Psychosocial treatment of cannabis disorders Thomas LundqvistClinical psychologist & associate professorDrug Addiction Treatment Centre, Lund University hospital, Sweden

Author year Country experiment-controll N evidence2006Psychosocial treatment of cannabis disorders: a review of 13 studies.In the studies 1-5 only a minority (20 -40 %) of the clientsachieve a complete abstinent condition during the period of treatment.However, they display a significant reduction in cannabis use and cannabis related problems.

1. Dennis2003USAshort cog beh vs long cog beh60022. Babor2003USAshort cog beh vs long cog beh45023. Copeland2001Australiashort cog beh vs long cog beh22924. Budney2000USAVoucher vs cog beh6025. Stephens*2000USARPT vs support29126. Lundqvist1995Swedencog edu vs Del treat1537. Azrin*1994USASoc skills vs couns2638. Stephens*1994USARPT vs support21239. Joanning*1992USAFam ter vs educat134310. Hengeler*1991USAFam ter vs couns200311. Lewis*1990USAFam ter vs ind ter84312. Szapocznik*1988UsaFam ther vs couns108313. Lundqvist2005SwedenProgram evaluation503

Interesting questions are:

How many sessions in how many months, and if there are follow-up sessions?

The treatment technique and the theoretical backgrounds?

Client characteristics?

Measures for treatment outcome?

Is reduction of use a positive outcome?

Treatment outcomes measuresIn five studies the following assessment tools were used.

Stephens 1994: Urine analysis, drug lifeline (first use and daily use) , Typical day use, modified version of the 20-item Drug abuse Screening test (DAST, Skinner, 1972)

Stephens 2000: same as above, how many sessions attended=compliance, DSM-IV, SCL-90 Global index,

Copeland 2001 same as above, Opiate Treatment index, Five item Severity of Dependence Scale SDS (Gossip et al 1992), Cannabis Problems questionnaire.

Lundqvist, 1995 Urine analysis, Sense of coherence.

Lundqvist, 2005 Urine analysis, Sense of coherence, SCL-90, subscales and Global index, Becks depression inventory.

It is necessary, for those who are dysfunctional, (about 10 % of the those who have tested cannabis once) to develop appropriate treatment programs based on

cognitive-behavioural technique or cognitive-educative technique or Motivational Interviewing technique or a combination of these.

A built-in flexibility to offer care to patients of all ages. (evidence 2)

A brief intervention, which has significantly larger reduction in substance related problems with the lowest severity clients, few sessions.(evidence 2) A more comprehensive intervention, which works better with high severity clients, with at least 14 sessions over a period of 4 months with follow-up sessions, more often at the beginning. (evidence 2) The subtle impairments in cognition within their agenda and work towards their resolution. (evidence 3) A focus on immediate abstinence and the possibility to have urine samples taken. (evidence 2) Sessions for family members and significant others. (evidence 3) The possibility of long-lasting cognitive deficits that affect both the performance of complex tasks and the ability to learn. (evidence 2)These programmes should incorporate:

A focus directly on use itself, and at the same time, help to improve the accompanying deficits in competence. (evidence 2) A help to critical examination of the drug-related episodic memory (memory for self-knowledge). (evidence 3) Strategies to enhance self-esteem that is not based on a drug-related episodic memory. (evidence 2) A set of adequate questions to enhance the recognition factor. The effectivity of the cue is dependent on the associative strength and encoding specificity. (evidence 3)continued

Two inter-related randomized trials conducted at 4 sites to evaluate the effectiveness and cost-effectiveness of 5 short-term outpatient interventions for adolescents with cannabis use disorders. Dennis, M et al USA 2003. short cog beh vs long cog behThe Cannabis Youth Treatment (CYT) Study: Main Findings from Two Randomized Trials.Trial 1 compared five sessions of Motivational Enhancement Therapy plus Cognitive Behavioral Therapy (MET/CBT) with a 12-session regimen of MET and CBT (MET/CBT12) and another that included family education and therapy components (Family Support Network [FSN]). Trial 2 compared the five-session MET/CBT with the Adolescent Community Reinforcement Approach (ACRA) and Multidimensional Family Therapy (MDFT).

The five treatment protocols include: A brief, basic, low cost treatment consisting of five sessions over six weeks using motivational enhancement treatment and cognitive behavioral therapy. 2. Adding to the basic treatment model seven additional group sessions of cognitive behavior therapy to create a 12 week treatment program. 3. Adding to the enhanced option (#2) three to four home visits for family therapy, six parent-education group meetings, and case management. 4. A 14-session intervention of individualized counseling that could be used for victimized youth, in rural areas, or anywhere that group formation might delay or increase the cost of treatment. 5. An approach that integrates family therapy and primary substance abuse treatment throughout the 12-week program rather than as an add-on.

All four study sites used option one. Two sites used options 2 and 3 with option 1 (incremental study arm). Two sites used options 4 and 5 with option 1 (alternate study arm). The researchers recruited 600 adolescents between the ages of 12-18 who reported using marijuana in the past 90 days, reported problems related to marijuana abuse or dependence and met criteria for outpatient, rather than inpatient, therapy.

The researchers found that: The brief intervention (#1) had significantly larger reductions in substance related problems with the lowest severity clients.

The enhanced, more comprehensive intervention (#3) worked better with high severity clients. At the six month mark, the more comprehensive treatment caught up with the brief intervention for low severity clients and continued to be the most effective with high severity clients. The brief and individual behavior therapy interventions (#4) reduced use of marijuana significantly more than the integrated family therapy (#5) in the beginning.

However, at the six months mark all improved further and the family therapy had caught up. The costs of all five of these therapies appear to be affordable as they are in line with what is currently being paid. The average weekly economic costs of the five types of outpatient treatment ranged from $105 to $244 per week.

The cost differences reflected both weeks of treatment and hours of formal sessions and variations in cost of living, and similar factors.

Babor, T USA 2003. short cog beh vs long cog beh TREATMENTS FOR CANNABIS DEPENDENCE. Brief Treatments for Cannabis Dependence: Findings from a Randomized Multi-Site Trial This study evaluated the efficacy of two brief interventions for cannabis dependent adults.

A multi-site randomized controlled trial compared cannabis use outcomes across three study conditions:

2 sessions of motivational enhancement therapy (MET); 9 sessions of multicomponent therapy that included MET, cognitive-behavioral therapy, and case management, 3) a delayed treatment control (DTC) condition. The 9-session treatment reduced marijuana smoking and associated consequences significantly more than the 2-session treatment, which also reduced marijuana use relative to the DTC condition.

Copeland Australia 2001. (Cognitive-behavioural therapy vs. delayed treatment).Copeland et al. A randomized controlled trial of brief cognitive-behavioral interventions for cannabis use disorder.

Clinical profile of participants in a brief intervention program for cannabis use.

Swift et al.: Characteristics of long-term cannabis users in Sydney, Australia. A total of 229 participants were assessed and randomly assigned to either a six-session brief cognitive-behavioral program (6CBT), a single-session CBT intervention (1CBT), or a delayed-treatment control (DTC) group.

Participants were assisted in acquiring skills to promote cannabis cessation and maintenance of abstinence.

A follow up median 237 days after last attendance. Participants in the treatments groups reported better treatment outcomes than the DTC group.

Budney 2000Adding voucher-based incentives to coping-skills and motivational enhancement improves outcomes during treatment for marijuana dependence. motivational enhancement (M), M plus behavioral coping skills therapy (MBT), or MBT plus voucher-based incentives (MBTV).Sixty individuals seeking outpatient treatment for marijuana dependence were randomly assigned to 1 of 3 treatments:

Budney 2000

Stephens USA 2000. (RPT vs. social support).Comparison of extended versus brief treatments for marijuana use.

Adult marijuana users (N=291) seeking treatment were randomly assigned to

an extended 14 session cognitive-behavioral group treatment (relapse prevention, support group; RSPG),

a brief 2-session individual treatment using motivational interviewing (individualized assessment and intervention;IAI),

or a 4-moth delayed treatment control (DTC) conditions.

Lundqvist, Lund Sweden 1995. (Cognitive-educational therapy vs. delayed treatment).Chronic cannabis use and the sense of coherence.

Chronic cannabis users undergoing 18 sessions in six weeks cognitive therapy were tested using the Sense of Coherence scale to determine the extent to which patients showed improvements in perceived comprehensibility, manageability, and meaningfulness of life.

The admission assessment was compared to marijuana users who were seeking treatment but have been drug free for six weeks before entering the programmeThe study indicates that abstinence is not enough to improve the accompanying deficits in psychosocial competence.

Azrin; USA, Ft Lauderdale, Fl. 1994. A controlled Outcome study, Follow-up results of supportive versus behavioural therapy for illicit drug use Social skills vs. counselling, cognitive-behavioural therapy vs. social support.The result showed that during the last month, 9% of youth receiving supportive counselling were abstinent vs. 73% of youth receiving the new behavioural treatmentThe result indicate favourable results appear attributable to the inclusion of family/significant others in therapy and the use of reinforcement contingent on urinalysis results.

Stephens USA 1994. Stephens et al.: Treating adult marijuana Dependence: A test of the relapse prevention model.Predictors of marijuana treatment outcomes: the roles of self efficacy. (RPT vs. social support).Men (161) and women (51) seeking treatment for marijuana use were randomly assigned to either a relapse prevention (RP) or a social support (SSP) group discussion intervention.

Data collected for 12 months posttreatment revealed substantial reductions in frequency of marijuana use and associated problemsThe predictor study:Result: the need to tailor measures specifically to the outcome of interest. Interestingly, the measures of pretreatment severity of abuse, and not frequency of use, were the stronger predictor of posttreatment problems.

The authors conclude that: Use is not equivalent to abuse and further research is needed.

Improvement in cognitive and social competence in adolescent chronic cannabis users.- Results from a manual based treatment programme at Maria Youth Centre, Stockholm, Sweden.

Thomas Lundqvist1, Birgitta Petrell2, Jan Blomqvist3. 1Drug Addiction Treatment Centre, Lund University hospital, S-22185 Lund, Sweden, 2Maria Youth Centre, S-11235 Stockholm, Sweden.3Centre for Social Research on Alcohol and Drugs, University of Stockholm, S-106 91 Stockholm Sweden

Session 11RelaxationFocus on emotions

Session 12Continued focus on emotionsGuilt and shame

Session 13 Norms and values-behavior-abuse

Session 14 Juhariwindow or something more suitable

Session 15The process of relapse

Session 16Continued relapse preventionTest: SOC, SCL-90, BDI scale focusing on relations.

Session 17 Assessment feedbackLook at the flipchart, repeat select the material to be used at the closing session.

Session 18 Closing sessionShow the flipchart for the family and others.

Graduation and Diploma

Session 1 Illustration of THC elimination and anxiety reactions. Info about physical reaction.Information about cannabis. Test: SOC, SCL-90, BDI scale focusing on relations.

Session 2Assessment feedback Positive and negative attitudes to cannabis useWhy do you want to quit now?What kind of help do you need?

Session 3Acute effects of cannabis

Session 4Chronic effect of cannabis

Session 5Cognitive function and dysfunction

Session 6Attitudes and patterns of use

Session 7Drug lifeline

Session 8Sociogram

Session 9Lifeline

Session 10 (or when it is appropriate)Session together with the parentsThe 18 sessions manual.

First time of use 14.2 (11-17)Years of use3.6 (1-8)Regular use (>3 times a week) 2.5 (1-6)

15 subjects reported problems with alcohol

Fifty adolescents (75 admissions) including 5 girls, with at least six months daily use, completed the programme between year 2000 and 2004.

The clients were assessed at admission, after six weeks and after one year after concluding the course.We used a battery of questionnaires consisting of Sense of coherence (SOC), Symptomchecklist-90 (SCL-90), Becks Depression Inventory (BDI) and CAGE, focusing on alcoholproblems Scales focusing on life situation and relationships.Assessments

the stimuli deriving from ones internal and external environments in the course of living are structured, predictable, and explicable (comprehensibility);

the resources are available to one to meet the demands posed by these stimuli (manageability); these demands are challenges, worthy of investment and engagement (meaningfulness).Aaron Antonovsky, 1987To get a good sense of coherence the individuals perceive that

29203142152TotalComprehensibilityManageabilityMeaningfulness174LowHighGood profileCMaMe

ComprehensibilityManageabilityMeaningfulnessTotalAdm. (M, sd) 3,71 ( 0,71) 4,32 ( 0,87) 4,26 ( 0,98)118,04 (19,97)6-weeks. (M, sd) 4,78 ( 0,71) 5,03 ( 0,77) 5,06 ( 0,89)137,84 (18,62) t df sign1N- 4,69 49 ***50- 5,50 49 *** 50- 5,86 49 ***50- 5,95 49 ***501-year (M, sd) 4,3 ( 0,8) 5,1 ( 1,0) 5,3 ( 1,2)141,2 (24,6) t- 0,7- 0,6- 1,6- 1,11 *** p < .001; ** p < .01; * p < .05; ns= non significant

df sign N 39 ns 40 39 ns 40 39 ns 40 39 ns 40Sense of Coherence

SCL-90 Key Features

The SCL-90 test contains only 90 items and can be complete in just 12-15 minutes.The test measure 9 primary symptom dimensions and is designed to provide an overview of a patient's symptoms and their intensity at a specific point in time.The progress report graphically displays patient progress for up to 5 previous administrations. By providing an index of symptom severity, the assessment helps facilitate treatment decisions and identify patients before problems become acute. The Global Severity Index can be used as a summary of the test.More than 1,000 studies have been conducted demonstrating the reliability, validity, and utility of the instrument.

Symptom Scales SOM - Somatization O-C - Obsessive-Compulsive I-S - Interpersonal Sensitivity DEP - Depression ANX - Anxiety HOS - Hostility PHOB - Phobic Anxiety PAR - Paranoid Ideation PSY - Psychoticism Global Indices Global Severity Index (GSI): Designed to measure overall psychological distress.

Positive Symptom Distress Index (PSDI): Designed to measure the intensity of symptoms. Positive Symptom Total (PST): Reports number of self-reported symptoms.

SomatizationObsessive-kompulsiveInterpersonal sensitivityDepressionAnxietyHostilityPhobic anxietyParanoid ideationPsychoticismGlobal Sever. Iind (GSI)Pos. Sympt. Distr Ind(PSDI)Total Pos Sympt (PST)Adm. (M, sd) 65,5 (15,5) 66,5 (13,5) 62,1 (16,0) 62,3 (13,0) 66,8 (14,6) 66,7 (15,3) 66,2 (21,6) 67,2 (15,5) 62,5 (14,5) 68,0 (14,7) 61,2 (10,7) 65,5 (10,8)6-weeks. (M, sd) 53,6 ( 9,1) 55,1 (10,1) 51,7 ( 8,9) 52,2 ( 8,7) 53,6 ( 9,1) 53,5 (10,6) 55,0 (13,5) 53,8 ( 9,6) 54,1 ( 8,6) 54,1 ( 8,5) 50,6 ( 7,6) 56,4 (10,2) t df 5,59 49 6,55 49 5,70 49 5,96 49 7,31 49 6,54 49 5,14 49 7,56 49 4,87 49 7,89 49 7,95 49 6,48 49Sign1 N*** 50*** 50*** 50*** 50*** 50*** 50*** 50*** 50*** 50*** 50*** 50*** 501-year. (M, sd) 53,7 (14,3) 52,9 (12,5) 52,0 (12,8) 52,6 (14,1) 54,4 (12,8) 54,0 (12,9) 52,8 (11,9) 55,2 (13,3) 53,2 (11,3) 53,7 (12,0) 54,5 (14,0) 54,7 (12,2) t 0,6 1,0 0,3- 0,1- 0,2 0,3 1,3 0,1 0,6 0,6- 1,7 1,3N4141414141414141414141411 *** p < .001; ** p < .01; * p < .05; ns= non significantSCL-90, standarized T-value; significance tested by mean (paired t-test)ns

Clients with a GSI score below 50 increased from 8 to 29 per cent. SCL 90 Symptom Checklist

SLC

65.553.650.9

66.555.450.4

62.151.949.7

62.352.349.8

66.853.952.1

66.753.651.7

66.255.251

67.253.952.6

62.554.451.3

6854.451

61.250.651.9

65.556.751.7

Admission

6-weeks

1-year follow up

KASAM

3.714.324.44

4.325.15.22

4.265.15.4

KASAM delvrden

Inskrivning

Utskrivning

Uppfljning

KASAM2

118.04138.2144.6

KASAM totalvrde

Inskrivning

Utskrivning

Uppfljning

Diagr1

13.96.47.1

8.34.14.9

5.62.72.2

BDI Becks depression inventory

Inskrivning

Utskrivning

Uppfljning

Blad1

Psykosociala aspekter:

Skattning av relationer (skala 1 10); signifikanstest av medelvrden (paired t-test)

InskrivningUtskrivningtdfsign1N

Relation till mor6,28 (2,7)7,38 (2,0)-3.328***29

Relation till far5,29 (2,8)6,11 (2,6)-2.327*28

Relation till syskon6,58 (2,5)7,62 (1,8)-3.925***26

Relation till kamrater7,66 (2,8)8,10 (2,2)-0.828ns29

Relation till pojk- el. flickvn8,86 (1,9)8,00 (2,2)1.116ns7

Total livssituation5,96 (2,0)7,07 (1,6)-3.927***28

SCL, standardiserade T-pong; signifikanstest av medelvrden (paired t-test)Inskrivn. (M, s)Utskrivn. (M, s)

Admission6-weekstdf1-year follow upNOriginal hrOriginal hr

Somatization65.553.65.594950.95065,5 (15,5)53,6 ( 9,1)

Obsessive-Compulsive66.555.46.554950.45066,5 (13,5)55,1 (10,1)

Interpersonal Sensitivity62.151.95.74949.75062,1 (16,0)51,7 ( 8,9)

Depression62.352.35.964949.85062,3 (13,0)52,2 ( 8,7)

Anxiety66.853.97.314952.15066,8 (14,6)53,6 ( 9,1)

Hostility66.753.66.544951.75066,7 (15,3)53,5 (10,6)

Fobic anxiety66.255.25.1449515066,2 (21,6)55,0 (13,5)

Parnoid Ideation67.253.97.564952.65067,2 (15,5)53,8 ( 9,6)

Psychoticism62.554.44.874951.35062,5 (14,5)54,1 ( 8,6)

Global Severity Index (GSI)6854.47.8949515068,0 (14,7)54,1 ( 8,5)

Pos Sympt Distress Index (PSDI)61.250.67.954951.95061,2 (10,7)50,6 ( 7,6)

Pos. symptom Total (PST)65.556.76.484951.75065,5 (10,8)56,4 (10,2)

Becks Depression Index (BDI):Inskrivn. (M, s)Utskrivn. (M, s)

InskrivningUtskrivningtdfUppfljningNOriginal hrOriginal hr

Somatisk affekt5.62.75.4292.2305,6 (3,2)2,7 (1,6)

Kognitiv affekt8.34.14.8294.9308,3 (5,2)4,1 (4,3)

Antal9.85.16.8295.1309,8 (4,3)5,1 (3,2)

Totalt13.96.46.2297.13013,9 (7,3)6,4 (4,9)

Knsla av sammanhang (KASAM):Inskrivn. (M, s)Utskrivn. (M, s)

InskrivningUtskrivningtdfUppfljningNOriginal hrOriginal hr

Begriplighet3.714.32-4.69494.44503,71 ( 0,71)4,78 ( 0,71)

Hanterbarhet4.325.10-5.50495.22504,32 ( 0,875,03 ( 0,77)

Meningsfullhet4.265.10-5.86495.40504,26 ( 0,98)5,06 ( 0,89)

Totalt118.04138.20-5.9549144.6050118,04 (19,97)137,84 (18,62)

Blad2

Blad3

1 *** p < .001; ** p < .01; * p < .05; ns= non significantSomatic affectiveCognitive affectiveAmount TotalAdm(M, sd) 5,6 (3,2) 8,3 (5,2) 9,8 (4,3) 13,9 (7,3) 6-weeks(M, sd) 2,7 (1,6) 4,1 (4,3) 5,1 (3,2) 6,4 (4,9) t 5,4 4,8 6,8 6,2 df 29 29 29 29sign1 *** *** *** ***N303030301-year(M, sd) 2,2 (2,2) 5,0 (6,1) 5,1 (4,6) 7,3 (7,9) t 0,4- 0,4 0,3- 0,2sign1 ns ns ns nsN24242424< 14 no depression

Who did better?

Those, who had a higher sense of coherence at admission. Those, with fewer symptoms according to SCL-90 at admission. Those, who lived together with both parents. Those, who applied on their own initiative.

Who did worse? Those, who had an early onset of abuse, polydrug use and alcoholproblems. Those, who had higher points on anxiety and depression at the 6-weeks assessment. Those, who had a low estimation on the relationship to the mother.

After six weeks of abstinence and treatment they display a significant improvement to normal values in sense of coherence and this improvement remained stable at the one year follow-up.

The result of SOC indicate that young chronic cannabis users seeking treatment at admission are characterised as:

having a mean that is considerably lower than normal. experiencing inner or outer stimuli as not comprehensible in a rational way, but rather that the information is unorganized and incoherent. convinced that they are able to manage the problems and stimuli they receive. having an emotional and cognitive motivation, with the feeling that there are some things in life worth some interest, commitment or devotion.

These results are concordant with the findings in a similar study focusing on old chronic cannabis users by Lundqvist (1995a).

The significant improvement in SCL-90 values between admission and the six-week assessment indicate emotional distress that may be caused by the impact of the cannabinoids on human emotion and cognition. This improvement remained stable at the one year follow-up. In our clients, the symptoms of depression disappeared after six weeks ofabstinence indicating that the cannabinoids creates depression like symptoms. Improvement was seen at six-week assessment, and it remained stable at the one year follow-up.At the one year follow-up, two-thirds were cannabis free (68%); 35 per cent had had no relapses and 33 per cent had had one brief relapse, 57 per cent were free from all problematic use, including alcohol.

Clients with initial problematic alcohol use were less successful.

Remaining symptoms of anxiety and depression were signs that indicate that extended support is needed. Finally, improvements could be seen in their overall life situation.

A way out off fog

A short presentation of the treatment manual Phase 2: a psychological focus lasting until the 21st day after smoking cessation. Phase 3: a psychosocial focus during the rest of the program. This phase has no time limits. Phase 1: a bio-medical focus lasting until the 12th day after smoking cessation. It is presented as a course in quitting

The chronic influence on the cognitive functions.The impact of the enhanced subjective perception.The need of professional guidance in the relearning process.The treatment manual focus on Critical examination of the drug-related episodic memory. Promotion of the psychological maturation. Enhancing the social competence and orientation to life. The self-regulation use of cannabis. Depression and phobic reaction following cessation of cannabis. The need to be given proposals.

The therapist is requested to: have good knowledge of the acute and chronic effects of cannabis. use a concrete and simple language. transform abstract reasoning into drawings and metaphors. be a leading authority in describing the detoxification process. The therapist is the prefrontal substitute.

An illustration of the screened off condition

Each discussion should containTo make the client notice what is happening.To make the client compare with earlier experiences.to make the client reflect and consider the topics of the discussion.

THC100 %50 %Weeks123456-8Phase 1 Bio-Medical focusPhase 2PsychologicalfocusPhase 3Psycho-Social focusAnxiety3 session/week3 sessions/week - 2 sessions/weekLundqvist & Ericsson 1988A treatment manual for chronic cannabis users

The structure is used inThe original programme, designing a concept for each individual.A manual based program with 18 sessions in six weeks focusing on 17-24 years old with a regular use more than six months A manual based short program with six sessions in six weeks focusing on younger user or those who have used less than six months regularly .For those who are experimenting, there is a three session course.A guide to quitting Marijuana and hashish

It is a structured six-week treatment programme including sessions three times a week. The main focus is on helping the cannabis users (17-20 year) to redirect cognitive patterns and to regain intellectual control. After completion of the six-week programme, the patients are advised to take part in supportive sessions once a week for six weeks. The programme is now a regular programme at the centre.

REITOX-Academy[1]Prevention and therapy of cannabis disturbances in Europe: status, projects, need for development29 March 30 March 2007 BerlinPrimary target group: Members of EMCDDAs National Focal Points, national experts [1] The main objective of the REITOX Academy training programme is to address in a coordinated manner and within a realistic timeframe identified training needs of the National Focal Points and the national experts in the EU Member States and Candidate Countries to the EU.

Internet-based prevention and intervention for cannabis users Quit the shit project) by Mr. Peter Lang, head of the prevention of substance abuse and addiction prevention unit, Federal Centre for Health Education, CologneShort intervention programme Realize it!, Mr. Peter Tossmann, Delphi - Gesellschaft fr Forschung, Beratung und Projektentwicklung, Berlin Introduction of the Cannabis Research Action Plan by Prof. Henk Rigter, University of Rotterdam / Netherlands.

INCANT: An international research study based on the Five-Countries Action Plan for Cannabis Research; needs and characteristics of (standard) cannabis treatment in Germany & France, Mr. Olivier Phan, l'Institut mutualiste Montsouris de Paris et du laboratoire 669 de l'Inserm, Paris & Mr. Andreas Gantner, Therapieladen, Berlin CANDIS A treatment program for persons who want to rethink, reduce or stop their cannabis use, Ms. Eva Hoch, project leader,

Evaluation of the cannabis programme at the Maria Youth Centre, Stockholm, Mr. Thomas Lundqvist, Drug Addiction Treatment Centre, Lund Presentation and first year evaluation of "cannabis outpatient clinics, Mr. Jean-Michel Costes, director National Focal Point France, OFDT, Paris & Ms. Ivana Obradovic, National Focal Point France, OFDT, Paris Project Way out and determinants for mature consumption (working title), Ms. Barbara Drobesch, Landesstelle fr Suchtprvention, Klagenfurt

Those who develop cannabis dependence willingly seek treatment for problems related to their use. (Stephens et al 1993). Interestingly, treatment admissions for individuals younger than age 20 comprise about 45 % of all admissions (Copeland et al 2001). They exhibit substantial psychosocial impairment and psychiatric distress, report multiple adverse consequences, report repeated unsuccessful attempts to stop using, and perceive themselves as unable to quit. They have psychological and social deficits, that have to be taken in to consideration during treatment.The first randomized controlled trial evaluating treatment for adult cannabis dependence did not appear in the literature until 1994 (Stephens et al 1994) three additional randomized trials have now been published (Budney et al, Copeland et al 2001, Stephens et al 2000).Result across the studies indicate that the same types of psychosocial treatments found effective for other substances dependence disorders are effective for cannabis dependence. Coping skills training, relapse prevention and motivational enhancement therapies have demonstrated efficacy compared to delayed treatment controls. (Copeland et al 2001) (Stephens et al 2000).However in the above mentioned studies only the minority (20 % - 40%) of cannabis-dependent patients achieve abstinence during the treatment, although more show clinically significant reductions in marijuana use and associated problems.The 600 cannabis users were predominately white males, aged 15-16. All five CYT interventions demonstrated significant pre-post treatment improvements during the 12 months after random assignment to a treatment intervention in the two main outcomes: days of abstinence and the percent of adolescents in recovery (no use or abuse/dependence problems and living in the community). Overall, the clinical outcomes were very similar across sites and conditions; however, after controlling for initial severity, the most cost-effective interventions were MET/CBT5 and MET/CBT12 in Trial 1 and ACRA and MET/CBT5 in Trial 2. It is possible that the similar results occurred because outcomes were driven more by general factors beyond the treatment approaches tested in this study; or because of shared, general helping factors across therapies that helped these teens attend to and decrease their connection to cannabis and alcohol.1. Patients have two individual sessions followed by three group sessions. This program is designed to motivate the patient to change marijuana use and identify high-risk situations that could increase the likelihood of relapse. The sessions help the patient establish a social network supportive of recovery and develop a plan for activities to replace marijuana-related activities. 2. This is a more intense version of the first therapy and is designed to help adolescents develop coping skills and alternative responses to cannabis use, and deal with problem solving, anger, criticism, psychological dependence, and depression management.3. This program is designed to improve family cohesion, parenting skills and parental support. It includes case management to promote parent engagement in the youth's treatment process. It also includes referral of parents to self-help support groups. The program allows counselors to tailor plans to fit a family's specific home situation. 4. The focus of this intervention is to identify reinforcers that make abstinence from marijuana more rewarding than use. This therapy includes 10 sessions with the adolescent alone, two with the caregiver alone and two with caregiver and child.5. This approach uses 12-15 family-focused treatment sessions as well as counseling sessions with both adolescent and parents. This type of therapy is designed to change the individual's relationships with family, peers and social systems, and includes case management to help resolve other problems. Participants were 450 adult marijuana smokers with a DSM-IV diagnosis of cannabis dependence. Assessments were conducted at baseline, and at 4, 9, and 15 months post-randomization. The 9-session treatment reduced marijuana smoking and associated consequences significantly more than the 2-session treatment, which also reduced marijuana use relative to the DTC condition. Most differences between treatments were maintained over the follow-up period. Discussion focuses on the relative efficacy of these brief treatments and the clinical significance of the observed changes in marijuana use.Participants in the treatments groups reported better treatment outcomes than the DTC group. They were more likely to report abstinence, were significantly less concerned about their control over their cannabis use, and reported significantly fewer cannabis-related problems than those in the DTC group. Those in the 6CBT also reported less cannabis consumption than DTC. While the therapist variable had no effect on any outcome, a secondary analysis of the 6CBT and 1Cbt groups showed that treatment compliance was significantly associated with decreased dependence and cannabis-related problems. This study supports the attractiveness and effectiveness of individual CBT interventions for cannabis use disorders.Concerning treatment compliance: The mean number of treatment sessions attended by those allocated to the 6CBT group was 4.2 (SD=2.2) Half 50%; n 39) attended all six session of the 6CBT, 9% (n=7) attended five, 7.7% (n=6) each attended three and four, 9% (n=7) attended two, and 7.7% (n=6) attended one session; 9% (n=7) attended the assessment only. The majority of those allocated to the 1CBT group (87.8%; n=72) attended their appointment. In total, just over two thirds (69.4%) of those allocated to an intervention completed all sessions to which they had been randomized. Less than one third (28.8%) had previously sought specialist assistance to moderate their cannabis useCheck the article for more details on the program.Sixty individuals seeking outpatient treatment for marijuana dependence were randomly assigned to 1 of 3 treatments: motivational enhancement (M), M plus behavioral coping skills therapy (MBT), or MBT plus voucher-based incentives (MBTV). In the voucher-based incentive program, participants earned vouchers exchangeable for retail items contingent on them submitting cannabinoid-negative urine specimens. MBTV engendered significantly greater durations of documented marijuana abstinence during treatment compared with MBT and M, and a greater percentage of participants in the MBTV group compared with the MBT or M groups were abstinent at the end of treatment. No significant differences in marijuana abstinence were observed between the MBT and M groups. The positive effects of the voucher program in this study support the utility of incentive-based interventions for the treatment of substance dependence disorders including marijuana dependence. Results indicated that marijuana use, dependence symptoms, and negative consequences were reduced significantly in relation to pretreatment levels at 1-, 4-, 7-, 13-, and 16 months follow-ups. Participants in the RSPG and IAI treatments showed significantly and substantially greater improvement than DTC participants at the 4-month follow-up. There were no significant differences between RSPG and IAI outcomes at any follow-up.The average number of RSPG treatment sessions attended was 8.42 (SD=3.51) out of possible 14. Fifty percent of RSPG participants attended 10 or more sessions. Forty-six RSPG participants (39%) had a supporter who attended at leas one of the four SG sessions.Seventy-six of the 88 IAI participants (86%) attended both sessions. A supporter accompanied 31 IAI participants (35%).IAI therapists were rated as more caring and less active than the RSPG therapist teams. IAI also were rated as significantly more competent than the RSPG therapists.An interesting findings was contrary to their predictions, RSPG participants did not achieve greater reductions in marijuana use than the IAI participants. In fact IAI participants reduced their marijuana use more during the first month of treatment; a finding that may be related to the difference in quitting promoted by the interventions. RSPG participants spent the first 4 weeks of treatment learning to identify high-risk situations for use and preparing to quit, whereas IAI participants developed plans for quitting during the first sessionAccording to the authors this is the second controlled trial to focus on the treatment of marijuana use disorders. It is notable that both an extended group intervention and a brief individual intervention produced substantial reductions in marijuana use and related problems relative to the delayed treatment condition. The result suggests that the brief individual treatment is just as effective as the more extended group therapy for this population.Check the article for more details.Improvement was demonstrated between admission and the completion of therapy six weeks later. Post-treatment scores were in the range of control subjects. Users who had quit using cannabis for more than 40 days at admission, but who had not participated in therapy, had somewhat higher scores than those who had quit for 17 days or less at admission. Patients in a methadone treatment program had scores below norms and did not show improvement during treatment. Poly-drug abusers, who had undergone psychosocial treatment, had scores somewhat below normative scores. Improvement in chronic cannabis users is discussed in the context of cognitive and psychosocial problems associated with chronic cannabis use. The study indicates that abstinence is not enough to improve the accompanying deficits in psychosocial competence. The resultsBefore and after cognitive-educative psychosocial treatment and abstinence of six weeks (15), Sense of coherence total score of 118.20/141.93, Comprehension score 3.58/4.40*, Manageability score 4.45/5.15* and Meaningfulness score 4.29/5.29*.A group (20) of cannabis users, who had abstained for at least 40 days before entering treatment Sense of coherence total score of 125.75, Comprehension score 3.92, Manageability score 4.57, Meaningfulness score 4.64.Twenty-six youth received six months of treatment (mean of 15 sessions) after random assignment to either a supportive counselling program or to a newly designed behavioural treatment, including several procedures to restructure family and peer relations and to control urges. The result showed that during the last month, 9% of youth receiving supportive counselling were abstinent vs. 73% of youth receiving the new behavioural treatment. A better social and psychological achievement, e.g. school performance and attendance, relationships, decreased depression, improved conducting ratings.Follow-up data (mean 9 months) were obtained for 74 subjects who had been treated for a mean of 8 months and 17 sessions in a controlled comparison of behavioural vs. supportive counselling for drug use. During the last month of treatment, 81% of the supportive treatment subjects and 44% of the behavioural treatment subjects were using drugs at least once. At the follow-up month, drugs were used at least once by 71% of the supportive vs. 42% of behavioural subjects. The result indicate favourable results appear attributable to the inclusion of family/significant others in therapy and the use of reinforcement contingent on urinalysis results.Men (161) and women (51) seeking treatment for marijuana use were randomly assigned to either a relapse prevention (RP) or a social support (SSP) group discussion intervention. Data collected for 12 months posttreatment revealed substantial reductions in frequency of marijuana use and associated problems. There were no significant differences between the cognitive-behavioral RP intervention and the SSP group discussion conditions on measures of days of marijuana use, related problems, or abstinence rates. Men in the RP condition were more likely than men in the SSP condition to report reduced use without problems at 3-month follow-up. Post-treatment increases problem associated with alcohol did not appear to relate to reduced marijuana use. More research needed on RP.

The Predictor study tested the ability of sets of demographic, socioeconomic, marijuana use/abuse, psychological distress, and self-efficacy variables to predict posttreatment indices of marijuana intake and problems related to use Subjects were 167 adults. Method; 10 two-hour group sessions during a 4-month treatment period. Treatment groups met weekly for the first 8 weeks and biweekly for the last 4 weeks in order to fade treatment. Two additional booster sessions occurred for all groups at the 3-month and 6-month follow-up sessions. Treatment was conducted in groups of 12 to 15 subjects that were led by four male-female cotherapist teams. Results: the measure of psychiatric status was relatively unimportant in predicting outcome in this sample. Pretreatment self-efficacy for avoiding use showed little, if any relationship to posttreatment problems, again suggesting the need to tailor measures specifically to the outcome of interest. Interestingly, the measures of pretreatment severity of abuse, and not frequency of use, were the stronger predictor of posttreatment problems. The authors conclude that: Use is not equivalent to abuse and further research is needed.