Relapse in outpatient treatment for marijuana dependence

Journal of Substance Abuse Treatment 25 (2003) 85 89 Regular article Relapse in outpatient treatment for marijuana dependence Brent A. Moore Ph.D. a, *, Alan J. Budney, Ph.D. a,b a Department of Psychiatry, University of Vermont, 111 Colchester Avenue, Burlington, VT 05401, USA b Department of Psychology, University of Vermont, 2 Colchester Avenue, Burlington, VT 05405, USA Received 7 February 2003; received in revised form 15 March 2003; accepted 1 May 2003 Abstract The current study provides an initial examination of lapse and relapse to marijuana use among 82 individuals who achieved at least 2 weeks of abstinence during outpatient treatment for marijuana dependence. Seventy-one percent used marijuana at least once (i.e., lapsed) within 6 months of initial abstinence, averaging 73 days (SD = 50) till lapsing. Similarly, 71% of those who lapsed, relapsed to heavier use defined as at least 4 days of marijuana use in any 7-day period. Early lapses were more strongly associated with consequent relapse. Previous studies have noted that marijuana-dependent outpatients experience difficulty initiating abstinence from marijuana much as do those dependent on other substances. The present data suggest that these similarities extend to difficulty maintaining abstinence. D 2003 Elsevier Inc. All rights reserved. Keywords: Relapse; Marijuana dependence; Cannabis; Treatment; Lapse 1. Introduction Perhaps the most frustrating aspect of substance abuse treatment is the frequency with which individuals achieve abstinence during treatment but subsequently return to use. Such use might be restricted to a single instance (lapse), yet often individuals relapse to problematic levels of use that require additional episodes of treatment. Lapse and relapse rates have been thoroughly examined with treatments for alcohol, cocaine, nicotine, and opiate dependence (Hunt, Barnett, & Branch, 1971; Siegal, Li, & Rapp, 2002). However, the scientific literature regarding treatment for marijuana use disorders is much younger, and only a handful of clinical trials have been conducted (e.g., Budney, Higgins, Radonovich, & Novy, 2000; Copeland, Swift, Roffman, & Stephens, 2001; Lang, Engelander, & Brooke, 2000; Stephens, Roffman, & Curtin, 2000). Detailed analysis of lapse and relapse rates observed with treatment for marijuana dependence have yet to be reported. Relapse is generally defined as a return to use following a period of abstinence. The degree of use can vary from a single instance, commonly referred to as a lapse, to more * Corresponding author. Yale University School of Medicine, 219S CMHC-SAC, 34 Park Street, New Haven, CT 06519. Tel.: +1-203-974-7382; fax: +1-203-974-7606. E-mail address: Brent.Moore@yale.edu ( B.A. Moore). frequent and problematic use, commonly referred to as relapse. In a seminal study on treatments for alcohol, opiates, and tobacco smoking, approximately 65% to 75% of patients had lapsed within 6 months of inpatient treatment (Hunt et al., 1971). More recently, even higher rates of lapse (65 80%) have been reported for alcohol, opiate, and tobacco dependence treatments (Brandon, Tiffany, Obremski, & Baker, 1990; Gossop, Green, Phillips, & Bradley, 1989; Hughes et al., 1992; Miller, 1996), and lower rates have been observed with cocaine dependence (45 50%; McKay, Alterman, Mulvaney, & Koppenhaver, 1999; Siegal et al., 2002). Rates for relapse vary across substances and are generally less consistent than lapse rates, primarily because definitions of relapse have varied substantially, from several uses to a return to pretreatment level of use. For example, 6-month relapse rates for treatment of heroin dependence have been reported as approximately 30% when defined as daily heroin use (Gossop et al., 1989), and as 90% when defined as at least 4 days of use in any 7-day period (Hall, Havassy, & Wasserman, 1990). Using the same criteria of at least 4 days of use in any 7-day period, relapse rates for alcohol and tobacco dependence were approximately 50%. Early research (i.e., Hunt et al., 1971) commonly examined relapse after inpatient treatment that defined the period of abstinence achieved. Unfortunately, later studies examining relapse in outpatient treatment generally have not controlled 0740-5472/03/$ see front matter D 2003 Elsevier Inc. All rights reserved. doi:10.1016/s0740-5472(03)00083-7

86 B.A. Moore, A.J. Budney / Journal of Substance Abuse Treatment 25 (2003) 85 89 for or documented the amount of abstinence achieved during treatment. The duration of initial abstinence achieved is an important factor that likely influences relapse (Higgins, Badger, & Budney, 2000). In general, rates of lapses and relapse are difficult to compare across studies due to differences in substance of abuse, duration and context of the initial abstinence period, length of followup, and characteristics of the sample. Previous studies of outpatient treatment for marijuana dependence have reported treatment outcomes (Budney et al., 2000; Copeland et al., 2001; Stephens et al., 2000), but detailed depictions of lapse and relapse including relapse rates, time to relapse, and patient characteristic predictors of relapse have not been published. One study examined characteristics of lapses that predict relapse to marijuana use following treatment (Stephens, Curtin, Simpson, & Roffman, 1994). Individuals who attributed their lapse to internal, stable, and global causes were more likely to relapse to regular use, and the frequency of marijuana use prior to treatment was found to predict future relapse. Among individuals who lapsed at 1 and 3-month followups, only 21% reported returning to regular marijuana use (relapse) by the 3-month followup. The current study provides an initial description of the relapse process among participants in outpatient marijuana dependence treatment who achieved 2 weeks of abstinence during treatment. Two weeks of abstinence was arbitrarily chosen because it is a longer period of abstinence than dependent marijuana users typically experience (Swift, Hall, & Copeland, 2000); it represents a clinically significant period of abstinence with other substances of abuse (Garvey, Bliss, Hitchcock, Heinold, & Rosner, 1992; Higgins et al., 2000; Morral, Belding, & Iguchi, 1999); and a significant proportion of marijuana-dependent outpatients achieved it in this study (54%). Lapse to single use of marijuana and relapse defined as use on at least 4 days of use in any 7-day period were examined. Such use subsequent to the 2-week abstinence period was studied during and after treatment rather than just post treatment because unlike inpatient treatment, the opportunity to lapse or relapse can occur during outpatient treatments. 2. Materials and methods 2.1. Participants Of 152 adult participants who enrolled in treatment for marijuana dependence during two clinical trials, 82 (54%; 66 men and 16 women) achieved 2 or more weeks of abstinence (Budney et al., 2000; Budney, Moore, & Rocha, 2002). The 2 weeks of abstinence could occur at any point during treatment, but occurred within the first 6 weeks for all but 8 (10%) participants. The studies were approved by the University of Vermont Medical Institutional Review Board, and all participants signed an informed consent prior to participation. Participants were not paid for participation in the research study, but instead received free marijuana treatment. The 2-week definition of abstinence was based on self-reported marijuana use during treatment. Because it can take 2 to 4 weeks of continuous abstinence for a chronic, daily marijuana smokers to test negative at the 50 ng/ml cutoff level for 11-nor-D-9-THC-9-carboxylic acid (D-9- THC; Hawks & Chiang, 1986), we regarded a single urine screen following self-reported abstinence as verification of at least 2 weeks of self-reported abstinence. Abstinence was verified by one or more cannabinoid-negative urine screens for 95% of the sample. Four individuals did not provide a cannabinoid-negative urine sample although they reported more than 3 weeks of abstinence. Participants were predominantly white (98%) and ranged in age from 18 to 55 years (M = 32.70, SD = 8.9). Most had at least a high-school education (93%), were employed full-time (63%), and about half (51%) were married. The DSM criteria checklist (Hudziak et al., 1993) is a semi-structured interview that was used to diagnose substance abuse and dependence. All participants met DSM-III-R (American Psychiatric Association, 1987) or DSM-IV (American Psychiatric Association, 1994) criteria for current marijuana dependence. All participants used marijuana 20 or more days during the month prior to treatment (M = 23.1, Mdn = 26, SD = 8.6), with an average frequency of 3.6 times (SD = 2.6) per day. Mean years of regular marijuana use was 14.7 years (SD = 8.8). Demographic, marijuana use, and other subject characteristics were comparable across the two trials, so data were collapsed across studies. Exclusion criteria were current dependence on alcohol or any other drug except nicotine (n = 12), active psychosis or other severe psychiatric or medical disorder that would impede participation in outpatient counseling (n = 3), or a legal problem for which incarceration was imminent (n = 5). Participants were not excluded for other substance abuse, which was rare (n = 2). 2.2. Procedure All participants received one of four 14-week treatments (see Budney et al., 2000, 2002). Motivational enhancement (M) included four 60 90 min individual therapy sessions adapted from an empirically-based treatment for alcohol dependence (National Institute on Alcohol Abuse and Alcoholism [NIAAA], 1992b). Motivational enhancement combined with behavioral coping-skills therapy (MBT) involved fourteen 60-min individual therapy sessions similarly adapted from an empirically-based treatment for alcohol dependence (NIAAA, 1992a). Motivation and behavioral treatment plus vouchers (MBTV) included the same therapy as MBT, integrated with an abstinence-based voucher program in which participants received vouchers twice-weekly for providing marijuana negative urine screens (Budney & Higgins, 1998). The fourth treatment was voucher only (V). Voucher participants received an

B.A. Moore, A.J. Budney / Journal of Substance Abuse Treatment 25 (2003) 85 89 87 individual introductory session and self-help materials (e.g., a brochure on quitting marijuana) in addition to the voucher program. Therapists encouraged abstinence as the primary goal in all conditions. The first trial compared M to MBT and MBTV (Budney et al., 2000), while the second trial examined MBT, MBTV and V (Budney et al., 2002). During the 14 weeks of treatment, participants came to the clinic on a twice-weekly fixed schedule. At each visit participants reported their marijuana and other drug use on a daily basis since their last visit and provided urine specimens under same-gender staff observation. Specimens were screened for D-9-THC using a cutoff of 50 ng/ml via an onsite Enzyme-Multiplied Immunoassay Technique (Dade- Behring, San Jose, CA) and failure to submit a specimen was treated as positive. Post-treatment followup assessments were scheduled on a monthly basis for 6 months after treatment. The Time-Line Follow-Back (TLFB; Sobell & Sobell, 1992) was used to record daily self-reported marijuana and other drug use since the participant s last assessment. The followup also included urinalysis; however, failure to complete a scheduled followup assessment was not treated as a positive urine screen. 2.3. Lapse and relapse The Time-Line Follow-Back was used to obtain amount and frequency of daily marijuana use for 30 days prior to the intake assessment, throughout treatment, and at subsequent followups. A lapse was defined as the first selfreported use of marijuana or a positive marijuana urine screen following the 2 weeks of initial abstinence. Relapse was defined as at least 4 days of marijuana use in any 7-day period consistent with Hall et al. (1990). Lapse and relapse data based on the TLFB were examined 6 months post each participant s initial 2-week abstinence period. TLFB data following relapse were not available for 6 participants because they dropped out of the followup process after relapsing. The process of lapse and relapse were examined descriptively using survival analysis and the percent of participants who lapsed or relapsed at specific time points. Because the clinical trials were designed to determine the efficacy of different treatments, Cox regression was used to examine whether survival curves differed among the treatment groups. Wald statistics are reported. regression survival analysis indicated that time till lapse was not significantly influenced by treatment group, z (3) = 0.65, p =.88. Additionally, the survival curves of the treatment groups appeared similar based on visual inspection (data not presented). 3.2. Relapse Of the 58 participants who lapsed to marijuana use, 71% (n = 41) fulfilled relapse criteria defined as use on at least 4 days of any 7-day period. The mean number of days till relapse was 83.2 (SD = 44.4), and all who relapsed did so within 90 days of their first lapse (M = 24.2, SD = 24.3). The extent to which early lapses predicted later relapse was examined using logistic regression. Participants who lapsed within 45 days of their initial 2-week period of abstinence were more likely to meet relapse criteria within the next 3 months (90%), than those who lapsed 45 to 90 days after achieving 2-week abstinence (69%), although this difference was not significant, m 2 = 3.36, p =.07. The time to relapse was not significantly influenced by treatment group, z (3) = 2.35, p =.50, nor did the individual treatment relapse curves appear substantially different (data not presented). For individuals who relapsed, we also examined the pattern of marijuana use following the relapse. Six months of TLFB data were available for 35 of the 41 participants who relapsed. Use was categorized for each month as either 0 to 5 days, 6 to 14 days, or 15 or more days. For example, two participants used 15 or more days per month for all of the 6 months following relapse, while one participant used 0 to 5 days per month for the first 2 months and then 15 or more days for months 3 through 6. All but one participant 3. Results 3.1. Lapse Seventy-one percent (n = 58) of participants lapsed to marijuana use within 6 months, 46% within 3 months, and 24% within 1 month (see Fig. 1). The mean number of days till lapse was 73.5 days (SD = 49.7) and rate of new lapses appeared relatively stable over the 6-month period. A Cox Fig. 1. Days to first marijuana use following 2 weeks of continuous abstinence during outpatient treatment.

88 B.A. Moore, A.J. Budney / Journal of Substance Abuse Treatment 25 (2003) 85 89 (97%) had some period of heavy marijuana use (15 or more days/month), and the majority (n = 25, 71%) used heavily for 4 or more months. Periods of minimal use (5 or fewer days/month) following heavy use were rare (n = 4), indicating that once relapse occurred, participants experienced substantial difficulty returning to reduced use during the 6- month period examined. 4. Discussion This initial study of the relapse process suggests that lapse and relapse are common among marijuana-dependent outpatients. The majority of participants (71%) who achieved 2 weeks of continuous abstinence during outpatient treatment for marijuana dependence lapsed to marijuana use within 6 months. These lapse rates appear similar to studies of alcohol, opiate, and tobacco smoking (Brandon et al., 1990; Gossop et al., 1989; Hughes et al., 1992; Miller, 1996), although higher than the few studies of cocaine (McKay, Alterman, Mulvaney, & Koppenhaver, 1999; Siegal et al., 2002). The current study also found that 71% of lapsers went on to exhibit full relapse defined as 4 or more days of use per week. These rates are substantially higher than the 21% reported by Stephens et al. (1994), the only other reported relapse rates among adult marijuana abusing individuals in outpatient treatment. The substantially lower relapse rate that they reported may be due to the different definitions of relapse or the different length of followup across studies, or possibly to the treatments provided. On the other hand, Hall and her colleagues (1990) did use the same relapse criteria used in the present study and found rates of 67% among cigarette smokers, 90% among alcohol dependent, and 92% among heroin-dependent clients. Several methodological limitations of the study warrant discussion. First, the selection criteria were limited to marijuana-dependent individuals who were not dependent on other substances. Individuals with multiple drug dependence disorders may be more susceptible to lapse and relapse (Gossop, Stewart, Browne, & Marsden, 2002). Note, however, that the sample in the current study only excluded 7% of subjects because of other dependence diagnoses, which is similar to that observed in other studies specific to treatment of marijuana-dependent adults (Stephens, Roffman, & Simpson, 1993). Second, the sample was predominantly male and white. Although marijuana users who seek treatment are most commonly male and white (Copeland, Swift, & Rees, 2001; Stephens et al., 1993), we did not examine gender or other group differences. Relapse rates for women and minority marijuana users may differ from those reported here, and at least one study has reported higher rates of relapse to tobacco use for women (Ward, Klesges, Zbikowski, Bliss, & Garvey, 1997). Third, marijuana use data during and after treatment was primarily based on selfreport, although some lapses were determined by positive urine screens despite reports of abstinence. Detection of even minimal use was likely during treatment due to frequent testing; however, undetected use could have occurred between followups. Despite its limitations, selfreported substance use is the basis of most other studies of lapse and relapse, and is considered to have acceptable reliability and validity (e.g., Gossop et al., 1989, 2002; Hall et al., 1990; Miller, 1996; Siegal et al., 2002). Fourth, this study examined lapse and relapse across different types of outpatient treatment. Although no treatment differences were observed in the survival analysis, the small sample size within each treatment modality provided insufficient power to fully determine the extent to which different treatments influence relapse. Last, the overall sample size was relatively small, and although lapse and relapse rates found in the current study were similar to rates found with other drugs of abuse, replication with larger samples of marijuana users in treatment is needed. We and others have previously noted that marijuanadependent outpatients experience similar difficulty initiating abstinence as do those dependent on other substances (Budney & Moore, 2002; McLellan, 2001). The present data suggest that these marijuana-dependent adults also experience similar difficulty maintaining abstinence. Consequently, as with those dependent upon other drugs of abuse, marijuana-dependent individuals may benefit from extended treatment or aftercare programs designed to assist individuals maintain initial gains achieved during treatment (McKay, Alterman, Cacciola, et al., 1999). Additional research is needed to identify individual, treatment, or post-treatment characteristics that predict sustained abstinence. Acknowledgments We wish to thank the staff and therapists of the Treatment Research Center for their contribution to this paper. This research was supported by grant R01-DA12157 and National Training Award T32-DA07242 from the National Institute on Drug Abuse. This paper was presented, in part, at the 2002 annual scientific convention of the American Psychological Association, Chicago, IL. References American Psychiatric Association. (1987). Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.). Washington, DC. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC. Brandon, T. H., Tiffany, S. T., Obremski, K. M., & Baker, T. B. (1990). Postcessation cigarette use: The process of relapse. Addictive Behaviors, 15, 105 114. Budney, A. J., & Higgins, S. T. (1998). A community reinforcement plus vouchers approach: Treating cocaine addiction. Rockville, MD: USDHHS. Budney, A. J., Higgins, S. T., Radonovich, K. J., & Novy, P. L. (2000). Adding voucher-based incentives to coping-skills and motivational

B.A. Moore, A.J. Budney / Journal of Substance Abuse Treatment 25 (2003) 85 89 89 enhancement improves outcomes during treatment for marijuana dependence. Journal of Consulting and Clinical Psychology, 68, 1051 1061. Budney, A. J., & Moore, B. A. (2002). Development and consequences of cannabis dependence. Journal of Clinical Pharmacology, 42, S1 S6. Budney, A. J., Moore, B. A., & Rocha, H. L. (2002). [Treatment outcome for 3 behavioral treatments of marijuana dependence]. (Unpublished raw data). Copeland, J., Swift, W., & Rees, V. (2001). Clinical profile of participants in a brief intervention program for cannabis use disorder. Journal of Substance Abuse Treatment, 20, 45 52. Copeland, J., Swift, W., Roffman, R., & Stephens, R. (2001). A randomized controlled trial of brief cognitive-behavioral interventions for cannabis use disorder. Journal of Substance Abuse Treatment, 21, 55 64. Garvey, A. J., Bliss, R. E., Hitchcock, J. L., Heinold, J. W., & Rosner, B. (1992). Predictors of smoking relapse among self-quitters: A report from the normative age study. Addictive Behaviors, 17, 367 377. Gossop, M., Stewart, D., Browne, N., & Marsden, J. (2002). Factors associated with abstinence, lapse or relapse to heroin use after residential treatment: Protective effect of coping responses. Addiction, 97, 1259 1267. Gossop, M., Green, L., Phillips, G., & Bradley, B. (1989). Lapse, relapse, and survival among opiate addicts after treatment: A prospective follow-up study. British Journal of Psychiatry, 154, 348 353. Hall, S. M., Havassy, B. E., & Wasserman, D. A. (1990). Commitment to abstinence and acute stress in relapse to alcohol, opiates, and nicotine. Journal of Consulting and Clinical Psychology, 58, 175 181. Hawks, R. L., & Chiang, C. N. (1986). Examples of specific drugs. In R. L. Hawks, & C. N. Chiang (Eds.), Urine testing for drugs of abuse. Washington, DC: U.S. Government Printing Office (NIDA Research Monograph # 73, pp. 84 112). Higgins, S. T., Badger, G. J., & Budney, A. J. (2000). Predictors of abstinence and relapse in behavioral treatments for cocaine dependence. Experimental and Clinical Psychopharmacology, 8, 377 386. Hudziak, J., Helzer, J. E., Wetzel, M. W., Kessel, K. B., McBee, B., Janca, A., & Przybeck, P. (1993). The use of the DSM-III-R Checklist for initial diagnostic assessments. Comprehensive Psychiatry, 34, 375 383. Hughes, J. R., Gulliver, S. B., Fenwick, J. W., Valliere, W. A., Cruser, K., Pepper, S., Shea, P., Solomon, L. J., & Flynn, B. S. (1992). Smoking cessation among self-quitters. Health Psychology, 11, 331 334. Hunt, W. A., Barnett, W., & Branch, L. G. (1971). Relapse rates in addiction programs. Journal of Consulting and Clinical Psychology, 27, 455 456. Lang, E., Engelander, M., & Brooke, T. (2000). Report of an integrated brief intervention with self-defined problem cannabis users. Journal of Substance Abuse Treatment, 19, 111 116. Morral, A. R., Belding, M. A., & Iguchi, M. Y. (1999). Identifying methadone maintenance clients at risk for poor treatment response: Pretreatment and early progress indicators. Drug and Alcohol Dependence, 55, 25 33. McKay, J. R., Alterman, A. I., Cacciola, J. S., O Brien, C. P., Koppenhaver, J. M., & Shepard, D. S. (1999). Continuing care for cocaine dependence: Comprehensive 2-year outcomes. Journal of Consulting and Clinical Psychology, 67, 420 427. McKay, J. R., Alterman, A. I., Mulvaney, F. D., & Koppenhaver, J. M. (1999). Predicting proximal factors in cocaine relapse and near miss episodes: Clinical and theoretical implications. Drug and Alcohol Dependence, 56, 67 78. McLellan, A. T. (2001). A commentary on A randomized controlled trial of brief cognitive-behavioral interventions for cannabis use disorder. Journal of Substance Abuse Treatment, 21, 65 66. Miller, W. R. (1996). What is a relapse? Fifty ways to leave the wagon. Addiction, 91, S15 S27. National Institute on Alcohol Abuse and Alcoholism. (1992a). Cognitivebehavioral coping skills therapy manual. Rockville, MD: Author (DHSS Publication No. ADM 92 1895). National Institute on Alcohol Abuse and Alcoholism. (1992b). Motivational enhancement therapy manual. Rockville, MD: Author (Vol. DHSS Publication No. ADM 92 1894). Siegal, H. A., Li, L., & Rapp, R. C. (2002). Abstinence trajectories among treated crack cocaine users. Addictive Behaviors, 21, 437 449. Sobell, L. C., & Sobell, M. B. (1992). Timeline follow-back: A technique for assessing self-reported alcohol consumption. In J. P. Allen & R. Z. Litten (Eds.), Measuring alcohol consumption: psychosocial and biochemical methods. ( pp. 41 72). Totowa, NJ: Humana Press. Stephens, R. S., Curtin, L., Simpson, E. E., & Roffman, R. A. (1994). Testing the abstinence violation effect construct with marijuana cessation. Addictive Behaviors, 19, 23 32. Stephens, R. S., Roffman, R. A., & Curtin, L. (2000). Comparison of extended versus brief treatments for marijuana use. Journal of Consulting and Clinical Psychology, 68, 898 908. Stephens, R. S., Roffman, R. A., & Simpson, E. E. (1993). Adult marijuana users seeking treatment. Journal of Consulting and Clinical Psychology, 61, 1100 1104. Swift, W., Hall, W., & Copeland, J. (2000). One year follow-up of cannabis dependence among long-term users in Sydney, Australia. Drug and Alcohol Dependence, 59, 309 318. Ward, K. D., Klesges, R. C., Zbikowski, S. M., Bliss, R. E., & Garvey, A. J. (1997). Gender differences in the outcome of an unaided smoking cessation attempt. Addictive Behaviors, 22, 521 533.