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Psychosocial treatment of cannabis disorders

Psychosocial treatment of cannabis disorders. Thomas Lundqvist Clinical psychologist & associate professor Drug Addiction Treatment Centre, Lund University hospital, Sweden. Psychosocial treatment of cannabis disorders: a review of 13 s tudies. 2006.

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Psychosocial treatment of cannabis disorders

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  1. Psychosocial treatment of cannabis disorders Thomas Lundqvist Clinical psychologist & associate professor Drug Addiction Treatment Centre, Lund University hospital, Sweden

  2. Psychosocial treatment of cannabis disorders:a review of 13 studies. 2006 Author year Country experiment-controll N evidence In the studies 1-5 only a minority (20 -40 %) of the clients achieve a complete abstinent condition during the period of treatment. However, they display a significant reduction in cannabis use and cannabis related problems.

  3. 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?

  4. Treatment outcomes measures In 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.

  5. 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.

  6. These programmes should incorporate: • 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)

  7. continued • 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)

  8. Dennis, M et al USA 2003. short cog beh vs long cog beh The Cannabis Youth Treatment (CYT) Study: Main Findings from Two Randomized Trials. 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. 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).

  9. 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.

  10. 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.

  11. 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.

  12. 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.

  13. 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.

  14. 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.

  15. Budney 2000 Adding voucher-based incentives to coping-skills and motivational enhancement improves outcomes during treatment for marijuana dependence. 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).

  16. Budney 2000

  17. 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.

  18. 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 programme The study indicates that abstinence is not enough to improve the accompanying deficits in psychosocial competence.

  19. 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 treatment • 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.

  20. (RPT vs. social support). 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. 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 The 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.

  21. 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

  22. The 18 sessions manual. 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 2 Assessment feedback Positive and negative attitudes to cannabis use Why do you want to quit now? What kind of help do you need? Session3 Acute effects of cannabis Session 4 Chronic effect of cannabis Session 5 Cognitive function and dysfunction Session 6 Attitudes and patterns of use Session 7 Drug lifeline Session 8 Sociogram Session 9 Lifeline Session 10 (or when it is appropriate) Session together with the parents Session 11 Relaxation Focus on emotions Session 12 Continued focus on emotions Guilt and shame Session 13 Norms and values-behavior-abuse Session 14 Juhariwindow or something more suitable Session 15 The process of relapse Session 16 Continued relapse prevention Test: SOC, SCL-90, BDI scale focusing on relations. Session 17 Assessment feedback Look at the flipchart, repeat select the material to be used at the closing session. Session 18 Closing session Show the flipchart for the family and others. Graduation and Diploma

  23. Fifty adolescents (75 admissions) including 5 girls, with at least six months daily use, completed the programme between year 2000 and 2004. • First time of use 14.2 (11-17) • Years of use 3.6 (1-8) • Regular use (>3 times a week) 2.5 (1-6) • 15 subjects reported problems with alcohol

  24. Assessments • 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), • Beck’s Depression Inventory (BDI) and • CAGE, focusing on alcoholproblems • Scales focusing on life situation and relationships.

  25. Aaron Antonovsky, 1987 To get a good sense of coherence the individuals perceive that • 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).

  26. 142 152 Total 29 203 Low 4 High 7 1 Comprehensibility Manageability Meaningfulness Me Ma C Good profile

  27. Sense of Coherence t - 0,7 - 0,6 - 1,6 - 1,1 df sign N 39 ns 40 39 ns 40 39 ns 40 39 ns 40 t df sign1N - 4,69 49 ***50 - 5,50 49 *** 50 - 5,86 49 ***50 - 5,95 49 ***50 Adm. (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) 1-year (M, sd) 4,3 ( 0,8) 5,1 ( 1,0) 5,3 ( 1,2) 141,2 (24,6) Comprehensibility Manageability Meaningfulness Total 1 *** p < .001; ** p < .01; * p < .05; ns= non significant

  28. 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.

  29. Symptom ScalesSOM - SomatizationO-C - Obsessive-CompulsiveI-S - Interpersonal SensitivityDEP - DepressionANX - AnxietyHOS - HostilityPHOB - Phobic AnxietyPAR - Paranoid IdeationPSY - 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.

  30. SCL-90, standarized T-value; significance tested by mean (paired t-test) 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 49 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 0,6 1,0 0,3 - 0,1 - 0,2 0,3 1,3 0,1 0,6 0,6 - 1,7 1,3 Sign1 N *** 50 *** 50 *** 50 *** 50 *** 50 *** 50 *** 50 *** 50 *** 50 *** 50 *** 50 *** 50 1-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) N 41 41 41 41 41 41 41 41 41 41 41 41 Somatization Obsessive-kompulsive Interpersonal sensitivity Depression Anxiety Hostility Phobic anxiety Paranoid ideation Psychoticism Global Sever. Iind (GSI) Pos. Sympt. Distr Ind(PSDI) Total Pos Sympt (PST) ns 1 *** p < .001; ** p < .01; * p < .05; ns= non significant

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

  32. t 5,4 4,8 6,8 6,2 df 29 29 29 29 t 0,4 - 0,4 0,3 - 0,2 sign1 ns ns ns ns N 30 30 30 30 1-year(M, sd) 2,2 (2,2) 5,0 (6,1) 5,1 (4,6) 7,3 (7,9) N 24 24 24 24 sign1 *** *** *** *** Adm(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) Somatic affective Cognitive affective Amount Total < 14 no depression 1 *** p < .001; ** p < .01; * p < .05; ns= non significant

  33. 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.

  34. 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.

  35. 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).

  36. 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 of abstinence 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.

  37. A way out off fog

  38. A short presentation of the treatment manual It is presented as a course in quitting • Phase 1: a bio-medical focus lasting until the 12th day after smoking cessation. • 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.

  39. The treatment manual focus on • The chronic influence on the cognitive functions. • The impact of the enhanced subjective perception. • The need of professional guidance in the relearning process. • 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.

  40. 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.

  41. An illustration of the screened off condition

  42. Each discussion should contain • To 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.

  43. A treatment manual for chronic cannabis users THC Lundqvist & Ericsson 1988 100 % 50 % Phase 3 Psycho-Social focus Phase 2 Psychological focus Phase 1 Bio-Medical focus Anxiety 3 sessions/week - 2 sessions/week 3 session/week Weeks 1 2 3 4 5 6-8

  44. The structure is used in The 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

  45. 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.

  46. REITOX-Academy[1] Prevention and therapy of cannabis disturbances in Europe: status, projects, need for development 29 March – 30 March 2007 ● Berlin Primary target group: Members of EMCDDA’s 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.

  47. 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, Cologne Short intervention programme “Realize it!”, Mr. Peter Tossmann, Delphi - Gesellschaft für 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,

  48. 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 für Suchtprävention, Klagenfurt

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