Psychosocial interventions for cannabis use disorder

Prevalence of Cannabis Use Disorder Among Primary Care Patients with Varying Frequency of Past-Year Cannabis Use

BACKGROUND

Valid, single-item cannabis screens for the frequency of past-year use (SIS-C) can identify patients at risk for cannabis use disorder (CUD); however, the prevalence of CUD for patients who report varying frequencies of use in the clinical setting remains unexplored.

OBJECTIVE

Compare clinical responses about the frequency of past-year cannabis use to typical use and CUD severity reported on a confidential survey.

PARTICIPANTS

Among adult patients in an integrated health system who completed the SIS-C as part of routine care (3/28/2019-9/12/2019; n = 108,950), 5000 were selected for a confidential survey using stratified random sampling. Among 1688 respondents (34% response rate), 1589 who reported past-year cannabis use on the SIS-C were included.

MAIN MEASURES

We compared patients with varying frequency of cannabis use on the SIS-C (< monthly, monthly, weekly, daily) to survey responses on the Composite International Diagnostic Interview Substance Abuse Module for CUD (any and moderate-severe CUD) and cannabis exposure measures (typical use per-week, per-day). Adjusted multinomial (categorical) and logistic regression (binary), weighted for population estimates, estimated the prevalence of outcomes across frequencies.

KEY RESULTS

Patients were predominantly middle-aged (mean = 43.3 years [SD = 16.9]), male (51.8%), white (78.2%), non-Hispanic (94.0%), and commercially insured (68.9%). The prevalence of any and moderate-severe CUD increased with greater frequency of past-year cannabis use reported on the SIS-C (p-values < 0.001) and ranged from 12.7% (6.3-19.2%) and 0.9% (0.0-2.7%) for < monthly to 44.6% (41.4-47.7%) and 20.3% (17.8-22.9%) for daily use, respectively. Greater frequency of use on the SIS-C in the clinical setting corresponded with greater per-week and per-day use on the confidential survey.

CONCLUSIONS

Among patients who reported past-year cannabis use as part of routine screening, the prevalence of CUD and other cannabis exposure measures increased with greater frequency of cannabis use, underscoring the utility of brief cannabis screens for identifying patients at risk for CUD.

Cannabis use disorder: from neurobiology to treatment

Cannabis has been legalized for medical and recreational purposes in multiple countries. A large number of people are using cannabis and some will develop cannabis use disorder (CUD). There is a growing recognition that CUD requires specific interventions. This Review will cover this topic from a variety of perspectives, with a particular emphasis on neurobiological findings and innovative treatment approaches that are being pursued. We will first describe the epidemiology and burden of disease of CUD, including risk factors associated with CUD (both in terms of general risk and genetic risk variants). Neurobiological alterations identified in brain imaging studies will be presented. Several psychosocial interventions that are useful for the management of CUD, including motivational enhancement therapy, behavioral and cognitive therapy, and contingency management, will be covered. Although no pharmacological interventions are yet approved for CUD, we present the most promising pharmacological interventions being tested.

Cannabis, cannabinoids and health: a review of evidence on risks and medical benefits

The legalization of cannabis for medical and recreational purposes has progressed internationally. Cannabis and cannabinoids are advocated for a plethora of medical indications. An increasing number of medical and nonmedical users regularly consume large doses of delta-9-Tetrahydrocannabinol (THC), the main active component of cannabis. Aim: to summarize the evidence on (1) risks of recreational cannabis use and (2) effectiveness and safety of medicinal cannabis. Findings on recreational use: Cannabis is mostly used to experience its acute rewarding effects. Regular use of high THC products can produce addiction (cannabis use disorder or CUD). Acute consumption of high THC doses (including unintentionally) can cause time-limited mental, gastrointestinal, and cardiovascular problems and motor vehicle accidents. Chronic patterns of cannabis use have been associated with multiple adverse outcomes that are of particular concern among adolescents and young adults, such as, disrupted learning, impaired cognitive performance, reduced educational attainment and an increased risk of CUD, psychosis/schizophrenia, mood and anxiety disorders and suicidal behaviors. There is debate about the extent to which cannabis use is a cause of these adverse outcomes. Physical health risks (e.g., respiratory and cardiovascular, prematurity and restricted fetal growth, hyperemesis syndrome among others) have also been linked with repeated consumption of cannabis with a high THC content. Findings on medical cannabis use: Herbal cannabis, medicines from extracted or synthetized cannabinoids-often used as adjuvants to standard medicines-may produce small to modest benefits. This is primarily the case in treating chronic pain, muscle spasticity, chemotherapy-induced nausea and vomiting, and refractory epilepsy (in the case of cannabidiol, CBD). The evidence is inconclusive on their value in treating mental disorders and other medical conditions. Safety: Cannabis-based medicine is generally well tolerated. There is a risk of mild to moderate adverse effects and CUD.

Prevalence and Treatment of Substance Misuse in Older Adults: Beyond Early Adulthood

Substance misuse, traditionally seen as a problem of early to mid-adulthood, is becoming increasingly prevalent among the older adult population (ages ≥65). Diagnosing and treating substance misuse in this vulnerable population is challenging because of multiple pre-existing medical comorbidities as well as polypharmacy. As such, it remains underdiagnosed and underrepresented in the literature. This review provides an overview of the three most commonly misused substances in older adults: alcohol, cannabis, and prescription drugs. It examines epidemiology, societal trends, and treatment options, highlighting the need for targeted research to address the unique challenges faced by older adults. This review also briefly comments on the prevalence and treatment of other illicit drugs in this population.

Significant Psychedelic Experiences Evaluated for Mystical Characteristics Associated with Cannabis Use Reduction and Psychological Flexibility Improvement: A Naturalistic Cross-Sectional Retrospective Survey

Treating cannabis use disorder remains a significant challenge in the field of addiction medicine. Some recent studies point to psychedelic-assisted psychotherapy as a potential treatment option for substance use disorders. The objective of this study was therefore to explore the impact of naturalistic psychedelic experiences on cannabis use and psychological flexibility. An online retrospective survey was carried out on 152 cannabis users who also reported a significant experience induced by psychedelics in the past. Following a psychedelic experience, there was a significant and sustained reduction of average CUDIT score (p < .001), frequency of cannabis use (p < .001), and acute duration of daily intoxication (p < .001). Cannabis use reduction during the first month post-experience was significantly associated with the intensity of the mystical experience (p = .01). Participants reported a concomitant increased lasting improvement of psychological flexibility following the experience (p < .001), which was correlated to the intensity of the mystical experience during the first month post-experience (p = .04). This study demonstrates that naturalistic psychedelic experiences may be followed by a decrease in cannabis use. Positive health outcomes appear potentially connected to the intensity of the mystical experience, as well as an improvement in psychological flexibility.

Cannabis-related treatment demand at the eve of German cannabis legalization - a 20-years trend analysis

Post-2000, the prevalence of cannabis consumption has been rising internationally. This paper investigates whether cannabis-related treatment demand in German outpatient addiction care facilities (OACFs) has been following this trend. Treatment demand related to cannabis use disorder (CUD) for the period 2001 to 2021 was investigated using data from the nation-wide standardized German Addiction Care Statistical Service. Analyses covered all and first-time treatment admissions, demographics, and treatment outcomes. We identified years with significant changes in slope or direction of trends through joinpoint regression. Trends within the CUD client population were contrasted with trends among the entire OACF client population. CUD is the second-most common cause for OACF admissions in Germany. Between 2001 and 2021, the share of CUD-related cases among total OACF caseload increased from 7.1 to 19.9%, whereby the share of first-time treatment admissions declined from 79.6 to 55.6%. The share of CUD client population > 35 years almost tripled from 6.0 to 17.4%, that of female client population rose from 15.6 to 18.1%. From 2001 to 2007, the share of CUD-related treatments completed with improved symptomatology increased from 54.7 to 65.6%, followed by a marginal decline. CUD-related treatment demand is growing in Germany's OACFs, involving a client population that is increasingly older and more experienced with the addiction care system. As current intervention programmes mainly target adolescents and young adults who have been consuming cannabis only for a short time, adapting service offers to the changing client profiles appears paramount to improve treatment effectiveness.

Effectiveness of cannabis use and cannabis use disorder interventions: a European and international data synthesis

This data synthesis examined the effectiveness of behavioural and pharmacological approaches for cannabis treatment. We integrated findings from high level evidence studies and prioritised data from Europe when available. The synthesis found that only a relatively small number of published behavioural and pharmacological studies on cannabis interventions have been conducted in Europe. Applying both European and non-European data, it was found that Cognitive Behavioural Therapy (CBT) and/or Motivational Enhancement Therapy (MET) improved short-term outcomes in the frequency of cannabis use and dependency severity, although abstinence outcomes were less consistent. These improvements were typically not maintained nine months after treatment. CBT and MET (or combined CBT + MET) treatments that extend beyond four sessions were more effective than fewer sessions over a shorter duration. Combining CBT or MET (or combined CBT + MET) with adjunctive Contingency Management (CM) improved therapeutic outcomes. No pharmacotherapies have been approved for the management of cannabis use, cannabis use disorders or cannabis withdrawal. Despite only weak evidence to support the use of pharmacological agents, some are used 'off-label' to manage withdrawal symptoms outside clinical trials.

Rethinking Substance Use as Social History: Charting a Way Forward

Physicians have traditionally asked about substance use within the Social History section of the consultation note. Drawing on social science theory and using the authors' own experiences as generalists and addiction scholars, we consider the possible unintended harms associated with this approach. The inclusion of the substance use history within the Social History reproduces the discourse of substance use disorders as "life-style choices" rather than medical conditions, and reinforces stigma among healthcare workers through the attribution of personal responsibility for complications associated with problematic substance use. The ongoing placement of the substance use history within the Social History may lead to a failure to diagnose and make appropriate management plans for clients with substance use disorders. These missed opportunities may include inadequate withdrawal management leading to discharge before medically advised, insufficient use of evidence-based pharmacotherapy and psychotherapy, polypharmacy, medical complications, and repeated admissions to hospital. We argue instead that the Substance Use History should be a stand-alone section within the consultation note. This new section would reduce the invisibility of substance use disorders within our medical systems and model that these chronic medical conditions are amenable to prevention, treatment and harm reduction through the application of evidence-based practices.

Digital Interventions for Recreational Cannabis Use Among Young Adults: Systematic Review, Meta-Analysis, and Behavior Change Technique Analysis of Randomized Controlled Studies

BACKGROUND

The high prevalence of cannabis use among young adults poses substantial global health concerns due to the associated acute and long-term health and psychosocial risks. Digital modalities, including websites, digital platforms, and mobile apps, have emerged as promising tools to enhance the accessibility and availability of evidence-based interventions for young adults for cannabis use. However, existing reviews do not consider young adults specifically, combine cannabis-related outcomes with those of many other substances in their meta-analytical results, and do not solely target interventions for cannabis use.

OBJECTIVE

We aimed to evaluate the effectiveness and active ingredients of digital interventions designed specifically for cannabis use among young adults living in the community.

METHODS

We conducted a systematic search of 7 databases for empirical studies published between database inception and February 13, 2023, assessing the following outcomes: cannabis use (frequency, quantity, or both) and cannabis-related negative consequences. The reference lists of included studies were consulted, and forward citation searching was also conducted. We included randomized studies assessing web- or mobile-based interventions that included a comparator or control group. Studies were excluded if they targeted other substance use (eg, alcohol), did not report cannabis use separately as an outcome, did not include young adults (aged 16-35 y), had unpublished data, were delivered via teleconference through mobile phones and computers or in a hospital-based setting, or involved people with mental health disorders or substance use disorders or dependence. Data were independently extracted by 2 reviewers using a pilot-tested extraction form. Authors were contacted to clarify study details and obtain additional data. The characteristics of the included studies, study participants, digital interventions, and their comparators were summarized. Meta-analysis results were combined using a random-effects model and pooled as standardized mean differences.

RESULTS

Of 6606 unique records, 19 (0.29%) were included (n=6710 participants). Half (9/19, 47%) of these articles reported an intervention effect on cannabis use frequency. The digital interventions included in the review were mostly web-based. A total of 184 behavior change techniques were identified across the interventions (range 5-19), and feedback on behavior was the most frequently used (17/19, 89%). Digital interventions for young adults reduced cannabis use frequency at the 3-month follow-up compared to control conditions (including passive and active controls) by -6.79 days of use in the previous month (95% CI -9.59 to -4.00; P<.001).

CONCLUSIONS

Our results indicate the potential of digital interventions to reduce cannabis use in young adults but raise important questions about what optimal exposure dose could be more effective, both in terms of intervention duration and frequency. Further high-quality research is still needed to investigate the effects of digital interventions on cannabis use among young adults.

TRIAL REGISTRATION

PROSPERO CRD42020196959; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=196959.

Predictors of effective therapy among individuals with Cannabis Use Disorder: a review of the literature

Treatment demand for Cannabis Use Disorder (CUD) has increased in the past decade in almost all European countries, and CUD is currently the most common reason for first-time drug-related treatment admission in the European Union. Even though several therapeutic approaches have been shown to benefit individuals with CUD, there is a lack of knowledge regarding factors associated with effective therapy and the underlying mechanisms of change among individuals with CUD presenting for treatment. The aim of the present paper was to review current knowledge on factors that have been shown to contribute to positive outcomes in CUD treatment. A scoping methodology was used, focusing on empirically evaluated studies that used defined, cannabis-related outcome measures. In eligible studies, factors of investigation were categorized as either 'mediators', i.e., treatment-related factors associated with the processes or mechanisms through which patients benefit from therapy, or 'moderators' which are patient-related characteristics that predict his/her odds to benefit from treatment or patient-related (i.e., moderators). Factors categorized as mediators were then classified 'specific factors' if they were related to a certain technique or treatment modality or 'common factors' if they were assessed beyond treatment modalities. Findings suggest that in CUD treatment, specific mediators include treatment duration, addressing motivation to change, acquiring coping skills, enhancing self-efficacy, and integrating several therapeutic components. Common mediators include therapeutic alliance, empathy, expectations and cultural adaptation. Moderators in CUD treatment include sex, ethnicity, age-related factors and comorbid disorders.

A phase III multisite randomised controlled trial to compare the efficacy of cannabidiol to placebo in the treatment of cannabis use disorder: the CBD-CUD study protocol

BACKGROUND

Cannabis use disorder (CUD) is increasingly common and contributes to a range of health and social problems. Cannabidiol (CBD) is a non-intoxicating cannabinoid recognised for its anticonvulsant, anxiolytic and antipsychotic effects with no habit-forming qualities. Results from a Phase IIa randomised clinical trial suggest that treatment with CBD for four weeks reduced non-prescribed cannabis use in people with CUD. This study examines the efficacy, safety and quality of life of longer-term CBD treatment for patients with moderate-to-severe CUD.

METHODS/DESIGN

A phase III multi-site, randomised, double-blinded, placebo controlled parallel design of a 12-week course of CBD to placebo, with follow-up at 24 weeks after enrolment. Two hundred and fifty adults with moderate-to-severe CUD (target 20% Aboriginal), with no significant medical, psychiatric or other substance use disorders from seven drug and alcohol clinics across NSW and VIC, Australia will be enrolled. Participants will be administered a daily dose of either 4 mL (100 mg/mL) of CBD or a placebo dispensed every 3-weeks. All participants will receive four-sessions of Cognitive Behavioural Therapy (CBT) based counselling. Primary endpoints are self-reported cannabis use days and analysis of cannabis metabolites in urine. Secondary endpoints include severity of CUD, withdrawal severity, cravings, quantity of use, motivation to stop and abstinence, medication safety, quality of life, physical/mental health, cognitive functioning, and patient treatment satisfaction. Qualitative research interviews will be conducted with Aboriginal participants to explore their perspectives on treatment.

DISCUSSION

Current psychosocial and behavioural treatments for CUD indicate that over 80% of patients relapse within 1-6 months of treatment. Pharmacological treatments are highly effective with other substance use disorders but there are no approved pharmacological treatments for CUD. CBD is a promising candidate for CUD treatment due to its potential efficacy for this indication and excellent safety profile. The anxiolytic, antipsychotic and neuroprotective effects of CBD may have added benefits by reducing many of the mental health and cognitive impairments reported in people with regular cannabis use.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trial Registry: ACTRN12623000526673 (Registered 19 May 2023).

Psychosocial interventions for stimulant use disorder

BACKGROUND

Stimulant use disorder is a continuously growing medical and social burden without approved medications available for its treatment. Psychosocial interventions could be a valid approach to help people reduce or cease stimulant consumption. This is an update of a Cochrane review first published in 2016.

OBJECTIVES

To assess the efficacy and safety of psychosocial interventions for stimulant use disorder in adults.

SEARCH METHODS

We searched the Cochrane Drugs and Alcohol Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, three other databases, and two trials registers in September 2023. All searches included non-English language literature. We handsearched the references of topic-related systematic reviews and the included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing any psychosocial intervention with no intervention, treatment as usual (TAU), or a different intervention in adults with stimulant use disorder.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included a total of 64 RCTs (8241 participants). Seventy-three percent of studies included participants with cocaine or crack cocaine use disorder; 3.1% included participants with amphetamine use disorder; 10.9% included participants with methamphetamine use disorder; and 12.5% included participants with any stimulant use disorder. In 18 studies, all participants were in methadone maintenance treatment. In our primary comparison of any psychosocial treatment to no intervention, we included studies which compared a psychosocial intervention plus TAU to TAU alone. In this comparison, 12 studies evaluated cognitive behavioural therapy (CBT), 27 contingency management, three motivational interviewing, one study looked at psychodynamic therapy, and one study evaluated CBT plus contingency management. We also compared any psychosocial intervention to TAU. In this comparison, seven studies evaluated CBT, two contingency management, two motivational interviewing, and one evaluated a combination of CBT plus motivational interviewing. Seven studies compared contingency management reinforcement related to abstinence versus contingency management not related to abstinence. Finally, seven studies compared two different psychosocial approaches. We judged 65.6% of the studies to be at low risk of bias for random sequence generation and 19% at low risk for allocation concealment. Blinding of personnel and participants was not possible for the type of intervention, so we judged all the studies to be at high risk of performance bias for subjective outcomes but at low risk for objective outcomes. We judged 22% of the studies to be at low risk of detection bias for subjective outcomes. We judged most of the studies (69%) to be at low risk of attrition bias. When compared to no intervention, we found that psychosocial treatments: reduce the dropout rate (risk ratio (RR) 0.82, 95% confidence interval (CI) 0.74 to 0.91; 30 studies, 4078 participants; high-certainty evidence); make little to no difference to point abstinence at the end of treatment (RR 1.15, 95% CI 0.94 to 1.41; 12 studies, 1293 participants; high-certainty evidence); make little to no difference to point abstinence at the longest follow-up (RR 1.22, 95% CI 0.91 to 1.62; 9 studies, 1187 participants; high-certainty evidence); probably increase continuous abstinence at the end of treatment (RR 1.89, 95% CI 1.20 to 2.97; 12 studies, 1770 participants; moderate-certainty evidence); may make little to no difference in continuous abstinence at the longest follow-up (RR 1.14, 95% CI 0.89 to 1.46; 4 studies, 295 participants; low-certainty evidence); reduce the frequency of drug intake at the end of treatment (standardised mean difference (SMD) -0.35, 95% CI -0.50 to -0.19; 10 studies, 1215 participants; high-certainty evidence); and increase the longest period of abstinence (SMD 0.54, 95% CI 0.41 to 0.68; 17 studies, 2118 participants; high-certainty evidence). When compared to TAU, we found that psychosocial treatments reduce the dropout rate (RR 0.79, 95% CI 0.65 to 0.97; 9 studies, 735 participants; high-certainty evidence) and may make little to no difference in point abstinence at the end of treatment (RR 1.67, 95% CI 0.64 to 4.31; 1 study, 128 participants; low-certainty evidence). We are uncertain whether they make any difference in point abstinence at the longest follow-up (RR 1.31, 95% CI 0.86 to 1.99; 2 studies, 124 participants; very low-certainty evidence). Compared to TAU, psychosocial treatments may make little to no difference in continuous abstinence at the end of treatment (RR 1.18, 95% CI 0.92 to 1.53; 1 study, 128 participants; low-certainty evidence); probably make little to no difference in the frequency of drug intake at the end of treatment (SMD -1.17, 95% CI -2.81 to 0.47, 4 studies, 479 participants, moderate-certainty evidence); and may make little to no difference in the longest period of abstinence (SMD -0.16, 95% CI -0.54 to 0.21; 1 study, 110 participants; low-certainty evidence). None of the studies for this comparison assessed continuous abstinence at the longest follow-up. Only five studies reported harms related to psychosocial interventions; four of them stated that no adverse events occurred.

AUTHORS' CONCLUSIONS

This review's findings indicate that psychosocial treatments can help people with stimulant use disorder by reducing dropout rates. This conclusion is based on high-certainty evidence from comparisons of psychosocial interventions with both no treatment and TAU. This is an important finding because many people with stimulant use disorders leave treatment prematurely. Stimulant use disorders are chronic, lifelong, relapsing mental disorders, which require substantial therapeutic efforts to achieve abstinence. For those who are not yet able to achieve complete abstinence, retention in treatment may help to reduce the risks associated with stimulant use. In addition, psychosocial interventions reduce stimulant use compared to no treatment, but they may make little to no difference to stimulant use when compared to TAU. The most studied and promising psychosocial approach is contingency management. Relatively few studies explored the other approaches, so we cannot rule out the possibility that the results were imprecise due to small sample sizes.

The Therapeutic Potential and Molecular Mechanisms Underlying the Neuroprotective Effects of Sativex® - A Cannabis-derived Spray

Sativex is a cannabis-based medicine that comes in the form of an oromucosal spray. It contains equal amounts of Δ9-tetrahydrocannabinol and cannabidiol, two compounds derived from cannabis plants. Sativex has been shown to have positive effects on symptoms of amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS), and sleep disorders. It also has analgesic, antiinflammatory, antitumoral, and neuroprotective properties, which make it a potential treatment option for other neurological disorders. The article reviews the results of recent preclinical and clinical studies that support the therapeutic potential of Sativex and the molecular mechanisms behind its neuroprotective benefits in various neurological disorders. The article also discusses the possible advantages and disadvantages of using Sativex as a neurotherapeutic agent, such as its safety, efficacy, availability, and legal status.

Motivational interviewing for substance use reduction

BACKGROUND

Substance use is a global issue, with around 30 to 35 million individuals estimated to have a substance-use disorder. Motivational interviewing (MI) is a client-centred method that aims to strengthen a person's motivation and commitment to a specific goal by exploring their reasons for change and resolving ambivalence, in an atmosphere of acceptance and compassion. This review updates the 2011 version by Smedslund and colleagues.

OBJECTIVES

To assess the effectiveness of motivational interviewing for substance use on the extent of substance use, readiness to change, and retention in treatment.

SEARCH METHODS

We searched 18 electronic databases, six websites, four mailing lists, and the reference lists of included studies and reviews. The last search dates were in February 2021 and November 2022.

SELECTION CRITERIA

We included randomised controlled trials with individuals using drugs, alcohol, or both. Interventions were MI or motivational enhancement therapy (MET), delivered individually and face to face. Eligible control interventions were no intervention, treatment as usual, assessment and feedback, or other active intervention.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane, and assessed the certainty of evidence with GRADE. We conducted meta-analyses for the three outcomes (extent of substance use, readiness to change, retention in treatment) at four time points (post-intervention, short-, medium-, and long-term follow-up).

MAIN RESULTS

We included 93 studies with 22,776 participants. MI was delivered in one to nine sessions. Session durations varied, from as little as 10 minutes to as long as 148 minutes per session, across included studies. Study settings included inpatient and outpatient clinics, universities, army recruitment centres, veterans' health centres, and prisons. We judged 69 studies to be at high risk of bias in at least one domain and 24 studies to be at low or unclear risk. Comparing MI to no intervention revealed a small to moderate effect of MI in substance use post-intervention (standardised mean difference (SMD) 0.48, 95% confidence interval (CI) 0.07 to 0.89; I2 = 75%; 6 studies, 471 participants; low-certainty evidence). The effect was weaker at short-term follow-up (SMD 0.20, 95% CI 0.12 to 0.28; 19 studies, 3351 participants; very low-certainty evidence). This comparison revealed a difference in favour of MI at medium-term follow-up (SMD 0.12, 95% CI 0.05 to 0.20; 16 studies, 3137 participants; low-certainty evidence) and no difference at long-term follow-up (SMD 0.12, 95% CI -0.00 to 0.25; 9 studies, 1525 participants; very low-certainty evidence). There was no difference in readiness to change (SMD 0.05, 95% CI -0.11 to 0.22; 5 studies, 1495 participants; very low-certainty evidence). Retention in treatment was slightly higher with MI (SMD 0.26, 95% CI -0.00 to 0.52; 2 studies, 427 participants; very low-certainty evidence). Comparing MI to treatment as usual revealed a very small negative effect in substance use post-intervention (SMD -0.14, 95% CI -0.27 to -0.02; 5 studies, 976 participants; very low-certainty evidence). There was no difference at short-term follow-up (SMD 0.07, 95% CI -0.03 to 0.17; 14 studies, 3066 participants), a very small benefit of MI at medium-term follow-up (SMD 0.12, 95% CI 0.02 to 0.22; 9 studies, 1624 participants), and no difference at long-term follow-up (SMD 0.06, 95% CI -0.05 to 0.17; 8 studies, 1449 participants), all with low-certainty evidence. There was no difference in readiness to change (SMD 0.06, 95% CI -0.27 to 0.39; 2 studies, 150 participants) and retention in treatment (SMD -0.09, 95% CI -0.34 to 0.16; 5 studies, 1295 participants), both with very low-certainty evidence. Comparing MI to assessment and feedback revealed no difference in substance use at short-term follow-up (SMD 0.09, 95% CI -0.05 to 0.23; 7 studies, 854 participants; low-certainty evidence). A small benefit for MI was shown at medium-term (SMD 0.24, 95% CI 0.08 to 0.40; 6 studies, 688 participants) and long-term follow-up (SMD 0.24, 95% CI 0.07 to 0.41; 3 studies, 448 participants), both with moderate-certainty evidence. None of the studies in this comparison measured substance use at the post-intervention time point, readiness to change, and retention in treatment. Comparing MI to another active intervention revealed no difference in substance use at any follow-up time point, all with low-certainty evidence: post-intervention (SMD 0.07, 95% CI -0.15 to 0.29; 3 studies, 338 participants); short-term (SMD 0.05, 95% CI -0.03 to 0.13; 18 studies, 2795 participants); medium-term (SMD 0.08, 95% CI -0.01 to 0.17; 15 studies, 2352 participants); and long-term follow-up (SMD 0.03, 95% CI -0.07 to 0.13; 10 studies, 1908 participants). There was no difference in readiness to change (SMD 0.15, 95% CI -0.00 to 0.30; 5 studies, 988 participants; low-certainty evidence) and retention in treatment (SMD -0.04, 95% CI -0.23 to 0.14; 12 studies, 1945 participants; moderate-certainty evidence). We downgraded the certainty of evidence due to inconsistency, study limitations, publication bias, and imprecision.

AUTHORS' CONCLUSIONS

Motivational interviewing may reduce substance use compared with no intervention up to a short follow-up period. MI probably reduces substance use slightly compared with assessment and feedback over medium- and long-term periods. MI may make little to no difference to substance use compared to treatment as usual and another active intervention. It is unclear if MI has an effect on readiness to change and retention in treatment. The studies included in this review were heterogeneous in many respects, including the characteristics of participants, substance(s) used, and interventions. Given the widespread use of MI and the many studies examining MI, it is very important that counsellors adhere to and report quality conditions so that only studies in which the intervention implemented was actually MI are included in evidence syntheses and systematic reviews. Overall, we have moderate to no confidence in the evidence, which forces us to be careful about our conclusions. Consequently, future studies are likely to change the findings and conclusions of this review.

Who responds to a multi-component treatment for cannabis use disorder? Using multivariable and machine learning models to classify treatment responders and non-responders

BACKGROUND AND AIMS

Treatments for cannabis use disorder (CUD) have limited efficacy and little is known about who responds to existing treatments. Accurately predicting who will respond to treatment can improve clinical decision-making by allowing clinicians to offer the most appropriate level and type of care. This study aimed to determine whether multivariable/machine learning models can be used to classify CUD treatment responders versus non-responders.

METHODS

This secondary analysis used data from a National Drug Abuse Treatment Clinical Trials Network multi-site outpatient clinical trial in the United States. Adults with CUD (n = 302) received 12 weeks of contingency management, brief cessation counseling and were randomized to receive additionally either (1) N-Acetylcysteine or (2) placebo. Multivariable/machine learning models were used to classify treatment responders (i.e. two consecutive negative urine cannabinoid tests or a 50% reduction in days of use) versus non-responders using baseline demographic, medical, psychiatric and substance use information.

RESULTS

Prediction performance for various machine learning and regression prediction models yielded area under the curves (AUCs) >0.70 for four models (0.72-0.77), with support vector machine models having the highest overall accuracy (73%; 95% CI = 68-78%) and AUC (0.77; 95% CI = 0.72, 0.83). Fourteen variables were retained in at least three of four top models, including demographic (ethnicity, education), medical (diastolic/systolic blood pressure, overall health, neurological diagnosis), psychiatric (depressive symptoms, generalized anxiety disorder, antisocial personality disorder) and substance use (tobacco smoker, baseline cannabinoid level, amphetamine use, age of experimentation with other substances, cannabis withdrawal intensity) characteristics.

CONCLUSIONS

Multivariable/machine learning models can improve on chance prediction of treatment response to outpatient cannabis use disorder treatment, although further improvements in prediction performance are likely necessary for decisions about clinical care.

A randomized controlled trial of brief intervention for patients with cannabis use disorder

Objectives

Effective interventions for cannabis use disorders are fairly limited. The present randomized controlled trial (RCT) aimed to compare the reduction in cannabis use (number of days cannabis used) with brief intervention and simple advice in patients with cannabis use disorder.

Materials and Methods

This non-blinded and parallel two-group RCT included 100 male patients with cannabis use disorder. A semi-structured pro forma and severity of dependence scale (SDS) were used. Participants were then randomized to either of the two arms (brief intervention and simple advice) in a 1:1 ratio. Cannabis use patterns and SDS scores were assessed over the phone at week 4, week 8, and week 12.

Results

The two groups were comparable in sociodemographics and cannabis use characteristics. Participants in both groups were using cannabis for 30 days in the past month before enrolment. The brief intervention group had a lesser number of days of cannabis use vis-a-vis the simple advice group at 4, 8, and 12 weeks. There was a significant time effect for change in SDS scores (F = 30.629, P < 0.001), but the group effect was not significant (F = 0.379, P = 0.541).

Conclusion

In this population of regular cannabis users, brief intervention may be useful in reducing cannabis usage. It can be integrated into routine assessments and management of those with regular use of cannabis.

Distinct neural networks predict cocaine versus cannabis treatment outcomes

Treatment outcomes for individuals with substance use disorders (SUDs) are variable and more individualized approaches may be needed. Cross-validated, machine-learning methods are well-suited for probing neural mechanisms of treatment outcomes. Our prior work applied one such approach, connectome-based predictive modeling (CPM), to identify dissociable and substance-specific neural networks of cocaine and opioid abstinence. In Study 1, we aimed to replicate and extend prior work by testing the predictive ability of the cocaine network in an independent sample of 43 participants from a trial of cognitive-behavioral therapy for SUD, and evaluating its ability to predict cannabis abstinence. In Study 2, CPM was applied to identify an independent cannabis abstinence network. Additional participants were identified for a combined sample of 33 with cannabis-use disorder. Participants underwent fMRI scanning before and after treatment. Additional samples of 53 individuals with co-occurring cocaine and opioid-use disorders and 38 comparison subjects were used to assess substance specificity and network strength relative to participants without SUDs. Results demonstrated a second external replication of the cocaine network predicting future cocaine abstinence, however it did not generalize to cannabis abstinence. An independent CPM identified a novel cannabis abstinence network, which was (i) anatomically distinct from the cocaine network, (ii) specific for predicting cannabis abstinence, and for which (iii) network strength was significantly stronger in treatment responders relative to control particpants. Results provide further evidence for substance specificity of neural predictors of abstinence and provide insight into neural mechanisms of successful cannabis treatment, thereby identifying novel treatment targets. Clinical trials registation: "Computer-based training in cognitive-behavioral therapy web-based (Man VS Machine)", registration number: NCT01442597 . "Maximizing the Efficacy of Cognitive Behavior Therapy and Contingency Management", registration number: NCT00350649 . "Computer-Based Training in Cognitive Behavior Therapy (CBT4CBT)", registration number: NCT01406899 .

Canadian Network for Mood and Anxiety Treatments (CANMAT) Task Force Report: A Systematic Review and Recommendations of Cannabis use in Bipolar Disorder and Major Depressive Disorder

BACKGROUND

Given the increasing acceptability and legalization of cannabis in some jurisdictions, clinicians need to improve their understanding of the effect of cannabis use on mood disorders.

OBJECTIVE

The purpose of this task force report is to examine the association between cannabis use and incidence, presentation, course and treatment of bipolar disorder and major depressive disorder, and the treatment of comorbid cannabis use disorder.

METHODS

We conducted a systematic literature review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, searching PubMed, Embase, PsycINFO, CINAHL and Cochrane Central Register of Controlled Trials from inception to October 2020 focusing on cannabis use and bipolar disorder or major depressive disorder, and treatment of comorbid cannabis use disorder. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach was used to evaluate the quality of evidence and clinical considerations were integrated to generate Canadian Network for Mood and Anxiety Treatments recommendations.

RESULTS

Of 12,691 publications, 56 met the criteria: 23 on bipolar disorder, 21 on major depressive disorder, 11 on both diagnoses and 1 on treatment of comorbid cannabis use disorder and major depressive disorder. Of 2,479,640 participants, 12,502 were comparison participants, 73,891 had bipolar disorder and 408,223 major depressive disorder without cannabis use. Of those with cannabis use, 2,761 had bipolar disorder and 5,044 major depressive disorder. The lifetime prevalence of cannabis use was 52%-71% and 6%-50% in bipolar disorder and major depressive disorder, respectively. Cannabis use was associated with worsening course and symptoms of both mood disorders, with more consistent associations in bipolar disorder than major depressive disorder: increased severity of depressive, manic and psychotic symptoms in bipolar disorder and depressive symptoms in major depressive disorder. Cannabis use was associated with increased suicidality and decreased functioning in both bipolar disorder and major depressive disorder. Treatment of comorbid cannabis use disorder and major depressive disorder did not show significant results.

CONCLUSION

The data indicate that cannabis use is associated with worsened course and functioning of bipolar disorder and major depressive disorder. Future studies should include more accurate determinations of type, amount and frequency of cannabis use and select comparison groups which allow to control for underlying common factors.

Increase of cannabis and cocaine use by pregnant women in France from 2005 to 2018: Insights of the annual cross sectional OPPIDUM survey

CONTEXT

Substance use disorders during pregnancy are associated with antenatal, neonatal and long-term adverse drug reactions in children. The aim of this study was to describe, using data from OPPIDUM survey, the evolution of illicit substance use or diverted prescription drug use among pregnant women visiting French addiction care centres from 2005 to 2018.

MATERIAL AND METHOD

The current study focused on women of childbearing age (15-44years old) identified as pregnant, and included in the OPPIDUM survey from 2005 to 2018. OPPIDUM is a French nationwide survey repeated each year since 1995, which anonymously collects information on drug abuse and dependence observed in patients recruited in addiction care centres. Patterns of illicit substance use, psychoactive medications, and opioid maintenance treatment (OMT) were described over time (by period of 2 years) and changes between 2005-2006 and 2017-2018 were investigated.

RESULTS

From 2005 to 2018, 784 pregnant women were included in the OPPIDUM survey (median age 28, interquartile range (IQR): 25-33). The proportion of women using exclusively cannabis (1.2% vs. 17.1%, P=0.0004) and cocaine (including crack) use (4.7% vs. 14.3%, P=0.0384) significantly increased over the period. Considering the first substance reported as leading to dependence, heroin significantly decreased (78.8% vs. 50.0%, P=0.0002) whereas cannabis significantly increased (5.9% vs. 25.7%, P=0.0005).

CONCLUSION

This study highlighted an important change of patterns of drug use by French pregnant women over a 14-year-period. Health professionals must be aware of these changes to adapt prevention and care among women of childbearing age and pregnant women.

Prevalence and risk factors associated with psychostimulant use among Black individuals: A meta-analysis and systematic review

BACKGROUND

Psychostimulants (e.g., cocaine, amphetamine) are among the most widely used drugs globally with detrimental short and long-term physical, psychological and social consequences. There is limited data on psychostimulant use for various racial and ethnic groups, including Black people, and the challenges they face living as minorities overcoming historical challenges including increased incarceration associated with drug possession.

METHODS

Peer-reviewed articles were identified in five databases (APA PsycInfo, CINAHL, Cochrane CENTRAL, Embase, MEDLINE). Eligible studies were published in French or English, provided empiral data on psychostimulant use in Black individuals living in a minority context. The PRISMA guideline was used for structuring the review. Random-effects meta-analyses were generated to estimate the pooled prevalence of lifetime and periodic psychostimulant use among Black individuals using STATA 16.

RESULTS

Sixty-three studies published from 1991 to 2022 with a sample size of 139,683 Black individuals were included in the current meta-analysis. Results indicate a pooled prevalence estimate of 11.4% for any form of psychostimulant use among Black individuals. The pooled prevalence estimates were 12.4% (95% CI, 8.4% - 16.4%) for cocaine, 8.3% (95% CI, 0% - 19.1%) for amphetamines, and 11.4% (95% CI, 4.6% - 18.1%) for other stimulants. Prediction intervals for all psychostimulant types were highly heterogenous ranging from 0% to as high as 51.2% for amphetamine suggesting prevalence of use in some studies of Black people could be found to be as low as zero. Subgroup analyses were conducted to examine differences between age groups, gender, reference period, and type of assessment.

CONCLUSIONS

High prevalence rates of psychostimulant use among Black people argues for greater access to evidence-based treatments. However, current psychosocial interventions are suboptimal, warranting further study. Consideration needs to be given to the challenges of the large range of prediction intervals, living in urban areas, racial discrimination experiences, race-based stress, and sociodemographic characteristics, including poverty, education level, age, gender.

Interventions Addressing Cannabis Use During Pregnancy: A Systematic Review

OBJECTIVES

The prevalence of cannabis use among pregnant women is increasing in the United States and places mothers and infants at risk of multiple adverse health outcomes. Given the uncertainty expressed by providers regarding how to approach cannabis use during pregnancy and the growing need for a systematic endeavor to curb use in this population, the aim of this study is to conduct a systematic review of interventions focused on reduction in cannabis use during pregnancy.

METHODS

We conducted a systematic search of MEDLINE, PsycINFO, CINAHL, Web of Science, SCOPUS, and Cochrane Library to identify studies of interventions that target individuals that engaged in cannabis use during pregnancy. We included studies if they were randomized controlled trials, controlled studies, feasibility studies, pilot studies, as well as observational studies. The primary diagnostic outcome of interest is reduction in cannabis use.

RESULTS

We identified 9 studies for inclusion with sample sizes ranging from 15 to 658 pregnant people. Interventions involved brief counseling, cognitive behavioral therapy (CBT), motivational interviewing (MI), motivational enhancement therapy + cognitive behavioral therapy (MET-CBT), computer-delivered psychotherapy, and psychoeducation. The interventions that were effective primarily used MI, CBT, and/or MET. There was just 1 study that implemented a home intervention and one that explored computer-based psychotherapy.

CONCLUSIONS

The studies uncovered through this systematic review suggest that interventions involving CBT and/or MI demonstrate promise for decreasing cannabis use during pregnancy. There is a tremendous need for high-quality studies focused on this population, and the potential for remote and computer-based interventions should be explored more fully.

Correlates of treatment engagement and client outcomes: results of a randomised controlled trial of nabiximols for the treatment of cannabis use disorder

INTRODUCTION AND AIMS

There is increasing interest and evidence for the use of cannabinoid medications in the treatment of cannabis use disorder, but little examination of the correlates of successful treatment. This paper is a secondary analysis of a randomised placebo-controlled trial of nabiximols for the treatment of cannabis use disorder (CUD), aiming to identify which client and treatment characteristics impact treatment engagement and outcomes.

METHOD

Bayesian multiple regression models were used to examine the impact of age, gender, duration of regular cannabis use, daily quantity of cannabis, cannabis use problems, self-efficacy for quitting, sleep, mental health, pain measures, and treatment group upon treatment engagement (retention, medication dose, and counselling participation) and treatment outcomes (achieving end-of-study abstinence, and a 50% or greater reduction in cannabis use days) among the 128 clients participating in the 12-week trial.

RESULTS

Among the treatment factors, greater counselling attendance was associated with greater odds of abstinence and ≥ 50% reduction in cannabis use; nabiximols with greater odds of ≥ 50% reduction and attending counselling, and reduced hazard of treatment dropout; and higher dose with lower odds of ≥ 50% reduction. Among the client factors, longer duration of regular use was associated with higher odds of abstinence and 50% reduction, and lower hazard of treatment dropout; greater quantity of cannabis use with reduced hazard of dropout, greater odds of attending counselling, and higher average dose; greater pain at baseline with greater odds of ≥ 50% reduction and higher average dose; and more severe sleep issues with lower odds of ≥ 50% reduction. Males had lower odds of attending counselling.

DISCUSSIONS AND CONCLUSIONS

These findings suggest that counselling combined with agonist pharmacotherapy may provide the optimal treatment for cannabis use disorder. Younger clients, male clients, and clients with sleep issues could benefit from extra support from treatment services to improve engagement and outcomes.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ACTRN12616000103460) https://www.anzctr.org.au.

Online interventions for cannabis use among adolescents and young adults: Systematic review and meta-analysis

BACKGROUND

Young people present high rates of cannabis use, abuse, and dependence. The United Nations estimates that roughly 3.8% of the global population aged 15-64 years used cannabis at least once in 2017. Cannabis use in young people may impair cognitive skills, interfere with learning, impact relationships, and lead to long term behavioural and psychological consequences. Online cannabis interventions (OCI) are increasingly popular, but their dissemination is not often supported by empirical evidence.

AIM

To systematically compile and analyse the effectiveness of OCI for the reduction of cannabis use among adolescents and young adults (AYA).

METHODS

Pooled effect sizes of cannabis use between treatment and control groups were estimated. For each comparison, Hedge's g was calculated using a random effects model.

RESULTS

The search strategy yielded 4531 articles. Of those, a total of 411 articles were retrieved for detailed evaluation resulting in 17 eligible studies (n = 3525). Analyses revealed that online interventions did not significantly reduce cannabis consumption (Hedge's g = -0.061, 95% CI [-0.363] to [-0.242], p = .695) and high heterogeneity was noted (Q = 191.290). More recent studies using structured interventions, daily feedback, AYA centred designs, and peer support, specifically targeting CU seemed to have positive effects to address CU in this population.

CONCLUSIONS

The lack of positive outcomes suggests that more specific and targeted interventions may be necessary to promote cannabis-related behavioural change among young people. These targeted interventions may include structured CU modules, daily feedback, peer support for increased adherence, user-centred design procedures, and input from key stakeholders such as families and service providers.

The impact of integrated care in community-based substance use treatment in Brazil: A longitudinal study

Integrated care (outpatient-inpatient) plays a vital function in community care for people with drug use problems. Its recent and innovative treatment model is representing a challenge for the deinstitutionalisation process. The purpose of this study was to assess the impact of integrated care using biopsychosocial indicators. We conducted a prospective longitudinal study with 122 clients from the baseline undergoing integrated care of two Psychosocial Care Centers for Alcohol and Other Drugs in São Paulo, Brazil, with three months follow-up (February 2019-January 2020). To assess the biopsychosocial indicators of the impact, we used the Substance Addiction Consequences (SAC), WHOQOL-BREF quality of life scales and the psychosocial rehabilitation axes (housing, work/income, and support network). We conducted a longitudinal analysis with linear mixed-effects models. The integrated care impacted the reduction in the days of substance use and increase of abstinence with a significant difference for cannabis (p < 0.001) and crack (p = 0.021). It reduced the substance use harms in all SAC scale dimensions (p < 0.001). Quality of life increased and remained mainly associated with the psychological size (p < 0.001). All psychosocial rehabilitation axes improved with a difference for income (p = 0.025). The increase in people's participation in treatment was relevant. The integrated care of Brazilian services has a positive impact on reducing substance use days and harms associated, improves the quality of life and contributes to the psychosocial rehabilitation of clients. Should be taken efforts to maintain long-term results.

Substance-Use Disorders in Children and Adolescents

BACKGROUND

The most common substance use disorders in childhood and adolescence have to do with alcohol and cannabis. These disorders begin as early as puberty, are often accompanied by other mental disorders, and, if untreated, very frequently persist into adulthood.

METHODS

This review is based on pertinent publications retrieved by a selective search in PubMed on substance use disorders in children and adolescents.

RESULTS

Substance use disorders are among the commonest mental disorders in childhood and adolescence. In Germany, approximately 10% of adolescents have tried cannabis at least once. The prognosis is negatively affected by individual (bio-)psychological traits, mental comorbidities, laws that facilitate consumption, socioeconomic disadvantage, consuming peers, and parental substance use disorders. A timely diagnosis, motivation by the pediatrician, and referral to specialized child and adolescent psychiatric services helps assure that those affected receive appropriate treatment, with the goal of abstinence from the substance as well as improvement in emotional regulation, affectivity, and attention. According to studies from the English-speaking countries and considering all treatment forms, treatment is completed by approximately 60% to 65% of children and adolescents; 20% to 40% of these patients are abstinent six months after the end of treatment. No studies of this type have been carried out to date in Germany.

CONCLUSION

As the results of treatment are generally poor, there is a major need for research on the treatment and care of children and adolescents with substance use disorders. In particular, the interfaces between outpatient and inpatient care need further improvement.

Getting High or Getting By? An Examination of Cannabis Motives, Cannabis Misuse, and Concurrent Psychopathology in a Sample of General Community Adults

OBJECTIVE:

Few studies have examined cannabis motives in adults and, although associations between cannabis use and psychiatric conditions are well documented, there has been limited investigation of the intersection of cannabis use, cannabis motives, and psychopathology. In a sample of community adults, the present study examined cannabis motives in relation to cannabis misuse, and investigated whether motives linked cannabis misuse with concurrent psychiatric symptoms.

METHOD:

Participants (N = 395; M_age = 34.8; %F = 47.6; % White = 81.3%) completed assessments related to cannabis misuse, cannabis use motives, and symptoms of depression, anxiety, PTSD, and somatic experiences. Bivariate correlations, hierarchical regressions, and indirect effect analyses were performed to examine associations between motives and cannabis misuse and to investigate mechanistic relationships between psychiatric symptoms and cannabis misuse.

RESULTS:

Regressions revealed significant associations between cannabis misuse and social (β = .13, P < .02), enhancement (β = .12, P < .02), and coping motives (β = .48, P < .001). Indirect effects were present such that coping motives consistently linked psychiatric and somatic symptoms with cannabis misuse (anxiety: unstandardized effect = 0.26,and 95% CI = 0.17-0.37; depression: unstandardized effect = 0.12, CI = 0.11-0.25; PTSD: unstandardized effect = 0.07, CI = 0.04-0.10; somatic symptoms: unstandardized effect = 0.20, CI = 0.11-0.30). In addition, enhancement motives exhibited an indirect effect (unstandardized effect = 0.02, CI = 0.002-0.04) between depressive symptoms and cannabis misuse.

CONCLUSION:

These results support a negative reinforcement motivational profile as the predominant pattern in adult cannabis users, albeit with links to enhancement and social motives. This motivational profile is especially pronounced with regard to comorbid psychopathology and cannabis misuse. These results support the importance of treatment strategies targeting maladaptive coping to address cannabis misuse and co-occurring psychopathology.

Cannabinoids in the Treatment of Cannabis Use Disorder: Systematic Review of Randomized Controlled Trials

BACKGROUND

The prevalence of cannabis use and cannabis use disorders (CUD) has significantly increased over time. However, there are no approved pharmacological treatments for CUD. The aim of this study was to determine the efficacy and safety of various medical cannabinoids in the treatment of CUD.

METHODS

We conducted a systematic review of randomized controlled trials which evaluated the therapeutic potential of medical cannabinoids in individuals with CUD and summarized the main study outcomes in terms of cannabis use, abstinence, withdrawal symptoms, craving, retention in treatment and adverse events.

RESULTS

We identified eight trials with a total of 667 study participants. Dronabinol reduced cannabis withdrawal symptoms whereas nabiximols, cannabidiol and PF-04457845, a fatty acid amide inhibitor, also reduced cannabis use and improved abstinence, compared to placebo. Nabilone failed to demonstrate efficacy in the treatment of CUD. All medications were well-tolerated.

CONCLUSIONS

Cannabinoid receptor agonists, i.e., dronabinol and nabilone, showed only limited or no therapeutic potential in the treatment of CUD. In contrast, modulators of endocannabinoid activity, i.e., nabiximols, cannabidiol and PF-04457845, demonstrated broader efficacy which covered almost all aspects of CUD. Endocannabinoid modulation appears to be a promising treatment approach in CUD, but the evidence to support this strategy is still small and future research in this direction is needed.

Promoting self-change in cannabis use disorder: Findings from a randomized trial

BACKGROUND

A growing body of literature supports the efficacy of cognitive-behavioral therapy (CBT) and motivational interviewing (MI) for the treatment of problematic cannabis use, diagnostically referred to as cannabis use disorder, though most individuals do not access formal treatment. Stepped-care-type models emphasize interventions across a continuum of severity and there is a need for more treatment options across this continuum. This project focused on the evaluation of the least intensive of the individual interventions - promotion of self-directed recovery.

METHODS

Using a three-arm randomized control trial design, adults (N = 186) with problematic cannabis use and who wished to recover with minimal professional support were recruited from across Canada and randomized to receive a self-directed treatment workbook based on CBT and MI principles (WB; n = 61), the workbook plus a single MI session (WMI; n = 61) or a delayed treatment control (DT; n = 65) condition. Participants completed 3-month and 6-month follow-up assessments.

RESULTS

Across conditions, GEE modeling revealed that the baseline to 3-month slopes differed significantly from zero, ps < 0.001. Participants in the WMI condition reduced their frequency of use to a greater extent than the WB alone, p = 0.005, and DT groups, p = 0.02. Chi-square analysis revealed that participants in the WMI condition also showed greater rates of abstinence at 3-months follow-up than participants in the WB or DT condition, p = 0.046. Changes in the frequency of cannabis use between 3-months and 6-months did not differ significantly between groups, ps > 0.05. For quantity of cannabis use, a significant effect of time emerged, p = 0.002. However, no between-group effects were significant from baseline to 3-months, or from 3- to 6-months, ps > 0.06.

CONCLUSION

Overall, results support the utility of a brief self-directed workbook in combination with a single MI session at promoting changes in cannabis use. This self-directed intervention has the potential to fill an important need in that the self-directed intervention can attract individuals who wish to recover with minimal professional support.

CLINICAL TRIAL REGISTRATION

[https://www.isrctn.com/], identifier [ISRCTN426 32893].

Clinical Approaches to Cannabis: A Narrative Review

Cannabis use in the United States is growing at an unprecedented pace. Most states in the United States have legalized medical cannabis use, and many have legalized nonmedical cannabis use. In this setting, health care professionals will increasingly see more patients who have questions about cannabis use, its utility for medical conditions, and the risks of its use. This narrative review provides an overview of the background, pharmacology, therapeutic use, and potential complications of cannabis.

Applications of technology in the assessment and treatment of cannabis use disorder

Cannabis use and Cannabis Use Disorder (CUD) have been increasing. There are no FDA approved medications and evidence-based psychotherapy is limited by insufficient providers, serving very few patients effectively. The lack of resources for prevention and treatment of CUD has resulted in a significant gap between the need for services and access to treatment. The creation of a scalable system to prevent, screen, refer and provide treatment for a chronic, relapsing diagnosis like CUD could be achieved through the application of technology. Many studies have utilized ecological momentary assessments (EMA) in treatment seeking and non-treatment seeking cannabis users. EMA allows for repeated, intensive, longitudinal data collection in vivo. EMA has been studied in cannabis use and its association with affect, craving, withdrawal, other substances, impulsivity, and interpersonal behaviors. EMA has the potential to serve as a valuable monitoring tool in prevention, screening, and treatment for CUD. Research has also focused on the development of internet and application-based treatments for CUD, including a currently available prescription digital therapeutic. Treatment options have expanded to more broadly incorporate telehealth as an option for CUD treatment with broad acceptance and change in regulation following the COVID-19 pandemic. While technology has limitations, including cost, privacy concerns, and issues with engagement, it will be a necessary medium to meet societal health needs as a consequence of an ever-changing cannabis regulatory landscape. Future work should focus on improving existing platforms while ethically incorporating other functions (e.g., sensors) to optimize a public and clinical health approach to CUD.

Public health monitoring of cannabis use in Europe: prevalence of use, cannabis potency, and treatment rates

Background

Cannabis is one of the most widely used substances worldwide. Heavy use is associated with an increased risk of cannabis use disorders, psychotic disorders, acute cognitive impairment, traffic injuries, respiratory problems, worse pregnancy outcomes, and there are indications for genotoxic and epigenotoxic adverse effects. International regulation of medical and non-medical cannabis use is changing rapidly and substantially, highlighting the importance of robust public health monitoring. This study aimed to describe the trends of key public health indicators in European Union (27 member states + UK, Norway and Turkey) for the period 2010 to 2019, their public health implications, and to identify the steps required to improve current practice in monitoring of cannabis use and harm in Europe.

Methods

Data on four key cannabis indicators (prevalence of use, prevalence of cannabis use disorder [CUD], treatment rates, and potency of cannabis products) in Europe were extracted from the United Nations Office on Drugs and Crime, European Monitoring Centre for Drugs and Drug Addiction and the Global Burden of Disease study. For prevalence of use and CUD, the first and last available estimate in each country were compared. For treatment rates and cannabis potency, linear regression models were conducted.

Findings

Between 2010 and 2019, past-month prevalence of cannabis use increased by 27% in European adults (from 3·1 to 3·9%), with most pronounced relative increases observed among 35-64 year-olds. In 13 out of 26 countries, over 20% of all past-month users reported high-risk use patterns. The rate of treatment entry for cannabis problems per 100,000 adults increased from 27·0 (95% CI: 17·2 to 36·8) to 35·1 (95% CI: 23·6 to 46·7) and has mostly plateaued since 2015. Modest increases in potency were found in herbal cannabis (from 6·9% to 10·6% THC) while median THC values tripled in cannabis resin (from 7·6% to 24·1% THC).

Interpretation

In the past decade, cannabis use, treatment rates and potency levels have increased in Europe highlighting major concerns about the public health impact of cannabis use. Continued monitoring and efforts to improve data quality and reporting, including indicators of high-risk use and cannabis-attributable harm, will be necessary to evaluate the health impact of international changes in cannabis regulation.

Funding

This study received no specific funding.

Prevalence and associated factors of cannabis consumption in medical students: the BOURBON nationwide study

France has been identified with one of the highest rates of cannabis consumption of Western European countries. Yet we lack data in medical students who are at risk of addictive behavior. The objective of the study is to determine the prevalence of cannabis consumption and cannabis use disorder (CUD) among French medical students and their association with psychotropic drug consumption and psychosocial factors. Medical students were recruited from 35 French universities of medicine through administration mailing lists and social networks, between December 2016 and May 2017. Cannabis consumption was self-declared by anonymous questionnaire and CUD was defined by a Cannabis Abuse Screening Test (CAST) score ≥ 3. 10,985 medical students with a mean age of 21.8 years (± 3.3) were included, 32% of which were men. Overall, 1642 [14.9 (14.3; 15.6)%] reported cannabis consumption and 622 [5.7 (5.2; 6.1)%] students were identified with CUD at screening. Men were at two-time higher risk of cannabis consumption and three-time higher risk of CUD (22.4% and 10.6% for men vs. 11.5% and 3.4%, respectively, for women). In multivariate analyses, men sex, alcohol use disorder, tobacco smoking, parents' divorce, and history of physical assault and lower rates of lower rates of ≥ 40 weekly worked hours were identified as common associated factors for cannabis consumption and CUD. Hypnotic consumption, psychiatric follow-up, and history of sexual assault were identified as factors associated specifically with CUD, suggesting that these factors were associated with more severe cannabis consumption. Only 17% of students identified with CUD reported a psychiatric follow-up. Altogether, these results suggest that health policies should target cannabis consumption in medical students that is frequent, especially in men, with low rates of psychiatric follow-up. We have identified psychological factors and increased hypnotic drug consumption in CUD participants suggesting that psychiatric follow-up should be systematically proposed to this group.

Non-abstinent treatment outcomes for cannabis use disorder

BACKGROUND

Abstinence remains a standard outcome for potential treatment interventions for Cannabis Use Disorder (CUD). However, there needs to be validation of non-abstinent outcomes. This study explores reductions in self-reported days of use as another viable outcome measure using data from three completed randomized placebo-controlled clinical trials of pharmacological interventions for CUD.

METHODS

The three trials tested the effect of quetiapine (QTP, n = 113); dronabinol (DRO, n = 156); and lofexidine + dronabinol (LFD, n = 122). Self-reported cannabis use was categorized into three use-groups/week: heavy (5-7 days/week), moderate (2-4 days/week) and light use (0-1 days/week). Multinomial logistic regressions analyzed the treatment by time effect on the likelihood of light and moderate use compared to heavy use in each study.

RESULTS

Across the three trials, there was no significant overall time-by-treatment interaction (QTP: p = .06; DRO: p = .15; LFD: p = .21). However, the odds of moderate compared to heavy use were significantly higher in treatment than in placebo groups starting around the midpoint of each trial. No treatment differences were found between the odds of light compared to heavy use.

CONCLUSIONS

While study-end abstinence rates have been a standard treatment outcome for CUD trials, reduction from heavy to moderate use has not been standardly assessed. During the last several weeks of each trial, those on active medication were more likely to move from heavy to moderate use, which suggests that certain medications may be more impactful than previously assessed. Future studies should determine if this pattern is associated with less CUD severity and/or improved quality of life.

Repetitive transcranial magnetic stimulation as a potential treatment approach for cannabis use disorder

The expanding legalization of cannabis across the United States is associated with increases in cannabis use, and accordingly, an increase in the number and severity of individuals with cannabis use disorder (CUD). The lack of FDA-approved pharmacotherapies and modest efficacy of psychotherapeutic interventions means that many of those who seek treatment for CUD relapse within the first few months. Consequently, there is a pressing need for innovative, evidence-based treatment development for CUD. Preliminary evidence suggests that repetitive transcranial magnetic stimulation (rTMS) may be a novel, non-invasive therapeutic neuromodulation tool for the treatment of a variety of substance use disorders (SUDs), including recently receiving FDA clearance (August 2020) for use as a smoking cessation aid in tobacco cigarette smokers. However, the potential of rTMS for CUD has not yet been reviewed. This paper provides a primer on therapeutic neuromodulation techniques for SUDs, with a particular focus on reviewing the current status of rTMS research in people who use cannabis. Lastly, future directions are proposed for rTMS treatment development in CUD, with suggestions for study design parameters and clinical endpoints based on current gold-standard practices for therapeutic neuromodulation research.

A systematic review of longitudinal studies investigating the impact of cannabis use in patients with psychotic disorders

Introduction: Research has established a link between cannabis use and adverse psychotic outcomes in psychosis patients. However, we have yet to determine if this relationship is maintained when controlling for important confounding variables. The following systematic review aims to investigate if the association between cannabis use and psychotic outcomes is preserved when accounting for important confounders, and if discontinued use mitigates any potential negative impacts.Areas covered: The authors conducted an exhaustive search of the MEDLINE database and Google Scholar to identify articles pertaining to the systematic review. Thirty-three articles were retained for meeting the eligibility criteria.Expert opinion: The evidence confirms an overarching pattern of negative psychotic outcomes of cannabis intake in psychosis populations, even when accounting for crucial confounders. Psychosis patients should be informed with evidence-based health information regarding the effects of cannabis use. Clinicians should systematically evaluate cannabis intake patterns in psychosis patients and offer intervention services geared toward reducing problematic consumption. Researchers should record confounding factors in a more systematic manner in future longitudinal investigations while paying careful attention to the potency and dose-response effects of the ingested cannabis. Deciders will need to investigate the impact of cannabis regulations on psychosis populations.

Reaching nontreatment-seeking cannabis users: Testing an extended marijuana check-up intervention

Some adult cannabis users report negative consequences of use but do not seek treatment. Nonjudgmental, brief interventions incorporating motivational interviewing techniques may be able to reach users who otherwise would not seek treatment and increase their motivation to change use. Previous studies have shown brief interventions with this population are efficacious in reducing use, but the absolute amount of change has not clearly translated into meaningful reductions in associated negative consequences. The current study used a marijuana check-up (MCU) model to attract nontreatment-seeking adults who used cannabis at levels that may have caused negative consequences. The study randomly assigned participants to 2-session (n = 93) and 6-session (n = 93) versions of the intervention and followed them for 12 months. The study designed the extended 6-session condition to build on the efficacy of the previously tested 2-session intervention. The study hypothesized that the opportunity to continue to consider the consequences of cannabis use would have the greatest impact on those who were in earlier stages of readiness for change. We used cognitive behavioral techniques to assist with change efforts when indicated. Results showed significant reductions in the frequency and daily duration of cannabis use at all follow-ups in both intervention conditions. The extended 6-session condition produced greater change only on a measure of the number of periods of the day in which cannabis was used. Reductions in dependence symptoms and problems related to cannabis use occurred in both conditions, but there was no effect of intervention condition. Participants who were less ready to make changes at the outset decreased use and negative consequences the least. Results suggested that some benefit of the extended session format of the check-up in reducing daily use, but the lack of a corresponding reduction in consequences suggested that the original 2-session MCU may be more cost effective.

Factor analysis of a short form of the Protective Behavioral Strategies for Marijuana scale

OBJECTIVE

The Protective Behavioral Strategies for Marijuana Scale (PBSM), a 17-item scale targeting strategies for mitigating the negative consequences of cannabis use, highlights a range of behaviors that can reduce harm beyond straightforward decreases in quantity or frequency. The 17-item scale's factor structure remains under-examined but could reveal meaningful distinctions among strategies. This study aimed to confirm the factor structure of the short form of the PBSM.

METHODS

This study recruited cannabis-using undergraduates (N = 454,M_age = 19.6, 68.8% female, 39% White), who reported using cannabis approximately 2.3 days per week with mild cannabis-related consequences (CAPQ; M = 9.74).

RESULTS

A confirmatory factor analysis demonstrated poor fit for the one-factor model of the PBSM, prompting an exploratory factor analysis. Analyses revealed two internally reliable factors: a "Quantity" factor, strategies specific to mitigating overuse and limiting amounts consumed and an "Context" factor loosely related to troubles with others. This two-factor model accounted for over half of the total variance; invariance testing indicated reduced fit as models became more restrictive. Though each of the factors covaried negatively with both days of use and problems, Context had a stronger relation to both variables compared to Quantity. Only Context predicted fewer cannabis problems and use.

CONCLUSIONS

The two-factor solution suggests further work on the psychometric properties of the scale could provide heuristic information to allow for more nuanced approaches in clinical and research settings. Theoretically, each factor might have novel links to some constructs but not others in ways that could assist harm-reduction strategies and treatment.

CANreduce 2.0 Adherence-Focused Guidance for Internet Self-Help Among Cannabis Users: Three-Arm Randomized Controlled Trial

Background

Despite increasing demand for treatment among cannabis users in many countries, most users are not in treatment. Internet-based self-help offers an alternative for those hesitant to seek face-to-face therapy, though low effectiveness and adherence issues often arise.

Objective

Through adherence-focused guidance enhancement, we aimed to increase adherence to and the effectiveness of internet-based self-help among cannabis users.

Methods

From July 2016 to May 2019, cannabis users (n=775; male: 406/575, 70.6%, female: 169/575, 29.4%; age: mean 28.3 years) not in treatment were recruited from the general population and were randomly assigned to (1) an adherence-focused guidance enhancement internet-based self-help intervention with social presence, (2) a similar intervention with an impersonal service team, and (3) access to internet as usual. Controls who were placed on a waiting list for the full intervention after 3 months underwent an assessment and had access to internet as usual. The primary outcome measurement was cannabis-use days over the preceding 30 days. Secondary outcomes included cannabis-dependence severity, changes in common mental disorder symptoms, and intervention adherence. Differences between the study arms in primary and secondary continuous outcome variables at baseline, posttreatment, and follow-up were tested using pooled linear models.

Results

All groups exhibited reduced cannabis-use days after 3 months (social presence: –8.2 days; service team: –9.8 days; internet as usual: –4.2 days). The participants in the service team group (P=.01, d=.60) reported significantly fewer cannabis-use days than those in the internet as usual group; the reduction of cannabis use in the social presence group was not significant (P=.07, d=.40). There was no significant difference between the 2 intervention groups regarding cannabis-use reduction. The service team group also exhibited superior improvements in cannabis-use disorder, cannabis-dependence severity, and general anxiety symptoms after 3 months to those in the internet as usual group.

Conclusions

The adherence-focused guidance enhancement internet-based self-help intervention with an impersonal service team significantly reduced cannabis use, cannabis-use disorder, dependence severity, and general anxiety symptoms.

Trial Registration

ISRCTN Registry ISRCTN11086185; http://www.isrctn.com/ISRCTN11086185

Technology-Based Psychological Interventions for Young Adults With Early Psychosis and Cannabis Use Disorder: Qualitative Study of Patient and Clinician Perspectives

Background

The persistence of cannabis use disorder (CUD) in young adults with first-episode psychosis (FEP) is associated with poor clinical and functional outcomes. Face-to-face psychological interventions are effective in treating CUD. However, their use in early intervention services (EISs) for psychosis is inconsistent because of barriers, including high workload and heterogeneity in training of clinicians and lack of motivation for treatment among patients. Tailoring new technology-based psychological interventions (TBPIs) to overcome these barriers is necessary to ensure their optimal acceptability.

Objective

The aim of this study is twofold: to explore psychological intervention practices and intervention targets that are relevant for treating CUD in individuals with early psychosis and to explore factors related to the development and implementation of a technology-assisted psychological intervention.

Methods

A total of 10 patients undergoing treatment for FEP and CUD in EISs participated in a focus group in June 2019. Semistructured individual interviews were conducted with 10 clinicians working in first-episode clinics in the province of Québec, Canada. A hybrid inductive-deductive approach was used to analyze data. For the deductive analysis, we used categories of promoting strategies found in the literature shown to increase adherence to web-based interventions for substance use (ie, tailoring, reminders, delivery strategies, social support, and incentives). For the inductive analysis, we identified new themes through an iterative process of reviewing the data multiple times by two independent reviewers.

Results

Data were synthesized into five categories of factors that emerged from data collection, and a narrative synthesis of commonalities and differences between patient and clinician perspectives was produced. The categories included attitudes and beliefs related to psychological interventions (eg, behavioral stage of change), strategies for psychological interventions (eg, motivational interviewing, cognitive behavioral therapy, psychoeducation, stress management), incentives (eg, contingency management), general interest in TBPIs (eg, facilitators and barriers of TBPIs), and tailoring of TBPIs (eg, application needs and preferences, outcome measures of interest for clinicians).

Conclusions

This study provides a comprehensive portrait of the multifaceted needs and preferences of patients and clinicians related to TBPIs. Our results can inform the development of smartphone- or web-based psychological interventions for CUD in young adults with early psychosis.

Psychosocial and pharmacological treatments for cannabis use disorder and mental health comorbidities: a narrative review

Cannabis is the most widely used illicit drug worldwide, and it is estimated that up to 30% of people who use cannabis will develop a cannabis use disorder (CUD). Demand for treatment of CUD is increasing in almost every region of the world and cannabis use is highly comorbid with mental disorders, where sustained use can reduce treatment compliance and increase risk of relapse. In this narrative review, we outline evidence for psychosocial and pharmacological treatment strategies for CUD, both alone and when comorbid with psychosis, anxiety or depression. Psychosocial treatments such as cognitive behavioural therapy, motivational enhancement therapy and contingency management are currently the most effective strategy for treating CUD but are of limited benefit when comorbid with psychosis. Pharmacological treatments targeting the endocannabinoid system have the potential to reduce cannabis withdrawal and cannabis use in CUD. Mental health comorbidities including anxiety, depression and psychosis hinder effective treatment and should be addressed in treatment provision and clinical decision making to reduce the global burden of CUDs. Antipsychotic medication may decrease cannabis use and cannabis craving as well as psychotic symptoms in patients with CUD and psychosis. Targeted treatments for anxiety and depression when comorbid with CUD are feasible.

Motivational Interviewing for Cannabis Use Disorders: A Systematic Review and Meta-Analysis

BACKGROUND

Cannabis is one of the most used drugs worldwide. There is no gold standard treatment for cannabis use disorder (CUD). Motivational interviewing (MI) has shown efficacy in some substance use disorders. Therefore, a systematic review was conducted to assess the effectiveness of MI in CUD.

METHODS

Randomized controlled trials or open-label studies published until September 2019 from 3 different databases (Pubmed, Scopus, and PsycINFO) were included, following the PRISMA guidelines and a predetermined set of criteria for article selection. Meta-analyses were conducted. The end point was determined as month 3, and 4 outcomes were analysed (abstinence rates, reduction in frequency of use, reduction in quantity of use, and reduction in cannabis use disorder symptoms) in 2 populations (adolescents and adults).

RESULTS

Forty studies were identified, of which 24 were performed in adults and 16 in adolescents. MI showed efficacy in achieving abstinence in both adults (odds ratio [OR] = 3.84, 95% confidence interval [CI] 2.40-6.16, p < 0.0001) and adolescents (OR = 2.02, 95% CI 1.42-2.89, p < 0.0001). MI showed efficacy in reducing frequency and quantity of use in adults but not in adolescents. Those adults who were in the MI group consumed less joints per day than those in the control group (mean difference = -0.69 joints per day, 95% CI -0.84 to -0.53, p < 0.001), and they consumed on less days per month (mean difference = -3.9 days per month, 95% CI -7.47 to -0.34, p = 0.0317) than those in the control group.

CONCLUSIONS

MI is an effective intervention to reduce cannabis use and achieve abstinence, especially among adults and patients with no prior history of psychotic disorder. Further investigation is needed to assess the effect on CUD symptoms. MI should be included in guidelines for treating cannabis use disorder as one of the essential psychological interventions.

Interventions for cannabis use disorder

How to treat adults and adolescents with a Cannabis Use Disorder is a burgeoning research area. This article reviews the empirical literature pertaining to several psychosocial approaches (cognitive-behavior therapy, motivational enhancement, and contingency management), all of which are associated with favorable outcomes. We also review the emerging research on the use of pharmacotherapy, brief interventions and technology-delivered interventions, and conclude with an overview of future research needs.

Care of the Patient Using Cannabis

The past 2 decades have seen a revolution in legal access to cannabis, driven largely by activists and business interests. As a result, the population of cannabis users nationwide-especially daily users-has grown significantly. An estimated 4.5-7 million persons in the United States now meet criteria for cannabis use disorder annually. This article focuses on the effects of cannabis use, intoxication, and withdrawal while also reviewing the developmental pathways of cannabis use disorder as well as evidence-based pharmacologic and psychosocial treatments.

Cannabinoid hyperemesis syndrome: definition, pathophysiology, clinical spectrum, insights into acute and long-term management

Although cannabinoid hyperemesis syndrome (CHS) was first reported more than 15 years ago, it still remains an unfamiliar clinical entity among physicians worldwide. CHS is categorized by Rome IV classification as a functional gastroduodenal disorder. It is characterized by stereotypical episodic vomiting in the setting of chronic, daily cannabis use, with cycles decreasing by the cessation of cannabis. CHS is also associated with abdominal pain reduced by hot baths and showers with comparative well-being between attacks. Thus, its clinical presentation resembles 'classic' cyclic vomiting syndrome, but eliciting a cannabis history is crucial in diagnosing this entity. In acute attacks, parenteral benzodiazepines are very effective. For prevention and long-term management, tricyclic antidepressants such as amitriptyline are the mainstay of therapy requiring doses in the range of 50-200 mg/d to achieve symptom control. In addition, counseling to achieve marijuana cessation, accompanied by antianxiety medications, is necessary for sustaining clinical outcomes. Once the patient is in remission and off marijuana for a period of 6-12 months, then tapering the dose of amitriptyline can be implemented, with the goal of no therapy being achieved in the majority of patients over time. With the legalization of marijuana in many states, CHS will become an increasingly prevalent clinical entity, so educating about CHS is an important goal, particularly for emergency department physicians who generally first encounter these patients.

Psychosocial and pharmacologic interventions for methamphetamine addiction: protocol for a scoping review of the literature

BACKGROUND

Methamphetamine use and harms are rising rapidly. Management of patients with methamphetamine use disorder (MUD) and problematic methamphetamine use (PMU) is challenging, with no clearly established best approach; both psychosocial and pharmacologic interventions have been described. Furthermore, given the diversity of individuals that use methamphetamines, there is a need to assess evidence for treatments for subgroups including youths; gay, bisexual, and other men who have sex with men; individuals with mental health comorbidities; and individuals in correction services. Establishing awareness of the messages regarding treatment from recent clinical practice guidelines (CPG) in the field is also of value. The first study objective will be to establish a greater understanding of the methods, populations, and findings of controlled studies for psychosocial and pharmacologic treatments for MUD and PMU. Investigation of this information can help establish the potential for advanced syntheses of the evidence (such as network meta-analysis) to compare therapies for this condition and to identify gaps related to key populations where more primary research is needed. Summarizing the recommendations regarding treatment of MUD/PMU from recent CPGs and systematic reviews will be an important secondary objective.

METHODS

A scoping review will be performed. Using the OVID platform, MEDLINE, Embase, PsycINFO, and relevant Cochrane databases from EBM Reviews will be searched (from databases' inception onwards). Eligibility criteria will include individuals described as having MUD or PMU, with designs of interest including randomized trials, non-randomized trials, and controlled cohort studies with three or more months of follow-up; systematic reviews and CPGs will also be sought. Two reviewers (with support from automation tools) will independently screen all citations, full-text articles, and chart data. Different approaches to handling and summarizing the data will be implemented for each type of study design. Tables and graphics will be used to map evidence sources and identify evidence gaps.

DISCUSSION

This research will enhance awareness of evidence addressing the effects of psychosocial and pharmacologic interventions for MUD/PMU overall and in sub-populations, both in terms of recent CPGs/reviews and primary studies; inspection of the latter will also help establish the feasibility of future syntheses to compare treatments, such as network meta-analysis. SYSTEMATIC REVIEW PROTOCOL REGISTRATION: Open Science Framework ( https://osf.io/9wy8p ).

Improving substance misuse outcomes in contingency management treatment with adjunctive formal psychotherapy: a systematic review and meta-analysis

OBJECTIVES

Contingency management (CM) is a treatment for substance misuse that involves the provision of incentives. This review examines the hypothesis that adding another formal psychotherapy, such as cognitive-behavioural therapy (CBT) or motivational enhancement therapy (MET), to CM improves substance use outcomes at both treatment end and at post-treatment follow-up compared with CM only.

DATA SOURCES

Searches were performed in December 2017 and July 2019 of seven electronic bibliographic databases (MEDLINE, PsycINFO, EMBASE, Scopus, Web of Science, CINAHL, PsycEXTRA), as well as online trial registries and EThoS, and were followed by reference list screening.

ELIGIBILITY CRITERIA

Included studies were randomised controlled trials of adults (18-65) who were using illicit substances, alcohol or tobacco. Studies featured an experimental arm delivering CM combined with a structured evidence-based psychotherapeutic intervention and a CM-only arm. Studies published up to July 2019 were included.

DATA EXTRACTION AND SYNTHESIS

The primary outcome was biometrically verified point prevalent abstinence (PPA) at treatment end. Secondary outcomes included biometrically verified PPA at post-treatment follow-up and self-reported days of use at treatment end and post-treatment follow-up. Pooled risk ratios for PPA outcomes and standardised mean differences for days of use were calculated using random effects models. Risk of bias was assessed using the Grading of Recommendations Assessment, Development and Evaluation.

RESULTS

12 studies (n=1654) were included. The primary analysis found no evidence of a synergistic effect in PPA at treatment end (relative risk (RR) 0.97, 95% CI 0.85 to 1.09; p=0.57). Sensitivity analysis of studies featuring CBT/MET also found no evidence of an effect (RR 0.92; 95% CI 0.79 to 1.08; p=0.32). None of the secondary outcomes showed any evidence of benefit.

CONCLUSION

The results of the meta-analyses found no evidence that combining CM with another intervention improves the short-term or long-term effects of CM treatment.

Cannabidiol for the treatment of cannabis use disorder: a phase 2a, double-blind, placebo-controlled, randomised, adaptive Bayesian trial

Background A substantial and unmet clinical need exists for pharmacological treatment of cannabis use disorders. Cannabidiol could offer a novel treatment, but it is unclear which doses might be efficacious or safe. Therefore, we aimed to identify efficacious doses and eliminate inefficacious doses in a phase 2a trial using an adaptive Bayesian design.

METHODS

We did a phase 2a, double-blind, placebo-controlled, randomised, adaptive Bayesian trial at the Clinical Psychopharmacology Unit (University College London, London, UK). We used an adaptive Bayesian dose-finding design to identify efficacious or inefficacious doses at a-priori interim and final analysis stages. Participants meeting cannabis use disorder criteria from DSM-5 were randomly assigned (1:1:1:1) in the first stage of the trial to 4-week treatment with three different doses of oral cannabidiol (200 mg, 400 mg, or 800 mg) or with matched placebo during a cessation attempt by use of a double-blinded block randomisation sequence. All participants received a brief psychological intervention of motivational interviewing. For the second stage of the trial, new participants were randomly assigned to placebo or doses deemed efficacious in the interim analysis. The primary objective was to identify the most efficacious dose of cannabidiol for reducing cannabis use. The primary endpoints were lower urinary 11-nor-9-carboxy-δ-9-tetrahydrocannabinol (THC-COOH):creatinine ratio, increased days per week with abstinence from cannabis during treatment, or both, evidenced by posterior probabilities that cannabidiol is better than placebo exceeding 0·9. All analyses were done on an intention-to-treat basis. This trial is registered with ClinicalTrials.gov (NCT02044809) and the EU Clinical Trials Register (2013-000361-36).

FINDINGS

Between May 28, 2014, and Aug 12, 2015 (first stage), 48 participants were randomly assigned to placebo (n=12) and to cannabidiol 200 mg (n=12), 400 mg (n=12), and 800 mg (n=12). At interim analysis, cannabidiol 200 mg was eliminated from the trial as an inefficacious dose. Between May 24, 2016, and Jan 12, 2017 (second stage), randomisation continued and an additional 34 participants were allocated (1:1:1) to cannabidiol 400 mg (n=12), cannabidiol 800 mg (n=11), and placebo (n=11). At final analysis, cannabidiol 400 mg and 800 mg exceeded primary endpoint criteria (0·9) for both primary outcomes. For urinary THC-COOH:creatinine ratio, the probability of being the most efficacious dose compared with placebo given the observed data was 0·9995 for cannabidiol 400 mg and 0·9965 for cannabidiol 800 mg. For days with abstinence from cannabis, the probability of being the most efficacious dose compared with placebo given the observed data was 0·9966 for cannabidiol 400 mg and 0·9247 for cannabidiol 800 mg. Compared with placebo, cannabidiol 400 mg decreased THC-COOH:creatinine ratio by -94·21 ng/mL (95% interval estimate -161·83 to -35·56) and increased abstinence from cannabis by 0·48 days per week (0·15 to 0·82). Compared with placebo, cannabidiol 800 mg decreased THC-COOH:creatinine ratio by -72·02 ng/mL (-135·47 to -19·52) and increased abstinence from cannabis by 0·27 days per week (-0·09 to 0·64). Cannabidiol was well tolerated, with no severe adverse events recorded, and 77 (94%) of 82 participants completed treatment.

INTERPRETATION

In the first randomised clinical trial of cannabidiol for cannabis use disorder, cannabidiol 400 mg and 800 mg were safe and more efficacious than placebo at reducing cannabis use.

FUNDING

Medical Research Council.