John Rodolico, Ph.D McLean Hospital Harvard Medical School

1. Marijuana…Weeding Out Fact From Fiction Short and Long Term Treatment Options John Rodolico, Ph.D McLean Hospital Harvard Medical School

2. Recent Trends in Marijuana Use

3. Recent Trends in Marijuana Use

4. Trends: • Past month MJ amongst teens is up 42% (up from 19% in 2008 to 27% in 2011), which is equivalent to about 4 million teens. • Past year MJ amongst teens is up 26% (up from 31% in 2008 to 39% in 2011), which is equivalent to about 6 million teens. • Lifetime MJ amongst teens is up 21% (up from 39% in 2008 to 47% in 2011), which is equivalent to about 8 million teens.

5. Background: • Over the last several decades, while MJ use has continued to increase, albeit slightly, the age of onset of first use has declined. • While previous investigations have reported alterations in both brain structure and function which are associated with onset of marijuana use, few have made direct comparisons between early and later onset MJ smokers.

6. Summary: Cognitive tasks and MJ use • Marijuana use among 12-17 year olds rose to 7.3% in 2009, a significant increase from 2008. Moreover, age of onset of use continues to drop, with a significant decrease from 2008-2009 from 17.8 to 17.0 years. • Early onset smokers used MJ 1.5 times as frequently per week and smoked more than 2.5 times as much MJ as later onset MJ smokers. • Early onset MJ smokers demonstrate significantly worse performance on cognitive tasks, specifically, those requiring executive function, relative to later onset MJ smokers and controls. • Significant associations were detected between performance on neurocognitve tasks and MJ use patterns (age of onset, number of smokes per week, and grams used per week)

7. Summary: Neuroimaging Results • As hypothesized, early onset MJ smokers demonstrated poorer performance and altered patterns of activation during frontal/inhibitory tasks relative to late onset smokers and control subjects. • Early age of onset of MJ use is associated with lower white matter microstructural integrity, suggesting structural brain changes secondary to early exposure to MJ. In this group, lower white matter integrity was associated with higher levels of impulsivity.

8. Implications • Early exposure to MJ during a critical period of development results in more significant alterations in neurocognitive performance, white matter microstructure, and brain activation patterns relative to later onset MJ use. • Brain regions associated with judgment, decision making and impulsivity are the last to develop, yet are critical for the ability to reason and inhibit inappropriate behaviors, making adolescent or young adults less likely to make the right choices in stressful situations without drugs ‘on board’. • These findings underscore the importance of early identification and treatment of early, regular MJ smokers, as exposure during a period of developmental vulnerability may result in neurophysiologic changes, which have long term implications.

9. Treatment Considerations

10. How do we tell the difference between kids who smoke and those who don’t in a treatment setting?

11. Kids who don’t smoke pot

12. Kids who smoke pot

13. Developmental Mismatch • Most adolescent treatment is based on an adult model • Operates on a passive vs assertive approach • Assumption: Build it and they will come…. • Reality: NO THEY WON’T • This may happen physically but not with overt motivation

14. What do we do in Treatment? Motivational Interviewing and CBT

15. Why use MI • The perception of harm is low and getting lower • One of the hardest addictions to treat because of this • MI is nonjudgmental so you can avoid the political/its natural discussion • Few adolescents volunteer for treatment they are usually bumped into treatment

16. Spirit of Motivational Interviewing with Adolescents

17. THE SPIRIT OF MOTIVATIONAL INTERVIEWING • COLLABORATION—Counseling involves a partnership that honors the client’s expertise and perspectives. The counselor provides an atmosphere that is conducive rather than coercive to change • EVOCATION—The resources and motivation for change are presumed to reside within the client. Intrinsic motivation for change is enhanced by drawing on the client’s own perceptions, goals, and values • AUTONOMY—The counselor affirms the client’s right and capacity for self-direction and facilitates informed choice • Patience, Patience, Patience

18. Fundamental Processes in MI Engaging • Focusing • Evoking • Planning

19. Motivational Interviewing with a Twist • Should use the same principles of empathy, discrepancy, evocation, and self-efficacy • Confrontation with a motivational style, creative empathic reflection • Be sure to keep your integrity with the facts • Use personal feedback to enhance motivation (DSM IV Criteria)

20. Cognitive Behavioral Therapy • Tremendous amount of evidence showing positive results for adults • Dearth of efficacy trials for adolescents, however gaining clinical support • Cannabis Youth Treatment Study: Showed significant increase in days of abstinence (combination of MI+CBT) • Strategies include; self monitoring, altering reinforcement contingencies, skills training

21. Family Therapy • Many different types of family based treatments with great success • Community Reinforcement and Family Training (CRAFT) (Waldron et al, 2007) • Contingency Management Approaches • Outcome depends on the treatment setting, number of sessions, and population • As with MI, it improves the potency of all interventions with adolescent substance abusers

22. Self-Help Groups • Difficult for adolescents to get to • Not enough groups for young people • Professional involvement has shown to enhance outcome • When it works, it works well • Extends benefits of treatment (Kelly et al, 2010) • Adolescents should be exposed to the principles of self-help groups

23. STEP ONE HISTORY(Combination of MI +CBT+TSF) • Obsession • Progression • Losses • Relapse • Family Interaction • Insanity • Behaviors • Relapse • Written history of substance use • Increases change talk • Moves patients from one stage of change to another

24. Cue Exposure • Rationale: Told to avoid cues/triggers, is it possible for adolescents? Urges decrease while in residential treatment giving a false sense of confidence • Exposure Planning: Patients develop a list of triggers and create a trigger hierarchy range from high to low • Skills Training: The first two exposures pts are encouraged to use skills coaching after that they will start this process on their own

25. Questions and Thank You!