Cannabis is the most widely used illicit drug in the United States. Despite the fact that there are large numbers of people with cannabis dependence, relatively little attention has been paid to the treatment of this condition. This article seeks to critically review the existing literature about the various psychosocial and pharmacologic treatments of cannabis dependence. We begin with a discussion of the early treatment literature which draws primarily from anecdotal experience and open, uncontrolled trials and proceed through two recent, large, randomized controlled trials of psychotherapies for the treatment of cannabis dependence. We conclude that while a number of psychotherapies have been found to be effective in treating this disorder, with the exception of adding vouchers to reinforce negative urine toxicology screens, no form of psychotherapy has been found to be more effective than any other. In addition, we review the only two clinical pharmacotherapy trials for cannabis dependence as well as the pre-clinical laboratory pharmacotherapy trials in cannabis dependent individuals. We also review pertinent dual-diagnosis pharmacotherapy trials and discuss potential future directions in treatment research for the pharmacotherapy of cannabis dependence.

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Introduction: Opioid abuse has reached epidemic levels. Evidence-based treatments such as buprenorphine maintenance therapy (BMT) remain underutilized. Offering BMT in primary care settings has the potential to reduce overall costs of care, decrease medical morbidity associated with opioid dependence, and improve treatment outcomes. However, access to BMT, especially in rural areas, remains limited. This article will present a review of barriers to adoption of BMT among family physicians in a primarily rural area in the USA. Methods: An anonymous survey of family physicians practicing in Vermont or New Hampshire, two largely rural states, was conducted. The survey included both quantitative and qualitative questions, focused on BMT adoption and physician opinions of opioids. Specific factors assessed included physician factors, physicians' understanding of patient factors, and logistical issues. Results: One-hundred and eight family physicians completed the survey. Approximately 10% were buprenorphine prescribers. More than 80% of family physicians felt they regularly saw patients addicted to opiates. The majority (70%) felt that they, as family physicians, bore responsibility for treating opiate addiction. Potential logistical barriers to buprenorphine adoption included inadequately trained staff (88%), insufficient time (80%), inadequate office space (49%), and cumbersome regulations (37%). Common themes addressed in open-ended questions included lack of knowledge, time, or interest; mistrust of people with addiction or buprenorphine; and difficult patient population. Conclusions: This study aims to quantify perceived barriers to treatment and provide insight expanding the community of family physicians offering BMT. The results suggest family physicians are excellent candidates to provide BMT, as most report regularly seeing opioid-addicted patients and believe that treating opioid addiction is their responsibility. Significant barriers remain, including inadequate staff training, lack of access to addiction experts, and perceived efficacy of BMT. Addressing these barriers may lower resistance to buprenorphine adoption and increase access to BMT in rural areas.

Objectives Rapidly escalating rates of heroin and prescription opioid use have been widely observed in rural areas across the United States. Although US Food and Drug Administration-approved medications for opioid use disorders exist, they are not routinely accessible to patients. One medication, buprenorphine, can be prescribed by waivered physicians in office-based practice settings, but practice patterns vary widely. This study explored the use of a learning collaborative method to improve the provision of buprenorphine in the state of Vermont. Methods We initiated a learning collaborative with 4 cohorts of physician practices (28 total practices). The learning collaborative consisted of a series of 4 face-to-face and 5 teleconference sessions over 9 months. Practices collected and reported on 8 quality-improvement data measures, which included the number of patients prescribed buprenorphine, and the percent of unstable patients seen weekly. Changes from baseline to 8 months were examined using a p-chart and logistic regression methodology. Results Physician engagement in the learning collaborative was favorable across all 4 cohorts (85.7%). On 6 of the 7 quality-improvement measures, there were improvements from baseline to 8 months. On 4 measures, these improvements were statistically significant (P < 0.001). Importantly, practice variation decreased over time on all measures. The number of patients receiving medication increased only slightly (3.4%). Conclusions Results support the effectiveness of a learning collaborative approach to engage physicians, modestly improve patient access, and significantly reduce practice variation. The strategy is potentially generalizable to other systems and regions struggling with this important public health problem.