Problematic Marijuana Use (Addiction): Characteristics, Prevalence, Treatment Outcomes Alan J. Budney, Ph.D. Dartmouth College, Geisel School of Medicine alan.j.budney@dartmouth.edu National Debate on Marijuana, Cancun, Mexico January 26, 2016
My Background Treatment Research for Substance Use (cannabis) problems for over 25 years Lab & Survey Studies: Cannabis Withdrawal DSM-5 Substance Use Disorders Workgroup
Goals / Conclusions for Today 1. Characterize cannabis use, misuse, or addiction - substantial abuse potential and consequences 2. Clinical Epidemiology: Prevalence of Problems - comparable or greater than other substances 3. Treatment Responsivity - efficacious treatments - but, like other substances: limited efficacy 4. Importance of dealing with cannabis in ways similar to other substances
Can Cannabis Use Lead to Addiction? Behavioral and Biological Evidence Functions as a reinforcer in the human laboratory People meet dependence criteria People seek help for marijuana problems Cannabinoid system in the brain Effects of administration and cessation on the brain are similar to that with other drugs of abuse Evidence for a Withdrawal syndrome It is difficult for those with problems to quit
Defining Addiction (Problem Use) Is Cannabis / Marijuana Addictive? DSM and ICD definitions Cannabis Use Disorder criteria are not different from other substances
How Does Cannabis Compare to Other Types of Dependence? Cannabis vs. Cocaine Cannabis Cocaine # of DSM criteria 6.3 (1.8) 7.7 (1.2)* Continued Use 97% 97% Cut Down 86% 93% Larger Amounts 80% 100%* Excessive time 73% 87%* Withdrawal 75% 81% Tolerance 63% 97%* Reduced Activities 41% 87%* indicates significant difference (Budney et al., 1998)
How Does Cannabis Dependence Compare to Other Types of Dependence? Treatment seekers meet 4.7-5.9 of the 7 DSM-IV criteria reflects a lower severity syndrome The structure of cannabis dependence is more similar than different than others - unidimensional, factor structure - full range of criterion items are endorsed - generally less severe Budney (2006)
Cannabis Use Disorder Similar to other SUDs Shmulewitz et al. 2015; Hasin et al. 2013 Review: Multiple International Studies (n > 30), large population-based studies Cannabis Use Disorder highly similar to other SUDS - unidimensional construct - full range of criterion are endorsed - most prevalent behind alcohol and tobacco
Cannabis Withdrawal Cannabis Withdrawal demonstrated in: Non-human studies (primate, rodent, dog) Clinical survey studies Human inpatient/outpatient laboratory studies Budney et al. 2004
True Withdrawal Syndrome (Hughes 1990) Reliable abstinence symptoms Not Rare Onset, with Transient Timecourse Pharmacological Specificity Clinical Importance
Severity Score Marijuana Withdrawal Withdrawal Discomfort Score (Budney et al. 2003) 10 8 6 4 * * * * * * 2 0 BL 1-5 1-3 4-6 7-9 10-12 13-15 16-18 19-21 22-24 25-27 28-30 Abstinence Days 31-33 34-36 37-39 40-42 43-45
Impact of oral THC (dronabinol) on Withdrawal Discomfort Score Budney et al, 2007 7 6 5 4 3 2 1 0 *** ** Base Placebo Base 10mg Base 30mg * diff from base, * diff from 10mg, * diff from 30mg
Mean Rating (0-3) Cannabis vs. Tobacco Withdrawal (Vandrey et al., 2005; Vandrey et al. 2008, Budney et al., 2009) Symptom Severity Cannabis Tobacco 3 2 1 0 Anger Diff Conc Dec App* Sleep Diff Shakiness Headache Str Dreams Irrit able Nausea Sweat* Rest less Craving* Depress Aggress Inc App* Stomach Pain Withdrawal Checklist Symptoms
Clinical Importance of Cannabis WD Similar in magnitude and severity to Tobacco Withdrawal - similar attributions about impact on quitting & relapse Cannabis users report using cannabis (or other substances) to relieve WD symptoms Patients complain of WD; indicate it makes quitting difficult # of WD symptoms predicts dependence severity 1-yr later and WD severity predicts rapid relapse (adolescents)
Cannabis Use Disorder is real, and when it occurs, it looks much the same as other types of SUDs
NESARC data 2002 vs. 2012 Prevalence of CUD Hasin et al. (2015)
NESARC data 2002 vs. 2012 Prevalence of CUD among Users Hasin et al. (2015)
NHSUD 2011 (Wu et al., 2013)
U.S. Treatment Admissions TEDS Data Set
Cannabis Use Disorder is common and it makes up a substantial proportion of treatment admissions!
How Effective is Treatment?
Published Randomized Trials Behavioral Treatments (Adults) Stephens, et al. (1994) SS, CBT Stephens, et al. (2000) Budney et al. (2000) Copeland et al. (2001) MTPG (2004) Budney et al. (2006) Carroll et al. (2006) Kadden et al. (2007) Kay-Lambkin (2009, 2011) Budney et al (2011, 2015) Carroll et al (2012, 2013) Litt et al. (2013) Hoch et al (2014) MET, CBT MET, MET/CBT, MET/CBT/CM MET/CBT MET, MET/CBT MET/CBT, CM, MET/CBT/CM MET/CBT, DC, MET/CBT/CM, DC/CM MET/CBT, CM, MET/CBT/CM MET/CBT (computerized) MET/CBT/CM (computerized) CBT, CM, CBT/CMabst, CBT/CMhmk CaseM, CBT/CMabst, CBT/CMhmk CANDIS (MET/CBT/Problem Solving)
Marijuana Treatment Project (2004) Reduction in Days of MJ Use
% Participants Abstinent % of Participants Abstinent (90 days) 80 70 60 50 40 30 20 10 0 DTC MET MET/CBT 4 Months 9 Months 15 Months
Add Motivational Incentives to MET/CBT (Budney et al. 2006); replicated in Carroll et al, 2006 and Kadden et al., 2007
Across Studies: Response Rates at Participant Level (unpublished) End Tx 6 m FU 12m FU MET Abstinent: 9% 10% 13% Improved: 17% 15% MET/CBT Abstinent: 23% 16% 23% Improved: 30% 25% MET/CBT/CM Abstinent: 43% 25-46% 28-37% CM only Abstinent: 40% 13-23% 14-17%
Summary of Adult Trials for CUD - MET, CBT, CM, MET/CBT are efficacious - Abstinence incentives (CM) enhance outcomes - Many people do not respond to these treatments ** Still much room for Improvement
Adolescent Treatment Literature Multiple types of family-based and group / individual behavioral efficacious interventions (Waldron 2008: review) Waldron et al. Liddle et al. Henggeler et al. Dennis et al./godley et al. Kaminer et al. Szapocznik et al. Stanger, Budney et al. FFT, CBT, combo MDFT MST MET/CBT, ACRA, FSN MET/CBT BSFT CM
Cannabis Youth Treatment Study Abstinence at Discharge (Dennis et al., 2004)
Incentives Enhance During and End of Treatment Marijuana Abstinence Stanger et al. 2015 MET/CBT MET/CBT/CM MET/CBT/CM/BPT 100 80 60 40 45 69 * * 72 * * * * 65 59 59 35 33 49 * 20 0 >=2 Wks >=4 Wks ETX
Post Treatment Abstinence 100 80 60 40 20 0 ETX 3 Months 6 Months 12 Months MET/CBT MET/CBT/CM MET/CBT/CM/BPT
Summary of Teen Trials for CUD/SUD - Multiple interventions are efficacious - Abstinence incentive (CM) enhance outcomes - % of teens improved appears lower than that observed with adults - Success rates in disadvantaged populations are low ** Still much, much room for Improvement
How Do We Improve? Behavioral and Neuro-science Provide Targets - Enhance Delivery Systems / Improve Access - Endogenous Cannabinoid System; Withdrawal Syndrome - Genetics - Impulsivity/Delay Discounting - Brain Function - Innovative Incentive Programs - Concurrent Tobacco Use - Target Non-responders - Innovative Use of Technology
Percentage of Participants Computer-assisted MET/CBT/CM Point Prevalence Abstinence Budney et al. 2011, 2015 60 MET n=16 tmet/cbt/cm n=29 cmet/cbt/cm n=30 50 40 30 20 10 0 ETX 3 mo 6 mo
Mean Cost Per Participant Study 2: Cost MET tmet/cbt/cm cmet/cbt/cm 700 600 500 400 300 200 100 0
Adaptive Treatments: Current Teen Study Sequential Multiple Assignment Randomized Trial (SMART): Targets Impulsive Decision Making and Nonresponders
Cannabis Use Disorders are not easily treated. Like for other SUDs, we have efficacious treatments, but many adults and teens do not respond. We need to find more effective treatments and treatment strategies!
CONCLUSIONS
CANNABIS HAS SUBSTANTIAL ADDICTIVE POTENTIAL! ADDICTION / PROBLEMATIC USE Pharmacology: e.g., impact on brain reward system (dopamine) dose, route of administration Availability / Access Cost Intrapersonal Factors (emotional/behavioral) Environmental Factors / Alternatives Societal Norms and Attitudes (perceived risk) Biological Vulnerability (genetic / congenital)
Cannabis is more similar than dissimilar to other substances that are considered substances of abuse Like other substances, cannabis is used primarily for its positive (and negative) reinforcing effects a subset of those who use cannabis will develop problems problems will range from mild to severe
Funding and Support National Institute on Drug Abuse: multiple research and training awards University of Vermont University of Arkansas for Medical Sciences Dartmouth College, Geisel School of Medicine
THANKS!!!! Faculty/Trainees Staff / Therapists Cathy Stanger Patty Costello Stephanie Fearer Eliza Wessinger Brent Moore Gray Norton Ryan Vandrey Leanna Delhey John Hughes Lee Whetstone Steve Higgins Doris Ogden Warren Bickel Jonathan Young Denise Walker Heath Rocha Roger Roffman Andrea Meier Bob Stephens Merrie Vannucci Pam Brown, Jen VanScoyoc Marlo Lowe Stacy Ryan Bobby Ward Amanda Elton / Clint Kilts Sarah Clark Jody Kamon Nancy Culbertson Dustin Lee, Jacob Borodovsky Stanley See, Hao Yang Ben Crosier Nick Tacke, Samantha Auty James Sargent Jennifer Darsie
Additional Slides
Cannabis Withdrawal Symptoms 1) irritability, anger, or increased aggression 2) nervousness or anxiety 3) sleep difficulty (insomnia) 4) decreased appetite or weight loss 5) restlessness 6) depressed mood 7) at least 1 physical symptom causing significant discomfort (stomach pain, shakiness/tremors, sweating, fever, chills, headache)
NSDUH 2011 (Wu et al., 2013)
Adolescent Treatment Admissions TEDS Data Set
Admissions x Criminal Justice Involvement TEDS Data Set