Treating Marijuana Disorders: Science and Practice Denise D. Walker, Ph.D. University of Washington Supported by NIDA Goals Context for the study of cannabis dependence Overview of the evidence for treatments for cannabis dependence Description of these interventions Highlight innovations Limitations and Future Directions
Is Cannabis Addictive? Small treatment literature Scientific community Cannabis addiction as secondary problem Would people seek treatment for cannabis? Societal perceptions Cannabis is not addictive Does not cause problems Hempfest
Needs Assessment Study Roffman & Barnhart, 1987 Anonymous telephone survey Purpose of the study was to determine: Did a cannabis dependent population exist? Not concurrently abusing alcohol or other drugs? Would they be interested in treatment for cannabis? 225 participants interviewed 74% had problems only with cannabis 92% were interested in treatment Cannabis Withdrawal Cannabis (cannabinoid) withdrawal has been demonstrated in: Non-human studies (primate, rodent, dog) Clinical survey studies Human inpatient/outpatient laboratory studies
Adult Treatment Outcome Literature Randomized Controlled Studies Stephens, Roffman et al. (1994) Stephens, Roffman et al. (2) Budney et al. (2) Copeland et al. (21) Marijuana Treatment Project (24) Budney et al. (26) Carroll et al. (26) Kadden et al. (27) Types of Treatment Adult Treatment Outcome Literature Social Support Group Cognitive Behavior Therapy (CBT) Group Individual Motivational Enhancement Therapy (MET) Contingency Management (CM)
Cognitive-Behavior Therapy (CBT) Cannabis use is a learned behavior Structured 45-6 minute sessions Teaching coping skills relevant to quitting cannabis and coping with other related problems that might interfere with good outcome. Drug refusal skills, coping with cravings, selfmanagement planning to avoid drug-use triggers, problem-solving, communication skills, lifestyle-goal management. Brief didactic introduction of skill, role-playing, interactive exercises, practice assignments Typically delivered in 9-12 sessions, but has been tested in a 1 and 6-session model. Motivational Enhancement Therapy (MET) Patient-centered and directive 45-9 minute sessions. Designed to help resolve ambivalence about quitting and strengthen motivation to change. Delivered in 1-4 sessions
Motivational Enhancement Therapy (MET) continued Use a motivational style to guide the patient towards commitment to and action towards an abstinence goal. Techniques: expression of empathy, reflection, summarization, affirmation of self-efficacy, exploration of pros and cons of drug use, rolling with resistance, forging a goal plan when ready Review of Personalized Feedback form Personalized Feedback Report (PFR) Assessment Report reviewed with counselor using MI skills PFR includes: Use patterns Normative data Consequences of Use Abuse and Dependence symptoms Pros and cons of quitting
CBT vs. Social Support Group Treatments (Stephens et al., 1994) % Ss Abstinent 1 9 8 7 6 5 4 3 2 1 CBT SS 3 mo 6 mo 12 mo CBT vs. Brief MET CBT: 14-sessions, MET: 2 sessions (Stephens et al., 2) % Ss Abstinent 1 9 8 7 6 5 4 3 2 1 CBT MET DTC 1mo 4 mo 7 mo
Marijuana Treatment Project (MTPG, 24) A Multi-site Study of the Effectiveness of Brief Treatment for Cannabis Dependence (N=398) 3 Groups: 9-session MET/CBT (individual) 2-session MET (individual) Delayed Treatment Control (No treatment) MTPG Study Questions Are brief treatments for Cannabis Dependence more effective than deferred treatment (referral to a waiting list control group)? Does a 9 session treatment produce better outcomes than a 2 session treatment? Do these treatments vary in effectiveness in diverse population groups in relation to gender, ethnicity, and employment status?
% Subjects Abstinent 25 2 15 1 5 Cannabis Abstinence (MTPG 24) DTC MET MET/CBT 4 Months 9 Months 15 Months % of Days of Cannabis Use MTPG (24) 9 8 7 6 5 4 3 2 DTC MET MET/CBT 1 Baseline 4-Month 9-Month
Percent Improved at 4-Months MTPG (24) 25 2 15 1 DTC MET MET/CBT 5 Improved Abstinent CBT / MET for Adults Good Data to Support Efficacy Outcomes are not satisfying
Contingency Management (Budney et al., 2) Intended to get participants invested in continued abstinence Voucher system that rewards non-use of cannabis Based on operant conditioning principles Voucher Program for Marijuana Dependence Weeks 1-2 were a washout period Weeks 3-14 earn points for each cannabis-negative urine specimen / self-report of no use Points have a monetary value Number of points increases with each consecutive cannabis-negative sample $1 bonus for each cannabis-negative week
Redeeming Vouchers No cash is provided Vouchers can be spent on approved items any time after they are earned Staff purchase retail items or services (restaurant gift certificates, sport equipment, movie passes, work clothes, etc.) consistent with treatment goals Mean Weeks of Continuous Cannabis Abstinence (Budney et al., 2) # of Weeks of Continuous Abstinence 5 4 3 2 1 MET/CBT/CM MET/CBT MET
Continuous Abstinence % of Subjects 7 6 5 4 3 2 MET/CBT/CM MET/CBT MET 1 > 3 Wks > 7 Wks Marijuana Abstinence End of Treatment 5 % of Subjects 4 3 2 1 MET/CBT/CM MET/CBT MET
Summary of Budney, et al., 2 Vouchers added to CBT/MET increase periods of continuous abstinence Only a post-treatment follow-up was included. Durability of effects post-treatment was not studied Questions about the contribution of vouchers Study 2 Adult Cannabis Dependence Budney et al. (26) Replication: Can vouchers enhance MET/CBT? (MET/CBT Vs. MET/CBT/CM ) Do effects endure post-treatment? Does MET/CBT enhance the effect of CM? (CM vs. MET/CBT/CM) Is CM alone feasible and efficacious? (CM vs. MET/CBT vs. MET/CBT/CM)
Voucher Program Same as Prior Study, except cutoff for cannabis positive was 5ng/ml. Continuous Abstinence During Treatment % of Participants 8 6 4 2 MET/CBT MET/CBT/CM CM >2 wks >4 wks >6 wks >8 wks
5 4 3 2 1 Point Prevalence Abstinence Post Treatment MET/CBT MET/CBT/CM CM ETX 3 6 9 12 Months Post-Treatment CM for Adult Cannabis Dependence (Kadden et al. 27) Voucher Program 12 Weeks 1x/weekly testing Total available: $435
Abstinence Post-Treatment (Kadden et al. 27) % Subjects Abstinent 3 25 2 15 1 5 2 MO 5 MO 8 MO 11 MO 14 M Control MET/CBT CM MET/CBT/CM Limitations to Contingency Management Additional cost of vouchers make it impractical for many programs to implement (urines + vouchers) Alternative voucher programs have been developed (fishbowl) to reduce costs Voucher programs have started showing up in the US, but dissemination is slow Requires additional staffing Philosophical concerns about rewarding cannabis abstinence with vouchers Counseling staff Programmatic concerns Paying people to abstain
Conclusions Cannabis treatments have been identified Current gold standard of treatment is CBT/MET/CM Relatively effective at reducing cannabis use Poor prolonged abstinence rates High rates of relapse post-treatment Future Directions Room for improvement in outcomes Improve ways to help achieve abstinence during treatment Find more efficient ways of delivering CBT/MET (computer) Aftercare interventions Help maintain treatment gains and motivation posttreatment Interventions to help people earlier in their addiction (Check-Up model)
Denise Walker Email: ddwalker@uw.edu