M., Mahony, A. L., Brooks, D. J., Mariani, J. J., & Levin, F. R. (2018). Open-label pilot study of injectable naltrexone for cannabis dependence. The American Journal of Drug and Alcohol Abuse., 44(6), 619–627. https://doi.org/10.1080/00952990.2017.1423321
    • Shamabadi A, Arabzadeh Bahri R, Karimi H, Heidari E, Akhondzadeh S. Emerging pharmacotherapy for the treatment of cannabis use disorder. Expert Opin Pharmacother. 2024 Apr;25(6):695-703. doi: 10.1080/14656566.2024.2353638. Epub 2024 May 15. PMID: 38717605.
  • Amitriptyline
    • Sharaf, R., Venkatesan, T., Shah, R. Management of cyclic vomiting syndrome in adults: evidence review. Neurogastroenterol Motil. 2019; 31, e13605

Patient Resources

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