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cannabis related disorder

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  2. 2. INTRODUCTION  Most widely used illegal drug in world.  Cannabis , more commonly called , marijuana, refers to the several varieties of Cannabis sativa, or Indian hemp plant, that contains the psychoactive drug Delta -9- tetrahydrocannabinol (THC).  Other name are grass, pot, weed, tea, mary Jane, dagga, sinsemilla, herb, reefer, dope, shunk, boom, gangster, kif. 2
  3. 3.  Cannabis –related disorder refers to the problem associated with the use of substances derived from this plant.  It is also known as gate-way drug. 3
  4. 4. HISTORY  It is used in China , India & middle east for approx 8000 year primarily for its fiber and secondarily for its medical properties.  It was introduce to Europe in early 19th century by Napoleon’s army returning from Egypt, and later in the same century to Britain for medical use by surgeon who served in India. 4
  5. 5. PREPARATION OF CANNABIS  Male and female plants separated.  Female contain highest concentration of THC.  Flowering top has highest THC concentration. MARIJUANA: Prepared from dried flowering tops and leave of plant.  THC concentration 0.5- 5%. HASHISH ( Hash or charas): consist of dried cannabis resin.  Light brown to almost black color.  THC concentration 5-8%. 5
  6. 6. HASH OIL: it obtained by extracting THC from Hasish or Marijuana in oil.  Clear pale yellow / green to brown black colour.  THC concentration 15-30%. GANJA: Buds and flowering top of female plant. BHANG: Cut and dried large leaves & stem of plants. 6
  7. 7. METHOD OF USE INHALATION: cannabis is typically smoked as marijuana in hand role cigarettes or JOINTS.  WATER PIPE or BONG is use to deliver bolus dose.  Hashish may smoke in joints or pipe with or without tobacco.  Hash oil is extremely potent, a few drop is applied on cigarette or joint. 7
  8. 8. ORAL ROUTE: By eating hashish baked in brownies or cookies. INDIA: in India bhang, ganja is a common form , that is use frequently at various occasions like (Holi, Shivratri ) in which use like milk based drink called THANDAI or typically smoked (ganja / charas) in CHILAM or mixed with tobacco of cigarettes. MANOKA a dry slightly sweetish preparation consisting of bhang paste. 8
  9. 9. EPIDEMOLOGY MAJOR DRUGS OF ABUSE IN INDIA Drug Type NHS (current prevalence, %) DAMS (% among treatment seekers) Cannabis 3.0% 11.6% Source : National Survey, 2004 NHS: National household survey DAMS: Drug abuse monitoring system 9
  10. 10. Annual Prevalence (%) of cannabis abuse among those 15 years and older India (NHS, 2001 past month use)- 3.0 Canada- 7.4. Russian Federation-0.9 Sri Lanka ( 1999)-1.4 Australia (1998)-17.9 Pakistan (1998)- 1.2 Bangladesh- 3.2. Nepal (1996)-2.8. Source : National Survey, 2004 Region NHS DAMS North- East Manipur ……… North ……….. Uttar Pradesh East Bihar Bihar Regional variation of Cannabis abuse in India (high use regions) 10
  11. 11. NEUROPHARMACOLOGY  Primary constituent is ∆9-THC.  ∆9-THC is rapidly converted to is active form 11- hydroxy ∆9-THC.  THC and its metabolite are highly fat soluble.  There are two type of cannabinoid receptor CB1 and CB2.  CB1 found primarily in brain and mediate psychological effect and behavioral effect of THC.  CB2 associated with immune system and modulate inflammatory responses.  CB1 & CB2 belong to G protein couple receptor. 11
  12. 12. PROBLEM RELATED TO CANNABIS USE  In ICD-10 cannabis is considered in F12.  But in ICD -10 the same diagnostic criteria are use for all substances, whereas in DSM-5 separate diagnostic criteria are present for individual substances. 12
  13. 13. CANNABIS DEPENDENCE: The compulsive need to use the drug , coupled with problems associated with chronic drug use. 13
  14. 14. DIAGNOSTIC CRITERIA FOR CANNABIS DEPENDENCE DISORDER (DSM -5) At least 2 of following, occurring within 12 month period: 1.Cannabis is often taken in larger amounts or over a longer period than was intended. 2.There is a persistent desire or unsuccessful efforts to cut down or control cannabis use. 3.A great deal of time is spent in activities necessary to obtain cannabis, use cannabis, or recover from its effects. 4.Craving, or a strong desire or urge to use cannabis. 5.Recurrent cannabis use resulting in a failure to fulfil major role obligations at work , school, or home. 14
  15. 15. 6.Continued cannabis use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of cannabis. 7.Important social, occupational activities are given up or reduced because of cannabis use. 8.Recurrent cannabis use in situations in which it is physically hazardous. 9.Cannabis use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by cannabis. 15
  16. 16. CANNABIS INTOXICATION  Most young people use cannabis in order to experience a “high,” characterized by feelings of mild euphoria, relaxation and perceptual alterations, including time distortion, and the intensification of ordinary experiences, such as eating, watching films, listening to music, and engaging in sex.  When used in a social setting, the high may be accompanied by infectious laughter, talkativeness, and increased sociability. 16
  17. 17.  Cognitive changes include impaired short-term memory and attention that make it easy for the user to become lost in pleasant reverie and difficult to sustain goal-directed mental activity.  Motor skills, reaction time, motor coordination, and many forms of skilled psychomotor activity are impaired while the user is intoxicated, increasing the risks of accidents if users drive an automobile. 17
  18. 18. CANNABIS INTOXICATED DELIRIUM  The delirium associated with cannabis intoxication is characterized by marked impairment on cognition and performance tasks.  Even modest dose of cannabis impair memory, reaction time, perception , motor coordination, and attention. High doses that also impair users, levels of conciousness have marked effect on cognitive measures . 18
  19. 19. CANNABIS AND SCHIZOPHRENIA  There is consistent clinical and epidemiological evidence that cannabis use can precipitate schizophrenia in vulnerable individuals or exacerbate its symptoms in those who have already developed the disorder.  Various study found dose–response relationships between frequency of cannabis use, early age of onset, and the risk of developing psychotic disorders. 19
  20. 20. CANNABIS-INDUCED ANXIETY DISORDER  Some user report increase anxiety, panic, a fear of going mad, and depression after using cannabis.  Mostly feel by new user.  The appearance of anxiety symptoms is correlated with the dose.  Most frequent adverse reaction to the moderate use of smoked cannabis. 20
  21. 21. CANNABIS WITHDRAWAL  Cessation of the use in daily cannabis user results in withdrawal symptom.  Appear within 24 hours , most marked within 10 days and may persist up to 28 days. 21
  22. 22.  Irritability, anger, or aggression.  Nervousness or anxiety.  Sleep difficulty (e.g., insomnia, disturbing dreams).  Decreased appetite or weight loss.  Restlessness.  Depressed mood.  Physical symptoms causing significant discomfort: abdominal pain, shakiness/tremors, sweating, fever, chills, or headache.  Fatigue ,yawing, difficulty in concentration etc.. 22
  23. 23. CANNABIS INDUCED PSYCHOTIC DISORDER  It is rare.  Transient paranoid ideation is more common.  Florid psychosis is common in country in which some person have long term assess to cannabis of high potency.  Rarely “bad-trip’’ experience which is often associated with hallucination intoxication. 23
  24. 24.  “HEMP INSANITY’’ term given by Dhunjibhoy for cannabis psychosis in 1930.  Characterised by • Acute schizophreniform disorder • Disorientation • Confusion o good prognosis. 24
  25. 25. COGNITIVE IMPAIRMENT  Long term use of cannabis may produce subtle form of cognitive impairment in higher cognitive functions of memory attention & organization of complex formation.  Longer the period of heavy cannabis use, the more pronounced the cognitive impairment. UNPECIFIED CANNABIS RELATED DISORDER Like mania , hypomania, sleep disorder, sexual dysfunction 25
  26. 26. FLASH BACKS: Users experiencing symptoms of cannabis intoxication that occur day or week after they last use cannabis. AMOTIVATIONAL SYNDROME:  Associated with long term heavy use.  Characterised by a person’s unwillingness to persist in a task- be it a school, at work , or in any sitting that require prolong attention. 26
  27. 27. EFFECT OF CANNABINOID USE Respiratory system:  It impair the functioning of large airway and causes symptoms of chronic bronchitis such as coughing, sputum, and wheezing.  Increases the risks of respiratory cancer. Pregnency : Cannabis use during pregnancy produces babies with smaller birth weights, perhaps as a consequence of shorter gestation.  Infant show behavioral & developmental effect when expose during first few month after birth 27
  28. 28. INVESTIGATION  Urine test can usually identified metabolite of cannabinoids, 11-hydroxy Δ-9 THC .  Because they are fat soluble, remain in body for extended period.  Individual who are chronic users of cannabinoids may show +ve urine test for 2-4 week after using.  It can also detect in head hair , pubic hair, urine, sweat, saliva and blood of users. 28
  29. 29. TREATMENT SETTING*  PHARMACOLOGICAL ASPECTS  PSYCHOSOCIAL ASPECTS  * SORCE: Basu D, Dalal PK. Clinical practice guideline for the assessment and management of substance use disorder; indian psychiatric society 2014; 1:271-285. 29
  30. 30. PHARMACOLOGICAL ASPECTS: CANNABIS INTOXICATION:  Usually mild, self limiting, mostly does not need pharmacological intervention.  T/t needed in severe distressing anxiety or psychotic symptom induced by intoxication.  Anti psychotic (preferably atypical) for psychosis.  Benzodiazepine in acute anxiety state.  Propanolol has little effect.  Duration not longer than one day. 30
  31. 31. CANNABIS WITHDRAWAL  Benzodiazepines are most commonly prescribe medication.  Dronabinol (cannabis receptor agonist) , synthetic THC (20-60 mg/day) for 7-10 days depending on duration of withdrawal symptom.  Beclofen (40 mg/day) or Lofexidine (α2 agonist ,2.4 mg/day) are another alternative. But not much effective. 31
  32. 32.  CANNABIS DEPENDENCE  No medication has been shown broadly effective for this , nor any approved by any regulatory authority.  Buspiron (up to 60 mg/ day) for 12 week is 1st choice.  Fluoxetine (20-40 mg/day) is another alternative.  Other drug like Dronabinol, mood stabilizer tried but not much effective. 32
  33. 33.  Emerging evidence of Baclofen(40-60 mg/day) another reasonable T/t option.  Rimonabent ( CB1 receptor antagonist) are marketed as appetite suppressant but withdraw due to its psychiatric side effect (specially sucidality). 33
  34. 34. PSYCHOSOCIAL ASPECT:  Motivational enhancement therapy (MET).  Cognitive behavior therapy (CBT).  Contingency management (CM).  Family and system intervention.  Combined psychosocial treatment. 34
  35. 35. MOTIVATIONAL ENHANCEMENT THERAPY (MET).  Designed to help resolve ambivalence about quitting and strengthen motivation to change.  Technique include, exploration of pores and cones of drug use, rolling with resistance, making goal plan etc .  Duration 1-4 session.  45-90 minute individual session. 35
  36. 36. COGNITIVE BEHAVIOR THERAPY (CBT).  45-60 minute group or individual counseling session.  Focus on coping skill relevant to quitting marijuana and other related problem that might interface with good outcome. • Development of self management plan to avoid or cope with drug use triggers • Drug refusal skill • Problem solving skill • Role playing • Interactive exercise  6-14 session. 36
  37. 37. CONTINGENCY MANAGEMENT (CM) (ABSTINENCE REINFORCEMENT THERAPY)  Central feature is systemic application of reinforcing or punishing consequence in order to achieve therapeutic goals.  Positive reinforcement to: • Increase abstinence from drug use • Facilitate other therapeutic changes • Include retention in T/t • Attendance at therapy session • Compliance with medication regimens. 37
  38. 38. FAMILY AND SYSTEM INTERVENTION.  There is reciprocal relation between family functioning and substance use.  According to family system theory substance abuse increase during period in which , patients away from his family, family conflict ( like marital problem), use of substance by other family member etc.  MULTIDIMENTIONAL FAMILY THERAPY is applied that approach to resolve this issues. 38
  39. 39. COMBINED PSYCHOSOCIAL TREATMENT  MET + CBT  MET + CBT + CM  MET + CBT + FSN (family support network)  According to cannabis youth treatment study(CTY) all are equally effictive.* * Diamond G, Godley SH, Liddle HA. Five output treatment modeles for aldolesent marijuana use: a description of the cannabis youth treatment intervention. Addiction 2002;97:70-83. 39
  40. 40. CANNABIS AND NDPS ACT Substance Small quantity Commercial quantity Ganja 1 kg 20 kg Charas 100 g 1 kg Quantity Punishment Small quantity Imprisonment up to 1 yr OR fine of 10000/- OR both Greater than Small quantity but Less than Commercial quantity Imprisonment up to 10 yr with fine up to 1 lakh Commercial quantity Imprisonment shall not be less than 10 yr. max extend up to 20 yr + fine not less than 1 lakh On repeat offence one & half time the punishment for offence. 40
  41. 41. THERAPUTIC EFFECT OF CANNABINOIDS Primarily to relieve symptoms rather than to cure . Analgesia:  Modest analgesic effects on acute postoperative and chronic pain including neuropathic pain.  Sativex , an oral spray consisting of natural cannabis extract for the T/t of cancer pain. Nausea and vomiting: Previously it was use to control over nausea induced by cisplatin( anti cancer drug). 41
  42. 42. Wasting syndrome and appetite stimulation in HIV/AIDS: THC stimulates appetite and assists in weight gain in HIV/ AIDS patients in short-term trials. Muscle spasticity: Epilepsy: Epidiolex ,containing cannabidiol was granted orphan drug status for the T/t of certain rare, intracable type of epilepsy in children. Glaucoma: It reduce IOP by 25 percent, but the effect lasts only 3 to 4 hours. 42
  43. 43. …Thank you 43