How can we optimise treatment of people who are cannabis dependent? Tom Freeman Clinical Psychopharmacology Unit University College London, UK

Transcription

1 How can we optimise treatment of people who are cannabis dependent? Tom Freeman Clinical Psychopharmacology Unit University College London, UK

2 Disclosure statement: I have no conflicts of interest

3 Outline of talk Overview of current treatment Strategies for improvement EMCDDA (April 2015)

4 CURRENT TREATMENT

5 What is the problem?

6 Current treatment Psychological Approaches

7 Current treatment Cannabis specific: CANDIS * * * * Hoch et al. 2011, 2012, 2014

8 Current treatment Cannabis specific: CANDIS MI resolve ambivalence & strengthen motivation to change * * * * CBT cannabis education, cognitions-emotions-behaviours, new coping skills Psychosocial problem solving (e.g. unemployment) MI: Motivational Interviewing; CBT: Cognitive Behavioural Therapy

9 Current treatment Cannabis specific: CANDIS End treatment: 46.3% abstinent vs. 17.7% in waiting list * * * * 6 months: 35.7% abstinent Hoch et al. 2011, 2012, 2014

10 Current treatment General approaches Based on similar concepts (e.g. MI/CBT) Tailored to individual need All drug groups treated together; cannabis users are younger with different problems

11 Unmet clinical need EMCDDA (April 2015)

12 STRATEGIES FOR IMPROVEMENT

13 1) Increase European investment Treatment provision Research funding

14 2) Refine psychological approaches MI (1-2 sessions) and CBT (4-14 sessions) beneficial CM may improve further Optimum number of sessions (cost effective?) Cannabis-specific vs. general approaches? Cooper et al. (2015) Health Technology Assessment

15 2) Refine psychological approaches Control group (drug trial)

16 2) Refine psychological approaches Control group (drug trial) Control group (psychological trial)

17 2) Refine psychological approaches Control group (drug trial) Control group (psychological trial) Placebo versus nocebo Move beyond everything works Consider single- or even double- blinding

18 3) Find effective pharmacotherapies Oral THC withdrawal, maintenance THC/CBD spray withdrawal, maintenance N-acetylcysteine (GLU modulator) 2.4 greater odds of negative urine Gabapentin (GABA modulator) use, withdrawal, depression, sleep, problems Allsop et al. (2014), Gray et al. (2012), Levin et al. (2011), Mason et al. (2012)

19 3) Find effective pharmacotherapies Placebo Dependent on cannabis & want to quit CBD 200mg CBD 400mg CBD 800mg 4 weeks 24 weeks Primary outcome: cannabis use during treatment

20 4) Prioritise specific populations Adolescence: huge clinical need & potentially the most vulnerable Co-morbid mental health problems: psychological interventions are not effective Cooper et al. (2015) Health Technology Assessment

21 5) Improve access to treatment Telephone & computer: small effect across 10 studies Computer vs. therapist MI/CBT/CM? Same attendance, retention and cannabis use outcomes Smartphone: promising area Jan Copeland (symposium on Friday) Budney et al. (2011), Tait et al. (2013)

22 6) Don t forget about tobacco Europe: 78 92% Australasia: 40 50% Americas: 7 12% Hindocha et al. (submitted)

23 6) Don t forget about tobacco Is cannabis a gateway for harder drugs? Reverse gateway: people are exposed to tobacco first by using cannabis Tobacco linked to greater cannabis dependence and relapse Dual abstinence: best outcome Haney et al. (2010), Hindocha et al. (2015), Patton et al. (2005)

24 6) Don t forget about tobacco Harm reduction? Pipes/bongs/vaporizers may facilitate use without tobacco 12 th Aug 2015

25 Conclusion Rising clinical need across Europe Specific/general psychological approaches How to optimise treatment? 1) Increase European investment 2) Refine psychological approaches 3) Find effective pharmacotherapies 4) Prioritise specific populations 5) Improve access to treatment 6) Don t forget about tobacco

26 Thanks to collaborators and funders Celia Morgan, Exeter Clinical Psychopharmacology Unit, UCL Adam Winstock, GDS Michael Lynskey, KCL

27 Tailor treatment to individual need DSM-5 Cannabis Use Disorder Continue despite problems: psychological/physical Time spent obtaining, using, recovering Use more/longer than intended Tolerance Craving/strong desire Give up other activities Unable to control use or quit Withdrawal Failure to meet important obligations Continue despite problems: social/interpersonal Use in hazardous situations