ගංජා භාවිතය සහ සෞඛ්ය පිලිබඳ ආචාර්ය මන්ඩේ ඉග්වේ (නයිජීරියාව) , විශේෂඥ මනෝ වෛද්ය උපාලි පීරිස් සහ මා විසින් ලියන ලද පත්රිකාව. මෙය අප තවමත් වැඩි දියුණු කරමින් සිටින අතර නුදුරු දිනෙක ප්රකාශයට පත් කිරීමට නියමිතය.
Cannabis use and Mental Health
Dr Monday N. Igwe, Dr. Upali P. K. Peris, Dr Ruwan M Jayatunge
Cannabis
sativa (marijuana) has been used throughout the world medically, recreationally
and spiritually for thousands of years (Maule, 2015). It is the most commonly
used illicit drug in the world (Wittchen et al., 2009). Despite being illegal
in many countries, it is easily obtained and even homegrown (Delisi et al.,
2006). According to the results from the 2011 National Survey on Drug Use and
Health, the rate of marijuana use has had a steady increase since 2007.
Cannabis use continues to constitute social and public health problem.
The
cannabis plant (Cannabis sativa) has a long history of use both as a medicinal
agent and intoxicant (ElSohly & Slade, 2005). There are over 400 chemicals
in marijuana. Active compounds of cannabis, called cannabidiols, have 64 active
isomers. Only one metabolite, tetrahydrocannabinol (THC) is reported to be an
active metabolite responsive for its effects (Morrison et al., 2009). THC
usually refers to the naturally existing isomer of delta-9-THC, but also may
include delta-8-THC. The delta-9-tetrahydrocannabinol contains psychoactive
properties. Marijuana produces a number of characteristic behaviors in humans
and animals, including memory impairment, antinociception, and locomotor and
psychoactive effects (Sim-Selley, 2003).
THC
leads to increased activation in frontal and paralimbic regions and the
cerebellum (Chang & Chronicle,
2007). Cannabinoids act on a specific receptor that is widely distributed in
the brain regions involved in cognition, memory, reward, pain perception, and
motor coordination (Adams & Martin, 1996). Cannabis produces euphoria and
relaxation, perceptual alterations, time distortion, and the intensification of
ordinary sensory experiences (Hall, Solowij & Lemon 1994).
Although
most people who smoke cannabis will develop neither severe mental health
problems nor dependence, regular use of cannabis may be associated with a range
of health, emotional, behavioural, social, and legal problems, particularly in
young, pregnant, and severely mentally ill people (Winstock, Ford & Witton,
2010). Cannabis users who also smoke tobacco are more dependent on cannabis,
have more psychosocial problems and have poorer cessation outcomes than those
who use cannabis but not tobacco (Peters, Budne & Carroll 2012).
Epidemiological
studies indicate that approximately 10% of lifetime cannabis users meet the
criteria for cannabis abuse or dependence (Anthony et al., 1994; Cottler et
al., 1995; Hall et al., 1999). The epidemiological literature shows that cannabis
use increases the risk of accidents (Hall, 2015) and risk of motor vehicle
crashes (Hall & Degenhardt, 2009). Cannabis is currently one of the leading
substances reported in arrests (Dennis et al., 2002).
Tolerance
and dependence to cannabinoids develop after chronic use, as demonstrated both
clinically and in animal models (Sim-Selley, 2003). According to Levin and
colleagues (2011) Cannabis dependence is a substantial public health problem. A
large body of evidence now demonstrates that cannabis dependence both
behavioral and physical, does occur in about 7-10% of regular users, and that
early onset of use, and especially of weekly or daily use, is a strong
predictor of future dependence (Kalant, 2004).
Cannabis dependence or cannabis use disorder is defined in the fifth
revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
as a condition requiring treatment (Gordon
Conley & Gordon, 2013).
Cannabis
withdrawal is an important component of cannabis dependence (Lee et al., 2014).
As many as 85% of users experience withdrawal (Budney et al., 2004; Winstock et
al., 2010). Cannabis withdrawal is characterized by craving, irritability,
nervousness, depressed mood, restlessness, sleep difficulty, and anger. With
the recent publication of the DSM-5, a cannabis withdrawal syndrome is now
officially recognized with defined criteria (APA, 2013).
Consequences of Cannabis Use
Studies
show significant negative effects of smoking marijuana on physical and mental
health as well as social and occupational functioning (Gazdek, 2014). Smoking
marijuana is known to have hemodynamic consequences (Mittleman et al., 2001).
Cannabis also has immunosuppressant and endocrine effects although the clinical
significance of these is still not clear (Ashton, 2001). Cannabis smoking shows
a dose-response relation with pulmonary risk in the same way that tobacco
smoking does. Although problems of cannabis use can arise at any level of use,
however low, cannabis use disorders and other problems are more likely to arise
in long term, heavy daily users than in casual, infrequent users. (Winstock, et
al., 2010).
Longitudinal
association between cannabis use and mental health has been studied by the
researchers. Cannabis use is a known risk factor for a range of mental health
problems (van Gastel et al., 2014). Cannabis use has been associated with
several adverse life outcomes including unemployment, legal problems,
dependence and early school leaving (Serafini et al., 2013). Furthermore,
Monshouwer and colleagues (2006) specify that cannabis use is associated with
aggression and delinquency. In addition Fergusson and Boden (2008) point out
that greater welfare dependence and lower relationship and life satisfaction
associated with cannabis abuse.
Majority
of studies have suggested a significant cognitive decline in cannabis abusers
compared to non-abusers and healthy controls (Shrivastava et al., 2011;
Solowij, 1988). According to Kalant (2004) Cannabis use has been linked to a
number of both short- and long-term health consequences, including depression,
paranoia, learning problems, memory and attention deficits. In addition
Cannabis use also causes symptoms of depersonalization, fear of dying and
irrational panic ideas (Khan & Akella 2009). Also cannabis use significantly
increase the risk for manic symptoms (Henquet, Krabbendam & Graaf, 2006)
and mania (Leweke & Koethe, 2008). Evidence indicates that cannabis use is
considerably associated with both attempted and completed suicides among
healthy youths (Serafini et al., 2013; Price et al., 2009).
Cannabis
intoxication can occur shortly after cannabis use. The intoxication by cannabis
is associated with subjective symptoms of euphoria, perceptual distortion,
continuous giggling, sedation, lethargy, impaired perception of time,
difficulties in the performance of complex mental processes, impaired judgment
and social withdrawal (Crippa et al. 2012). Some clinicians have noticed panic
attacks with cannabis intoxication. Cannabis intoxication symptoms are usually
gone after a maximum of one week abstinence (Lishman, 1988).
Heavy
cannabis use could lead to an ‘amotivational syndrome which has been described
as personality deterioration with loss of energy and drive to work (Tennant
& Groesbeck, 1972; Johns, 2001). Cannabis-induced amotivational syndrome
negatively impacts on volition, self care and social performance.
Cannabis-induced
psychotic disorder (CIPD) refers to psychotic symptoms that arise in the
context of cannabis intoxication (Morales-Muñoz et al., 2014). Cannabis use is
a risk factor for the development of incident psychotic symptoms (Arendt et al,
2005; Kuepper et al., 2011) and exacerbates psychosis (Hall et al., 2004). Hall and team (2004) state that cannabis use
can precipitate schizophrenia in vulnerable individuals. Deficits in prepulse
inhibition (PPI) and cannabis abuse are consistently found in schizophrenia
(Morales-Muñoz et al., 2015).
Cannabis
use in adolescence leads to a two to three fold increase in relative risk for
schizophrenia or schizophreniform disorder in adulthood (Arseneault et al.,
2004). The abuse of cannabis by patients with psychiatric disorders such as
schizophrenia and mood and anxious disorders has a negative impact both in the
acute and advanced stages of these conditions (Diehl, Cordeiro &,
Laranjeira, 2010).
Exposure
to marijuana during a critical period of neural development may interrupt
maturational processes (Jacobus et al., 2009). Adolescents appear more
adversely affected by heavy use than adults (Schweinsburg, Brown & Tapert ,
2008). Chronic
cannabis use may alter brain structure and function in adult and adolescent
population (Batalla et al., 2013). Sami and colleagues (2015) suspect cannabis
use may be associated with dopamine
signaling alterations. Fontes and team (2011) point out that cannabis use has
been associated with prefrontal cortex (PFC) dysfunction.
Arseneault
and colleagues (2004) were of the view that cases of psychotic disorder could
be prevented by discouraging cannabis use among vulnerable youths. Consequently
Moore and team (2007) emphasize that sufficient evidence to warn young people
that using cannabis could increase their risk of developing a psychotic illness
later in life.
According
to El Marroun and team (2009) maternal cannabis use, even for a short period,
may be associated with several adverse fetal growth trajectories. Cannabinoids
have the ability to cross the placental barrier to the foetus and are
detectable in the breast milk of mothers who use cannabis (Liebke, 2001).
Current evidence indicates that cannabis use both during pregnancy and
lactation, may adversely affect neurodevelopment, especially during periods of
critical brain growth both in the developing fetal brain and during adolescent
maturation, with impacts on neuropsychiatric, behavioural and executive
functioning. (Jaques et al., 2014). Prenatal marijuana exposure is associated
with adverse perinatal effects (Astley & Little, 1990).
Medical Uses of Cannabis
The
use of cannabis for medical purposes is a controversial but an important topic
of public and scientific interest (Ware, Adams &Guy, 2005). According to
Grotenhermen and Müller-Vahl (2012)
cannabinoids are useful for the treatment of various medical conditions.
Medicinal marijuana has been prescribed in chronic pain management,
antiepileptic treatment in partial epilepsy, symptomatic relief in multiple
sclerosis and chronic neuropathic pain. However severe risks are associated
with the non-medicinal use of cannabis. Hill (2015) emphasizes that physicians
should educate patients about medical uses of marijuana to ensure that it is
used appropriately and that patients will benefit from its use.
Although
cannabis has valid medical applications, it has addictive potential. Heavy
cannabis use may contribute to the development of significant psychosocial and
health-related problems (Budney,, Vandrey and
Stanger 2010 ). Cannabis use clearly has serious implications for young
people who are particularly sensitive to its psychotogenic effects (Kolliakou
et al., 2012). Early interventions are essential in treating cannabis related
disorders.
Management of Cannabis Use
The
prevalence of marijuana abuse and dependence disorders has been increasing
among adults and adolescents. They continue to smoke the drug despite social,
psychological, and physical impairments, commonly citing consequences such as
relationship and family problems, guilt associated with use of the drug,
financial difficulties, low energy and self-esteem, dissatisfaction with
productivity levels, sleep and memory problems, and low life satisfaction (
Gruber et al , 2003 ; Budney et al,
2007).
Despite
the fact that there are large numbers of people with cannabis dependence,
relatively little attention has been paid to the treatment of this condition
(Nordstrom & Levin, 2007) and also the
preventative strategies are still limited (Deoganet al., 2015).
Pharmacological
and psychological interventions are recommended for the cannabis use disorder.
Allsop and team (2014) propose cannabis extract nabiximols (Sativex) as a
medication for cannabis withdrawal. Levin and colleagues (2011) suggest
Dronabinol for the treatment of cannabis dependence. Haney et al (2013)
recommend the FDA-approved synthetic analogue of THC nabilonewhich has higher
bioavailability and clearer dose-linearity than dronabinol.
Steinberg
and team (2002) suggest psychosocial treatment for cannabis dependence. Among the psychological interventions
Cognitive and behavioral therapies and motivational enhancement therapies have
proven to be effective in cannabis withdrawal and dependence (Benyamina et al.,
2008).
Motivational
enhancement therapy is designed to help resolve ambivalence about quitting and
strengthen motivation to change (Elkashef et al., 2008). Cognitive behavioral
therapy (CBT) has demonstrated efficacy as both a monotherapy and as part of
combination treatment strategies (McHugh, Hearon & Otto, 2010).
CBT
for marijuana dependence has typically been delivered in 45 to 60- minute
individual or group counseling sessions. The overall focus is the teaching of
coping skills relevant to quitting marijuana and coping with other related
problems that might interfere with good outcome. Such coping skills include
functional analysis of marijuana use and cravings, development of
self-management plans to avoid or cope with drug-use triggers, drug refusal
skills, problem-solving skills, and lifestyle management (Elkashef et al.,
2008). In addition Litt and team (2008) highlight the efficacy of contingency
management treatments for marijuana dependence.
Treatment
of cannabis use among people with psychotic or depressive disorders is
imperative. Available studies indicate that effectively treating the mental
health disorder with standard pharmacotherapy may be associated with a
reduction in cannabis use and that longer or more intensive psychological
intervention rather than brief interventions may be required, particularly
among heavier users of cannabis and those with more chronic mental disorders
(Baker, Hides & Lubman 2010).
As
safer alternative, some propose cannabis substitution which is a method of harm
reduction. Harm reduction refers to
policies and programmes that aim to reduce the harms associated with the use of
drugs. Cannabis substitution can be an effective harm reduction method for
those who are unable or unwilling to stop using drugs completely (Lau et al.,
2015). Based on principles of public health, harm reduction offers a pragmatic
yet compassionate set of strategies designed to reduce the harmful consequences
of addictive behavior for both drug consumers and the communities in which they
live (Marlatt, 1996).
Conclusion
Cannabis
abuse can have a profound effect on the health of individuals, their families,
and their communities. Prevention and intervention programs for marijuana abuse
are highly essential. Early intervention initiatives and psycho education
strategies are important in preventive actions.
Acknowledgements:
·
Mark D. Litt, Ph.D.
Professor of Psychology University of Connecticut
·
Dr. Ilan Nachim, HBSc,
MSc, MD, CCFP Toronto Canada
·
Dr. Krishna
Balachandra, M.D., FRCPC - Assistant clinical professor at the University of
Alberta
About
the Authors
Dr. Monday Igwe - Lecturer/Head of
Department in Department of Psychological Medicine Faculty of Medicine College
of Health Sciences Ebonyi State University, Abakaliki Nigeria.
Dr M.U.P.K.Peris MBBS, MD(Psych),
FSLCPsych, MRCPsych Head and Senior Lecturer in Psychiatry - Faculty of
Medicine, University of Kelaniya Sri Lanka Consultant Psychiatrist - North
Colombo Teaching Hospital, Ragama Sri Lanka
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