Research into pharmacotherapy for CUD has steadily grown from the late 1990s and early 2000s to the present. Given the nature of CUD and limitations noted above with psychosocial interventions, effective pharmacotherapy for CUD has been a goal of researchers and clinicians in the field of addiction treatment. The same issues with in person delivery in terms of success rates appear to apply to technologically delivered psychotherapy, in addition to being a nascent field requiring further research and the development of interfaces with larger scale implementation capabilities. Because of this, recent interest and promising studies utilizing technology to provide adherent psychotherapy demonstrates a role in the treatment of CUD ( Tait et al, 2013). In addition, coverage for psychotherapy from insurance companies is frequently limited both in number of sessions and reimbursement. Further, implementing CM techniques, including financial based incentives or vouchers can be challenging and requires a creative and motivated treatment setting. Notably, access to evidence-based psychotherapy is frequently limited ( Olmstead et al, 2012), and poor adherence to evidence-based psychotherapy by therapists is common ( Martino et al, 2009 Santa Ana et al, 2008). Longer duration of psychotherapy is associated with improved outcomes ( Sherman and McRae-Clark, 2016). CM can lead to longer periods of abstinence during treatment by incentivizing abstinence, and CBT can work to enhance abstinence following treatment (preventing relapse). Generally, MET is effective at engaging individuals who are ambivalent about treatment. These include motivational enhancement treatment (MET), cognitive behavioral therapy (CBT), and contingency management (CM), all of which have demonstrated effectiveness in reducing frequency and quantity of cannabis use, but abstinence rates remain modest (~20% continuous abstinence rates) and decline after treatment ( Gates et al, 2016).

Evidence-based psychotherapies have been studied to treat CUD, and various approaches have been shown to have clinical utility ( Budney et al, 2000 Budney et al, 2006 Copeland et al, 2001). Most heavy cannabis users interested in changing their use, are unsuccessful when left to their own devices ( Hughes et al, 2016). While this is only a small proportion of the estimated 4.2 million people who have CUD, there is a clear demand for treatment. Fifteen percent of all substance abuse treatment admissions were related to cannabis as the primary, presenting problem in 2014, amounting to roughly 300 000 people seeking treatment for a CUD in the United States ( SAMHSA, 2016). CUD results in significant impairment and disability ( Degenhardt et al, 2013), psychiatric and medical morbidity, poor performance, and legal consequences ( Dennis et al, 2002). In the United States, 4.2 million people have past-year CUD ( SAMHSA, 2015). It is estimated that anywhere from 8 to 12% of regular cannabis users will develop moderate-severe cannabis use disorder (CUD) over time ( Moss et al, 2012 Perkonigg et al, 2008). In terms of large-scale epidemiology, worldwide, cannabis is the most commonly used illicit psychoactive substance, and third overall, coming after alcohol and tobacco ( UN Office on Drugs and Crime, 2015). Coming to a consensus as a field and addressing these gaps in future research will likely lend itself to further advances in improving the lives of patients with CUD. As a field, the body of work also exposes some areas in need of improvement in study design, selection of outcome measures, interpretation of results, and the overall process of evaluating candidate medications. The current state of pharmacology research for CUD highlights the need to consider particular characteristics of patients, such as gender, impulsivity, and severity of cannabis use, when selecting a medication in the off-label treatment of CUD or cannabis withdrawal. While there are no clearly efficacious medication treatments for CUD, 20 years of committed and high-quality research in the human laboratory and clinical settings have resulted in medications with demonstrated effectiveness in the treatment of cannabis withdrawal, the ability to reduce cannabis use, and results that point to promising future work. Cannabis use disorder (CUD) commonly occurs and carries a notable economic and functional burden at both individual and societal levels.

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