Substance Use Disorders

Chapter G.2

Cannabis Use and

Misuse

Alan J Budney &

Catherine Stanger
DEPRESSION IN CHILDREN AND
ADOLESCENTS

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Adapted by Thomas Campbell & Julie Chilton
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mental-health

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 Cannabis Use and Misuse
Outline
• What is cannabis and
how does it work?
• Adverse effects
• Epidemiology
• Gateway effect
• Screening, assessment,
and diagnosis
• Treatment and outcome
• Prevention
• Medical marijuana and
legalization
• References
 Cannabis Use and Misuse
Background
• Cannabis Sativa
• Weed, ganja, marijuana,
hashish, dagga, pot, and
reefer
• Use > 166 million people
• Controversy
• Legal status
• Medical use
• Addictive potential
• Medical and
psychosocial
consequences
• “Gateway drug”
Cannabis Use and Misuse
Resources
 Cannabis Use and Misuse

Cannabis Throughout History

• Appeared 4000 years ago
– China
– Clothing, rope, and paper
• Medicinal and spiritual use
• 1870 U.S. pharmacopeia
• Government research: not
addictive and potential health
benefits Advertisement in the
Jan 1895 issue of the
"Medical Advance Journal"
• Early-mid 1900’s: Increasing
public controversy over racist
fears
 Wet and dry pattern
Cannabis Use and Misuse
Cannabis Throughout History
• 1924: International Opium Conference
– labeled a narcotic, strict controls
• 1941
– Declared illegal in Britain
– Taxed in US and removed from pharmacopeia
• 1944: New York Academy of Sciences
– Public concerns exaggerated, but negative side effects
• 1972: US National Commission
– Recommendation to decriminalize
• 1999: Institute of Medicine
– Negative aspects but potential medical benefits
 Cannabis Use and Misuse
What Is Cannabis and How Does It Work?

• Delta-9tetrahydrocannabinol
(THC)
produces high
• Research mixed on cannabidiol
• Three pressing issues:
– Cannabis vs. pure THC used Chemical structure of THC

medically
– Synthetic THC (K2) vs Cannabis
– Health effects of inhaled cannabis
 Cannabis Use and Misuse

How is cannabis prepared and consumed?

• Dried
– Whole plant (2%-5% THC)
– Hashish (10-15%)
– Unfertilized flowers (up to 20% THC)
– Hash oil resin (up to 60%)
• Increased potency over past 20 years
• Smoking most common
– Joints, blunts, pipes, bongs
– Combining with tobacco
– “Vaporizing”= inhalation without combustion
• Edible cannabis -> becoming more popular
 Cannabis Use and Misuse

Synthetic Cannabinoids
 Cannabis Use and Misuse
What Are the General Effects of Cannabis Use?

• Administration
– Smoked (start 1-2 minutes -> ends 4 hours)
– PO (start 30 minutes -> ends 6 hours)
• General effects of Cannabis use:
– Potential Positives:
• Euphoria, relaxation, laughing, >appreciation for
music
– Potential Negatives:
• Anxiety, fear, paranoia, or panic
• Hallucinations (rare)
• Dissipate with time
 Cannabis Use and Misuse

Acute Effects
• Dry mouth
• Stimulated appetite (munchies)
• Antiemetic (low doses)
• Nausea and vomiting (high doses)
• Dilate blood vessels (red eyes)
• Increased heart rate
• Orthostatic hypotension
• Impaired:
– Attention
– Short term memory
– Some complex cognitive processes,
– Motor abilities

• Most effects are dose dependent and moderated by tolerance,

comparable to those of moderate doses of alcohol (BAC approximately
0.05%)
 Cannabis Use and Misuse
Effects with Long Term Use

• Impaired cognition
– Attention
– Memory
– Problem solving
– Mental flexibility
• Altered brain function on neuroimaging:
– Prefrontal cortex
– Cerebellum
– Hippocampus

*Likely reversed following extended abstinence*

 Cannabis Use and Misuse
How Does Cannabis Interact with the Brain?

• Endogenous cannabinoid receptors (CB1,

CB2) and 5 endogenous ligands
• CB1
– Psychoactive and reinforcing effects
– Highest concentrations
• Basal ganglia (reward, learning, motor control)
• Cerebellum (sensorimotor coordination)
• Hippocampus (memory)
• Cortex (planning, inhibition, higher-order cognition)
– Dose and time dependent
– Euphoria: increased dopamine in reward center
 Cannabis Use and Misuse
How Does Cannabis Interact with the Teen Brain?

Chronic or frequent use

– Impaired executive function
– Impaired higher-level control of
attention
– Impaired working memory
– Decreased cortical thickness
– Possible decreased myelination
 Cannabis Use and Misuse
Behavioral, Medical, and Psychiatric Adverse Effects

Adolescents with regular use:

– Try other substances
– Develop substance use disorders
– Poor academic performance
– Drop out of school
– More delinquent behavior
– Psychiatric problems
– Emergency department visits
– Risky behavior
• Drugged driving
• Sexually transmitted diseases
 Cannabis Use and Misuse
Cannabis and Schizophrenia

• Using Cannabis psychotic disorders

– Association repeatedly demonstrated
• Higher risk
– Frequent use
– Early onset
• Prior schizophrenia diagnosis
– Negative effect on course and treatment
– Possible positive effect on cognition
 Cannabis Use and Misuse
Neurobiology and Genetics

• Effects + endogenous cannabinoids

– Addiction biologically plausible
– Parallel other drug pathways
• Genetics
– 30-80% Risk
– Substance specific
– Substance non-specific
– Environmentally modifiable
 Cannabis Use and Misuse
Cannabis Withdrawal

• Experienced by most heavy users

• Cannabinoid antagonist  withdrawal
• Resume THC and symptoms abate
• Cannabis withdrawal syndrome
– Begins 1-2 days after stopping
– Peaks in 2-4 days
– Lasts for 1-3 weeks
– No major medical/psychiatric consequences
– More severe withdrawal=worse prognosis
 Cannabis Use and Misuse
Cannabis Withdrawal Symptoms

• Irritability/anger
• Nervousness/anxiety
• Sleep difficulty
• Decreased appetite
• Depressed mood
• Physical symptoms
– Stomach pain Photo: Tony Fischer

– Tremor, headache
– Fever, chills, sweating
 Cannabis Use and Misuse
Epidemiology of Cannabis Use Disorder (CUD)

• Most users do not develop a use disorder

– 9% of cannabis users = CUD
• 15% of cocaine users
• 25% heroin users
– # of patients with CUD > other drug use disorders
– increasing # of patients with CUD
- Stable rates of cannabis use
- Increased potency
- Earlier onset of use
 Cannabis Use and Misuse
Severity of Cannabis Use Disorder

- Adults in treatment
- Average = 10 years using
- Multiple failed quit attempts
- Use despite consequences
- Withdrawal
- Differences in severity (compared with other drugs)
- < DSM criteria met
- < Health effects
- < Psychosocial consequences

***NOT EASIER TO QUIT***

 Cannabis Use and Misuse
Epidemiology of Cannabis Use Disorder:
Recent trends in the US

• Daily marijuana use in teens is mostly steady

• Use is higher among high school students in states
with medical marijuana laws
• The number of teens who think marijuana use is
harmful is declining
 Cannabis Use and Misuse
Epidemiology of Cannabis Use Disorder:
Treatment Admissions

- Primary CUD admissions

- More CUD
- Recognition and acceptability
- Availability of treatment
- Adolescent’s #1 substance
- 40% CUD admissions < 20 years old
- Adolescents develop CUD faster than adults
 Cannabis Use and Misuse
Gateway Effect

- Cannabis  “harder” drugs

- Alcohol/tobacco same
- Causally related?
- Possible hypothesis:
- Neurobiology
- Contact with drug dealers
- Altered decision making
- Interpersonal/environment characteristics
- Conduct problems
- Neighborhood
- Parental factors
 Cannabis Use and Misuse
Screening, Assessment, and Diagnosis
- Similar to other SUDs
- Diagnostic interview
- Cannabis Use Disorder Identification Test
- Cannabis Problems Questionnaire
- Adult and adolescent versions
- Marijuana Screening Inventory
- CRAFFT Questionnaire
- Alcohol + other drug use
- If +  further drug specific assessment
- Two Instruments assessing change
- Marijuana Problem Inventory
- Marijuana Withdrawal checklist
 Cannabis Use and Misuse
Screening, Assessment, and Diagnosis:
Testing for cannabis use

- Screening + treatment outcome

- Dipstick methods
- Cheap + Qualitative
- Gas Chromatography/Mass Spec
- Expensive
- Ensure integrity of sample
- Observation of specimen provision
- Urine temp
- Trained Personnel
- Saliva/hair samples
 Cannabis Use and Misuse
Treatment and Outcome

- Abstinence and relapse = other SUDs

- Behavioral interventions showing promise:
- Group/Individual Cognitive Behavioral Therapy (CBT)
- CBT + Motivational Interviewing (MI)
- MI or CBT + contingency management, community
reinforcement
- Multisystemic therapy
- Multidimensional, functional, or brief strategic family
therapy
- Family support network
- Family behavior therapy
 Cannabis Use and Misuse
Treatment and Outcome

- Treatment = modest effects

- Largest clinical trial (600 adolescent w/ CUD)
- (MI + CBT5) vs (MI + CBT12) vs (MI + CBT12 +
family support) vs (adolescent community
reinforcement counseling) vs multidimensional
family therapy
- Comparable significant with each
- 2/3 significant CUD persisted
- Better treatment needed
 Cannabis Use and Misuse
Treatment and Outcome:
Contingency and Management Interventions

- Systemic environmental consequences

- Reinforcement and punishment
- Teens rarely seek treatment
- Often do not see problem
- Parents initiate treatment
- Contingency management:
- Incentive program rewarding abstinence
- Behavioral parenting
- Abstinence-based contract
- Incentives for parents
- Weekly CBT/MI
Intervention Components Description

Motivational enhancement therapy/ • Positive/negative aspects of use

cognitive behavior therapy (CBT) • Coping skills related to use
• Goals for future + treatment

Clinic based contingency management • Teens earn incentives at visit

• Incentive increase with abstinence
• Relapse resets incentives

Twice weekly urine drug testing • Objective evidence for contingency plan
• Evaluate treatment progress

Substance monitoring contract • Home incentives for abstinence

Appendix G.2.1 • Specific consequence for relapse

Family management curriculum • “adolescent transitions program”

• Teaches parents skills and principles

Parent Incentives • Attending sessions and drug testing

• Enforcing substance use contract
 Cannabis Use Disorder
Treatment

• Clinic Delivered Incentive Program

– Negative Urine test = Incentive
– Parents utilize breathalyzers
– Monitor alcohol use
– No alcohol = incentive

• Parent-Delivered Contingency
Management Program
– Model appropriate substance use
– Clear + consistent consequences
– Monitor youth’s behavior
– Motivate drug abstinence
 Cannabis Use Disorder
Treatment

• Objective Testing
– Motivation for teens to lie
– Observed urine collection twice weekly
– 2 weeks no cannabis ~ negative test
• Results
– Contingency management w/ ME + CBT vs. ME +
CBT + parent education + attendance incentive
• Twice weekly urine test in both
• Contingency management group = abstinence
• Effect stopped post treatment
• Abstinence in both groups
 Cannabis Use and Misuse
Treatment: Pharmacotherapy

– No strong evidence for any medication

– No approved medications for CUD
– N-acetylcysteine (glutamate)
• One study for CUD in adolescents and young adults
• Small open label trial
• Controlled follow-up study
– New research
• CB1 agonists
• CB1 antagonists (rimonabant)
– Lofexidine & zolpidem withdrawal symptoms
 Cannabis Use and Misuse
Maintaining Treatment Effects

“Assertive Continuing Care”

• Case management after
inpatient
– 90 days of weekly home visits
– Engagement in outpatient
services
– Pro-social activities
– New social support system
– Reinforcement strategies
– Higher long-term abstinence
 Cannabis Use and Misuse
Secondary Prevention
• “Check-up” intervention
– Ambivalent adult users
– Computerized assessment + 2 ME sessions
• Randomized for check up vs delayed treatment
• Similar reduction in use
• Another study with similar sample
– ME vs “education feedback control” vs delayed feedback
control group
• 2 active treatments cannabis use
– ME >> reduction in use
– 3 more studies support ME cannabis use

• Reduction NOT abstinence

• Development of effective treatments needed
 Cannabis Use and Misuse
Risk Factors

• Genetic
• Environmental
– *Availability*
– Delinquent Behavior
– Chaotic Home Cannabis coffee shop in Amsterdam

– Low socio-economic status

– Other psychopathology
– Low perceived risk of harm
– Peer/Family Use
– Use of other substances
• Earlier initiation risk of CUD
Cannabis Use and Misuse
Resources
 Cannabis Use and Misuse
Prevention

• Minimal treatment available  Prevention

• Strategies = other SUDs
– Perception cannabis harmful
– Parent education/training
– Balanced, science based, and rational education
• No “scare-tactics”
– School based prevention programs
– Targeted educational programs for high risk youth
 Cannabis Use and Misuse
Medical Marijuana and Legalization

• Controversial
• Legality affects teens’ perception of risk
• Suggestion of evidence for targeted
compounds
– Data: potential benefits for many conditions
• Nabilone for AIDS wasting syndrome + cancer patients
• Oral spray for muscle spasticity (Canada/New Zealand)
– Smoked vs oral
– Delta-8-THC + cannabidiol
– Adverse effects of smoking
– Increase intoxication +risk for CUD
 Cannabis Use and Misuse
Legalization
Pros
• Alcohol use -> more harmful
• Regulation/tax -> fiscal benefits + quality control
• Addictive potential relatively low
• Reduced crime and consequences
• Medical benefits: pain, eating disorders or appetite problems
neuromuscular/neurodegenerative/autoimmune disorders

Cons
• Psychosocial, health, psychiatric consequences
• Possible increase use
• Many illegal drugs have medical benefit potential
• Reduced perceived harm
• Driving under influence -> accidents
 Cannabis Use and Misuse
Conclusion

• Misuse, abuse, dependence & withdrawal

– Real & common
– Problem especially for adolescents/teens
• Similar to other SUDs
• Some level of cannabis = harmful effects
• Most users significant consequences
• Valuable new research
Parenti ng Programs

Thank You!