A 12-step treatment approach for marijuana (Cannabis) dependence

The state of clinical outcome assessments for cannabis use disorder clinical trials: A review and research agenda

There is considerable variability in the use of outcome measures in clinical trials for cannabis use disorder (CUD), and a lack of consensus regarding optimal outcomes may have hindered development and approval of new pharmacotherapies. The goal of this paper is to summarize an evaluation of assessment measures and clinical endpoints for CUD clinical trials, and propose a research agenda and priorities to improve CUD clinical outcome assessments. The primary recommendation is that sustained abstinence from cannabis should not be considered the primary outcome for all CUD clinical trials as it has multiple limitations. However, there are multiple challenges to the development of a reliable and valid indicator of cannabis reduction, including the lack of a standard unit of measure for the various forms of cannabis and products and the limitations of currently available biological and self-report assessments. Development of a core toolkit of assessments is needed to both allow flexibility for study design, while facilitating interpretation of outcomes across trials. Four primary agenda items for future research are identified to expedite development of improved clinical outcome assessments for this toolkit: (1) determine whether minimally invasive biologic assays could identify an acute level of cannabis use associated with psychomotor impairment or other cannabis-related harms; (2) create an indicator of quantity of cannabis use that is consistent across product types; (3) examine the presence of cannabis-specific functional outcomes; and (4) identify an optimal duration to assess changes in CUD diagnostic criteria.

A preliminary investigation of acceptance and commitment therapy as a treatment for marijuana dependence in adults

In this investigation, 3 adults who met criteria for marijuana dependence were treated using an abbreviated version of acceptance and commitment therapy (ACT). The treatment was delivered in eight weekly 90-min individual sessions. The effects of the intervention were assessed using a nonconcurrent multiple baseline across participants design. Self-reported marijuana use, confirmed through oral swabs, reached zero levels for all participants at posttreatment. At a 3-month follow-up, 1 participant was still abstinent and the other 2 were using but at a lower average level of consumption compared to baseline. Depression, anxiety, withdrawal symptoms, and general levels of experiential avoidance generally improved. This preliminary test suggests that additional development and testing of ACT for marijuana use are warranted.

Psychotherapeutic interventions for cannabis abuse and/or dependence in outpatient settings

BACKGROUND

Cannabis use disorder is the most common illicit substance use disorder in general population. Despite that, only a minority seek assistance from a health professional, but the demand for treatment is now increasing internationally. Trials of treatment have been published but to our knowledge, there is no published systematic review .

OBJECTIVES

To evaluate the efficacy of psychosocial interventions for cannabis abuse or dependence.

SEARCH STRATEGY

We searched the Cochrane Central Register of Trials (CENTRAL) The Cochrane Library Issue 3, 2004; MEDLINE (January 1966 to August 2004), PsycInfo (1985 to October 2004), CINAHL (1982 to October 2004), Toxibase (until September 2004) and reference lists of articles. We also contacted researchers in the field.

SELECTION CRITERIA

All randomized controlled studies examining a psychotherapeutic intervention for cannabis dependence or abuse in comparison with a delayed-treatment control group or combinations of psychotherapeutic interventions.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data

MAIN RESULTS

Six trials involving 1297 people were included. Five studies took place in the United States, one in Australia. Studies were not pooled in meta-analysis because of heterogeneity. The six included studies suggested that counseling approaches might have beneficial effects for the treatment of cannabis dependence. Group and individual sessions of cognitive behavioral therapy (CBT) had both efficacy for the treatment of cannabis dependence and associated problems, CBT produced better outcomes than a brief intervention when CBT was delivered in individual sessions. Two studies suggested that adding voucher-based incentives may enhance treatment when used in combination with other effective psychotherapeutic interventions. Abstinence rates were relatively small overall but favored the individual CBT 9-session (or more) condition. All included trials reported a statistically significant reductions in frequency of cannabis use and dependence symptoms. But other measures of problems related to cannabis use were not consistently different.

AUTHORS' CONCLUSIONS

The included studies were too heterogenous and could not allow to draw up a clear conclusion. The studies comparing different therapeutic modalities raise important questions about the duration, intensity and type of treatment. The generalizability of findings is also unknown because the studies have been conducted in a limited number of localities with fairly homogenous samples of treatment seekers. However, the low abstinence rate indicated that cannabis dependence is not easily treated by psychotherapies in outpatient settings.

Cannabis-associated psychosis: current status of research

Cannabis has been used for recreational, medicinal and religious purposes in different cultures since ancient times. There have been various reports of adverse effects due to or associated with cannabis consumption, including psychotic episodes. Historically, our understanding of these clinical observations has been significantly hindered by a lack of knowledge regarding their underlying neurobiological and pharmacological processes. However, the discovery of the endogenous cannabinoid system has allowed a greater understanding of these adverse effects to develop. From a clinical perspective, toxic or transient psychotic reactions to the administration of herbal cannabis preparations or specific cannabinoid compounds have to be differentiated from longer-lasting, persistent schizophrenia-like disorders associated with the use of cannabis/cannabinoids. The latter are most likely to be associated with a predisposition or vulnerability to schizophrenia. Interestingly, the recently suggested role of the endogenous cannabinoid system in schizophrenia not related to previous cannabinoid consumption introduces an additional perspective on the mechanism underlying cannabis-associated schizophrenia-like disorders, as well as on the effects of cannabis consumption in schizophrenia. At present, acute psychopharmacological treatment options for cannabis-associated transient and persistent schizophrenia-like psychotic episodes are similar and are based on the use of benzodiazepines and antipsychotics. However, new pharmacological strategies using the endogenous cannabinoid system as a primary target are under development. Long-term psychotherapeutic treatment options involve case management strategies and are mainly based on specialised psychotherapeutic programmes to encourage cannabis users to stop their use of the drug.

A peek into Pandora's box: the medical excuse marijuana controversy

The smoking of marijuana for medicinal applications is a volatile and difficult issue for the medical and regulatory communities which has reached the forefront of discussions of public policy. Any consideration of this issue must take into account the substantial toxicity, impurity, and morbidity associated with marijuana use. Several states have passed ballot initiatives or legislation that allow a medical excuse for possession of marijuana. These initiatives bypass the Food and Drug Administration process of proving safety and efficacy, and they have created serious regulatory dilemmas for state regulatory boards. Several examinations of the issue have consistently drawn question to the validity of smoking an impure substance while voicing concern for the well being of patients in need. The historical, social, medical, and legal issues are examined.

The Marijuana Treatment Project: rationale, design and participant characteristics

AIMS

Recent findings regarding the prevalence of marijuana dependence and associated consequences indicate the need for empirically validated treatments for this population. The Marijuana Treatment Project (MTP) was a multi-site study of two treatments for adults with marijuana dependence.

DESIGN

Participants (N= 450) were randomly assigned to one of three conditions at each of three sites: 1) a 9-session cognitive behavioral treatment (CBT) with motivational enhancement therapy (MET) and case management (CM) components; 2) a 2-session MET intervention; or 3) a delayed treatment control (DTC).

SETTING

The study was conducted in outpatient drug treatment clinics in three U.S. cities.

PARTICIPANTS

Participants were individuals aged 18 or over who met diagnostic criteria for cannabis dependence and who voluntarily presented for treatment.

MEASUREMENT

Study variables included DSM-IV dependence criteria, timeline follow-back assessment of drug use, Addiction Severity Index composite scores, and problems related to marijuana use.

FINDINGS

Participants were daily users, who smoked marijuana multiple times per day, and had been doing so for more than 15 years. They reported multiple dependence symptoms and negative consequences related to marijuana use. Approximately 32% of the sample was female, and 30% of the sample was either Hispanic (17%), African American (12%), or of mixed racial backgrounds (1%).

CONCLUSIONS

The multi-site nature of the MTP allowed for the recruitment of a more ethnically and gender diverse sample than had been studied previously but there were few differences in the clinical characteristics of participants at the geographically and sociodemographically diverse study sites.

Marijuana use among adolescents

More than half of US adolescents will experiment with marijuana. Of those who try marijuana more than once, approximately one third will subsequently use marijuana regularly, although most will have stopped by their late 20s. Although genetic predisposition plays the most important role in determining who will develop dependence, environmental factors influence who will initiate marijuana use. One of the challenges for prevention and treatment programs is that the immediate adverse effects of marijuana use are not extreme, and many adolescents have difficulty in making decisions based on future risks. Therefore, the consequences of leaving school early, having unprotected sex, and driving while intoxicated are often insufficient to deter adolescents from using marijuana. Thus, it is not surprising that current prevention and treatment programs have had limited success in decreasing the rates of initiation and regular use of marijuana among adolescents. However, the accumulation of data about marijuana use in adolescents has the potential to enable the development of more effective prevention and treatment programs.

Marijuana Use: Current Issues and New Research Directions

Due to recent evidence of the increasing frequency of marijuana use among adolescents and young adults, and due to the many remaining research issues regarding this drug, it is appropriate to summarize some of the important data about marijuana and to suggest some directions for research and service. This article first provides a review of the history, botany, active ingredients, effects, and negative consequences of marijuana use. Next, prevention and cessation of marijuana use are discussed. Finally, this paper provides a selective examination of current issues in marijuana research. Several salient issues are highlighted including its preference among certain subgroups (high risk youth and ethnic differences), its relations with illegal behavior (marijuana use and driving, current marijuana-related legislation, and marijuana use and violence), and its recent portrayal in the media.

Biopsychosocial changes associated with cessation of cannabis use: a single case study of acute and chronic cognitive effects, withdrawal and treatment

A 35 year old male was cognitively assessed prior to cessation of 18 years of daily cannabis use and monitored for several weeks post cessation. Brain event-related potential (ERP) measures of selective attention reflecting a difficulty in filtering out complex irrelevant information showed no indication of improvement over 6 weeks of abstinence. In contrast, when tested in the acutely intoxicated state prior to cessation of use, a dramatic normalisation of the ERP signature of this individual was observed. A treatment program based on supportive-expressive psychotherapy was administered and depression, anxiety and general psychological health were monitored over the course of withdrawal from cannabis.