Do adverse effects occur in patients who report no symptoms of a cannabis use disorder? a reply to nixon
Year: 2003
Type: article
Abstract: Sir—We appreciate Dr Nixon's thoughtful response [1], and we suspect that neither our data nor our philosophies are truly in disagreement. It does appear that patients in Dr Nixon's clinic are using cannabis more frequently, on average, than patients in our clinic, and that his patients are far less likely to be abstinent from cannabis. No direct comparison is possible in terms of metabolite concentrations because our urine specimens were analysed only in terms of a 50 ng/mL cut-off. This is part of the reason we referred to our highest-use patients as ‘frequent’ users, not ‘heavy’ users. We wonder how many of Dr Nixon's patients would, if asked, report symptoms of a cannabis use disorder. Considering the quantity and frequency of their use, it seems likely that many of them would. If so, then Dr Nixon's observations are consistent with our findings: in our clinic, patients who reported symptoms of a cannabis use disorder at the start of treatment were more likely to report psychosocial problems (such as imprisonment or family conflict) at follow-up assessments during the year after discharge from treatment [2]. It would be a different matter if Dr Nixon found deleterious psychosocial effects of heavy cannabis use in patients who reported no symptoms of a cannabis use disorder. This would indeed suggest that heavy use is cause for concern regardless of what the patient reports. We don’t reject this possibility out of hand. For example, we are aware of experimental data in non-human primates supporting the existence of a cannabis-induced amotivational syndrome [3], and we imagine that some users might experience such a syndrome without recognizing a causal connection to their cannabis use. In fact, some clinicians have reported exactly that: [Some patients] present with a sense of dissatisfaction in achieving life goals, especially in the area of career. Many of these people appear functional and even successful in the outside world, but in their internal experience they do not feel that they measure up to their original hopes and plans for their lives. Chronic [cannabis] users often describe a mild boredom, lack of zest, or low-level depression that they rarely connect to their use of marijuana[emphasis added], but which dissipates when they become abstinent . . . [S]ome clinicians doing long-term work are beginning to suspect that the full flowering of the benefits of abstinence does not occur until 15–18 months into recovery. [4] Unfortunately, the clinicians who reported this impression did not specify the number of patients whose initial presentation or subsequent clinical course they were describing. Moreover, we do not know of any systematic attempts to confirm their impression. Perhaps the matter could be clarified by recruiting individuals (in methadone clinics or elsewhere) who feel that their frequent cannabis use is not problematic, then randomly assigning them to cessation, reduction or continuation of cannabis use for at least 18 months. Enrollment and retention in such a study would be challenging at best, and any attempt to maintain blind conditions would soon fail. Still, the results would provide much-needed guidance for situations in which the clinician feels that the patient's cannabis use is excessive, while the patient does not. For now, what is empirically clear from our data is this: adverse psychosocial outcomes are predicted by patient-reported symptoms of a cannabis use disorder, not by the mere detection of cannabinoids in urine. Like Dr Nixon, we would be interested in seeing whether this finding is replicable in his clinic's heavy users.
Source: Addiction
Authors: DAVID H. EPSTEIN, KENZIE L. PRESTON
Institution: National Institute on Drug Abuse
Language: English
Subfield: Pharmacology
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W1972765380