Recent studies offer new insights into the prevalence and processes of remission/recovery from cannabis use disorders.
When I first entered the rising addiction treatment system in the United States nearly half a century ago, there existed no clinical concept of cannabis dependence and thus no concept of recovery from this condition. In early treatment settings, cannabis was not consider a "real" drug, the idea of cannabis addiction was scoffed at as remnants of "Reefer Madness", and casual cannabis use was not uncommon among early staff working in addiction treatment programs of the 1960s. In the years since, in spite of waves of pro-marijuana agitation, there are clear data supporting the dependency-producing properties of cannabis, a clear conceptualization of cannabis use disorders (CUD) and cannabis dependence (CD)--with 1.6% of the U.S. general population reporting CD, and 18% of people entering addiction treatment in the U.S. reporting cannabis as their primary drug. But what do we know from the standpoint of science about long-term recovery from CUDs Until recently, very little, but two new studies offer important starting points.
The first study by Farmer and colleagues examined the long-term course of CUD from childhood to age 30 among a subset of 816 youth participating in the Oregon Adolescent Depression Project who met CUD diagnostic criteria. The second study by Feingold and colleagues followed 414 individuals who met CUD diagnostic criteria within two waves of the National Epidemiologic Survey on Alcohol and Related Conditions. Three earlier studies led respectively by von Sydow, Lopez-Quintero, and Perkonigg as well as a systematic review by Calabria and colleagues add to the robustness of the initial conclusions we will outline below from these latest studies.
First it is important to note that there are continued differences in the definitions of remission and recovery that make comparison across studies difficult. CUD remission most often refers to individuals who met lifetime CUD diagnostic criteria at baseline but did not meet CUD criteria during the past 12 months preceding follow-up, with both abstinence and non-abstinence patterns of remission included in the reported remission rates. The broader concept of recovery has been increasingly defined as sobriety (or diagnostic remission), plus enhancements in global health, and positive changes in the person-community relationship (See here, here, and here). The studies highlighted here focus primarily on remission outcomes and reveal that:
- Full remission from cannabis-related problems is possible and probable. Remission from CUD Is the norm, with high rates of recovery reported in the short term follow-up (67% by 3 years) and long-term follow-up (82% by age 30; 90% lifetime remission rate) of those meeting initial CUD criteria.
- Remission patterns vary by gender, but remission rates do not. CUD remission rates are similar for men and women, but women with CUDs in available studies experienced a more rapid onset and stabilization of remission than men.
- Remission takes time. The mean time span between CUD onset and stable remission (including the one year stabilization period) has been reported as 32.5 months.
- CUD remission styles vary. Some people with CUDs achieve remission through deceleration of the frequency and intensity of cannabis use rather than through total abstinence (37% in Feingold study), with the overall odds of successful non-abstinence remission less likely for those diagnosed with more severe disorders, e.g., CD.
- Problem severity matters, but all efforts to decrease or cease use can contribute to remission and recovery across levels of severity. Heavy cannabis users in remission were less likely to achieve abstinence-based remission, but were able to decelerate use and its consequences below diagnostic levels.
- Multiple drug use matters; these broader risk factors must be personally and clinically addressed. Cannabis users reporting multiple drug use and greater medical problems were more likely to achieve remission compared to the cannabis only users perhaps a function of greater consequences of their total drug use.
- Abstinence styles of CUD remission may bring added benefits. Abstinence-based CUD remissions were more likely to produce enhancements in global functioning (e.g., full-time employment following remission) than non-abstinent remission patterns.
- CUD remission can be fragile during its early stages but strengthens over time, suggesting the need for assertive and continuous management, particularly during the first months and years of remission. Once achieved (one-year of continuous remission), the recurrence rate for CUDs before age 30 was reported by Farmer and colleagues at 28%, with CUD recurrence rare after 60 months of stable remission. The mean time from remission to recurrence was 46 months--a finding that supports the use of recovery check-ups and the availability of recovery support services during the first 5 years of remission.
As is always the case with scientific studies breaking new ground, the preliminary conclusions outlined above remain on probation pending future replication and refinement in study methodologies. We are beginning to learn about the prevalence and processes of remission from cannabis use disorders, but the question remains about the quality of life of those who once experienced such disorders. Answering those questions will require studies that go beyond remission to explore the more global process of recovery. These first rigorous studies on remission and recovery in cannabis use disorders offer hope to affected individuals and families, and they provide critical information for the design of long-term recovery support strategies. The day is past when those with cannabis use disorders are invisible within the worlds of addiction treatment and recovery support.
Study References
Calabria, B., Degenhardt, L., Briegleb, C., Vos, T., Hall, W. Lynskey, M., McLaren, J. (2010). Systematic review of prospective studies investigatingremission? from amphetamine, cannabis, cocaine or opioid dependence. Addictive Behaviors, 35, 741-749.
Farmer, R. F., Kosty, D. B., Seeley, J. R., Duncan, S. C., Lynskey, M. T., Rohde, P., et al. (2014). Natural course of cannabis use disorders. Psychological Medicine, 45, 63?72.
Feingold, D., Fox, J., Rehm, J., & Lev-Ran, S. (2015). Natural outcome of cannabis use disorder:A 3-year longitudinal follow-up. Addiction, 110, 1963-1974.
Lopez-Quintero, C., Hason, D. J., de los Cobas, J. P., Pines, A., Wang, S., Grant, B. F., & Blanco, C. (2010). Probability and predictors of remission from life-time nicotine, alcohol, cannabis or cocaine dependence: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Addiction, 106(3), 657-669.
Perkonigg, A., Lieb, R., H?fler, M., Schuster, P., Sonntag, H., & Wittchen, H. U. (1999). Patterns of cannabis use, abuse and dependence over time: incidence, progression and stability in a sample of 1228 adolescents. Addiction, 94(11), 1663-78.
von Sydow, K., Lieb, R., Pfister, H., H?fler, M., Sonntag, H., & Wittchen H.U. (2001). The natural course of cannabis use, abuse and dependence over four years: a longitudinal community study of adolescents and young adults. Drug & Alcohol Dependence, 64, 347?61.