A randomized controlled trial of brief cognitive-behavioral interventions for cannabis use disorder

Contingency Management for Cannabis Use Disorder Treatment

INTRODUCTION

Although recreational cannabis use and abuse are expressive worldwide, the comparison of worldwide used psychotherapies, such as cognitive behavior therapy, with contingency management in the treatment of cannabis use disorder remains inconclusive.

METHODS

We screened all articles published on MEDLINE (via PubMed) published until October 2023 and conducted a systematic review with meta-analysis.

RESULTS

Sixteen studies were included, and contingency management intervention likely promotes abstinence outcomes and more negative urinalyses for adults or adolescents with cannabis use disorder.

DISCUSSION

This review provides moderate- to high-quality evidence that contingency management can be used to treat cannabis use disorder. However, further trials need to be developed to analyze the quantity of substance use, personal achievements, and operational improvements after treatment.

Validation of the Reasons for Quitting Smoking Cannabis Scale Among People with Cannabis Use Disorder

BACKGROUND

The prevalence of cannabis use disorder (CUD) has increased in the last ten years with medicinal and recreational legalization across the United States and increasing accessibility worldwide. Estimates suggest that 8-18% of individuals who use cannabis meet diagnostic criteria for CUD, leading to significant impairments across functioning. However, there are currently no measures that assess the reasons for quitting smoking cannabis to use in treatments with validation evidence in those with CUD.

METHOD

We validated the Reasons for Quitting Smoking Cannabis Scale (RQSCS) in adults (n = 133) who meet the diagnostic criteria for CUD as part of a laboratory-based clinical trial on transdermal nicotine patches for cannabis withdrawal symptoms (R01DA031006). We conducted standard psychometric testing, including exploratory factor analyses, estimating internal consistencies, exploring demographic variation, and testing construct validity.

RESULTS

The RQSCS demonstrated a four-factor structure, including: (1) cognitive health, (2) social functioning, (3) health problems, (4) reputation, and a single item that assesses experimental incentive; λs > .410), with acceptable to high internal consistencies for each subscale (αs > .725). The scale demonstrated strong construct validity and minor demographic variation. Finally, all subscales were sensitive to detecting reasons for quitting cannabis and differentially predicted cannabis use 31 days after the study.

CONCLUSION

The RQSCS is a psychometrically robust, timely instrument for assessing the reasons for quitting smoking cannabis in individuals with CUD. The scale has the potential to provide useful information for clinicians attempting to help those with CUD reduce or cease their cannabis use, informing individualized treatment plans and enhancing motivation for change.

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.

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.

Cannabis use and cannabis use disorders and their treatment in the Europe

This paper introduces the special issue on cannabis use in Europe. It describes data on the prevalence of cannabis use in Europe and the more limited data on the prevalence of cannabis use disorders, one of the most common forms of drug problem treated in many countries in Europe. It summarises what research has indicated about the adverse effects of acute and chronic cannabis use and discusses potential health system responses that may reduce some of these harms. These include public education about the risks of cannabis use; screening and brief interventions in primary medical settings; and specialist treatment for cannabis use disorders. It briefly indicates the special issues that may need to be addressed in dealing with the high rates of comorbidity between cannabis use disorders, other types of drug use disorders, and common mental disorders.

Efficacy of Cognitive Behavioral Therapy Combined with Pharmacotherapy Versus Pharmacotherapy Alone in Adult ADHD: A Systematic Review and Meta-Analysis

BACKGROUND

ADHD diagnosis rates are rising; however, currently, no effective treatment method that has been identified. This study compared the efficacy of CBT + M with M for adult ADHD.

METHODS

PubMed, Embase, WOS, and Cochrane Library databases were searched up to July 29, 2023. Literature screening and data analysis were conducted.

RESULTS

The six randomized controlled studies included. Meta-analysis showed that CBT + M was more effective than M in improving ADHD symptoms. Subgroup analysis showed developed countries significant in ADHD symptoms improvement. At the 3-month, CBT + M was superior to M, but at the 6 and 9 months, no statistically significant differences were observed.

CONCLUSION

CBT + M is more effective than M in improving adult ADHD symptoms and maintains an advantage for at least 3 months. It is recommended to intensifying CBT treatment after 3 months. Country and economy may influence results. Combined therapy for ADHD should be prioritized in developed countries.

IUPHAR-review: The integration of classic psychedelics into current substance use disorder treatment models

Substance use disorders (SUDs) have an enormous impact on public health. With classic psychedelic-assisted therapies showing initial promise in treating multiple SUDs, it is possible that these treatments will become legally available options for patients with SUDs in the future. This article highlights how classic psychedelic-assisted therapies might be integrated into current clinical practice. We first describe contemporary evidence-based treatments for SUDs and highlight how classic psychedelic-assisted therapies might fit within each treatment. We suggest that classic psychedelic-assisted therapies can be integrated into most mainstream evidence-based SUD treatments that are currently used in clinical settings, indicating broad compatibility of classic psychedelics with contemporary SUD treatment paradigms.

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.

Implementation and Preliminary Evaluation of a 12-Week Cognitive Behavioural and Motivational Enhancement Group Therapy for Cannabis Use Disorder

Background

The purpose of this paper is to provide a preliminary evaluation of treatment outcomes, retention and client satisfaction following a 12-week combined cognitive behavioural therapy (CBT) and motivational enhancement therapy (MET) group treatment for cannabis use disorder (CUD) delivered in an outpatient setting. Implementation of the program is also described.

Methods

A retrospective observational cohort study was conducted using data collected from medical records and self-report assessments. Participants were treatment-seeking cannabis users at the Centre for Addiction and Mental Health, Toronto. Cannabis use, cannabis-related problems, craving, withdrawal symptoms, self-efficacy for remaining abstinent, depression and anxiety were assessed pre- and post-treatment. Treatment retention was calculated by inspecting clinic attendance records, and client satisfaction was evaluated using an anonymous feedback survey. Potential predictors of treatment outcomes and retention were investigated in exploratory analyses.

Results

Cannabis use was lower and days of abstinence higher post-treatment (vs pre-treatment). Post-treatment improvements in cannabis-related problems, craving, withdrawal symptoms, self-efficacy and mood were also observed. Completion of group treatment (⩾75% of sessions attended) was 57% and moderate levels of treatment satisfaction were reported.

Conclusions

This study provides preliminary evidence that a 12-week combined CBT and MET treatment for cannabis use disorder delivered in a novel group setting improves cannabis use outcomes. Potential predictors of reduced cannabis use and retention were identified. Future controlled studies are warranted, and strategies for increasing retention should be explored.

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.

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.

Reducing Cannabis Use in Young Adults With Psychosis Using iCanChange, a Mobile Health App: Protocol for a Pilot Randomized Controlled Trial (ReCAP-iCC)

BACKGROUND

Cannabis use is the most prevalent among adolescents and young adults; frequent consumption is associated with cannabis use disorder (CUD) and psychosis, with a high prevalence (up to 50%) of CUD in individuals with first-episode psychosis (FEP). Early Intervention Services (EIS) for psychosis include face-to-face psychosocial interventions for CUD, because reducing or discontinuing cannabis use improves clinical and health care service use outcomes. However, multiple barriers (eg, staff availability and limited access to treatment) can hinder the implementation of these interventions. Mobile health (mHealth) interventions may help circumvent some of these barriers; however, to date, no study has evaluated the effects of mHealth psychological interventions for CUD in individuals with FEP.

OBJECTIVE

This study describes the protocol for a pilot randomized controlled trial using a novel mHealth psychological intervention (iCanChange [iCC]) to address CUD in young adults with FEP. iCC was developed based on clinical evidence showing that in individuals without psychosis, integrating the principles of cognitive behavioral therapy, motivational interviewing, and behavioral self-management approaches are effective in improving cannabis use-related outcomes.

METHODS

Consenting individuals (n=100) meeting the inclusion criteria (eg, aged 18-35 years with FEP and CUD) will be randomly allocated in a 1:1 ratio to the intervention (iCC+modified EIS) or control (EIS) group. The iCC is fully automatized and contains 21 modules that are completed over a 12-week period and 3 booster modules available during the 3-month follow-up period. Validated self-report measures will be taken via in-person assessments at baseline and at 6, 12 (end point), and 24 weeks (end of trial); iCC use data will be collected directly from the mobile app. Primary outcomes are intervention completion and trial retention rates, and secondary outcomes are cannabis use quantity, participant satisfaction, app use, and trial recruiting parameters. Exploratory outcomes include severity of psychotic symptoms and CUD severity. For primary outcomes, we will use the chi-square test using data collected at week 12. We will consider participation in iCC acceptable if ≥50% of the participants complete at least 11 out of 21 intervention modules and the trial feasible if attrition does not reach 50%. We will use analysis of covariance and mixed-effects models for secondary outcomes and generalized estimating equation multivariable analyses for exploratory outcomes.

RESULTS

Recruitment began in July 2022, and data collection is anticipated to be completed in July 2024. The main results are expected to be submitted for publication in 2024. We will engage patient partners and other stakeholders in creating a multifaceted knowledge translation plan to reach a diverse audience.

CONCLUSIONS

If feasible, this study will provide essential data for a larger-scale efficacy trial of iCC on cannabis use outcomes in individuals with FEP and CUD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05310981; https://www.clinicaltrials.gov/ct2/show/NCT05310981.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/40817.

Successful outcomes with low-threshold intervention for cannabis use disorders in Norway - an observational study

AIMS

Cannabis is the most commonly used regulated drug by European youths. Yet, few cannabis-specific interventions have been examined in Europe. The Cannabis Cessation Program (CCP) was developed in Sweden in the 1990s and has been implemented in some Norwegian municipalities. The present study aimed to examine outcomes of this intervention in the Norwegian setting.

METHOD

The respondents (N = 102) were recruited in four community-based CCPs in Norway. We examined their changes in cannabis use, other substance use, mental distress, well-being, sense of coherence (SoC), and social networks, from baseline (T0) to post-treatment (T1) and up to a 3-month follow-up period (T2). Changes were evaluated with pair-wise t-tests.

RESULT

Seventy-six participants (75%) completed the 8-week program, according to plan. All participants reported a significant reduction in cannabis use at T1 (average reduction ~16 days per month) and at T2 (N = 59; ~13 days per month). Among those that completed the program, 67% was abstinent from cannabis at T1 and 37% was abstinent at T2. An intention-to-treat analysis showed that 50% (51/102) and 22% (22/102) were abstinent from cannabis use at T1 and T2, respectively. In parallel to abstinence, we observed a substantial reduction in mental distress and an increase in well-being and SoC. Respondents socialized with fewer friends with current substance use, but drug-free social networks were not expanded.

CONCLUSION

Our findings suggested that the CCP was a valuable, low-threshold manual-based intervention for cannabis use disorders. It showed considerable potential for reducing individuals' cannabis use.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov no. NCT04989205. Registered 12 July 2021, i.e., the study was retrospectively registered.

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.

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].

Psychotherapeutic interventions for cannabis use disorder. What do we know and what should we do?

BACKGROUND

Cannabis use disorder is the most commonly reported illegal substance use disorder and demand for treatment is growing worldwide.

OBJECTIVES

Our aim was to compare the two last Cochrane systematic reviews of the literature concerning psychotherapeutic and psychosocial interventions for cannabis use disorder to determine what new evidence emerged and how craving was considered as a treatment mediator.

METHOD

We extracted raw data from both reviews regarding their titles, objectives, methods and results. This information was analyzed by face validity to distinguish apparent differences from real differences. It enabled us to describe similarities and differences between reviews. We also screened both reviews looking for craving or related words.

RESULTS

The objective and methods of both reviews were mostly similar. Although the second review covered a wider range of psychotherapies, including drug counseling and mindfulness-based meditation as an intervention group and minimal treatment as a control group. Five of the six studies included in the first review were also included in the second review. One study excluded from the first review was included in the last review that included an additional 17 studies published after the first review. The 2016 review performed a meta-analysis whereas the first review was descriptive. Both reviews supported the efficacy of motivational enhancement therapy and cognitive and behavioral therapy interventions with adjunction of contingency management for abstinence when possible. There was no relevant mention of craving in the 2006 review and very few in the 2016 review.

CONCLUSION

The methods and results of the last two Cochrane reviews on psychosocial interventions for cannabis use disorder were mostly similar. Consistent with other reviews on the same subject and reviews of psychotherapies for other substance use disorders, the 2016 review confirmed evidence already available in the 2006 review. Instead of confirming already confirmed evidence, future research is needed to determine if craving focused treatment would increase efficiency and how to maintain initial treatment outcomes long-term.

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.

Treating cannabis use disorder: Exploring a treatment as needed model with 34-month follow-up

Research has demonstrated that motivational enhancement (MET) and cognitive behavioral therapy (CBT) are some of the most effective interventions for adults with cannabis use disorder (CUD). As few as two sessions of combined MET and CBT has produced abstinence and reductions in cannabis use greater than delayed treatment controls. Despite their efficacy, outcomes in previous studies yielded abstinence rates from cannabis in the range of 20-30% at follow-ups of 6 to 12 months, and CUD remained a chronic condition for many. Additional models of providing treatment "as needed" (PRN), rather than as a single fixed-dose, are necessary to meet the different needs of adults with CUD and reengage those who do not respond to treatment initially or who relapse later. In the current study, 87 adults who met DSM-IV criteria for cannabis dependence were randomly assigned to receive either a fixed-dose of nine sessions of MET/CBT or to a PRN condition that provided a smaller initial dose of treatment, but allowed repeated access to treatment for 28 months. Cannabis use and associated problems were assessed every six months throughout a 34-month period. More than one-third of participants in the PRN condition accessed additional treatment episodes, but the total number of treatment sessions that participants utilized was comparable across conditions. Both treatments yielded significant reductions in cannabis use and associated problems at each follow-up. Contrary to hypotheses, the PRN condition did not yield better outcomes at the longer-term follow-ups. The fixed-dose condition produced greater rates of abstinence at the first follow-up, but otherwise there were no between group differences in outcomes. Future studies should test active approaches to reengaging participants with treatment when initial outcomes are less than optimal.

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.

Screening for Unhealthy Drug Use: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Illicit drug use is among the most common causes of preventable morbidity and mortality in the US.

OBJECTIVE

To systematically review the literature on screening and interventions for drug use to inform the US Preventive Services Task Force.

DATA SOURCES

MEDLINE, PubMed, PsycINFO, Embase, and Cochrane Central Register of Controlled Trials through September 18, 2018; literature surveillance through September 21, 2019.

STUDY SELECTION

Test accuracy studies to detect drug misuse and randomized clinical trials of screening and interventions to reduce drug use.

DATA EXTRACTION AND SYNTHESIS

Critical appraisal and data abstraction by 2 reviewers and random-effects meta-analyses.

MAIN OUTCOMES AND MEASURES

Sensitivity, specificity, drug use and other health, social, and legal outcomes.

RESULTS

Ninety-nine studies (N = 84 206) were included. Twenty-eight studies (n = 65 720) addressed drug screening accuracy. Among adults, sensitivity and specificity of screening tools for detecting unhealthy drug use ranged from 0.71 to 0.94 and 0.87 to 0.97, respectively. Interventions to reduce drug use were evaluated in 52 trials (n = 15 659) of psychosocial interventions, 7 trials (n = 1109) of opioid agonist therapy, and 13 trials (n = 1718) of naltrexone. Psychosocial interventions were associated with increased likelihood of drug use abstinence (15 trials, n = 3636; relative risk [RR], 1.60 [95% CI, 1.24 to 2.13]; absolute risk difference [ARD], 9% [95% CI, 5% to 15%]) and reduced number of drug use days (19 trials, n = 5085; mean difference, -0.49 day in the last 7 days [95% CI, -0.85 to -0.13]) vs no psychosocial intervention at 3- to 4-month follow-up. In treatment-seeking populations, opioid agonist therapy and naltrexone were associated with decreased risk of drug use relapse (4 trials, n = 567; RR, 0.75 [95% CI, 0.59 to 0.82]; ARD, -35% [95% CI, -67% to -3%] and 12 trials, n = 1599; RR, 0.73 [95% CI, 0.62 to 0.85]; ARD, -18% [95% CI, -26% to -10%], respectively) vs placebo or no medication. While evidence on harms was limited, it indicated no increased risk of serious adverse events.

CONCLUSIONS AND RELEVANCE

Several screening instruments with acceptable sensitivity and specificity are available to screen for drug use, although there is no direct evidence on the benefits or harms of screening. Pharmacotherapy and psychosocial interventions are effective at improving drug use outcomes, but evidence of effectiveness remains primarily derived from trials conducted in treatment-seeking populations.

Gambling and Cannabis Use: Clinical and Policy Implications

Eleven US States and the District of Columbia legally allow personal (i.e., recreational) cannabis use by adults, and an additional 22 states allow use of cannabis for medicinal purposes. Of these jurisdictions, only two do not have some form of legalized gambling available (https://www.casino.org/local/guide/). In contrast to this rapid increase in legally available marijuana is the limited knowledge about the intersection of cannabis use and gambling. This paper strives to define the current status of the relevant literatures and consider the implication for future gambling research. We describe the research literature on the prevalence of cannabis use and co-existing gambling problems and the effects of cannabis use on gambling-related cognitive functions and decision-making. We also discuss clinical considerations with treating problem gamblers with a cannabis use disorder. Finally, the potential implications for responsible gambling practices and policies and the most pressing gaps in the research literature are offered.

Video intervention for the psychiatric waiting room: proof-of-concept randomised controlled trial of RESOLVE (Relaxation Exercise, SOLVing problem and cognitive Errors)

BACKGROUND

The waiting room in psychiatric services can provide an ideal setting for offering evidence-based psychological interventions that can be delivered through electronic media. Currently, there is no intervention available that have been developed or tested in mental health.

AIMS

This proof-of-concept study aimed to evaluate a pilot design of RESOLVE (Relaxation Exercise, SOLving problem and cognitiVe Errors) to test the procedure and obtain outcome data to inform future, definitive trials (trial registration at Clinicaltrials.gov NCT02536924, REB Number: PSIY-477-15).

METHOD

Forty participants were enrolled and equally randomised to the intervention, RESOLVE plus treatment as usual arm (TAU), or to a control group (TAU only). Those in the intervention group watched RESOLVE in a room adjacent to the waiting area. Participants in the control received routine care. Outcome measures included the Hospital Anxiety and Depression Scale; the Clinical Outcomes in Routine Evaluations outcome measure; and the World Health Organization Disability Assessment Schedule. These measures were performed by a masked assessor at baseline and at 6-week follow-up. Additionally, we measured the number of contacts with mental health services during the prior 4 weeks. Both intention-to-treat and per protocol analyses were performed.

RESULTS

The study proved feasible. We were able to recruit the required number of participants. There was a statistically significant improvement in depression (P < 0.001), anxiety (P < 0.001), general psychopathology (P < 0.001) and disability (P = 0.0361) in favour of the intervention group. People in the intervention group were less likely to contact the service (P = 0.012) post-intervention.

CONCLUSIONS

Findings provide preliminary evidence that evidence-based psychosocial interventions can be delivered through electronic media in a waiting-room setting. The outcome data from this study will be used for future definitive trials.

DECLARATION OF INTEREST

None.

Reward, Control & Decision-Making in Cannabis Use Disorder: Insights from Functional MRI

The recreational consumption of cannabis has increased significantly across the world with an estimated 180 million people currently using. In the United States, 4.1 million are currently diagnosed with cannabis use disorder. Cannabis dependence and abuse was combined into a single entity as a behavioral disorder with a problematic pattern of cannabis use and termed cannabis use disorder by the Diagnostic and Statistical Manual of Mental Disorders. Chronic use of cannabis has been linked with region-specific effects across the brain mediating reward processing, cognitive control and decision-making that are central to understanding addictive behaviors. This review presents a snapshot of the current literature assessing the effects of chronic cannabis use on human brain function via functional MRI. Studies employing various paradigms and contrasting cognitive activation amongst cannabis users and non-users were incorporated. The effects of trans-del-ta-9-tetrahydrocannabinol (Δ9-THC) in marijuana and other preparations of cannabis are mediated by the endocannabinoid system, which is also briefly introduced.Much variation exists in the current literature regarding the functional changes associated with chronic cannabis use. One possible explanation for this variation is the heterogeneity in study designs, with little implementation of standardized diagnostic criteria when selecting chronic users, distinct time points of participant assessment, differing cognitive paradigms and imaging protocols. As such, there is an urgent requirement for future investigations that further characterize functional changes associated with chronic cannabis use.

A smartphone app intervention for adult cannabis users wanting to quit or reduce their use: a pilot evaluation

Background

Smartphone applications (apps) offer a promising alternative to face-to-face treatment due to their ease of access and convenience. However, there is a lack of evidence-based apps for cannabis users wishing to reduce their use.

Objectives

The current study evaluated the feasibility and acceptability of a smartphone app intervention (called Assess, Plan, Track, and Tips [APTT]) for cannabis users wanting to reduce their use.

Method

The current study included 111 cannabis users (68% male, aged 18–50 yrs) who had used cannabis in the past month, were not currently in treatment, and who wanted to reduce/quit their use. Participants were given access to APTT for 1 month. Participants reported on their cannabis use and related problems, confidence in resisting use, severity of dependence, and stage of change at baseline, post-intervention (4 weeks), and at 1-month follow-up. At post-intervention, participants also reported on their usage and satisfaction with the app.

Results

The current study found that APTT was acceptable, with over 40% of participants using the app over 20 times over the course of a month. Participants showed a reduction in dependence and cannabis related problems over the course of the study. Further, participants’ stage of change at baseline predicted changes in cannabis use.

Conclusions/importance

These findings support the feasibility and acceptability of APTT as an engaging app for cannabis users wishing to better manage their use and support the need for future RCTs to assess the efficacy of mobile-based interventions for cannabis users.

Electronic supplementary material

The online version of this article (10.1186/s42238-019-0009-6) contains supplementary material, which is available to authorized users.

Alcohol, tobacco, and marijuana consumption is associated with increased odds of same-day substance co- and tri-use

BACKGROUND

Little is known about event-level patterns of marijuana co- or tri-use with alcohol and tobacco. Thus, the study goal was to examine patterns of same-day alcohol, cigarette, and marijuana co- and tri-use at the individual level in non-treatment-seeking alcohol users.

METHODS

Participants (N = 551) completed an in-person interview for alcohol, cigarette, and marijuana use over the previous 30 days, and the event-level substance use patterns of n = 179 participants who reported using each of these substances at least once per month were analyzed.

RESULTS

The use of alcohol, marijuana, or cigarettes independently increased the probability of subsequent, simultaneous co-use of one of the two remaining substances. The co-use of alcohol with cigarettes and marijuana with cigarettes produced generally additive effects on the odds of same day tri-use of marijuana and alcohol, respectively. Conversely, the co-use of alcohol and marijuana produced sub-additive effects on likelihood of cigarette use. Sex moderated several of the observed patterns of co- and tri-use: the relationship between alcohol or cigarette use predicting marijuana co-use was stronger in men, whereas the observed additive relationships between drug co-use leading to tri-use was stronger in women.

CONCLUSIONS

The presented results may aid in the understanding of how simultaneous co-use of marijuana with alcohol and/or tobacco relates to the etiology, maintenance, and treatment of comorbid and trimorbid substance use disorder. Replication and extension of the results in treatment seeking populations using more fine-grained analysis approaches, e.g. ecological momentary assessment, is needed.

Psychosocial and Pharmacological Interventions for the Treatment of Cannabis Use Disorder

(Reprinted with permission from Sabioni P and Le Foll B. Psychosocial and pharmacological interventions for the treatment of cannabis use disorder [version 1; referees: 3 approved]. F1000Research 2018, 7(F1000 Faculty Rev):173 (https://doi.org/10.12688/f1000research.11191.1)).

Systematic review of outcome domains and measures used in psychosocial and pharmacological treatment trials for cannabis use disorder

Cannabis use disorder (CUD) is prevalent and demand for treatment is increasing, yet few individuals engage in formal treatment and the efficacy of established interventions for CUD is modest. Existing clinical trials evaluating psychosocial and pharmacological treatments for CUD have incorporated a wide variety of measures for assessing cannabis use outcomes, including abstinence, self-reported frequency and quantity used, withdrawal, use/dependence severity, and other psychosocial outcomes. The heterogeneity of measures and outcomes has limited quantitative analyses of the comparative effectiveness of existing interventions. The purpose of this systematic review is to: 1) identify and characterize approaches for measuring cannabis use in existing CUD intervention trials, including abstinence, frequency and quantity of use, and 2) summarize measures used to assess treatment efficacy in other outcome domains (e.g., cannabis use severity, psychosocial functioning, cannabis withdrawal), and provide a platform for future research to evaluate which outcome measures are most likely to reflect treatment efficacy and clinically significant improvement in other outcome domains.

Sex differences in stress reactivity after intranasal oxytocin in recreational cannabis users

Cannabis is the most widely used illicit drugs and the changing legal, political and cultural climate will likely increase cannabis use further. One factor that may underlie the transition from recreational use to problematic use is stress. The hormone oxytocin (OXT) modulates stress and may have therapeutic efficacy for substance use disorders, but few studies have examined OXT in cannabis users. Another factor is sex; although more men smoke cannabis, the transition from recreational to problematic use is faster in women. Using a within-subjects design, the effects of intranasal (i.n.) oxytocin (OXT; 40 IU) administration on stress reactivity (using the Trier Social Stress Test; TSST) and cannabis (5.6% THC) self-administration was assessed in recreational cannabis using men (n = 31) and women (n = 32) relative to i.n. placebo (PBO) and no-stress (NST) conditions. The TSST produced expected subjective and cardiovascular effects compared to the NST. However, in the i.n. OXT-TSST condition, positive subjective effects were lower and negative subjective effects were higher in women compared to PBO administration and compared to men. Further, latency to self-administer cannabis was longer in women than men and women self-administered less cannabis than men regardless of stress condition. There were no differences in cannabis craving as a function of sex, stress, or medication. These results suggest that OXT administration may lead to greater stress reactivity in recreational cannabis users, particularly women, and support growing evidence that sex differences should be carefully considered when examining the therapeutic potential of OXT.

Web-Based Intervention to Reduce Substance Abuse and Depression: A Three Arm Randomized Trial in Mexico

BACKGROUND

Web-based cognitive-behavioral interventions to reduce substance use can be a useful low-cost treatment for a large number of people, and an attractive option in countries where a greater availability of treatment is needed.

OBJECTIVE

To evaluate the feasibility and initial effectiveness of a web-based cognitive-behavioral intervention for the reduction of substance use and depression compared with treatment as usual, with and without a printed self-help manual.

METHOD

Individuals seeking outpatient treatment for substance use were randomly assigned to one of the following: (1) the web-based Help Program for Drug Abuse and Depression (n = 23); (2) an in-person session with an addiction therapist and use of the Alcohol, Smoking, and Substance Involvement Screening Test Self-Help Strategies guide, followed by treatment as usual (n = 25), or (3) treatment ordinarily offered in the participating treatment centers (n = 26). The study took place in 2013-2014 (trial registration: ISRCTN25429892), and participants completed baseline, posttreatment, and 1-month follow-up evaluation interviews.

RESULTS

Treatment retention and data availability were comparable in all three conditions. A reduction was observed from baseline to follow-up in average days of use [F(1,28) = 29.70, p < 0.001], severity of use [F(2,28) = 143.66, p < 0.001], and depressive symptomatology [F = (4)16.40, p < 0.001], independent of the type of treatment provided.

CONCLUSIONS

The findings suggest that the web-based intervention to reduce substance abuse is feasible, although it is not more effective than other intervention modalities; its effectiveness must be evaluated in a larger sample. Attrition was a main limitation; future studies must improve retention and assess cost-effectiveness.

A Model of Δ9-Tetrahydrocannabinol Self-administration and Reinstatement That Alters Synaptic Plasticity in Nucleus Accumbens

BACKGROUND

Cannabis is the most widely used illicit drug, but knowledge of the neurological consequences of cannabis use is deficient. Two primary components of cannabis are Δ9-tetrahydrocannabinol (THC) and cannabidiol (CBD). We established a THC+CBD model of self-administration and reinstated drug seeking to determine if, similar to other addictive drugs, cannabis produces enduring synaptic changes in nucleus accumbens core (NAcore) thought to contribute vulnerability to drug reinstatement.

METHODS

Sprague Dawley rats were trained to self-administer THC+CBD (n = 165) or were used as vehicle self-administering control animals (n = 24). Reinstatement was initiated by context, cues, drug priming, and stress (yohimbine injection). Enduring neuroadaptations produced by THC+CBD self-administration were assayed using four measures: dendritic spine morphology, long-term depression, alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid/N-methyl-D-aspartate ratios, and behavioral pharmacology.

RESULTS

We described a novel rodent model of cannabis relapse involving intravenous THC+CBD self-administration and drug seeking induced by conditioned context, cues, and stress. Cued reinstatement of THC+CBD seeking depended on a sequence of events implicated in relapse to other addictive drugs, as reinstatement was prevented by daily treatment with N-acetylcysteine or acute intra-NAcore pretreatment with a neuronal nitric oxide synthase or matrix metalloprotease-9 inhibitor, all of which normalize impaired glutamate homeostasis. The capacity to induce N-methyl-D-aspartate long-term depression in NAcore medium spiny neurons was abolished and dendritic spine density was reduced, but alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid/N-methyl-D-aspartate ratio was unaltered in THC+CBD-trained animals, akin to opioids, but not to psychostimulants.

CONCLUSIONS

We report enduring consequences of THC+CBD use on critical relapse circuitry and synaptic physiology in NAcore following rat self-administration and provide the first report of cue- and stress-induced reinstatement with this model.

A scoping review and meta-analysis of psychosocial and pharmacological treatments for cannabis and tobacco use among African Americans

The rates of co-occurring cannabis and tobacco use are higher among African Americans relative to other racial/ethnic groups. One plausible approach to treating co-use among African Americans is to examine the effectiveness of treatments for the sole use of cannabis and tobacco to identify effective approaches that might be combined to treat the dual use of these substances. The current meta-analysis sought to include studies that reported cannabis and/or tobacco use outcomes from randomized clinical trials (RCTs) with 100% African American samples. A total of 843 articles were considered for inclusion, 29 were reviewed by independent qualitative coders, and 22 were included in the review. There were no articles on cannabis use treatment with a 100% African American sample, resulting in a need to lower the threshold (60%) and conduct a scoping review of cannabis studies. Preliminary evidence from a small number of studies (k = 7) supports the use of Motivational Interviewing and Cognitive-Behavioral Therapy to treat cannabis use among African Americans, but not Contingency Management. Results from a meta-analysis of 15 tobacco studies found higher rates of smoking abstinence in the treatment condition relative to control conditions overall and across short and long-term follow-up periods. Significant differences in smoking abstinence were also found when examining the effects of pharmacological treatments relative to their control conditions. The clinical and research implications of these findings for future psychosocial and pharmacological trials for cannabis and tobacco use and co-use among African Americans are described. (PsycINFO Database Record

Preliminary Outcomes of a Computerized CBT/MET Intervention for Depressed Cannabis Users in Psychiatry Care

Although depression is common among cannabis users, there is a paucity of targeted interventions addressing depression and cannabis use disorders concurrently. In the present pilot study, we examine the feasibility, acceptability, and preliminary outcomes of a computer-assisted intervention combining cognitive behavioral therapy (CBT) and motivational enhancement therapy (MET) techniques for adults with comorbid major depressive disorder (MDD) and cannabis use disorder (CUD) presenting for care in a psychiatric setting. Adults with MDD and CUD (N=26) recruited from mental health care settings were enrolled in a 10-week, computer-assisted psychosocial intervention: Self-Help for Alcohol and other Drug Use and Depression (SHADE). Feasibility, acceptability, perceived helpfulness, treatment retention, completion, and clinical outcomes including cannabis use and depression were assessed. Participants found the SHADE intervention to be acceptable and helpful in facilitating action towards their therapeutic goals concerning depression and cannabis use. Treatment completion, achieved by the majority (85%) of participants, was excellent. On average, participants reduced their past 30 day cannabis use from baseline (mean percentage of days using = 69%) to follow-up (M=44%) (t(22)= 2.3, p<0.05; Effect Size= 0.79). Concurrently, they evidenced reductions in depressive symptom severity, from the moderately severe range at baseline to the mild range at follow-up (t(24)=7.3, p<0.001; Effect Size=1.52). Addressing comorbid CUD and MDD using a computer-assisted, evidence-based treatment strategy is feasible in a psychiatric care setting, and may produce improvements in both depressive symptoms and cannabis use.

When and How to Treat Possible Cannabis Use Disorder

Cannabis (marijuana) is a drug product derived from the plant Cannabis sativa. Cannabinoid is a general term for all chemical constituents of the cannabis plant. Legalization of marijuana in numerous US states, the availability of cannabis of higher potency, and the emergence of synthetic cannabinoids may have contributed to increased demand for related medical services. The most effective available treatments for cannabis use disorder are psychosocial approaches. There is no pharmacotherapy approved treatment. This article reviews the current state of knowledge regarding effective treatments for cannabis use disorder.

Impact of cannabis legalization on treatment and research priorities for cannabis use disorder

An increasing proportion of the world has legalized cannabis for medicinal or recreational use. The legalization trend appears to be continuing. These changes in the legislative landscape may have important health, treatment, and research implications. This review discusses public health outcomes that may be impacted by increases in cannabis availability and use. It additionally considers potential research and treatment priorities in the face of widespread cannabis legalization.

A randomised controlled trial of a brief intervention for illicit drug use linked to ASSIST screening in a primary healthcare setting: results from the Australian component of the World Health Organization Phase III ASSIST studies

This report presents the findings from the Australian component of the Phase III World Health Organization (WHO) Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) randomised controlled trial investigating the effectiveness of a 5-10-min brief intervention (BI) for illicit drug use delivered in primary healthcare (PHC) settings. Participants (n=171) recruited from a South Australian PHC setting (sexual health clinic) who scored in the 'moderate risk' range on the ASSIST were randomly allocated to an intervention group or wait-list control group at baseline and were followed up 3 months later. The ASSIST was administered to both groups at baseline and follow up as a measure of relative risk. Those in the intervention group received a prescribed 10-step BI at baseline. The majority (n=63) of participants received the BI for amphetamine-type stimulants (ATS) or cannabis (n=17). There was a significant reduction in total illicit substance (P<0.001) and ATS Involvement (P<0.01) for those receiving the ASSIST-linked BI, compared with control participants. There was no significant effect on cannabis involvement. The results of this study demonstrate that the ASSIST-linked BI may be a reasonably easy and effective way of reducing illicit substance use by Australian PHC clients.

Psychosocial and pharmacological interventions for the treatment of cannabis use disorder

Cannabis use has been continuously increasing, and cannabis use disorder (CUD) has become a public health issue. Some psychosocial interventions have demonstrated the ability to reduce cannabis use; however, there are no pharmacotherapies approved for the treatment of CUD. Some drugs have shown limited positive effects on use and withdrawal symptoms, but no controlled studies have been able to show strong and persistent effects on clinically meaningful outcomes. The aim of this review is to synthesize the evidence from the available literature regarding the effectiveness of psychosocial and pharmacological treatments for CUD among adults (that is, 18 years old or older). An analysis of the evidence shows that the current best psychosocial intervention to reduce cannabis use is the combination of motivational enhancement therapy and cognitive-behavioral therapy, preferably accompanied by a contingency management approach. In regard to pharmacological interventions, there are mostly unclear findings. Some drugs, such as CB1 agonists, gabapentin, and N-acetylcysteine, have been shown to produce improvements in some symptoms of CUD in single studies, but these have not been replicated. Other classes of medications, including antidepressants and antipsychotics, have been unsuccessful in producing such effects. There is an imminent need for more clinical trials to develop more effective treatments for CUD.

Planning research in psychosocial interventions

A number of research designs have been used to study the efficacy of psychosocial interventions in addictive disorders, including open label studies and randomised controlled trials. Only through a rigorously conducted research, evidence base for effectiveness of a psychosocial intervention can be established. However, research on these interventions are fraught with a number of challenges. It is imperative for researchers to ask appropriate research questions based on sound theoretical understanding of psychiatric disorders, psychosocial interventions and research designs. This would help in choosing the less studied, relevant areas for in depth study as well as in using pragmatic, realistic research designs. Defining intervention clearly is as crucial, as is its uniform implementation across various treatment arms. In addition, tapping the mediators, moderators and confounders of treatment using appropriate methods while assessing the factors that directly impact the outcome is important to determine actual effects of psychosocial intervention. Barriers at different stages must be gauged proactively and dealt with, wherever possible.

Interventions for cannabis misuse

Cannabis is the most commonly used illicit drug in the UK and a significant proportion of users have symptoms of dependence. In addition, there are a number of adverse consequences of use, including an association with psychotic disorders. Thus there is a need for effective treatment of cannabis misuse. Psychological therapies have been developed based on principles of motivational interviewing, cognitive–behavioural therapy and relapse prevention. The evidence base for these therapies is explored in this review, and studies targeting both adult users and young people are considered. Possible new pharmacological treatments are also discussed.

The Indirect Effects of Self-Efficacy on Cannabis Use via Cannabis Protective Strategies: A Preliminary Study

Cannabis use has more than doubled in the past decade and nearly three of 10 users develop a cannabis use disorder. The increase in users, combined with the ongoing changes in the medical, legal and social status of cannabis, has contributed to interest in the antecedents of cannabis use. In the current preliminary study, we gathered information from a community sample (N = 54) of regular cannabis using young adults. Assessments included perceived self-efficacy for reducing intake or abstaining (SE-R/A), use of cannabis protective strategies (CPS), and average quantity of cannabis use per day. We systematically explored which specific CPS were most strongly associated with self-efficacy and cannabis use. Three clinically relevant subgroups of CPS emerged from this analysis: strategies strongly associated with only self-efficacy, only cannabis use, and both variables. We hypothesized that self-efficacy would be associated with less cannabis use via use of CPS. Among specific CPS examined, "Use a little and then wait to see how you feel before using more" had the strongest association with self-efficacy while "Avoid methods of using cannabis that can make you more intoxicated than you would like" had the strongest negative association with cannabis use. We observed a significant indirect relationship from self-efficacy to cannabis use through use of CPS. Our findings suggest that use of CPS is a potential mechanism by which cannabis users reduce use, and a more proximal antecedent of cannabis use than personal confidence in one's ability to stop using. These preliminary findings highlight the value of studying individual strategies. They also may have implications for promoting use of cannabis protective strategies when treating those with cannabis use problems.

The Current State of Pharmacological Treatments for Cannabis Use Disorder and Withdrawal

Cannabis use disorder (CUD) commonly occurs and carries a notable economic and functional burden at both individual and societal levels. While there are no clearly efficacious medication treatments for CUD, 20 years of committed and high-quality research in the human laboratory and clinical settings have resulted in medications with demonstrated effectiveness in the treatment of cannabis withdrawal, the ability to reduce cannabis use, and results that point to promising future work. The current state of pharmacology research for CUD highlights the need to consider particular characteristics of patients, such as gender, impulsivity, and severity of cannabis use, when selecting a medication in the off-label treatment of CUD or cannabis withdrawal. As a field, the body of work also exposes some areas in need of improvement in study design, selection of outcome measures, interpretation of results, and the overall process of evaluating candidate medications. Coming to a consensus as a field and addressing these gaps in future research will likely lend itself to further advances in improving the lives of patients with CUD.

The Acceptability and Feasibility of Screening for Alcohol and Drug Misuse in a Hospital Emergency Department

Supplemental Digital Content is available in the text.

Objectives:

Screening and brief intervention (SBI) is an evidence-based technique for reducing harmful consumption of alcohol and other drugs, which has been shown to be effective in Emergency Departments (EDs). The feasibility of SBI in the ED, however, remains contentious and no studies have been conducted on this topic in a New Zealand ED.

Materials and Methods:

This study recruited 8 experienced ED nurses who attempted to provide SBI, using the ASSIST-Lite tool, to as many of their patients as possible over one calendar month. All nurses participated in a comprehensive 1-day training workshop on the administration and interpretation of the ASSIST-Lite and linked brief intervention.

Results:

Only 46 (11.79%) of the 390 eligible patients were given the opportunity to participate over the data collection period. Analysis of the data showed there was a significant, negative correlation between the number of patients in the ED and the average number of screens that were performed by the nurses, and that the number of screens waned immediately after SBI training. Following the data collection period, the nurse participants were interviewed about their experience. These interviews revealed 3 main themes that contextualized the willingness to, but inherent difficulty of, administering the SBI within the ED environment.

Conclusions:

High patient-to-nurse ratios in the ED currently preclude nurses from providing consistent SBI to all eligible patients; however, there are several practical considerations highlighted here that might help nurses increase the participation rate.

DSM-5 cannabis use disorder, substance use and DSM-5 specific substance-use disorders: Evaluating comorbidity in a population-based sample

Cannabis use disorder (CUD) is frequently associated with concurrent substance use and/or comorbid substance use disorders (SUDs); however there is little specificity with regard to commonly abused individual drug types/classes. This study therefore aimed to provide insight into the degree of these co-occurring relationships across several specific newer and older generation illicit and prescription drugs. 36,309 adults aged 18+ from wave 3 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III) were assessed. Weighted cross-tabulations and multivariable logistic regression analyses were used to evaluate comorbidity between current DSM-5 CUD, substance use and DSM-5 SUD. Current DSM-5 CUD is associated with greater lifetime use of all examined drug classes, and previous 12-month use of several newer-class illicit and prescription stimulant-based substances (all p< 0.05). Current DSM-5 CUD was similarly associated with increased incidence of a range of DSM-5 SUDs and was independently associated with concurrently reporting current DSM-5; sedative (Adjusted OR= 5.1, 95%CI 2.9-9.0), cocaine (AOR= 9.3, 95%CI 5.6-15.5), stimulant (AOR= 4.3, 95%CI 2.3-7.9), club drug (AOR= 16.1, 95%CI 6.3-40.8), opioid (AOR= 4.6, 95%CI 3.0-6.8) and alcohol-use disorder (AOR= 3.0, 95%CI 2.5-3.7); but not heroin or 'other' drug use disorder (both p>0.05). High comorbidity exists between DSM-5 CUD and many specific DSM-5 SUDs. Newer-class illicit and prescription stimulant-based drug use disorders are overrepresented among those with DSM-5 CUD. These findings underscore the need for tailored treatment programs for those presenting with DSM-5 CUD, and for greater treatment specification where poly-drug use is evident.

Motor impulsivity differentiates between psychiatric inpatients with multiple versus single lifetime suicide attempts

A history of multiple suicide attempts conveys greater risk for suicide than a single attempt. Impulsivity may partially explain the association between multiple attempts and increased risk. We examined trait impulsivity, ability to engage in goal-directed behaviors, and impulse control among psychiatrically hospitalized United States military personnel and their dependents. Individuals with a history of multiple versus single attempts had significantly higher motor impulsivity, indicating spur of the moment action. Providers are encouraged to directly assess and treat motor impulsivity among suicidal individuals. Further research should explore whether motor impulsivity is a mechanism of change in psychosocial suicide prevention interventions.