John Rodolico, Ph.D

1
MarijuanaWeeding 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
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 dont in a treatment setting?
11
Kids who dont 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 WONT
• 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

• COLLABORATIONCounseling involves a partnership
  that honors the clients expertise and
  perspectives. The counselor provides an
  atmosphere that is conducive rather than coercive
  to change
• EVOCATIONThe resources and motivation for change
  are presumed to reside within the client.
  Intrinsic motivation for change is enhanced by
  drawing on the clients own perceptions, goals,
  and values
• AUTONOMYThe counselor affirms the clients 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 MICBT)
• 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 CBTTSF)

• 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!