marijuana abuse / dependence and its treatment€¦ · behavioral science and neuroscience provide...
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Marijuana Abuse / Dependence
and Its Treatment
Alan J. Budney, Ph.D.
Center for Addiction Research
University of Arkansas for Medical Sciences
Supported by research grants from National Institute on Drug Abuse
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Today’s Plan
• Show how research on marijuana can and has lead to improved treatments?
• Progress and Limitations:
– My and others NIDA-funded research
• Discuss current and future directions that will provide continued, important advancements
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US Treatment Admissions
by Primary Substance
0
4
8
12
16
20
Cocaine Opiates Marijuana
% o
f ad
mis
sion
s
1992 1997 2007
Illustrates the increase in treatment enrollment for marijuana
over the last 15-20 yrs (NIDA Household Survey, 2009)
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What We Have Learned From
Treatment Research?
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Specific Behavioral Treatments Work
• Coping Skills Training; Enhance Motivation
– Deal with cravings
– Handle peer pressure and social situations
– Manage moods and stress
• Engage Social Support
• Develop Prosocial Alternatives
• Provide Motivational Incentives
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Marijuana Treatment Project (2004)
Dose of Treatment Matters
Reduction in Days of MJ Use
0
20
40
60
80
100
Baseline 4 Months 9 Months 15 Months% D
ay
s o
f U
se (
pa
st 9
0 D
ay
s)
DTC session MET-2 session MET/CBT-9
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0
10
20
30
40
50
60
4 Months 9 Months 15 Months
% P
art
icip
an
ts A
bst
inen
t
DTC MET MET/CBT
Dose of Treatment Matters
Increased Abstinence From Marijuana
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Motivational Incentives Improve Outcomes Contingency Management (CM)
0
10
20
30
40
50
ETX 3 6 9 12
Months Post Treatment
% o
f P
arti
cip
an
ts A
bst
inen
t
MET/CBT MET/CBT/CM CM
Budney et al. (2006)
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Incremental Improvements with
Behavioral Innovations
Across Multiple Studies
0
10
20
30
40
50
ETX 6 month 12 month
Months Post Treatment
% o
f P
arti
cip
an
ts A
bst
inen
t
MET MET/CBT MET/CBT/CM
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What about Adolescents? Specific Behavioral Treatments Work
Family-based and group / individual behavioral treatments
- Waldron et al. -- FFT, CBT, CBT/FFT
- Liddle et al. -- MDFT
- Henggeler et al. -- MST
- Dennis et al. - MET/CBT, ACRA. FSN
- Santisteban et al. - BSFT
- Stanger, Budney et al. (2009) - MET/CBT+CM
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Cannabis Youth Treatment Study
Treatments Reduce Marijuana Use
0
10
20
30
40
50
0 3 6 9Months from Intake
Days
of
Mari
juan
a U
se
(ou
t of
90)
MET/CBT5 ACRA MDFT MET/CBT12 MET/CB12+ FSN
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Cannabis Youth Treatment Study
Treatments Engender Marijuana Abstinence
% Abstinent at Discharge
0
10
20
30
40
M/CBT5 M/CBT12 FSN CRA MDFT
% o
f A
do
les
ce
nts
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Add Motivational Incentives
Combine 2 Abstinence-Based CM Interventions
- Provide social and/or monetary-based incentives contingent on drug abstinence
A) Clinic-based incentives (same as adults)
B) Parent-based: home-based contract
- reward abstinence
- punish use
- low cost, long-term application, natural
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CM (Incentives) Improves Outcomes for
Adolescent Marijuana Abuse
0
20
40
60
80
100
> 8 wks 3 months 6 months 9 months
% o
f T
ee
ns
MET/CBT+CM MET/CBT
Stanger, Budney et al. (2009)
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Abstinence and Ethnicity/Race/SES
Arkansas Study
0
2
4
6
8
10
CM No-CM
Wk
s o
f A
bs
tin
en
ce )n=22(White )n=44(African Am
Main effect of ethnicity/SES on outcome
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Current Status We are developing effective treatments, but….
Room for Improvement in Outcomes
- Initiation of Abstinence
- Maintenance of Positive Effects
Limited Access and Availability
- efficacious treatments not available
- integrity/fidelity of treatment delivery
- cost (e.g., incentive programs, therapy)
- resistance to seeking treatment
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How Do We Improve?
Behavioral Science and Neuroscience
Provide a Number of Potential Targets
Better Understanding of Marijuana Dependence
- Marijuana Withdrawal Syndrome
- Endogenous Cannabinoid System
- Genetics
- Impulsivity
- Impact on Brain Function
- Innovative Incentive Programs
- Concurrent Tobacco Use
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Marijuana Withdrawal Withdrawal Discomfort Score
(Budney et al. 2003)
0
2
4
6
8
10
1-5 1-3 4-6 7-9 10-
12
13-
15
16-
18
19-
21
22-
24
25-
27
28-
30
31-
33
34-
36
37-
39
40-
42
43-
45
Abstinence Days
Severit
y S
core
*
*
* *
*
BL
*
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Marijuana and Tobacco Withdrawal:
Similar Symptom Severity
(Vandrey et al., 2005; Vandrey et al. 2008, Budney et al., 2009)
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Marijuana Withdrawal
Symptom List (proposed for DSM-V)
1) irritability, anger, or increased aggression
2) nervousness or anxiety
3) sleep difficulty (insomnia)
4) decreased appetite or weight loss
5) restlessness
6) depressed mood
7) at least 1 physical symptom causing significant discomfort (stomach pain, shakiness/tremors, sweating, fever, chills, headache)
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Neurobiology of Marijuana Use and Abuse
Endogenous System / Cannabinoid Receptor
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How Do We Improve?
Pharmacotherapy / Medications
- Withdrawal: mood, sleep, anxiety, irritability, restlessness
- Agonist substitution treatments
- Antagonist treatments (block the effects at the CB1 receptor site)
- Enzymatic targets (FAAH)
Meds: dronabinol, lofexedine, gabapentin, zolpidem...
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Genetics and Outcomes
Ongoing Adolescent Study Stanger, Budney et al., ongoing
Collecting saliva samples to genotype the adolescents who enter our treatment
Specific genes:
marijuana-related: CNR1, FAAH
respond to incentives: DRD4, 5-HTTLPR, CRHR1
Perform treatment x genotype interactions
Improve? Matching; Medications
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Impulsivity
- Measure via a Delay Discounting procedure
• Would you like $50 or $75 in one week?
• Calculate a Discounting Rate (k)
… substance abusers are more likely to pick sooner rather than later amounts (higher k)
- impulsive decision making
- lack of future orientation
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Appears to Hold for Adolescents
Discounting relates to Outcomes Adolescent Treatment
Stanger, Budney et al., in preparation
Low Socioeconomic Status and Tobacco
Dependence are associated with greater
discounting
Greater Discounting related to poorer
marijuana abstinence outcomes
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Adolescent Impulsivity
(Stanger et al., ongoing)
k-values (discounting rates) are correlated with
brain activity while doing a delay discounting
task
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What can we do to Improve? Executive Function / Future Orientation
Therapy
Train executive systems of the brain to bolster decision-
making, future orientation, planning skills:
• Computerized Cognitive Training Programs and
Therapeutic Games
- working memory, decision making, impulse control
- choice games: consequences are experienced
- reward delayed choices
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How Else Can We Improve?
Enhance Behavioral Treatments and
Delivery Systems
- Develop and Apply Technology
- Innovative Incentive Programs
- Target Tobacco: 50% of marijuana
treatment seekers smoke Tobacco
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Computerized MET/CBT/CM (Budney et al. in press)
% Participants Abstinent
0
10
20
30
40
50
60
> 4 Wks > 8 Weeks
% A
bst
inen
t
Computer Therapist
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Target Disadvantaged Minorities with
Culturally-Based Behavioral Treatments
Topography of the Program
- Incentive or Consequence Program?
- Community-based (church or community center)
- Occur in the community
- Culturally relevant incentives?
- Access to recreational / learning center
- Parent programs occur in community
- Social RF from greater community….
- Treatment extenders: community health workers
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Target: Marijuana-Tobacco Relationship
- 70% marijuana users report past month tobacco use
- 50% of marijuana treatment seekers smoke tobacco regularly
- Shared heritability
Enhances high?:
Smoked as a mixture (blunts, spliffs)
Use as a chaser
Makes quitting more difficult
- Tobacco use negative predictor of marijuana cessation outcome
- Marijuana use negative predictor of tobacco cessation outcome
- Why? cues related to smoking behavior, more reinforcing, brain reward systems
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Making Excellent Progress, but
We Need to Continue to Improve Look to Neuroscience:
Medication Development
Genetics
Brain Function / Impulsivity
- executive function therapy
- future orientation focus
Develop Behavioral Treatments and Delivery Systems
- Develop Technological Interventions
- Innovative Incentive Programs / Focus on the Disadvantaged
- Target Tobacco
- Chronic Care Models
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END
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Will or Has Medical Marijuana
Controversy affected Perceived Risk and
Prevalence of Use?
Monitoring the Future study
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Synthetic Marijuana: K2, Spice…
Sprayed on plant materials: potent CB1 agonists
Effects??: similar to Marijuana / less reliable / more
adverse effects
Internet, head shops, and other convenience stores