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Try out PMC Labs and tell us what you think. Learn More. The prevalence of marijuana abuse and dependence disorders has been increasing among adults and adolescents in the United States. This paper reviews the problems associated with marijuana use, including unique characteristics of marijuana dependence, and the of laboratory research and treatment trials to date.
It also discusses limitations of current knowledge and potential areas for advancing research and clinical intervention. Although some people question the concept of marijuana dependence or addiction, diagnostic, epidemiological, laboratory, and clinical studies clearly indicate that the condition exists, is important, and causes harm Budney, ; Budney and Hughes, ; Copeland, ; Roffman and Stephens, Marijuana dependence as experienced in clinical populations appears very similar to other substance dependence disorders, although it is likely to be less severe.
Adults seeking treatment for marijuana abuse or dependence average more than 10 years of near-daily use and more than six serious attempts at quitting Budney, ; Copeland et al. They continue to smoke the drug despite social, psychological, and physical impairments, commonly citing consequences such as relationship and family problems, guilt associated with use of the drug, financial difficulties, low energy and self-esteem, dissatisfaction with productivity levels, sleep and memory problems, and low life satisfaction Gruber et al.
Most perceive themselves as unable to stop, and most experience a withdrawal syndrome upon cessation. Approximately half of the individuals who enter treatment for marijuana use are under 25 years of age. These patients report a distinctive profile of associated problems, perhaps due to their age and involvement in other risky behaviors Tims et al. Adolescents who smoke marijuana are at enhanced risk of adverse health and psychosocial consequences, including sexually transmitted diseases and pregnancy, early school dropout, delinquency, legal problems, and lowered educational and occupational aspirations.
Some 4. Marijuana produces dependence less readily than most other illicit drugs. Some 9 percent of those who try marijuana develop dependence compared to, for example, 15 percent of people who try cocaine and 24 percent of those who try heroin. However, because so many people use marijuana, cannabis dependence is twice as prevalent as dependence on any other illicit psychoactive substance cocaine, 1. During the past decade, marijuana use disorders have increased in all age groups. Contributing factors may include the availability of higher potency marijuana and the initiation of use at an earlier age.
Among adults, marijuana use disorders increased despite stabilization of rates of use. An increased prevalence of disorders among young adult African-American and Hispanic men and African-American women appears to for the overall rise among youth Compton, The reasons for the upward trend in disorders among minority young people are not clear. Speculation has pointed to the deleterious effects of acculturation on Hispanic youth; growing s of minority youth attending college, where they may experience increased exposure to marijuana use; and environmental and economic factors.
Paralleling the rise in marijuana use disorders, treatment admissions for primary marijuana dependence have increased both in absolute s and as a percentage of total admissions, from 7 percent in to 16 percent in SAMHSA, The extent of marijuana use and its associated consequences clearly indicate a public health problem that requires systematic effort focused on prevention and intervention. The percentage of substance abuse treatment admissions that were due to marijuana nearly doubled from to SAMHSA, b.
Marijuana s for most adolescent drug treatment admissions and progressively smaller proportions of admissions in each successive higher age group SAMHSA, b. Systematic research on psychosocial treatments for marijuana abuse or dependence began approximately 20 years ago, yet the of controlled studies remains small.
Behavioral treatments, such as motivational enhancement therapy MET , cognitive-behavioral therapy CBT , and contingency management CM , as well as family-based treatments have been carefully evaluated and have shown promise. Outpatient treatments for marijuana abuse among adolescents have recently received increasing attention in the scientific literature. Seven published, randomized efficacy trials for primary adult marijuana abuse and dependence have consistently demonstrated that outpatient treatments can reduce marijuana consumption and engender abstinence.
The most commonly tested interventions are adaptations of interventions initially developed to treat alcohol or cocaine dependence, in particular MET and CBT also known as coping skills training. The cumulative findings indicate that 1 each of these interventions represents a reasonable and efficacious treatment approach; 2 the combination of MET and CBT is probably more potent than MET alone; and 3 an intervention that integrates all three approaches—MET, CBT, and CM— is most likely to produce positive outcomes, especially as measured by rates of abstinence from marijuana.
Brief Counseling for Marijuana Dependence Steinberg et al. Multisystemic Therapy for Adolescents Henggeler et al. MET addresses ambivalence about quitting and seeks to strengthen motivation to change. A typical MET regimen consists of one to four to minute individual sessions. Therapists use a nonconfrontational counseling style to guide the patient toward commitment to and action toward change. Therapeutic techniques include using strategic expression of empathy, reflecting, summarizing, affirming, reinforcing self-efficacy, exploring pros and cons of drug use, rolling with resistance, and forging goals and plans to achieve them.
CBT focuses on teaching patients skills relevant to quitting marijuana and avoiding or managing other problems that may interfere with good outcomes. Patients learn functional analysis of marijuana use and cravings, self-management planning to avoid or cope with drug use triggers, drug refusal skills, problem-solving skills, and lifestyle management. CBT for marijuana dependence is typically delivered in to minute, weekly individual or group counseling sessions; tested CBT interventions have ranged from 6 to14 sessions.
Each session involves analysis of recent marijuana use or cravings, development of planned responses to situations that may trigger use or craving, brief training on a coping skill, role-playing or other interactive exercises, and practice asments. Days of use, of uses per day, dependence symptoms, and problems related to use also fell ificantly compared with those measures in the DTC group, and gains were generally maintained throughout the month followup. No ificant differences were observed between CBT and MET conditions on any of these outcome measures, suggesting that brief motivational interventions may be as effective as longer CBT interventions.
However, this study confounded treatment modality group vs. A similar study showed that a six-session CBT and a one-session MET treatment, both delivered in individual therapy sessions, produced greater rates of abstinence than DTC, but again little difference was observed between the active treatment groups Copeland et al. A positive relation between therapist experience and outcome was reported across both treatment conditions.
However, in this trial, MET-CBT was associated with ificantly greater long-term abstinence and greater reductions in frequency of marijuana use compared with MET alone. Findings generalized across three sites and were not dependent on ethnicity or gender. In an effort to enhance outcomes further, researchers have begun to examine the efficacy of CM for treating marijuana dependence Budney et al.
The marijuana CM intervention adapts the abstinence-based voucher approach originally developed and demonstrated effective for treating cocaine dependence Budney and Higgins, ; Higgins et al. The vouchers are contingent on marijuana abstinence, confirmed by twice-weekly drug testing, and their value escalates with each consecutive negative drug test. Patients exchange them for prosocial retail items or services that, it is hoped, will serve as alternatives to marijuana use.
In a second trial conducted to extend these findings Budney et al. The magnitude of the CM incentives was identical to that used in the prior study. This trial produced three notable outcomes. During the following year, the MET-CBT plus CM patient group sustained overall positive outcomes somewhat better than those of the CM group, although differences in abstinence rates were not statistically ificant at later followups.
As in the CM trials, patients in the CM and non-CM conditions self-reported similar rates of marijuana use throughout, illustrating the importance of obtaining subjective and objective indices of use. There were three key findings from this trial: 1 A relatively small percentage of participants 37 percent made use of the continuing care sessions, and 2 the PRN condition overall was not more efficacious than the fixed-dose condition, although 3 the few individuals who attended the greatest of continuing care sessions mean of Most information on marijuana treatment efficacy among young people derives from trials that have included users of various drugs and have not focused specifically on marijuana use.
Nevertheless, most patients in these studies have been primary marijuana users. Empirical support for group or individual CBT and family-based treatments has begun to emerge Waldron and Kaminer, The CBT interventions studied have been similar to those studied for adults in scope and duration.
Specific forms of family-based treatment that have been tested include functional family therapy Waldron et al. Description of these models is beyond the scope of this paper. However, they each involve structured, skills-based interventions for family members and are well described in their respective manuals. The largest clinical trial of outpatient treatment for adolescent substance abuse focused on marijuana use Dennis et al. Five treatment models were tested in a multisite study: MET-CBT 5 2 individual and 3 group sessions , MET-CBT 12 2 individual and 10 group sessions , MET-CBT 12 plus family support network 6 parent education group sessions, 4 home visits, and case management , the community reinforcement approach 10 individual sessions focused on behavioral change in drug use and lifestyle change, and 4 parent sessions focused on effective parenting, communication, and problem solving , and MDFT 12 to 15 family systems-focused sessions: 6 individual, 3 with parents alone, and 6 with family.
ificant decreases in drug use and symptoms of dependence were observed following each of the treatments. However, robust between-treatment differences in outcomes were not observed, which unfortunately precludes drawing strong conclusions about their efficacy. Although were promising compared with prior treatment studies, two-thirds of the youth continued to experience ificant substance-related symptoms, suggesting that adolescent treatments can be improved and alternative treatment models should be explored Compton and Pringle, The voucher program was of the same schedule and magnitude as that used in the ly mentioned adult trials by Budney and colleagues.
However, participants could earn vouchers only if urine toxicology screens were negative for all drugs tested and if parents reported that, to their knowledge, the adolescent had not used any drugs or alcohol. The parenting intervention included a contract that directed parents to provide tangible incentives for abstinence and to deliver negative consequences for continued use.
Parents also participated in a weekly behavioral training program called Adolescent Transitions Dishion and Kavanagh, , a treatment of choice for adolescents with conduct disorder. Preliminary data from an initial randomized trial suggest that the MET-CBT plus CM improved rates of marijuana abstinence and effectively maintained abstinence post-treatment compared with MET-CBT combined with weekly parent psychoeducational counseling.
The rates of abstinence achieved appeared greater than those reported in prior studies; however, comparison across trials is problematic because of differences in patient characteristics and differences in the way outcomes are measured. Two other tests of CM with adolescents and young adults have produced promising . A CM abstinence-based voucher program enhanced drug use outcomes and abstinence when added to a potent outpatient therapy i.
Lastly, adding incentives for treatment attendance to MET increased treatment participation by young adult marijuana abusers involved with the judicial system, but did not lead to increased marijuana abstinence Sinha et al. In summary, a of behaviorally based interventions appear efficacious for treating adolescent marijuana abuse, and combining interventions like MET, CBT, CM, and family-based programs is likely to enhance efficacy. Sufficient evidence has accumulated to conclude that behaviorally based interventions can help many of those who seek treatment for marijuana use disorders.
Even with MET-CBT plus CM, the most highly efficacious treatment for adults, only about one-half of those who enroll in treatment achieve an initial 2-week period of abstinence, and among those who do, approximately one-half use within a year Budney et al. An additional percentage of adults report a reduction in use and in problems associated with use; however, many adults show no evidence of progress. The treatment outcome data for adolescents paint a similar picture. For example, in the large Cannabis Youth Treatment study, abstinence rates at the end of treatment were only 11 to 15 percent Dennis et al.
Clearly, there remains much room for improvement in marijuana outpatient treatment. Most clinical issues in treatment for marijuana use disorders parallel those that arise in treatments for other drug use disorders, though sometimes with distinctive aspects. Such secondary marijuana use is commonly viewed as a ificant risk factor for relapse or treatment failure, although the empirical support for this is equivocal Epstein and Preston, Some investigators have explored CM-based approaches targeting marijuana use in this clinical population, reasoning that explicit reinforcement or penalty interventions tied to marijuana use may motivate and prompt change in individuals not currently interested in changing.
Calsyn and Saxon devised a marijuana CM program to function as an adjunct to an existing CM program that required 6 months of urinalysis-confirmed abstinence from all drugs, except for cannabis, in order to earn methadone take-home privileges twice a week. The new intervention simply increased the requirement for obtaining twice-weekly take-home status to include marijuana-negative urinalysis .
In this small study, 50 percent of the participants responded to the contingency by stopping their marijuana use, while the other 50 percent accepted curtailment of their take-home privileges and continued to use marijuana. Fifteen patients who tested positive only for marijuana during a 6-month baseline period were informed that, from then on, a positive test for marijuana or any other substance would increase their counseling requirements from 1 hour per week to 4.
Ten of the patients discontinued marijuana use when informed about the new counseling rule. The other five—who were among the heaviest users—continued to test positive for marijuana and were required to attend the additional counseling sessions.
Of those, four responded to the intensified counseling, eventually discontinuing use and returning to the lower-level schedule. One patient did not respond and dropped out of treatment. In the cocaine clinic, where many patients do not endorse a goal of stopping marijuana use, the clinician must decide how best to approach this issue without adversely affecting treatment for cocaine dependence Budney, Higgins, and Wong, One study of a small of patients explored a sequential strategy of initially targeting abstinence from cocaine with an abstinence-based voucher CM program, then targeting marijuana once cocaine abstinence had been achieved Budney et al.
The rationale for this approach was that the experience of achieving cocaine abstinence and the associated positive effects might increase awareness of how marijuana use negatively affects a prosocial lifestyle. Moreover, an initial success with a voucher program for cocaine might motivate participation in a similar program that targets marijuana.
In this study, two participants quit using cocaine during a week voucher program, but continued to use marijuana regularly despite counseling that encouraged abstinence. Both entered a second week program that required abstinence from cocaine and marijuana to earn vouchers. Both achieved abstinence from the two drugs and stayed off cocaine throughout a 5-month followup period.How addictive is weed compared to other drugs
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