Management of Marijuana Addiction Martha T. Kane, PhD Clinical Director, Center for Addiction Medicine Associate Director, Ambulatory Psychiatry Massachusetts General Hospital
Does marijuana addiction really exist? Mounting evidence of addictive process Recent estimates: 9% of those who use marijuana will eventually meet DSM-IV standard for dependence Higher estimates for youth (onset <21) More significant use (daily) = greater risk Some estimates as high as 25-50% (Volkow, et al, 2014) Greatest risk with onset in early teens
Short Term Effects (Volkow, et al, 2014; Hall, 2014) Cognitive Memory Impairment Psychological impacts Altered judgment Paranoia, question of association with psychosis Physical Motor coordination effects
Long Term Effects (Hall, 2014; Volkow, et al, 2014) Most severe effects seen with persistent heavy use beginning in early teens Greater risk of addiction Risk of damage to brain structures critical to neural connections Greater risk of poor school performance and loss of up to 8 IQ points Greater risk to achievement of life milestones and satisfaction unemployment, underemployment, incarceration, chronic stress
And a few more risks Road safety risk of accident increases 100% when using cannabis Mental Health issues Increased risk psychotic symptoms Increased panic and other anxiety symptoms Health risks Increased risk for cardiovascular issues, respiratory issues, and some cancers
Special Challenges Often used in conjunction with other drug Cannabis users at higher risk to use other substances Recent legalization with or w/o medical marijuana card Positive spin in social media Recent on study on Twitter chatter found pro messages out numbered negative messages by 15-1 ratio (Cavazos-Rehg, et al, 2015)
Numerous Targets to Manage Factors affecting early onset Factors related to early identification and treatment entry Factors related to effective treatment Factors related to medicalization and legalization Factors related to public awareness
Early Onset Early onset drug use associated with other health risk behaviors in early adolescent Issues within the family Issues with structure and supervision Parental modeling and substance use Communication Parental warmth, engagement Social stress, particularly low SES Peer networks
To Address Early Onset Most promising strategies Broad based interventions focused on a number of overall health risk behaviors Designed to increase positive peer network norms, improve family structure and parental engagement Strengthening Families (Midford, 2009): focus on parent skills training to reduce risk by increasing strong family bonds, with improved peer networks
To Address Early Onset Small Effect or Less promising Efforts targeted to individual level change Classroom based initiatives e.g. Life Skills Training (Botvin, et al, 1995) Initiatives sponsored by law enforcement e.g. D.A.R.E
Effective Treatment Key elements Motivational enhancement, incentives Recovery coping skills training Craving Peer pressure Communication and Problem Solving Mood and stress management skills Family/parental involvement Prosocial activities
Effective Treatment Treatment for Adults Each is effective Motivational Enhancement Therapy Cognitive Behavioral Therapy Contingency Management Efficacy increased in combination 1-2 sessions of MET combined with 7-12 sessions of CBT, with CM strategies incorporated
Effective Treatment For Youth: CYT (Dennis, 2004) large trial focused on cannabis treatment specifically for youth Cognitive Behavioral treatment generally effective to reduce use and promote abstinence Adolescent Community Reinforcement Approach MET + CBT, 5 session version or 12 session version Family based therapy Functional Family Therapy Multidimensional Family Therapy
Novel Ideas Web based delivery (Rooke, etal, 2014; Hoch, 2014) Combinations of cognitive, behavioral, and motivational approaches Short term (<12 sessions) Fewer days of use and fewer dependence symptoms at 3 months, compared to controls Phone based (Gates, etal, 2012) 4 sessions of CBT plus Motivational Interviewing At 12 weeks post tx, greater confidence in abstaining and greater percentage of days abstinent Stronger treatment effects, lower drop out in phone based tx (Rooke, etal, 2014)
Novel Ideas Cognitive enhancement (Sofuoglu, etal, 2013) Based on observation of cognitive dysfunction in chronic addiction Targeted at executive function in order to increase inhibitory control Both behavioral and pharmacological interventions of interest Pharmacology No medications currently indicated N-acetylcysteine (amino acid) effective in one RCT Area of heavy research interest, large studies underway
Public Policy Issues Medicalization and Legalization (Wilkinson, 2014) Medicalization can be construed as de facto legalization Legalization continues to be controversial: Conveys sense of safety, no lasting harm No evidence of increased use among youth Highlights the conflict medical utility and occasional recreational use vs. affect on vulnerable populations, especially youth Criminalization? Racial disparities, lack of treatment access
More Questions Than Answers? Marijuana Pros and Cons Both medicinal and recreational uses Distinct risk of addiction for vulnerable populations Greater risk for youth Effective Treatment modalities exist Available? Early intervention in schools and homes? How to engage communities in this effort? Public Policy and Awareness Medicalization, legalization, criminalization?
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