Treating a Patient with Cannabis Use Disorder Kevin P. Hill, M.D., M.H.S. 41 st Annual Governor s Conference on Substance Abuse, Des Moines IA 4/19/18 Division of Addiction Psychiatry, Beth Israel Deaconess Medical Center khill1@ bidmc.harvard.edu, DrKevinHill.com, @DrKevinHill Disclosures Grants from NIDA, World Health Organization. Book- Hazelden Publishing. Three Areas of Focus Clinical work: Director of Addiction Psychiatry, private practice, pro sports teams and leagues. Clinical research: cannabis clinical trials. Educational outreach: Science vs. public perception, schools, policymakers. 1
Why Cannabis? Addiction treatment: 40% alcohol, 40% opioids, 20% everything else. Around 60%: time when smoked cannabis daily for years. How many of these folks would you see down the road if an effective cannabis intervention existed? In The Middle National Statistics: Not Going Away About 22 million Americans used cannabis in the past year, use doubled in past 10 years (Hasin et al. 2015). Powerful messages medical marijuana, legalization, celebrities. Most messages off the mark, contribute to gap between science and public perception. 2
Current Trends in Cannabis Use Compton, Lancet Psychiatry (2016) Pharmacology of Cannabis 100+ pharmacologicallyactive cannabinoids. THC: euphoria, antiinflammatory, psychosis. CBD: non-psychoactive, anti-anxiety, antipsychotic? Potency Rising 60s, 70s, 80s: avg THC content 3-4%. Now: avg THC content 12% (ElSohly 2016). BUT you can get cannabis (plant not oil) in the 20s and low 30s. 3
Other Forms of Cannabis Treatment Cannabis Treatment Access and Utilization Only 6% of those seeking substance abuse treatment sought treatment for cannabis use disorder. Most people do not think cannabis use requires treatment. No generally accepted treatments. 4
Diagnosis Preparation. Conversation. Evaluation. Referral. How to have the Conversation 5
What to Look for Social problems caused by or worsened by cannabis. Gives up important activities. Use in dangerous situations. Use despite obvious physical, psychological problems. Thorough Evaluation Motivational interviewing. Careful history. Alliance. Recommendations. What does treatment look like? Medical detox not necessary. 30 days of rehab is unlikely. Get prospective patient to talk to somebody. Readiness/alliance work/family support. Medication if appropriate. 6
Challenges Patients not coming on their own accord. Public and peer perception of cannabis addictiveness and harm. The rest of my life Having to give up something you enjoy, often when your peers are not. Case: Rick Rick, a 29-year-old software engineer, has used daily for years. He says it helps him relax and manage anxiety. He doesn t see his cannabis use as a big problem, but his wife does. She is frustrated by the time he spends smoking and feels he needs to grow up. They have discussed having their first child and she cannot see herself having a child with him if he is using cannabis every day. Case: Rick Approach? Positive Prognostic Indicators? Potential Barriers? 7
Behavioral Interventions Why Use? Enhance recreational activity. Relax/escape. Anxiety. Insomnia. CBT Approach After initial Motivational Interviewing Different smoking situations, different thought processes. Alternatives while acknowledging the differences. Challenging automatic thoughts, etc. 8
Medications for Cannabis Use Disorder No FDA-Approved Medications Meds plus therapy paradigm. NAC, gabapentin. What would happen to these patients if there was an effective medication available? 9
N-acetylcysteine Antioxidant, glutamate modulator. Gray (AJP, 2012): NAC plus contingency management participants 2.4x more likely to produce THC-negative urine. 1200mg twice a day, no titration. Drowsiness, nausea, GI upset- minor overall. GABA modulator. Gabapentin Mason et al. (2012): 1200mg twice a day X 12 weeks. Reduced use (biochemical and self-report) and withdrawal symptoms. Our Cannabis Clinical Trials Nabilone. (Hill et al. AJA 2017) Dronabinol and clonidine in patients with significant mental illness. Cannabidiol. 10
Case: Rick Weekly psychotherapy: CBT. Continue SSRI, add NAC 1200 mg twice daily. Marijuana Anonymous. Clinically-significant reduction (but not abstinence). Treatment Outcomes Self-report. Biochemical verification, lab data. Active participation in adjunct treatments. Collateral from family or other treaters. Summary Use good clinical principles to make a diagnosis. No consensus treatments. Labor intensive, but these patients do get better. 11
Acknowledgments Matt Palastro Questions? DrKevinHill.com @DrKevinHill 12