14h30_05_A1_23_Tom Freeman

7/25/2019 14h30_05_A1_23_Tom Freeman

1/27

How can we optimise treatment of people

who are cannabis dependent?

Tom Freeman

Clinical Psychopharmacology UnitUniversity College London, UK

7/25/2019 14h30_05_A1_23_Tom Freeman

2/27

Disclosure statement:I have no conflicts of interest

7/25/2019 14h30_05_A1_23_Tom Freeman

3/27

EMCDDA (April 2015)

Overview ofcurrent treatment

Strategies forimprovement

Outline of talk

7/25/2019 14h30_05_A1_23_Tom Freeman

4/27

CURRENT TREATMENT

7/25/2019 14h30_05_A1_23_Tom Freeman

5/27

What is the problem?

7/25/2019 14h30_05_A1_23_Tom Freeman

6/27

Current treatment

Psychological Approaches

7/25/2019 14h30_05_A1_23_Tom Freeman

7/27

Cannabis specific:CANDIS

Current treatment

*

* *

*

Hoch et al. 2011, 2012, 2014

7/25/2019 14h30_05_A1_23_Tom Freeman

8/27


MI resolve ambivalence &strengthen motivation to change

CBT cannabis education,

cognitions-emotions-behaviours, newcoping skills

Psychosocial problem solving (e.g.

unemployment)

MI: Motivational Interviewing; CBT: Cognitive Behavioural Therapy

Current treatment

*

* *

*

7/25/2019 14h30_05_A1_23_Tom Freeman

9/27


End treatment: 46.3% abstinentvs. 17.7% in waiting list

6 months: 35.7% abstinent

Hoch et al. 2011, 2012, 2014

*

* *

*

Current treatment

7/25/2019 14h30_05_A1_23_Tom Freeman

10/27

General approaches

Based on similar concepts

(e.g. MI/CBT)

Tailored to individual need

All drug groups treated together;cannabis users are younger with

different problems

Current treatment

7/25/2019 14h30_05_A1_23_Tom Freeman

11/27

Unmet clinical need

EMCDDA (April 2015)

7/25/2019 14h30_05_A1_23_Tom Freeman

12/27

STRATEGIES FOR IMPROVEMENT

7/25/2019 14h30_05_A1_23_Tom Freeman

13/27

1) Increase European investment

Treatment provision

Research funding

7/25/2019 14h30_05_A1_23_Tom Freeman

14/27

2) Refine psychological approaches

MI (1-2 sessions) and CBT (4-14 sessions) beneficial

CM may improve further

Optimum number of

sessions (cost effective?)

Cannabis-specific vs. general approaches?

Cooper et al. (2015) Health Technology Assessment

7/25/2019 14h30_05_A1_23_Tom Freeman

15/27


Control group (drug trial)

7/25/2019 14h30_05_A1_23_Tom Freeman

16/27


Control group (drug trial) Control group (psychological trial)

7/25/2019 14h30_05_A1_23_Tom Freeman

17/27


Control group (drug trial) Control group (psychological trial)

Placebo versus nocebo

Move beyond everything works

Consider single- or even double- blinding

7/25/2019 14h30_05_A1_23_Tom Freeman

18/27

3) Find effective pharmacotherapies

Oral THCwithdrawal, maintenance

THC/CBD spray

withdrawal, maintenance

N-acetylcysteine (GLU modulator)

2.4 greater odds of negative urine

Gabapentin (GABA modulator)

use, withdrawal, depression, sleep, problems

Allsop et al. (2014), Gray et al. (2012), Levin et al. (2011), Mason et al. (2012)

7/25/2019 14h30_05_A1_23_Tom Freeman

19/27

Placebo

CBD 200mg

CBD 400mg

CBD 800mg

4 weeks

24 weeks

Dependent on

cannabis &

want to quit

Primary outcome: cannabis use during

treatment

http://www.mrc.ac.uk/

7/25/2019 14h30_05_A1_23_Tom Freeman

20/27

4) Prioritise specific populations

Adolescence: huge clinical need & potentially the mostvulnerable

Co-morbid mental health problems: psychological

interventions are not effective

Cooper et al. (2015) Health Technology Assessment

7/25/2019 14h30_05_A1_23_Tom Freeman

21/27

5) Improve access to treatment

Telephone & computer: small effect across 10 studies

Computer vs. therapist MI/CBT/CM?Same attendance, retention and cannabis use outcomes

Smartphone: promising area Jan Copeland (symposium on Friday)

Budney et al. (2011), Tait et al. (2013)

7/25/2019 14h30_05_A1_23_Tom Freeman

22/27

Hindocha et al. (submitted)

6) Dont forget about tobacco

Europe: 78 92%

Australasia: 40 50%

Americas: 7 12%

7/25/2019 14h30_05_A1_23_Tom Freeman

23/27

Is cannabis a gateway for harder drugs?

Reverse gateway: people are exposed to tobacco first by

using cannabis

Tobacco linked to greater cannabis dependence and relapse

Dual abstinence: best outcome

Haney et al. (2010), Hindocha et al. (2015), Patton et al. (2005)


7/25/2019 14h30_05_A1_23_Tom Freeman

24/27

Harm reduction?

Pipes/bongs/vaporizers may facilitate use without tobacco


12thAug 2015

7/25/2019 14h30_05_A1_23_Tom Freeman

25/27

Rising clinical need across Europe

Specific/general psychological approaches

How to optimise treatment?

1) Increase European investment



4) Prioritise specific populations

5) Improve access to treatment


Conclusion

7/25/2019 14h30_05_A1_23_Tom Freeman

26/27

Clinical Psychopharmacology Unit, UCL

Celia Morgan, Exeter

Adam Winstock,GDS

Michael Lynskey,KCL

Thanks to collaborators and funders
http://www.mrc.ac.uk/

7/25/2019 14h30_05_A1_23_Tom Freeman

27/27

Tailor treatment to individual need

DSM-5 Cannabis Use Disorder

Continue despite problems: psychological/physicalTime spent obtaining, using, recovering

Use more/longer than intended

Tolerance

Craving/strong desire

Give up other activities

Unable to control use or quit

Withdrawal

Failure to meet important obligations

Continue despite problems: social/interpersonal

Use in hazardous situations

Documents

14h30_05_A1_23_Tom Freeman