Psychosocial treatment of cannabis disorders

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 attendedcompliance,
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 (N291) 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
interventionIAI), or a 4-moth delayed
treatment control (DTC) conditions.
18
Lundqvist, Lund Sweden 1995. (Cognitive-education
al 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? Session
3 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 (gt3 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),
• Becks 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
4
Low
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 Tot
al
1 p lt .001 p lt .01 p lt .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 lt .001 p lt .01 p lt .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
sign1
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
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
lt 14 no depression
1 p lt .001 p lt .01 p lt .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-Academy1 Prevention and therapy of
cannabis disturbances in Europe status,
projects, need for development 29 March 30
March 2007 ? Berlin Primary 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.
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