Smoking cessation (cannabis)

Cannabis is the most widely used illicit drug in the Western world but there is plenty of documented evidence to suggest a desire for users to find ways to assist them to stop using cannabis, and the demand for treatment for cannabis dependency is increasing internationally. There are a number of ways to quit cannabis and increasing evidence-based treatments for cannabis users wishing to change the patterns of their use. This article deals with the different interventions to assist in the cessation of cannabis use.

Cannabis dependence
Cannabis dependence criteria include tolerance to cannabis, withdrawal, using more or using longer than intended, a persistent desire to use/ unsuccessful efforts to control use, a great deal of time spent obtaining, using and recovering from cannabis use, giving up or reducing important activities and continued use despite the knowledge of physical or psychological problems.

Withdrawal
A US study in the Journal of Drug and Alcohol Dependence found that quitting cannabis can cause withdrawal symptoms as severe as those from quitting tobacco. The study of 12 adults who were heavy users of both cannabis and cigarettes, found that stopping either substance triggered similar withdrawal symptoms. (Similar, but not to the degree of each-other) As with nicotine, quitting cannabis caused symptoms such as irritability, anxiety, sleep problems and difficulty sleeping. Copeland et al stipulate that the most common withdrawal symptoms also include nervousness, restlessness, anger and aggression, and symptoms typically emerge after one to three days of abstinence, peak between days two and six, and last from four to 14 days. However, it is known that the detox period can last from 9-90 days depending on how frequent cannabis use was in the user. Symptoms of withdrawal can also consist of temporary palinopsia and sensitivity to light (Lasting anywhere from 9-90 days), temporary depersonalization (although it can be strictly related to cannabis cessation, it is frequently prolonged and fueled by anxiety and stress), paranoia, depression, loss of appetite, vivid dreams and nightmares, and, in those susceptible, episodic or temporarily chronic migraines. Although it is also reported to be very effective in treating and/or preventing migraines in some individuals, it must be noted that there appears to be a strong possibility of rebound headaches when frequently using marijuana to treat migraine attacks.

Cannabis users in drug counseling
According to the 2008 SAMHSA, cannabis is responsible for most illicit drug admissions in the USA, with a 32% increase in the proportion of admissions for cannabis-related problems from 12% in 1996 to 16% in 2006. In 2006, admissions were more likely to be male, while 62% reported this to be their first treatment episode. In addition, cannabis was the primary drug concerned in more than half of all admissions aged 15-19. Copeland and Swift identify the most commonly accessed forms of treatment as 12-step programs, physicians, rehabilitation programs, and detox services, with inpatient and outpatient services equally accessed (each approximately 10%). Most treatment falls into the categories of psychological or psychotherapeutic, intervention, pharmacological intervention or treatment through peer support and environmental approaches. In the EU, approximately 20% of all primary admissions and 29% of all new drug clients in 2005, particularly in outpatient settings, had primary cannabis problems, second only to heroin. From 1999-2005 the proportion of clients seeking treatment for primary cannabis use increased in all the countries that reported data In Australia between 2006 and 2007, cannabis was the second most common principle drug of concern for which treatment was sought after alcohol, accounting for 23% of closed treatment episodes. Among 10-19 year old clients, cannabis represented 47% of episodes compared to 29% for alcohol.

Treatment
Most interventions used for cannabis dependence have been adaptations of alcohol interventions, eg. Miller and Gold ; Zweben and O'Connell (1992). The National Cannabis Centre in Australia (NCPIC) lists main treatment types into three categories, psychological interventions, pharmacological interventions and peer support.

Psychological intervention
Psychological interventions for cannabis use include counseling, particularly that based on cognitive behavioral therapy (CBT) and motivational enhancement approaches. CBT includes the teaching and practice of behavioral and cognitive skills to deal with triggers that can lead to a return to use: It focuses on creating a better understanding of how triggers, thoughts and behaviors are linked and develops skills to avoid the triggers and/ or develop better means of minimizing the their impact. Motivational enhancement approaches are also incorporated into treatments for cannabis problems. Motivational enhancement does not confront individuals about the need to change, but works to encourage and build motivation to change. Copeland et al suggest that among young people with complex psycho-social and substance use-related problems, intensive family therapy-based interventions show particular promise, especially if they also attend to broader issues such as peer and community influences. In addition to these psychological interventions, combining contingency management (which provides money or other incentives for attending appointment of drug negative urinalysis) with MET/ CBT seems to improve abstinence outcomes during and after treatment. However, it is unknown whether advantages of combined CM with MET/ CBT outweigh the costs associated with contingency management.
 * Drug refusal
 * Coping with cravings
 * Managing moods swings
 * Avoiding high risk environments
 * Managing relationships
 * Finding alternative activities.

Pharmacological intervention
According to a number of researchers there are several drugs that may either ease the symptoms of cannabis withdrawal or block the effects of cannabis. Drugs such as Buproprion, Nefazodone and Lithium Carbonate have all been tested with variable results. . According to the Cannabis Centre a psychological intervention that is showing promise is oral THC, an agonist medication, which reduced cannabis withdrawal symptoms, as methadone does for opioid dependence. An antagonist medication has also been developed but recently taken off the market due to safety concerns in its treatment for depression.

Peer support
Cannabis users may find peer-support programs helpful. A self-help group is categorised as any group that has the aim of providing support, practical help and care for group members who share a common problem. The most common self help groups are Marijuana Anonymous/ Narcotics Anonymous and Self Management and Recovery Training (SMART).The SMART groups are based on CBT principles and teach group members to: In an internal evaluation of Sydney participants of a SMART program, more than four out of every five (83%) respondents indicated that they thought that the program had given them "lots of help".
 * Enhance and maintain motivation to abstain
 * Cope with urges
 * Problem-solve (managing thoughts, feelings and behaviors)
 * Balance their lifestyles (balancing momentary and enduring satisfactions)

Self-help groups that strongly endorse the therapeutic potential of peer support, such as Narcotics Anonymous (NA), are increasingly used as an approach to cannabis dependency. The only requirement for membership at NA is a 'desire to stop using drugs'. Twelve step programs such as NA view addiction as a disease, with complete abstinence the only option for recovery; the support of a former addict helping another is at the core of the program's philosophy and people who become a part of the NA program acquire a 'sponsor', someone who provides personal support and helps recovering addicts implement the 12 steps. These steps include belief in a higher power and keeping a fearless moral inventory of oneself. Evaluations of Marijuana Anonymous programs, modelled on the 12-step lines of Alcoholics Anonymous and Narcotics Anonymous, have shown small beneficial effects for general drug use reduction.

Other treatment types
Hamilton et al. provide evidence for the intensive and family-focused approach of the Family Support Network (FSN) for adolescent cannabis dependency, which is designed to improve family cohesion, parenting skills and parental support, presumed to increase the likelihood of both initial and sustained change, and designed to run alongside MET/ CBT therapy. Godley et al. discuss the Adolescent Community Reinforcement Approach (ACRA), the primary focus of which is helping the adolescent identify reinforcers incompatible with drug use and rearranging environmental contingencies so that abstinence from marijuana is more rewarding than use. Multidimensional family therapy (MDFT) is an intensive, family-focused, developmental, ecological, multiple-systems approach for treating adolescent substance abuse. The model targets adolescent and parent individual functioning, family interaction patterns and the extended social system.

Cannabis Centre treatment studies
To provide an example of treatment options, Australia's Cannabis Centre (NCPIC)currently provides a range of research studies for people seeking assistance to reduce or eliminate cannabis from their lives. , including:
 * The Cannabis Information and Helpline Study, a free telephone-based cannabis treatment study. The treatment is based on cognitive behavioral and motivational interviewing strategies and is complimented by a self-help ‘quitting cannabis workbook’. The treatment involves four sessions, or calls, over four weeks made by counselors from the Cannabis Information and Helpline;
 * Web-Intervention Study: Reduce Your Use, which is a free, web-based treatment for cannabis use and related problems that is also a study to test the effectiveness of the new treatment. The confidential online delivery attempts to make assistance more accessible for those in need and uses established counseling practices. It is available world-wide to participants who are 18 years or older, want to quit or reduce their cannabis use and have regular access to the internet.
 * Cannabis Check-Up+ for Young Adults - in conjunction with the Brain and Mind Research Institute, the Cannabis Centre is running a brief intervention for young people who smoke cannabis and have mental health difficulties who might want a chance to talk about their cannabis use without worrying about feeling any pressure to change. The principle focus of the intervention is to help identify values and improve quality of life.
 * Mail-based cannabis study - a free mail-based treatment study using modalities that include cognitive behavioral therapy, motivational interviewing and adherence strategies.

Referral
According to Australia's Institute of Health and Welfare report on the national minimum data set in Australia in 2007-2008, self referral was the most common source of referral (26% of episodes), whilst referrals form police diversion and court diversion rose from 17% to 19% and 11% to 14% respectively. 91% of cannabis users smoked the drug, followed by vapour (4%) and approximately 2% who ingested cannabis. Counseling was reported as the most common treatment type in each year of the collection, accounting for more than 37% of episodes each year. Withdrawal management (detoxification) has consistently been reported as around 16-19% of main treatments, with assessment only recorded in 12-15% of main treatments. The remaining treatments (Rehabilitation; support and case management; information and education) each make up less than 10% of treatments each year.