September-October 2018

Use of cannabis can lead to dependence. On average, 9% of individuals who initiate cannabis use will develop cannabis use disorder (CUD) in their lifetime.¹ By comparison, 15-22% of individuals who initiate alcohol use will develop alcohol use disorder in their lifetime^1,2 and 8-12% of patients prescribed opioids will develop an opioid use disorder in their lifetime.^3,4,5 It is estimated that approximately 30% of current cannabis users have symptoms of CUD.⁶

Initiating cannabis use at an earlier age and increasing frequency of use are significantly associated with developing CUD.⁷ According to the most recent Diagnostic and Statistical Manual of Mental Disorders (DSM-5), increasing frequency of cannabis use is also associated with a syndrome of problematic cannabis misuse—where cannabis negatively impacts a person’s life—but does not meet the criteria of CUD.⁸ (See "Cannabis Use Disorder: DSM-5" below.) Cannabis use is also associated with an increased risk of developing dependencies on substances other than cannabis.⁷

Screening for Cannabis Use

Due to the high prevalence of cannabis use and significant risk of developing problem use, clinicians are encouraged to screen patients for cannabis use (e.g., “Are you using any cannabis or cannabis products such as marijuana, hemp, THC, or CBD?”). Affirmative answers should be followed up with questions about whether their cannabis use is causing problems.

The following screening tools can be used to help determine problematic cannabis use:

• CAGE Adapted to Include Drug Use (CAGE-AID) is a simple and multi-purpose screening tool for alcohol use and adapted to include drug use.⁹ CAGE-AID can be used to quickly determine if alcohol or other drug use, including cannabis, is problematic. Any “yes” response on CAGE-AID serves as a positive screen and should trigger an offer for substance use disorder treatment. CAGE-AID screening questions are:
  • Have you ever felt that you ought to Cut down on your drinking or drug use?
  • Have people Annoyed you by criticizing your drinking or drug use?
  • Have you ever felt bad or Guilty about your drinking or drug use?
  • Have you ever had a drink or used drugs first thing in the morning (Eye-opener) to steady your nerves or get rid of a hangover?
• The Cannabis Use Problems Identification Test (CUPIT) is an 8 to 10 minute screening tool specific to cannabis. CUPIT can be self-administered by patients prior to appointments and provides information on frequency and intensity of cannabis use in the past 12 months, cannabis use in the past 3 months, cannabis-induced problems, and risk of harm and dependence currently and in the past 12 months.¹⁰

Substance Use Disorder Treatment Referrals

When determining if a patient might benefit from CUD treatment, healthcare providers should focus on two key criteria during their brief visit:

1. If cannabis use is causing the patient problems and
2. If the patient is amenable to treatment.

If cannabis use is causing problems and the patient is amenable, a referral for CUD treatment is generally warranted.

To refer a patient for specialty substance use disorder treatment through the County, use one of the following referral mechanisms:

• Substance Abuse Service Helpline (SASH)
  844-804-7500
  Call to connect with SASH, which will conduct a brief phone triage screening and refer the patient to the most appropriate SUD provider.


• Service and Bed Availability Tool (SBAT)
  http://sapccis.ph.lacounty.gov/sbat
  Refer the patient directly to one of the County’s provider sites via SBAT, which is a web-based service locator for specialty SUD services throughout Los Angeles County. The tool has a filtering capability based on level of care, languages, types of services delivered, and special populations served (e.g., perinatal, criminal justice, lesbian/gay/bisexual/transgender).

References

1. Lopez-Quintero C, Pérez de los Cobos J, Hasin DS, et al. Probability and predictors of transition from first use to dependence on nicotine, alcohol, cannabis, and cocaine: Results of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Drug Alcohol Depend. 2011;115(1-2):120-130. doi:10.1016/j.drugalcdep.2010.11.004
2. Anthony JC, Warner LA, Kessler RC. Comparative epidemiology of dependence on tobacco, alcohol, controlled substances, and inhalants: Basic findings from the National Comorbidity Survey. Exp Clin Psychopharmacol. 1994;2(3):244-268. doi:10.1037/1064-1297.2.3.244
3. Carlson RG, Nahhas RW, Martins SS, Daniulaityte R. Predictors of transition to heroin use among initially non-opioid dependent illicit pharmaceutical opioid users: A natural history study. Drug Alcohol Depend. 2016;160:127-134. doi:10.1016/j.drugalcdep.2015.12.026
4. Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The Changing Face of Heroin Use in the United States: A Retrospective Analysis of the Past 50 Years. JAMA Psychiatry. 2014;71(7):821-826. doi:10.1001/jamapsychiatry.2014.366
5. Muhuri PK, Gfroerer JC, Davies MC. Associations of Nonmedical Pain Reliever Use and Initiation of Heroin Use in the United States. Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. CBHSQ Data Rev. Published August 2013.
6. Hasin DS, Saha TD, Kerridge BT, et al. Prevalence of Marijuana Use Disorders in the United States Between 2001-2002 and 2012-2013. JAMA Psychiatry. 2015;72(12):1235–1242. doi:10.1001/jamapsychiatry.2015.1858
7. National Academies of Sciences, Engineering, and Medicine. The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. Washington, DC: The National Academies Press; 2017. doi:10.17226/24625
8. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Arlington, VA: American Psychiatric Association; 2013.
9. Brown RL, Rounds LA. Conjoint screening questionnaires for alcohol and other drug abuse: criterion validity in a primary care practice. Wis Med J. 1995;94(3):135-140.
10. Bashford J, Flett R, Copeland J. The Cannabis Use Problems Identification Test (CUPIT): development, reliability, concurrent and predictive validity among adolescents and adults. Addiction. 2010;105(4):615-625. doi:10.1111/j.1360-0443.2009.02859.x