Long-term cannabis abuse and early-onset cannabis use increase the severity of cocaine withdrawal during detoxification and rehospitalization rates due to cocaine dependence
Introduction
Early-onset drug use is considered a significant predictor of the subsequent development of drug abuse and dependence (Sintov et al., 2009, Trenz et al., 2012). Around 34% of adolescents in the U.S. reported early-onset use of tobacco, alcohol and illicit substances (Moss et al., 2014), but during this period cannabis is the most popular illicit drug (Chadwick et al., 2013). Therefore, previous studies have shown that a significant percentage of teens (5.6%) who initiate cannabis use before the age of 15 report daily substance use and further drug abuse (Johnston et al., 2004), suggesting that early-onset cannabis use is a risk factor for further drug-related problems (Lynskey et al., 2003). However, the debate regarding the harmful consequences of cannabis consumption is still ongoing and the main reasons for this include the poor quality of current evidence and the small number of studies on this topic (Calabria et al., 2010).
Early-onset cannabis use and abuse are also associated with potential progression to the use of other illicit substances such as cocaine. Estimations regarding the prevalence of cannabis use among primary cocaine users range between 50 and 70% (Hall and Lynskey, 2005, Lynskey et al., 2003, Wagner and Anthony, 2002). Moreover, the treatment of cocaine dependence conventionally involves detoxification programs for the management and reduction of drug craving and abstinence symptoms. However, the severity of withdrawal symptoms can vary among drug users (Francke et al., 2013), and multiple factors, including the history of other substance consumption, could impact treatment response (Ahmadi et al., 2008). In this sense, recent evidence indicated that concomitant cocaine and long-term cannabis use might increase craving for cocaine during drug abstinence (Fox et al., 2013). Therefore, a potential role of patterns of cannabis consumption in cocaine dependence-related problems is suggested.
Despite that, research has yet to address the consequences of cannabis use on specific clinical manifestations during the initial period of cocaine detoxification. This topic is of particular interest given that the severity of cocaine withdrawal symptoms at the first two weeks of treatment is a robust predictor of the ensuing treatment response (Kampman et al., 2001, Kampman et al., 2004). Therefore, the aim of this follow-up study was to investigate whether long-term cannabis abuse and early-onset cannabis use could impact cocaine withdrawal severity and cocaine craving intensity during the first two weeks of detoxification treatment. In addition, we investigated the impact of cannabis consumption patterns in the rehospitalization rates due to cocaine dependence after 2.5 years of assessment.
Section snippets
Participants
One hundred and twenty-two female cocaine-dependent inpatients of a detoxification treatment public hospital unit in Southern Brazil took part in this study. Inclusion criteria were as follows: (1) age 18 to 45; (2) diagnosis of physiological dependence on cocaine (smoked or snorted) according to the Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM-IV). Participants were excluded from this study if (1) for any reason they did not report or did not provide reliable
Descriptive statistics
All participants reported having smoked cocaine and 89% reported having snorted cocaine as well. Overall, 66% of the sample reported early-onset cannabis use and 52% reported long-term cannabis abuse.
Participants with early-onset cannabis use presented a higher severity of cocaine withdrawal symptoms and specific cocaine craving symptoms at the 14° day of detoxification compared with those with late-onset cannabis use (see Table 1). In addition, a trend association was found between early-onset
Discussion
The current study shows that long-term cannabis abuse and early-onset cannabis use are associated with a worse detoxification treatment response in a cohort of female inpatients with cocaine dependence. More specifically, patients who exhibit more severe cocaine withdrawal symptoms at the end of two weeks of detoxification also reported early-onset cannabis use or a prolonged history of cannabis abuse. Such histories of cannabis consumption were associated with an increase, instead of a
Role of funding source
This study was supported by MCT/CT-Saúde—DECIT/SCTIE/MS, Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) (Grant number 402723/2010-4) and Fundação de Amparo à Pesquisa do Estado do Rio Grande do Sul (FAPERGS) (Grant number 11/1302-7). The funding source had no involvement in study design, in the collection, analysis and interpretation of data, in the writing of the report, and in the decision to submit the paper for publication.
Contributors
Authors Viola T.W., J.C. Pezzi and Grassi-Oliveira R. designed the study and wrote the protocol. Authors Viola T.W., Tractenberg S.G., Wearick-Silva, L.E. and Rosa, C.S.O., managed the literature searches and summaries of previous related work. Authors Viola T.W., Wearick-Silva, L.E. and Grassi-Oliveira R. undertook the statistical analysis, and authors Viola T.W. and Tractenberg S.G. wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript.
Conflict of interest
All authors declare that they have no conflicts of interest.
Acknowledgements
The authors would like to thank all members of GNCD and Sistema de Saúde Mãe de Deus.
References (41)
- et al.
Prevalence of cocaine use in Brazil: data from the II Brazilian National Alcohol and Drugs Survey (BNADS)
Addict. Behav.
(2014) - et al.
Contingency management is efficacious and improves outcomes in cocaine patients with pretreatment marijuana use
Drug Alcohol Depend.
(2011) - et al.
Sex differences in drug abuse
Front. Neuroendocrinol.
(2008) - et al.
Neural mechanisms of risky decision-making and reward response in adolescent onset cannabis use disorder
Drug Alcohol Depend.
(2013) - et al.
Childhood neglect and increased withdrawal and depressive severity in crack cocaine users during early abstinence
Child Abuse Negl.
(2013) - et al.
Reliability and validity of the cocaine selective severity assessment
Addict. Behav.
(1998) - et al.
Psychometric properties of the sixth version of the Addiction Severity Index (ASI-6) in Brazil
Rev. Bras. Psiquiatr.
(2012) - et al.
Early adolescent patterns of alcohol, cigarettes, and marijuana polysubstance use and young adult substance use outcomes in a nationally representative sample
Drug Alcohol Depend.
(2014) - et al.
Dose- and sex-dependent effects of the neurotoxin 6-hydroxydopamine on the nigrostriatal dopaminergic pathway of adult rats: differential actions of estrogen in males and females
Neuroscience
(2003) - et al.
Early onset of drug and polysubstance use as predictors of injection drug use among adult drug users
Addict. Behav.
(2012)
Addiction science: uncovering neurobiological complexity
Neuropharmacology
From first drug use to drug dependence; developmental periods of risk for dependence upon marijuana, cocaine, and alcohol
Neuropsychopharmacology
Concurrent cannabis use during treatment for comorbid ADHD and cocaine dependence: effects on outcome
Am. J. Drug Alcohol Abuse
Postdischarge cannabis use and its relationship to cocaine, alcohol, and heroin use: a prospective study
Am. J. Psychiatry
Cocaine withdrawal symptoms identify “Type B” cocaine-dependent patients
Am. J. Addict.
Types of alcoholics, I. Evidence for an empirically derived typology based on indicators of vulnerability and severity
Arch. Gen. Psychiatry
Sex differences in the neural mechanisms mediating addiction: a new synthesis and hypothesis
Biol. Sex Differ.
Does cannabis use increase the risk of death? Systematic review of epidemiological evidence on adverse effects of cannabis use
Drug Alcohol Rev.
Cannabis use during adolescent development: susceptibility to psychiatric illness
Front. Psychiatry
Reliability of the structured clinical interview for dsm-iv—clinical version translated into portuguese
Braz. J. Psychiatry
Cited by (19)
Examining predictors of cocaine withdrawal syndrome at the end of detoxification treatment in women with cocaine use disorder
2024, Journal of Psychiatric ResearchCannabis use to manage stimulant cravings among people who use unregulated drugs
2024, Addictive BehaviorsCo-exposure of cocaine and cannabinoids and its association with select biological, behavioural and health outcomes: A systematic scoping review of multi-disciplinary studies
2021, European NeuropsychopharmacologyCitation Excerpt :A Brazilian-based study with women undergoing a three-week inpatient treatment for cocaine use disorder (DSM-5) with occasional (n=29), frequent (n=47) or without (n=138) pre-enrolment cannabis use found frequent cannabis users to have higher cocaine withdrawal (p=0.028, 95%CI[0.61, 14.32], d=0.431) and depressive symptoms (p=0.030, 95%CI[0.31, 8.62], d=0.437) than non-cannabis users at treatment discharge (Viola et al., 2020). Data from a two-week inpatient cocaine detoxification treatment, also in Brazil, showed early-onset cannabis use (n=62) to be associated with elevated cocaine withdrawal and craving (p=0.044; p=0.004); long-term cannabis use (n=49) was associated with increased withdrawal symptoms (p=0.016; p=0.041) at select time-points and predicted higher re-hospitalisation at 2.5 years follow-up (p=0.036) (Viola et al., 2014). Another study among 1,183 individuals undergoing an outpatient-based treatment for cocaine use disorder, found that frequent (last 30 days, n=146) cannabis users had more cocaine use (f/x²=13.5, p<0.001), legal (f/x²=3.37, p=0.034) and psychiatric problems (f/x²=4.32, p=0.014) than occasional (n=403) or non- (n=634) cannabis users (Lindsay et al., 2009).
Distinct effects of cocaine and cocaine + cannabis on neurocognitive functioning and abstinence: A six-month follow-up study
2019, Drug and Alcohol DependenceCitation Excerpt :A more controlled study designed with both users of intranasal and smoked cocaine has shown that early age at first cannabis use and long-term exposure to cannabis were associated with more abstinence symptoms and craving for cocaine. Also, long-term cannabis use was associated with higher incidence of rehospitalization after 2.5 years of the first assessment (Viola et al., 2014). Confirming these findings, Giasson-Gariépy et al (2017) reported that cocaine-addicted individuals who also have cannabis abuse or dependence present a more relevant and persistent craving on cocaine.
Peripheral blood microRNA levels in females with cocaine use disorder
2019, Journal of Psychiatric ResearchCitation Excerpt :The hallmarks of the systemic pathophysiology of cocaine use disorder (CUD) include metabolic syndrome, as well as altered levels of neurotrophins, oxidative stress parameters, neuroendocrine hormones, and inflammatory cytokines (Grassi-Oliveira et al., 2012; Levandowski et al., 2016; Viola et al., 2015; Viola et al., 2014a,b; Virmani et al., 2007; Zaparte et al., 2015).
Trends and correlates of cocaine use and cocaine use disorder in the United States from 2011 to 2015
2017, Drug and Alcohol DependenceCitation Excerpt :Aharonovich et al. (2005) found that cocaine dependent patients who continuously used cannabis after treatment discharge had increased odds of relapsing to CU following sustained remission. Likewise, another study showed that early-onset cannabis use and long-term cannabis use disorder were associated with greater severity in cocaine withdrawal symptoms, increased cocaine craving, and rehospitilizations among cocaine dependent inpatients (Viola et al., 2014). Given the increased prevalence of cannabis use and cannabis use disorder among adults in the U.S. (Hasin and Grant, 2016), more research is needed to better understand how CU may intensify cannabis use problems and vice versa.