Treatment of Marijuana Users

Robert S. Stephens, Ph.D.Virginia Tech

Presented at the Conference on the Advances in the Treatment of Marijuana UsersFederal University of Sao Paulo

Acknowledgment

The studies described in this presentation were conducted in collaboration with Roger A. Roffman, D.S.W. of the School of Social Work, University of Washington, Seattle, Washington

Marijuana Treatment Project Study 1

• Conducted 1987 – 1989• No controlled treatment-outcome studies for

marijuana use• Most commonly used illicit substance in the U.S.• Evidence of psychosocial impairments in surveys

of frequent marijuana users• Misconceptions regarding dependence potential

and concurrent polydrug abuse

MTP Study 1Design

• Random assignment to two treatment conditions– Relapse Prevention (Cognitive Behavioral Treatment)

– Social Support (Group Process)

• Both treatments consisted of 10 group sessions over three months

• Follow-up assessments at end-of-treatment, 1, 3, 6, 9, and 12 months posttreatment

MTP Study 1Relapse Prevention

• Focus on identifying high risk situations for marijuana use

• Teaching of coping skills• Lifestyle balance• Restructuring cognitions related to relapse

MTP Study 1Social Support Condition

• Focus on using group support to aid quitting• Therapists introduced topics related to quitting

and facilitated discussion• No coping skills training or focus on cognitions

related to quitting

MTP Study 1Subject Characteristics

Age (years) 31.9

Male 76%

White 95%

Married 44%

Some college 40%

Employed 85%

MTP Study 1Pretreatment Marijuana Use

Mean SD

Age of first use 16.17 4.25

Age of daily use 19.94 5.55

Years of use 15.39 5.05

Days of use

(past 90 days) 80.67 15.47

MTP Study 1Posttreatment Abstinence Rates

05

1015202530354045

% Abstinent

3 6 12 Cumulative

Months Posttreatment

RPSS

MTP Study 1Marijuana Use Outcomes

0

5

10

15

20

25

30

Pretreatment 3 6 9 12

Months Posttreatment

Day

s of

Mar

ijua

na U

se P

er

Mon

th RPSS

MTP Study 1Implications and Limitations

• Considerable interest in marijuana-specific treatment

• Substantial changes in marijuana use• No advantage of the RP (cognitive-behavioral

treatment)• Motivation for change may account for findings

rather than treatment participation

MTP Study 2 Purpose

• Test an extended version of the RP group treatment

• Compare to a brief motivational enhancement intervention

• Compare both active treatments to a delayed treatment control

MTP Study 2 Treatment Conditions

• Relapse Prevention Support Groups (RPSG)– 14 Group Sessions over 18 Weeks

– Cognitive-Behavioral Emphasis

– 4 Session Optional Partner Groups

• Individualized Assessment and Intervention (IAI)– 2 Individual Sessions One Month Apart

– Motivational Enhancement & Cognitive-Behavioral

– Personalized Feedback

– Optional Partner Attendance of Second Session

• Delayed Treatment Control – 4 Months

Motivational InterviewingBasic Principles

• Express Empathy• Develop Discrepancy• Avoid Argumentation• Roll with Resistance• Support Efficacy

Motivational InterviewingEarly Strategies

• Ask open-ended questions• Listen reflectively• Affirm• Summarize• Elicit self-motivational statements

MTP Study 2 Participant Demographics (N = 291)

• Age (M, SD) 33.96 6.85• Male 77%• White 95%• Married 45%• Employed 88%• Some College 41%

MTP Study 2 Baseline Marijuana Use (N = 291)

M SD• Age of First Use 15.93 3.90• Age of Daily Use 19.60 5.60• Days of Use in

Past 90 Days 74.60 18.56• DSM-IIIR Dependence

Symptoms 6.74 1.97

MTP Study 2

0

5

10

15

20

25

30

Baseline 4 7 13 16

Months Since Treatment Started

Days of Marijuana Use

Per Month

RPSGIAIDTC

MTP Study 2Abstinence Rates

0%

5%

10%

15%

20%

25%

30%

35%

40%

4 7 13 16

Months Since Treatment Started

90 Day Abstinence

Rates

RPSGIAIDTC

MTP Study 2 – Conclusions and Limitations

• The 2-session MI intervention produced outcomes comparable to the 14 session, cognitive behavioral intervention

• Both interventions reduced marijuana use and associated problems significantly relative to the delayed treatment control

• Treatment conditions were confounded by differences in modality (group vs. individual) and therapist experience

• Sample was still homogenous and likely highly motivated for treatment

Marijuana Treatment ProjectMulti-site Study

A Multi-site Study of the Effectivenessof Brief Treatment for Cannabis Dependence

A Cooperative Agreement funded by

SAMHSA-CSAT

Rationale for a Multi-site Trial

– Previous single-site clinical trials have demonstrated the efficacy of brief and extended treatments with relatively homogenous samples, in research settings

– Further research is needed to test the robustness of effect and its generalizability to different population groups

MTP Multi-site Collaborating Sites

• Sponsoring Agency– Substance Abuse and Mental Health Services Administration/Center

for Substance Abuse Treatment

• Coordinating Center– University of Connecticut, School of Medicine, Farmington, CT

• Yale University, New Haven, CT

• Clinical Research Units– University of Washington, Seattle, WA– University of Connecticut, School of Medicine, Farmington, CT– The Village, Inc., Miami, FL

Study Design

D e la y e dT r e a tm e nt C o ntr o l

(D T C )

F o llo w -up E v a lua t io n4 , 9 , a nd 1 5 m o nths

B r ie fT r e a tm e nt

(B T )

E xte nd e dT r e a tm e nt

(E T )

R a nd o m A ss ig nm e nto f 4 5 0 p a r t ic ip a nts

B a se line A sse ssm e nt

E nr o llm e nt a ndInfo r m e d C o nse ntfo r tho se e lig ib le

S c r e e n ing o f 1 2 1 1 c hr o n ic m a r ijua na use r s thr o ug ha d v e r t is ing a nd r e fe r r a l

Treatment Conditions

• Brief Treatment Group (N=146)– 2 sessions of Motivational Enhancement Therapy– Delivered over a 5-week period

• Extended Treatment Group (N=156)– 9 sessions

• 2 of Motivational Enhancement Therapy• 5 of Cognitive Behavioral Therapy• 2 of Clinical Case Management

– Delivered over a 12-week period

• Delayed Treatment Control Group (N=148)– Treatment initiation scheduled 4 months after date of study enrollment– Choice of brief or extended treatment at end of delay period

Inclusion Criteria

• DSM-IV Diagnosis of Cannabis Dependence

• Has smoked cannabis on at least 40 of the last 90 days

• Does not meet DSM-IV dependence criteria for other drugs or alcohol

• Is not involved in concurrent therapy or 12-step meetings

• Does not have a medical or psychiatric diagnosis that would interfere with treatment

Demographic Characteristics of MTP Participants (N=450)

Characteristic

Mean Age 36

SexMaleFemale

68%32%

EthnicityEuropean AmericanAfrican AmericanHispanic AmericanOther

69%17%12%02%

Demographic Characteristics of MTP Participants, cont. (N=450)

Characteristic

Marital StatusNot MarriedMarried/Cohabiting

60%40%

Mean Years Education 14

EmployedFull TimePart TimeUnemployedStudent/Retired/Homemaker

69%14%12%05%

Mean Number Years/Present Job 5

Marijuana Use Characteristics at Baseline (N=450)

Characteristic Mean

Years of Regular Marijuana Use 17.9

Years of Problem Marijuana Use 8.9

Number of Marijuana DependenceSymptoms (of 7)

5.4

Number of Marijuana-RelatedProblems (of 19)

9.4

Marijuana Dependence Symptoms Endorsed at Baseline (N=450)

Symptom

Marijuana taken in larger amounts or over alonger period than intended

77%

Persistent desire or one or more unsuccessfulattempts to cut down or control use

96%

A great deal of time spent in activities necessaryto get, use, or recover from the effects ofmarijuana

83%

Important social, occupational or recreationalactivities given up because of marijuana use

64%

Marijuana Dependence Symptoms Endorsed at Baseline, cont. (N=450)

Symptom

Continued use despite knowledge of a physical orpsychological problem caused or exacerbated bymarijuana use

95%

The need for markedly increased amounts ofmarijuana to achieve the desired effect (tolerance)

68%

Experienced withdrawal Appetite disturbance Sleep disturbance Night sweats Headaches Irritability

78%

Problems Attributed to Marijuana Use (N=450)

Marijuana Related Problems

Feeling bad about marijuana use 90%

Low energy level 86%

Procrastination 86%

Memory loss 76%

Low productivity 75%

Low self-esteem 74%

Lack self confidence 68%

Problems Attributed to Marijuana Use, cont. (N=450)

Marijuana Related Problems

Interpersonal problem / partner 58%

Financial difficulties 49%

Difficulty sleeping 46%

Problems with family 44%

Neglect of family 38%

Medical problems 34%

Interpersonal problems / friends 26%

Lifetime Treatment History (N=450)

Number of TimesTreated in Lifetime

%

Drug Abuse 012

3 or More

82%12% 2% 4%

Alcohol Abuse 012

93% 4% 3%

Number of Days of Marijuana Use in the Past 90 Days - Baseline (N=450)

Mean = 80.0SD = 14.6

Number of Days Smoked Marijuana in the Past 90 Days

90

87

84

81

78

75

72

69

66

63

60

57

54

50

47

44

40

37

33

27

Perc

ent

30

20

10

0

Number of “Joints” Smoked Per Day in the Past 90 Days - Baseline (N=450)

Mean = 2.9SD = 2.3

Number of Joints Smoked per Day in the Past 90 Days

18.0014.0012.0010.008.006.004.002.00.00

Perc

ent

50

40

30

20

10

0

Number of Hours “High” Per Day in the Past 90 Days - Baseline (N=450)

Mean = 6.6SD = 4.6

Number of Hours Felt High in the Past 90 Days

2017151311975310

Perc

ent

20

10

0

Marijuana Use Within 1 Hour Prior to Driving in the Past 90 Days - Baseline (N=450)

Marijuana Used Within 1 Hour Prior to Driving

Daily/Almost Daily

Less than Daily

Weekly

Less than Weekly

Never

Per

cent

60

50

40

30

20

10

0

Marijuana Use Within One Hour Prior to Working on a Paid Job in the Past 90 Days - Baseline (N=373)

Marijuana Used Within 1 Hour Prior to Working

Daily/Almost Daily

Less than Daily

Weekly

Less than Weekly

Never

Per

cent

50

40

30

20

10

0

MTP Multi-siteTreatment Attendance (N=450)

Number of Sessions % Brief % Extended

0 6.8 8.31 93.2 91.72 71.9 84.63 78.24 71.15 66.06 60.97 56.48 51.99 42.3

Mean Sessions Attended(SD)

1.65(.61)

6.03(3.31)

6

MTP Multi-site % of Days Smoked Marijuana, first 4 months (N=398)

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

% o

f D

ays

Sm

oked

per

Wee

k

DTCBTET

MTP Multi-site% of Participants Abstinent for Past 90 Days at 4

Month Assessment (N=398)

3.6%

8.6%

22.6%

0%

5%

10%

15%

20%

% o

f Par

tici

pant

s

Delayed TreatmentBrief TreatmentExtended Treatment

MTP Preliminary Results: Baseline, 4, 9, & 15-months% of Days Smoked Marijuana

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

BL 4-mo 9-mo 15-mo

% o

f D

ays

Smok

ed p

er W

eek

Delayed TreatmentBrief TreatmentExtended Treatment

MTP Multi-siteConclusions and Implications

Extended Treatment was more effective than Brief Treatment Effects of Extended Treatment and Brief Treatment were robust

across sites, ethnicities, employement The effects are not due to sampling bias or self-report bias

Comparison with MTP Study 2

• Stephens, Roffman, & Curtin (2000) found a brief, 2-session intervention to produce outcomes equivalent to a 14-session group treatment and abstinence rates in were greater in all conditions, including the delayed treatment condition

• These differences might be explained by:– delivery of the extended intervention in individual rather than

group format– greater socioeconomic and ethnic diversity of participants in the

Multi-site study– use of more experienced therapists in the prior study of brief

treatment

Other Recent Treatment Studies with Marijuana Users

• Budney, Higgins, Radonovich, & Novy (2000) – Compared contingency management (CM) with cognitive

behavioral and motivational enhancement conditions– Found that CM resulted in greatest abstinence rates but no long-

term follow-ups

• Copeland, Swift, Roffman, & Stephens (2002)– Australian study compared 6 versus 1 sessions of CBT– Significant reductions in both treatments relative to a delayed

treatment control– Evidence for superiority of either treatment was mixed

The Marijuana Check-Up: Background and Rationale

• Overcoming barriers to treatment entry

• The Stage of Change model predicts that many drug users are in a precontemplation or contemplation stage and are not ready for treatment

• Stigma associated with treatment and beliefs that marijuana does not produce dependence or significant problems may also deter treatment seeking

• The Marijuana Check-Up was a brief intervention designed to attract users who would not seek treatment

MCU-IDescription

• The MCU-I was a randomized clinical trial aimed at reducing marijuana use in an ambivalent marijuana abusing and/or dependent adult sample

• The MCU was advertised as an opportunity to receive objective feedback about marijuana use and was not offered as treatment.

• Hypothesis: Personalized feedback with MET will produce greater reductions in marijuana use and associated problems in comparison with general information on marijuana effects or no intervention.

MCU-I: Experimental Conditions

• Personalized Feedback (PF)– Personal Feedback Report based on comparisons of

participant’s baseline data with normative data– MI style when delivering feedback

• Multimedia Feedback (MMF)– Unbiased research findings on the effects of marijuana– Presented via computerized slides and video

• Delayed Treatment (DF)– No intervention for 7 weeks– Followed by choice of feedback intervention– Not followed-up at 6 and 12 months

MCU-I:Participant Demographics (n=188)

Mean Age in years (SD)

Male

White

Marital Status (Single)

Employed Full-Time

Highest Grade Completed

31.83 (10.33)

74.5%

87.2%

76.8%

56.9%

13.5

MCU-I: Marijuana Use Characteristics

Days smoked in last 90 75.54 (15.50)

Number of times smoked per day 3.23 (1.66)

Ounces of marijuana smoked per week 0.21 (0.26)

Age of regular use 17.37 (3.76)

MCU-I: Abuse and Dependence

Number of DSM-IV criteria met for:– marijuana abuse 1.28 (0.76)

– marijuana dependence 3.45 (1.90)

Number of marijuana problems endorsed6.00 (3.87)

MCU-I: Stage of Change Analysis

Stage of Change– Precontemplation 39.4%

– Contemplation 30.3%

– Preparation 21.3%

– Action 7.4%

– Maintenace 1.6%

MCU-INumber of Days Smoked per Week

4

4.5

5

5.5

6

6.5

BASELINE 7-WK 6-MO 12-MO

PF

MMF

DF

MCU-IQuarters Smoked per Smoking Day

1.5

1.6

1.7

1.8

1.9

2

2.1

2.2

2.3

2.4

2.5

BASELINE 7-WK 6-MO 12-MO

PF

MMF

DF

MCU-I:Conclusions

• Participants closely resembled treatment-seeking participants in earlier studies in terms of marijuana use patterns but they reported fewer problems related to their marijuana use and met fewer dependence criteria.

• A large number of marijuana users, mostly dependent on (64%) or abusing marijuana (89.4%), presented to the study that likely would not have presented for traditional treatment.

• Overall, these data suggest that the MCU reached a more ambivalent group of adult marijuana users who may not have sought treatment otherwise.

MCU-I:Conclusions (continued)

• The Personalized Feedback with MET condition reduced days of marijuana use and periods of use per day more than general information and delayed feedback control conditions at the 7-week follow-up.

• Differences between PF and MMF conditions on measures of marijuana use did not reach statistical significance at the 6-month follow-up but were significant at the 12- month follow-up, indicating some maintenance of the initial changes in use.

MCU-I:Implications and Limitations

• Reductions in marijuana use were small and were not accompanied by changes in problems or dependence symptoms.

• The effects may not be clinically significant.

• Given the success in attracting ambivalent users, future MCU interventions should try increasing the dose in order to get larger effects.

MCU-II (in progress)Rationale and Design

• To improve on the magnitude of change seen in the MCU-I

• Participants randomly assigned to either a 2-session or 6-session PF condition

MCU-IIThe 6-Session Condition

• Variable Scheduling of Sessions • Assessment of Readiness to Change• Precontemplation/Contemplation stage options –

videotapes, Guide to Quitting, discussion with friend, letter from the future

• Preparation/Action stage options – coping skill training modules

MCU-II: Related Marijuana Use Measures at Baseline

Number of DSM-IV criteria met for:– Marijuana abuse 1.31 (0.97)

– Marijuana dependence 4.19 (1.89)• 80% met DSM-IV diagnosis of dependence

Number of marijuana problems endorsed6.86 (3.80)

MCU-II: Number of Days Smoked per Week (N=105)

3.63.8

44.24.44.64.8

55.25.45.65.8

66.26.4

BASELINE 6-wk

2-session

6-session

MCU-II: Quarters Smoked per Smoking Day

1.5

1.6

1.7

1.8

1.9

2

2.1

2.2

2.3

2.4

2.5

BASELINE 6-wk

2-session

6-session

MCU-IIPreliminary Results

• At the 6-week follow-up, participants in both conditions significantly reduced the number of days of marijuana use and the number of quarters used per day

• No differences between conditions• Magnitude of change similar to MCU-I

MCU-IIImplications and Future Analyses

• Possible that additional sessions ineffective with more ambivalent users

• Possible that differences between conditions will emerge at later follow-ups when more of the additional sessions have been completed

• Examination of subgroups that may profit from longer intervention (SOC, severity, etc.)

The School of Social Work, University of Washington1

and the Department of Psychology, Virginia Tech2

Roger Roffman1, James Berghuis1, Robert Stephens2

Teen Marijuana Check-Up

Background

• Supplemental funding from NIDA supported a pilot study with an adolescent version of the adult marijuana check-up.

• We were interested in developing and testing an intervention that would elicit voluntary participation from marijuana-using teens.

Recruiting Teens Directly

• Interactive presentation about marijuana in high school classes

• Highlighted facts and myths

• Presenter gave an overview of the Teen Marijuana Check-Up

• Anonymous evaluation - a private way of indicating interest

Pilot Study Overview

• Single group pre-test post-test design

• For teens (14-18 years of age)

• At least 1 use of marijuana in the past month

Overview (continued)

• 2-session intervention (assessment & feedback session)

• Follow-up interview 3 months after the assessment

• All sessions were one-on-one

Overview (continued)

• 7 month recruitment period (N=54)

• no parental consent

• $15 coupons as incentives - feedback session and follow-up interview

Demographic Characteristics (Pilot study: N=54)

Variable N %

GenderMaleFemale

3915

7228

Race/EthnicityCaucasianHispanic

African American Asian American Multi-Racial/Other

364617

677

112

13Stage of Change

PrecontemplationContemplationPreparationAction

Maintenance

14118

211

262015374

Other Demographics (Pilot study: N=54)

Variable TotalSample

LightSmokers1

HeavySmokers2

Age 15.4 (1.0) 15.4 (1.0) 15.5 (1.0)

Age at First Use 12.6 (1.7) 13.0 (1.4) 12.2 (1.9)

1 smoked 1-8 days in past 30; n=272 smoked 9-30 days in past 30; n=27

Use Characteristics & Outcomes (Pilot study: N=54)

Variable TotalSample*

LightSmokers1

HeavySmokers2*

Days Smoked(out of last 30):

Baseline-M(SD) Median

10.3 (8.2)8

3.6 (2.0)4

17.0 (6.2)17

3-Month-M(SD) Median

8.4 (9.0)5

3.9 (5.1)3

12.9 (9.9)10

1 smoked 1-8 days in past 30 at baseline; n=272 smoked 9-30 days in past 30 at baseline; n=27* p<.05

Pilot Study Findings

• Succeeded in recruiting non-treatment-seeking marijuana-using teens

• Significant reductions reported overall and among heavier users

• At follow-up, 54% reported having made voluntary reductions in use

Findings (continued)

• Nearly 15% had been abstinent for the previous 30 days

• 98% felt their counselor had listened to them

• 98% reported the TMCU was helpful

• 91% perceived the counselor as having been non-judgmental

New Study Overview – in progress

• RCT (Delayed feedback control condition)

• For teens (14-19) who use regularly• 3-sessions (1 assessment & 2 feedback

sessions) • Follow-up assessment 3 months later• Computer assisted assessments to

facilitate accurate reporting

Summary

• Positive responses to TMCU from teens and school personnel (presentations and referrals)

• To date have screened 184 teens, 102 were eligible, and 97 areparticipating

• Diverse sample in terms of age, ethnicity, and gender

Summary (continued)

• Reaching teens at earlier stages of change (precontemplators and contemplators)

• Participants are often experiencing some symptoms of marijuana abuse/dependence