Marijuana: The Blunt Truth Recovery Month Conference

Transcription

1 Marijuana: The Blunt Truth Recovery Month Conference Christian Thurstone, M.D. Associate Professor of Psychiatry University of Colorado Denver September 19, 2012

2 Trends in use Why adolescent MJ use matters Prevention and Treatment

3 Trends

4 Son, if you re going to smoke pot, let me know so that I can get you a green card. Thanks, dad. Please don t tell your mother

5 Change in adolescent past month MJ use in Los Angeles 30 % % 22.2 % 18.1 % 21.4 % 19.3 % 22.4 % Youth Risk Behavior Survey, 2012

6 Limitations of CDC data Does not include teens not in school Still awaiting data on availability, norms, attitudes No statistically significant changes

7 School Expulsions for Drugs - CO #

8 Drugged Driving # of + DREs for THC Year

9 Drugged Driving 12 # fatalities with driver + for THC Year

10 Teens in substance tx (N=80) N = 38/80 49% N = 42/80 51% 0 Have you ever obtained MJ from someone with a MMJ license? Thurstone et al.,

11 Primary Care Sample (N=66) N = 12/66 18% N = 44/66 82% 0 Have you ever obtained MJ from someone with a MMJ license?

12 Variable Used someone s MMJ n=122 Not used someone s MMJ n=42 p-value Male (%) 80.3% 64.3% # days of MJ use in past 6 months days 81.6 days # MJ use d/o sx s Salomonsen-Sautel et al., 2012

13 N = 137 Yes or unsure No Is MJ safe for children < 13 yrs? Is MJ safe for teens yrs? 11.7% 88.3% 38.2% 61.8% Is MJ safe for pregnant women? 27.9% 72.1% Shuman et al., 2012

14 Epidemiology Marijuana and the adolescent brain Hall and Degenhardt, 2009; NSDUH, 2011

15 17% who try MJ before 18 years develop abuse/dep, compared to 4% for >18 yrs 58% of new users are <18 years 67% of teens substance tx admits are for MJ 20% of all substance tx admits are for MJ 40% of all MJ substance tx admits are teens Hall and Degenhardt, 2009; NSDUH, 2011

16 Adolescent exposure to MJ may be toxic to brain development

17 Casey et al., 2008 Functional Development Limbic system Prefrontal system Adolescen ce Age

18 Adolescent MJ use increases the odds of other ilicit substance use 2-3 times by young adulthood Agrawal et al., 2004; Fergusson et al., 2000; Fergusson et al., 2005; Grau et al., 2007; Kandel et al., 1986; Lessem et al., 2006; Lynskey et al., 2003; Mayet et al., 2011; van Ours et al., 2003; Yamaguchi and Kandel, 1984

19 Adolescent MJ use is toxic to adolescent brain development: psychosis 7 cohorts confirm adolescent exposure to MJ predicts psychosis (OR= ) The risk is dose-dependent Risk is not accounted for by intoxication effect, reverse-causation or confounds Andreasson et al., 1987; Arseneault et al., 2002; Fergusson et al., 2003; Henquet et al., 2005; Tien et al., 1990; van Os et al., 2002; Wiles et al., 2006

20 Adolescent MJ use may be toxic to adolescent brain development: cognition Those using MJ before 17 compared to after have: VIQ (103.5 vs 115.6, p<0.001) (Pope et al., 2003) verbal fluency (# of objects in a category named) (Pope et al., 2003) word recall in 30 minutes (Pope et al., 2003) visual scanning ability (but not divided attention, working memory, flexibility) (Ehrenreich et al., 1999) visual scanning reaction time (but not for the other measures) (Ehrenreich et al., 1999) difficulty learning, remembering and focus at age 27 with MJ expsure between yrs (Brook et al., 2008) Whole brain volume, % cortical gray matter (Wilson et al., 2000) CBF (Wilson et al., 2000)

21 Animal Studies - adolescent exposure is toxic to brain development Jager and Ramsey, 2008, Rubino et al., 2009 Domain Outcome Motivation Social interaction Memory Attention anxiety short-term recognition filtering of unnecessary stimuli Hippocampus neurons, synaptic density

22 Dunedin Study N=1, { WISC-R Cannabis dependence Cannabis >3X/wk At age 38, WAIS-IV and Attention and Memory Meier et al., 2012

23 Dunedin Study Results: Cannabis dependence predicted in IQ was dose-dependent Decline in IQ accounted for by adolescent onset users Cessation of use at age 38 did not change in IQ in all four indices of IQ: working memory, processing speed, perceptual reasoning, verbal comprehension Friends/family noticed significantly more memory/attention problems Meier et al., 2012

24 Dunedin Study in IQ not accounted for by: past 24 hour cannabis use past week cannabis use tobacco dependence alcohol dependence other substance dependence schizophrenia Meier et al., 2012

25 Adolescent MJ use predicts less educational achievement Teens using MJ for the first time after 18 years (or never) compared to those using by 15 years are: 3.6 times more likely to get a HS degree 2.3 times more likely to enroll in college 3.7 times more likely to get a college degree Fergusson et al.,

26 MJ and School % -3% 8-17% Fergusson et al.,

27 Adolescent MJ use predicts aggression Low dose THC (0.1 mg/kg) aggression (Taylor et al., 1976) High dose THC ( mg/kg) aggression (Salzman et al., 1976) Marijuana withdrawal aggression on days 3, 7 but baseline on day 28 (Kouri et al., 1999)

28 Adolescent MJ use and HIV, STD, teen pregnancy Adolescent MJ use is associated with: early onset sex (mean=13.1 years) lifetime partners (mean=6.2) condom use (55% report sometimes or never) rates of STD s (14%) Among 656 Denver teens on probation at 12-month f/u: freq. of MJ use predicts STD diagnosis # of dep. sx s predicts non-condom use in last 6 months Bellis et al., 2008; Brodbeck et al., 2006; Crosby et al., 2003; Guo et al., 2005; Hendershot et al., 2010; Malow et al., 2001; Mertz et al., 2000; Shrier et al., 1997; Wu et al., 2009; Yan et al., 2007

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33 Marketing 1966: We do not favor smoking by young people. - J. Cullman, president Philip Morris 1991: 31% of 3-year-olds and 91% of 6-year-olds match Joe Camel with a picture of a cigarette - Fischer et al., : We have made a significant effort... to connect only to adult smokers. spokesperson for Philip Morris 2012:...despite claims from cigarette manufacturers...,the evidence is sufficient to conclude that marketing efforts...by tobacco companies show a consistent doseresponse relationship in the initiation and progression of tobacco use among young people. U.S. Surgeon general

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37 Conclusions Some indicators of teen MJ use increasing but more data needed Teens have easy access to MMJ Teens are especially vulnerable to the effects of MJ Difficult to protect youth in a legalized, regulated environment UN Rights of a Child: State parties shall take all appropriate measures...to protect children from the illicit use of narcotic drugs and psychotropic substances...

38 Marijuana: Treatment Update Recovery Month Conference Christian Thurstone, M.D. Associate Professor of Psychiatry University of Colorado Denver September 19, 2012

39 Treatment Conduct d/o 53% ADHD 38% GAD 23% MDD 18% PTSD or acute stress d/o 14% Past-year assault 66% Suicidal acts/thoughts 9% Dennis et al., 2004

40 Treatment Condition SUD Conduct d/o ADHD GAD MDD PTSD or acute stress d/o Treatment Family therapy, CBT Family therapy, CBT Medications, CBT CBT CBT CBT

41 Integrated MH/Substance tx Contingency management Continuing care CBT Case management ENCOMPASS

42 New Treatment Research Study Methods Results Riggs et al., yo s with ADHD and SUD OROS/PBO + CBT for 16 weeks OROS>PBO for ADHD OROS had more - UDS (3.8 v 2.8) Riggs et al., yo s with MDD, CD and SUD FLX/PBO + CBT for 16 weeks FLX>PBO for MDD MDD remission SUD response

43 New Treatment Research Study Methods Results Stanger et al., yo s in tx for MJ MI/CBT +/- CM for 14 wks CM>no CM DURING tx Ramo et al., teens followed for 6 months after inpt tx 88% relapsed in 6 mo s, MJ involved in 58% of relapses Waldron and Turner, 2008 Review of 17 RCT s since 1998 for adolescent substance tx FT CBT Maintained ES at f/u: CBT: 10/12 FT: 6/13

44 Earlier Intervention Before court-involvement Primary care School-based Treating substance misuse

45 NA C Patients: yo s Methods: 8 weeks, NAC/PBO 1200mg bid + CM Results: 41% v 27% negative UDS, p=ns, welltolerated, OR=2.4 of - UDS Limitations: 8 weeks, 40% drop-out Gray et al., 2012

46 Gabapentin 50 adults in tx for cannabis dependence for 12 weeks Gabapentin (1200 mg/day) v placebo Gabapentin had greater decrease in grams and days per week (5 days to 0.75 for gabapentin or 1 for PBO) and urine THC levels Mason et al., 2012

47 Summary MI/CBT Need to increase accessibility Need to provide continuing care Need to provide integrated treatment