Review of the Validity and Significance of Cannabis Withdrawal Syndrome
Addict Sci Clin Pract. 2007 Dec; four(1): 4–16.
Marijuana Dependence and Its Handling
Alan J. Budney
i University of Arkansas for Medical Sciences, Lilliputian Rock, Arkansas
Roger Roffman
2 University of Washington, Seattle, Washington
Robert Due south. Stephens
3 Virginia Polytechnic Constitute and Country University, Blacksburg, Virginia
Denise Walker
2 University of Washington, Seattle, Washington
Abstract
The prevalence of marijuana corruption and dependence disorders has been increasing among adults and adolescents in the U.s.. This paper reviews the problems associated with marijuana apply, including unique characteristics of marijuana dependence, and the results of laboratory research and treatment trials to date. Information technology also discusses limitations of current knowledge and potential areas for advancing enquiry and clinical intervention.
Marijuana remains the most widely used illicit substance in the U.s. and Europe (European Monitoring Middle for Drugs and Drug Addiction, 2006; Substance Abuse and Mental Health Services Administration (SAMHSA), 2007). Although some people question the concept of marijuana dependence or addiction, diagnostic, epidemiological, laboratory, and clinical studies clearly indicate that the condition exists, is important, and causes harm (Budney, 2006; Budney and Hughes, 2006; Copeland, 2004; Roffman and Stephens, 2006). Marijuana dependence equally experienced in clinical populations appears very similar to other substance dependence disorders, although it is likely to exist less astringent. Adults seeking handling for marijuana abuse or dependence boilerplate more than 10 years of near-daily utilize and more than six serious attempts at quitting (Budney, 2006; Copeland et al., 2001; Stephens et al., 2002). They continue to smoke the drug despite social, psychological, and physical impairments, usually citing consequences such as relationship and family bug, guilt associated with use of the drug, fiscal difficulties, low energy and self-esteem, dissatisfaction with productivity levels, sleep and memory problems, and low life satisfaction (Gruber et al., 2003; Stephens et al., 2002). Nigh perceive themselves equally unable to end, and well-nigh experience a withdrawal syndrome upon cessation.
Approximately half of the individuals who enter handling for marijuana use are under 25 years of age. These patients report a distinctive profile of associated problems, perhaps due to their historic period and involvement in other risky behaviors (Tims et al., 2002). Adolescents who smoke marijuana are at enhanced risk of adverse health and psychosocial consequences, including sexually transmitted diseases and pregnancy, early school dropout, delinquency, legal problems, and lowered educational and occupational aspirations.
Some iv.3 percent of Americans accept been dependent on marijuana, as defined in the Diagnostic and Statistical Manual of Mental Disorders, fourth Edition, Text Revision (DSM-IV-TR; American Psychiatric Clan, 2000), at some fourth dimension in their lives. Marijuana produces dependence less readily than well-nigh other illicit drugs. Some 9 percent of those who endeavour marijuana develop dependence compared to, for example, xv per centum of people who try cocaine and 24 pct of those who try heroin. All the same, because and so many people utilise marijuana, cannabis dependence is twice equally prevalent as dependence on any other illicit psychoactive substance (cocaine, one.8 pct; heroin, 0.7 percent; Anthony and Helzer, 1991; Anthony, Warner, and Kessler, 1994).
During the by decade, marijuana apply disorders have increased in all age groups. Contributing factors may include the availability of college dominance marijuana and the initiation of utilize at an earlier age. Among adults, marijuana use disorders increased despite stabilization of rates of use. An increased prevalence of disorders amidst young adult African-American and Hispanic men and African-American women appears to business relationship for the overall rise among youth (Compton, 2004). The reasons for the upward trend in disorders among minority young people are not clear. Speculation has pointed to the deleterious effects of acculturation on Hispanic youth; growing numbers of minority youth attention college, where they may experience increased exposure to marijuana employ; and ecology and economic factors. For example, young people may turn to marijuana abuse when they have difficulty obtaining tobacco and alcohol, and recent college prices and stricter governmental policies may restrict minorities' more than than Caucasians' admission to legal psychoactive substances.
Paralleling the ascension in marijuana use disorders, handling admissions for primary marijuana dependence have increased both in absolute numbers and equally a pct of total admissions, from 7 percentage in 1993 to 16 percent in 2003 (SAMHSA, 2004). The extent of marijuana use and its associated consequences clearly bespeak a public wellness problem that requires systematic try focused on prevention and intervention.
Figure 1
The percentage of substance corruption treatment admissions that were due to marijuana nearly doubled from 1993 to 2005 (SAMHSA, 2006b)
Figure ii
Marijuana accounts for nearly adolescent drug treatment admissions and progressively smaller proportions of admissions in each successive higher age group (SAMHSA, 2006b)
Handling EFFICACY RESEARCH
Systematic research on psychosocial treatments for marijuana corruption or dependence began approximately xx years ago, notwithstanding the number of controlled studies remains pocket-size. Behavioral treatments, such as motivational enhancement therapy (MET), cognitive-behavioral therapy (CBT), and contingency management (CM), too as family-based treatments accept been advisedly evaluated and take shown promise. Outpatient treatments for marijuana abuse amidst adolescents accept recently received increasing attending in the scientific literature.
Adults
Seven published, randomized efficacy trials for chief adult marijuana corruption and dependence take consistently demonstrated that outpatient treatments can reduce marijuana consumption and engender abstinence. The about commonly tested interventions are adaptations of interventions initially adult to treat alcohol or cocaine dependence, in particular MET and CBT (also known as coping skills training). Recently, trials have examined the use of CM to enhance the potency of MET- and CBT-based treatments. The cumulative findings indicate that (ane) each of these interventions represents a reasonable and efficacious treatment approach; (2) the combination of MET and CBT is probably more potent than MET alone; and (three) an intervention that integrates all three approaches—MET, CBT, and CM— is near likely to produce positive outcomes, peculiarly as measured by rates of forbearance from marijuana.
MET addresses ambivalence about quitting and seeks to strengthen motivation to alter. A typical MET regimen consists of one to four 45- to ninety-minute private sessions. Therapists use a nonconfrontational counseling mode to guide the patient toward commitment to and action toward change. Therapeutic techniques include using strategic expression of empathy, reflecting, summarizing, affirming, reinforcing cocky-efficacy, exploring pros and cons of drug use, rolling with resistance, and forging goals and plans to achieve them. An online manual, Cursory Counseling for Marijuana Dependence, describes the employ of MET intervention with adult marijuana users.
CBT focuses on teaching patients skills relevant to quitting marijuana and avoiding or managing other problems that may interfere with proficient outcomes. Patients learn functional analysis of marijuana use and cravings, self-management planning to avoid or cope with drug utilise triggers, drug refusal skills, problem-solving skills, and lifestyle direction. CBT for marijuana dependence is typically delivered in 45- to threescore-minute, weekly individual or group counseling sessions; tested CBT interventions have ranged from 6 to14 sessions. Each session involves analysis of contempo marijuana use or cravings, development of planned responses to situations that may trigger apply or craving, brief training on a coping skill, role-playing or other interactive exercises, and practice assignments. Brief Counseling for Marijuana Dependence describes the content and carry of CBT sessions in item (Steinberg et al., 2005; see "Web Links to Treatment Manuals").
A serial of four trials demonstrated the efficacy of both CBT and MET for adult marijuana dependence (Tabular array ane). After an initial trial showed promising results for a CBT group intervention (Stephens, Roffman, and Simpson, 1994), a 2d trial tested a 14-session group CBT intervention against 2 individual MET sessions or a delayed treatment control (DTC) status (Stephens, Roffman, and Curtin, 2000). At the 4-month followup, the CBT and MET groups had accomplished significantly greater rates of forbearance than the DTC group. Days of use, number of uses per mean solar day, dependence symptoms, and bug related to use also fell significantly compared with those measures in the DTC group, and gains were generally maintained throughout the 16-month followup. No significant differences were observed between CBT and MET weather condition on whatever of these event measures, suggesting that brief motivational interventions may exist as effective as longer CBT interventions. However, this written report confounded treatment modality (grouping vs. individual) and therapist experience (provision of MET past more experienced therapists) with handling length. A similar study showed that a six-session CBT and a one-session MET treatment, both delivered in private therapy sessions, produced greater rates of forbearance than DTC, but again little deviation was observed betwixt the active handling groups (Copeland et al., 2001). A positive relation betwixt therapist experience and effect was reported beyond both handling atmospheric condition.
Table 1
Randomized Trials for Adult Marijuana Handling
| Author(South) | N | INTERVENTION | OUTCOME |
|---|---|---|---|
| MET and CBT | |||
| Stephens, Roffman, and Simpson, 1994 | 212 | CBT vs. social support group discussion intervention | Both groups had significant reductions in marijuana apply. No meaning differences between groups. |
| Stephens, Roffman, and Curtin, 2000 | 291 | xiv-session CBT group treatment vs. 2-session MET handling vs. DTC | Treatment groups showed greater improvement than DTC. No differences in outcomes between treatment groups. |
| Copeland et al., 2001 | 229 | half dozen-session MET vs. one-session MET vs. DTC | Both treatment groups reported meliorate outcomes (higher rates of forbearance, fewer marijuana-related problems) than DTC. |
| Marijuana Treatment Project Research Group, 2004 | 450 | nine-session MET-CBT vs. two-session K ET vs. DTC | Both treatment groups reported amend outcomes than DTC. 9-session MET-CBT engendered greater long-term abstinence and reductions in frequency of utilize than brief MET. |
| Stephens et al., 2006 | 87 | 9-session MET-CBT vs. 4-session M ET-CBT + pro re nata (PRN; standing intendance) | No between-condition outcome differences observed. Only 37 per centum of PRN subjects used continuing intendance sessions; suggestive testify that use of PRN increased abstinence. |
| | |||
| CM (Abstinence-Based Vouchers) | |||
| Budney et al., 2000 | 60 | 4-session MET vs. 14-session MET-CBT vs. 14-session MET-CBT + CM | No differences in abstinence between MET and MET-CBT. MET-CBT+CM engendered greater abstinence during and at the end of treatment than M ET or MET-CBT. |
| Budney et al., 2006 | 90 | xiv-session MET-CBT vs. MET-CBT + CM vs. CM solitary | Two CM conditions engendered meliorate abstinence outcomes during treatment than MET-CBT. MET-CBT+CM had better post-treatment abstinence rates than the other groups. |
| Kadden et al., 2007 | 240 | 9-session MET-CBT vs. Thousand ET-CBT + CM vs. CM alone vs. case management | Two CM conditions engendered better abstinence outcomes, with only the MET-CBT+CM showing superior abstinence rates during the 1-yr followup. |
The nigh comprehensive trial (north = 450) of MET and CBT compared nine sessions of combined MET-CBT with a two-session MET-but intervention and with a DTC (Marijuana Treatment Projection Research Group, 2004). MET-CBT and MET-just again produced better abstinence outcomes than DTC. All the same, in this trial, MET-CBT was associated with significantly greater long-term forbearance and greater reductions in frequency of marijuana use compared with MET lonely. Findings generalized across three sites and were non dependent on ethnicity or gender.
In an effort to enhance outcomes farther, researchers have begun to examine the efficacy of CM for treating marijuana dependence (Budney et al., 2001). The marijuana CM intervention adapts the abstinence-based voucher approach originally developed and demonstrated effective for treating cocaine dependence (Budney and Higgins, 1998; Higgins et al., 1994). The vouchers are contingent on marijuana abstinence, confirmed past twice-weekly drug testing, and their value escalates with each consecutive negative drug test. Patients exchange them for prosocial retail items or services that, it is hoped, volition serve equally alternatives to marijuana use.
An initial trial of CM for adult marijuana dependence compared a four-session MET, a 14-session combined MET-CBT, and a 14-session MET-CBT plus CM (Budney et al., 2000). Individuals could earn upwardly to $570 in vouchers if they provided consistently negative urine samples throughout handling weeks iii through fourteen. The MET-CBT plus CM condition produced the highest abstinence rate during treatment. In a 2d trial conducted to extend these findings (Budney et al., 2006), 90 adults received MET-CBT, MET-CBT plus CM, or CM alone (no counseling). The magnitude of the CM incentives was identical to that used in the prior written report. The MET-CBT-alone intervention differed from the initial report in one regard: vouchers ($5) contingent on providing a urine specimen as scheduled (twice per week) were provided to ensure equivalent retention and handling contact. This trial produced 3 notable outcomes. First, MET-CBT plus CM and CM alone both engendered greater initial rates of abstinence than MET-CBT. 2nd, MET-CBT plus CM produced outcomes that were similar to those of CM alone during treatment, but superior post-treatment.
A recent study by some other research group plant similar results with a modified CM program (weekly urine testing, $385 maximum voucher earnings for complete abstinence) in a more diverse (40 percent minority) and larger sample (n = 240; Kadden et al., 2007). During 7 weeks of handling, MET-CBT plus CM and CM alone produced continuous abstinence outcomes that were similar to each other and superior to those seen with MET-CBT. During the following year, the MET-CBT plus CM patient group sustained overall positive outcomes somewhat better than those of the CM group, although differences in abstinence rates were non statistically pregnant at later followups. As in the previous CM trials, patients in the CM and non-CM conditions self-reported similar rates of marijuana employ throughout, illustrating the importance of obtaining subjective and objective indices of use. In summary, MET, CBT, and CM each has empirical support for its efficacy, and CM in combination with MET-CBT has demonstrated the most authority in outpatient treatment for developed marijuana dependence, particularly for engendering longer periods of abstinence.
Recognizing that many people overcome dependence only after multiple handling exposures, Stephens and Roffman (2005) developed and initially tested a creative, chronic intendance model of treatment that they termed "marijuana dependence treatment PRN." Following an initial 4 sessions of MET-CBT, participants were given the option of determining the number and schedule of treatment sessions they would attend over a 28-month period. The comparison status in this trial was the same fixed-dose 9-session MET-CBT intervention used in the large multisite trial mentioned before (Marijuana Treatment Projection Inquiry Group, 2004). At that place were three key findings from this trial: (1) A relatively pocket-size per centum of participants (37 per centum) fabricated employ of the standing intendance sessions, and (2) the PRN condition overall was non more efficacious than the fixed-dose condition, although (3) the few individuals who attended the greatest number of continuing intendance sessions (mean of 13.4 sessions) had a high level of ninety-twenty-four hour period abstinence (approximately 60 percent) at followup.
Adolescents and Young Adults
Virtually information on marijuana treatment efficacy among young people derives from trials that have included users of various drugs and accept not focused specifically on marijuana use. Nevertheless, most patients in these studies have been primary marijuana users. Empirical support for group or private CBT and family-based treatments has begun to emerge (Waldron and Kaminer, 2004). The CBT interventions studied have been like to those studied for adults in scope and duration. Specific forms of family-based treatment that accept been tested include functional family therapy (Waldron et al., 2001), multidimensional family therapy (MDFT; Liddle et al., 2001), multisystemic therapy (Henggeler et al., 2006), family unit back up network intervention (Dennis et al., 2004), and brief strategic family therapy (Azrin et al., 1994; Santisteban et al., 2003). Description of these models is beyond the telescopic of this paper. Nonetheless, they each involve structured, skills-based interventions for family members and are well described in their respective manuals.
The largest clinical trial of outpatient treatment for adolescent substance abuse focused on marijuana use (Dennis et al., 2004). V treatment models were tested in a multisite written report: MET-CBT v (ii individual and 3 group sessions), MET-CBT 12 (2 individual and 10 group sessions), MET-CBT 12 plus family support network (vi parent instruction grouping sessions, 4 home visits, and case direction), the community reinforcement approach (10 individual sessions focused on behavioral change in drug use and lifestyle alter, and 4 parent sessions focused on constructive parenting, communication, and problem solving), and MDFT (12 to 15 family systems-focused sessions: vi individual, three with parents lonely, and 6 with family). Significant decreases in drug use and symptoms of dependence were observed following each of the treatments. Notwithstanding, robust betwixt-treatment differences in outcomes were not observed, which unfortunately precludes drawing potent conclusions almost their efficacy. Although results were promising compared with prior handling studies, ii-thirds of the youth continued to experience significant substance-related symptoms, suggesting that adolescent treatments can be improved and alternative handling models should exist explored (Compton and Pringle, 2004).
As they are doing with treatments for adults, researchers are attempting to heighten youths' outcomes by calculation a CM intervention to MET-CBT-blazon interventions. Positive results were observed in an initial pilot study of MET-CBT plus a CM intervention that incorporated an abstinence-based voucher program and parent-based CM (Kamon, Budney, and Stanger, 2005). The voucher program was of the same schedule and magnitude as that used in the previously mentioned developed trials past Budney and colleagues. Nonetheless, participants could earn vouchers just if urine toxicology screens were negative for all drugs tested and if parents reported that, to their cognition, the adolescent had not used whatsoever drugs or alcohol. The parenting intervention included a contract that directed parents to provide tangible incentives for forbearance and to deliver negative consequences for continued use. Parents likewise participated in a weekly behavioral training plan called Adolescent Transitions (Dishion and Kavanagh, 2003), a treatment of pick for adolescents with conduct disorder. Preliminary data from an initial randomized trial suggest that the MET-CBT plus CM improved rates of marijuana abstinence and effectively maintained forbearance post-treatment compared with MET-CBT combined with weekly parent psychoeducational counseling. The rates of forbearance achieved appeared greater than those reported in prior studies; however, comparison across trials is problematic because of differences in patient characteristics and differences in the mode outcomes are measured.
Two other tests of CM with adolescents and young adults have produced promising results. A CM abstinence-based voucher program enhanced drug use outcomes and abstinence when added to a potent outpatient therapy (i.e., multisystemic therapy) amongst juvenile offenders enrolled in drug courtroom (Henggeler et al., 2006). Lastly, calculation incentives for handling attendance to MET increased treatment participation by immature adult marijuana abusers involved with the judicial organisation, merely did not lead to increased marijuana forbearance (Sinha et al., 2003). In summary, a number of behaviorally based interventions appear efficacious for treating adolescent marijuana abuse, and combining interventions like MET, CBT, CM, and family unit-based programs is likely to enhance efficacy.
Effectiveness
Sufficient evidence has accumulated to conclude that behaviorally based interventions tin can help many of those who seek handling for marijuana use disorders. Unfortunately, as with handling for other dependencies, the rates of "success" are minor. Even with MET-CBT plus CM, the most highly efficacious treatment for adults, only about one-half of those who enroll in treatment achieve an initial 2-week menses of forbearance, and amid those who practice, approximately one-half resume apply inside a year (Budney et al., 2006; Kadden et al., 2007). Across studies, one-twelvemonth abstinence rates have ranged between xix and 29 percent for MET-CBT, and between 9 and 28 percent for MET. An boosted percentage of adults study a reduction in use and in issues associated with apply; even so, many adults prove no bear witness of progress.
The treatment outcome data for adolescents paint a similar picture. For example, in the large Cannabis Youth Treatment study, abstinence rates at the stop of handling were only 11 to 15 per centum (Dennis et al., 2004; see also the preliminary findings of Dennis and colleagues reported at www.chestnut.org/LI/cyt/findings/index.html), and rates at 12 months mail service-treatment, defined by self-study of no substance use in the prior calendar month, were 17 to 34 percent across the 5 treatments. Conspicuously, there remains much room for improvement in marijuana outpatient treatment.
CLINICAL ISSUES
Most clinical issues in treatment for marijuana use disorders parallel those that arise in treatments for other drug use disorders, though sometimes with distinctive aspects. Among the clinical features that distinguish marijuana dependence are the drug's relatively mild withdrawal effects and marijuana users' frequent want to pursue a goal of reducing—rather than abstaining from—use.
Marijuana as a Secondary Drug of Corruption
In add-on to being the illicit drug most normally used by the general population, marijuana is too the most common "other drug" used by those seeking treatment for stimulant or opiate dependence. Such secondary marijuana utilize is commonly viewed as a significant risk cistron for relapse or handling failure, although the empirical support for this is equivocal (Epstein and Preston, 2003).
Many individuals who enter handling for heroin/opiate dependence or cocaine dependence practise not consider their marijuana use problematic; thus, their readiness to quit or reduce their marijuana use is low. Some investigators have explored CM-based approaches targeting marijuana use in this clinical population, reasoning that explicit reinforcement or penalty interventions tied to marijuana use may motivate and prompt change in individuals not currently interested in changing.
Calsyn and Saxon (1999) devised a marijuana CM programme to office as an adjunct to an existing CM program that required 6 months of urinalysis-confirmed abstinence from all drugs, except for cannabis, in order to earn methadone take-home privileges twice a calendar week. The new intervention only increased the requirement for obtaining twice-weekly take-dwelling status to include marijuana-negative urinalysis results. In this small study, 50 percentage of the participants responded to the contingency by stopping their marijuana utilize, while the other 50 percent accepted curtailment of their take-habitation privileges and continued to use marijuana.
Kidorf and colleagues (2007) tested a similar "motivated stepped intendance" approach to reducing cannabis utilize in methadone maintenance patients. 15 patients who tested positive just for marijuana during a 6-month baseline period were informed that, from then on, a positive exam for marijuana (or any other substance) would increase their counseling requirements from 1 60 minutes per calendar week to 4. Ten of the patients discontinued marijuana utilise when informed about the new counseling dominion. The other v—who were among the heaviest users—continued to test positive for marijuana and were required to attend the boosted counseling sessions. Of those, four responded to the intensified counseling, eventually discontinuing use and returning to the lower-level schedule. Ane patient did not respond and dropped out of treatment.
In the cocaine clinic, where many patients do not endorse a goal of stopping marijuana apply, the clinician must decide how all-time to approach this effect without adversely affecting treatment for cocaine dependence (Budney, Higgins, and Wong, 1996). One study of a pocket-sized number of patients explored a sequential strategy of initially targeting abstinence from cocaine with an forbearance-based voucher CM program, then targeting marijuana once cocaine abstinence had been achieved (Budney et al., 1991). The rationale for this approach was that the experience of achieving cocaine abstinence and the associated positive effects might increase sensation of how marijuana apply negatively affects a prosocial lifestyle. Moreover, an initial success with a voucher programme for cocaine might motivate participation in a similar program that targets marijuana. In this written report, ii participants quit using cocaine during a 12-week voucher programme, simply continued to utilise marijuana regularly despite counseling that encouraged abstinence. Both entered a second 12-calendar week plan that required abstinence from cocaine and marijuana to earn vouchers. Both accomplished abstinence from the two drugs and stayed off cocaine throughout a v-month followup flow. Unfortunately, both resumed marijuana utilize during the followup.
These studies demonstrate how systematic approaches to secondary marijuana corruption can be implemented without having pregnant adverse effects on treatment for master opiate or cocaine corruption. Using stepped care or sequential CM approaches appears effective for initiating forbearance among those clashing about stopping their marijuana use. However, longer term contingencies or additional interventions may be needed to obtain enduring furnishings (Kidorf et al., 2007).
Marijuana Withdrawal
As noted earlier, many people question whether one tin truly become dependent on marijuana. The ground for skepticism is typically doubt that marijuana utilize can produce "physiological" dependence—i.e., that cessation of use produces a withdrawal syndrome. A review of the literature relevant to this effect is beyond our telescopic here. Nonetheless, research over the past 10 to 15 years has (1) established a neurobiological basis for a marijuana withdrawal syndrome via an endogenous cannabinoid system in the primal nervous system; (2) established the reliability, validity, and fourth dimension course of a marijuana withdrawal syndrome through human laboratory research and clinical studies; and (3) demonstrated the potential clinical importance of the withdrawal syndrome (Budney et al., 2004; Budney and Hughes, 2006).
The marijuana withdrawal syndrome resembles those associated with other drugs, particularly tobacco. Patients experience irritability, anger, depression, difficulty sleeping, craving, and decreased appetite. Many bespeak that these symptoms adversely impact their attempts to quit and motivate use of marijuana or other drugs for relief (Copersino et al., 2006). Well-nigh symptoms begin within 24 to 48 hours of abstinence, peak within 4 to 6 days, and concluding from 1 to 3 weeks, although significant individual differences occur in withdrawal expression.
The marijuana withdrawal syndrome does not announced to include major medical or psychiatric consequences and may be considered balmy compared with heroin and severe alcohol withdrawal syndromes. Nonetheless, myriad patient reports advise that additional inquiry to understand and develop effective clinical responses to the withdrawal syndrome may enhance outcomes and promote successful abeyance attempts.
Pharmacotherapy
To date, a handful of human being laboratory studies and one small clinical trial on potential pharmacotherapies for marijuana dependence take appeared in the literature (Hart, 2005). The majority of these efforts have targeted the marijuana withdrawal syndrome. Bupropion, divalproex, naltrexone, nefazodone, and orally administered Δ9-tetrahydrocannabinol (THC) have all been evaluated in studies with marijuana-dependent participants who were non seeking treatment or planning to quit. Divalproex has also been evaluated in an outpatient placebo-controlled trial (Levin et al., 2004). But orally given THC and, to a lesser extent, nefazodone have shown promise. THC reduced craving and ratings of anxiety, feelings of misery, difficulty sleeping, and chills (Haney et al., 2004). In addition, participants could not distinguish agile THC from placebo. These findings were replicated in an outpatient study, which establish that a moderate oral dosage of THC (10 mg, three times daily) suppressed many marijuana withdrawal symptoms and that a college dosage (30 mg, three times daily) almost completely abolished withdrawal symptoms (Budney et al., 2007). Nefazodone decreased ratings of some withdrawal symptoms (feet and muscle pain), but other ratings (irritability, feelings of misery, and difficulty sleeping) remained high (Haney et al., 2003).
In summary, the developing literature on pharmacotherapy for marijuana dependence supports farther testing of THC, an approach that parallels the use of agonist medications such as methadone and the nicotine patch. Continued exploration of compounds that target mood, sleep difficulty, craving, and appetite appears warranted given the strong and reliable symptoms observed in withdrawal studies. Other promising strategies for pharmacotherapies include targeting the underlying physiology of withdrawal—specifically, the decreases in dopamine activity in the mesolimbic dopamine pathway—and treating comorbid disorders such as depression or anxiety. Researchers likewise are exploring the possibility of medications to help abstinent individuals avoid relapse past blocking marijuana's rewarding effects. One such chemical compound, the cannabinoid receptor antagonist SR141617A (rimonabant), has been shown to block the drug's subjective and physiological furnishings (Huestis et al., 2001).
Tobacco Smoking Among Marijuana Users
Like users of other drugs of abuse, regular marijuana users have a higher rate of tobacco apply than the general population; approximately fifty pct of heavy cannabis users as well smoke tobacco (Ford, Vu, and Anthony, 2002; Moore and Budney, 2001). Moreover, many adolescents and, to a lesser extent, adults use tobacco and marijuana together, either mixing the substances, smoking blunts (hollowed out cigars filled with marijuana), or smoking one immediately after the other.
At least one study suggests that, among cannabis-dependent individuals, tobacco smokers have worse psychosocial issues and poorer cannabis cessation outcomes (Moore and Budney, 2001). Whether this indicates that treatments for marijuana dependence should simultaneously address tobacco smoking is non clear. No clinical studies take focused on this issue. However, inquiry suggests that handling that promotes smoking cessation does not disrupt alcohol forbearance and may actually enhance the likelihood of longer-term sobriety (Gulliver, Kamholz, and Helstrom, 2006).
I laboratory written report compared withdrawal symptoms during simultaneous abeyance of marijuana and tobacco to withdrawal from each substance solitary (Vandrey et al., 2007). Withdrawal was more severe during simultaneous abeyance, but the differences were of brusk elapsing and not robust, and substantial individual differences were noted. Interestingly, five participants rated dual forbearance as the most difficult of the three weather condition; four rated cannabis abstinence and three rated tobacco forbearance as the near difficult. The reason simultaneous abstinence was not uniformly experienced as most astringent may exist that both substances are smoked. Individuals quitting ane drug might take had withdrawal intensified past the smoking cues associated with continuing use of the other, while individuals quitting both were spared such cues.
Should we encourage individuals trying to quit marijuana use to try also to quit tobacco? Certainly nosotros should discuss this selection with clients, equally tobacco forbearance may make marijuana abstinence easier and increase chances of maintaining marijuana forbearance for a longer term. However, as with treatments for other substance dependence disorders, mandating tobacco cessation as a treatment goal might create a bulwark to handling seeking or trigger treatment dropout.
Handling Goals: Abstinence or Moderation?
Because marijuana is perceived as less harmful than cocaine or heroin, some people propose that apply reduction, instead of forbearance, may exist an acceptable clinical goal. Indeed, many individuals who enter treatment are ambivalent near giving upwards marijuana completely.
The only published study (n = 291) that systematically assessed the goals of adults enrolling in marijuana treatment reported that 71 percent sought forbearance, 28 percentage wanted to moderate their apply to 3 days or less per week, and 1 pct wished only to incur fewer adverse consequences from their smoking (Lozano, Stephens, and Roffman, 2006). Patient goals were measured again at the stop of handling and repeatedly during a 12-month followup catamenia. Ultimately, the portion desiring to exist abstinent declined to 49 pct, while those wishing only for fewer negative furnishings increased to 26 percent. Almost notably, patient goals predicted outcomes: 40 to 65 percent of those aiming for abstinence or moderation had achieved their desired outcome at the following assessment. The 2nd most frequent outcome among those with abstinence goals was moderation, while the second most frequent event amongst those with moderation goals was connected problematic use. In summary, forbearance goals predicted meliorate outcomes. That said, because the focus of treatment in this study was forbearance, those with moderation goals were not necessarily provided with treatment that best matched their goals.
Niggling is known about what constitutes nonharmful utilise of marijuana, and whether and when moderation may be an appropriate clinical goal for treatment. Clinical epidemiological studies conspicuously demonstrate that many individuals experiment with marijuana, and some even use the drug regularly without reporting meaning consequences. This finding clearly parallels what is observed with booze use. The thin information available on goals discussed earlier are fairly consistent with what is observed in the alcohol treatment literature—that is, patients who aim for abstinence appear to obtain amend outcomes. Some individuals who make moderation their objective can achieve it, but the likelihood of declining is greater with this goal. Moderation-focused treatments for marijuana have yet to exist tested. Thus, no guidelines or predictors be apropos which patients might succeed with this approach. Moreover, marijuana's illegality complicates whatsoever consideration of treatment goals other than abstinence.
Early Intervention and Secondary Prevention
Although more people are seeking assist for issues with marijuana today, they still represent only a small pct of those who may benefit from treatment. Of the approximately 4 million persons in the United States who reported problems consequent with a marijuana use disorder in a 2005 survey (SAMHSA, 2006a), only nigh seven to viii percentage received treatment. Adolescents who report signs of problematic use—a relatively small percentage—seldom nowadays for treatment. Those who practice most never self-refer; they are typically "forced" into treatment by parents, the juvenile justice organization, or their school administration, and virtually exercise non acknowledge that their use is problematic (Diamond et al., 2006). Responding to this situation, i group of researchers recently adult "check-upward" interventions to reach marijuana users who have not sought treatment, either because they are ambivalent about stopping or practise not perceive their use to be a problem, or at to the lowest degree not a problem severe plenty to warrant handling (Stephens et al., 2004; Walker et al., 2006).
The Teen Marijuana Check-Up (TMCU), designed for commitment in high schools, is advertised as an opportunity to "take stock" of marijuana use and is intended to facilitate a candid, in-depth evaluation of a teen's use. The program features a brief MET intervention, consisting of a computerized assessment and two thirty-minute sessions, which encourages participation by demanding minimal effort. The programme treats adolescents as experts and decision makers regarding their marijuana employ, does non label marijuana users as having a problem, and views ambiguity about the drug as normal. An initial randomized trial conducted in four high schools compared the TMCU with a delayed handling condition (Walker et al., 2006). Teens in both conditions significantly reduced their marijuana employ over a 3-calendar month period; nevertheless, no significant between-group differences were observed. Despite the absence of a clear effect of the TMCU, this study showed that adolescents using marijuana would volunteer to participate in an intervention provided at their school, a response that holds promise for reducing problematic levels of marijuana utilize.
A similar Marijuana Check-Up (MCU) for adults was designed to accomplish marijuana users who were experiencing adverse consequences, but were ambivalent about modify and not likely to enter handling (Stephens et al., 2004). Marijuana users called the clinic in response to advertisements stating that objective, upward-to-appointment information on marijuana use and its effects was available. Upon contact, callers were told that this was not a handling study and were invited to the clinic for an assessment that would so be followed by a ane-session personalized feedback session, a 1-session therapist-guided multimedia session (documentary and slide show providing objective information on marijuana and its furnishings), or a session (MET or multimedia) delayed past 7 weeks. Respondents to the advertisements were nigh-daily marijuana users, 2-thirds of whom were in the precontemplation or contemplation phase of change. Over 12 months, the MCU condition resulted in greater reductions in marijuana use and in associated problems than the multimedia condition; nonetheless, absolute levels of alter were relatively small-scale. Nonetheless, like the TMCU for adolescents, this study showed that this intervention model attracted a "unique" sample of clashing marijuana users who may be ideal candidates for secondary prevention interventions like the MCU. Continued exploration of more than potent MCU models may yield a method for reaching marijuana users who would otherwise not contact the typical treatment system, at least not at this phase of their employ.
FUTURE DIRECTIONS FOR Treatment RESEARCH
Over the terminal fifteen years, we take witnessed great advances in the empirical base for treatment approaches to marijuana utilize disorders. Clear show has accumulated for the efficacy of behavioral treatments similar to those used for disorders involving alcohol and other drugs of abuse. The goals for future research are more than stiff treatment approaches and intervention strategies.
A ameliorate understanding of the mechanisms of action of marijuana treatments and predictors of upshot will lead, it is hoped, to innovations that can better match individuals to specific therapeutic modalities or upshot in modifications to approaches that deliver more of the "agile ingredients" necessary for alter. For example, with CM interventions, factors related to the frequency, duration, and magnitude of the incentive schedule used to reinforce abstinence are likely to impact the potency of the intervention and influence result (Lussier et al., 2006). In addition, researchers demand to continue exploring the potential use of pharmacotherapies as a primary or secondary treatment approach. Recent advances in the agreement of the neurobiology of marijuana'southward deportment make this a very promising area of investigation. Continued development of cost-effective interventions remains a priority. Other areas that warrant focus include standing intendance protocols to foreclose or reduce the severity of lapses or relapses, exploration of dissimilar magnitude and schedules of reinforcement in CM interventions, and use of innovative technologies—such as computers and the Cyberspace—to help in delivery of handling or continued intendance.
Equally of import to handling development research is the pressing need to tackle issues related to broadcasting of effective treatments. Unfortunately, the substance abuse services delivery system continues to lag far behind research advances that delineate effective handling approaches. Serious challenges related to access and toll impede adoption of important scientific advances in drug dependence handling in general. The current handling organisation experiences difficulty recruiting, preparation, and retaining treatment staff; inadequate financing to provide handling; insufficient treatment availability to run into demand; and slow adoption of research-based handling innovations—all of which contribute to limited access to the most effective treatments (Carroll and Rounsaville, 2007; McLellan, Carise, and Kleber, 2003). The availability of the proven treatments for marijuana disorders—MET, CBT, and CM—is depression, even though evidence of their efficacy with substance dependence issues other than marijuana dependence has been documented for many years. Although the 3 treatments are mainstream amongst treatment researchers, few customs-based substance abuse counselors are currently trained to provide quality MET-CBT, and treatment providers remain ambivalent about CM interventions considering of their cost and CM's basic premise of providing incentives for forbearance (Kirby et al., 2006; Ritter and Cameron, 2007). Handling services enquiry must go on to investigate novel, efficient, and effective methods for treatment dissemination and implementation.
The practiced news is that the increased recognition that marijuana can cause addiction and significant negative consequences in a subset of users has prompted the development of marijuana-specific interventions and treatment materials paralleling those for other substance use disorders. These advances have increased users' and caregivers' perceptions that it is acceptable to seek and provide treatment for marijuana apply and have contributed to an increase in the number of individuals requesting help. Optimistic expectations for enhancements to electric current handling approaches announced warranted, as our growing understanding of the principles underlying behavioral treatments continues to produce innovative applications that demonstrate incremental gains in efficacy. Rapid advances in the neurobiology associated with marijuana and the cannabinoid system provide further hope for increasingly effective handling options. As well, check-upwardly interventions agree promise both for preventing more severe cases of marijuana dependence and for increasing therapeutic contacts with marijuana abusers who might benefit from treatment.
ACKNOWLEDGMENTS
Training of this paper was supported by research grants from the National Institute on Drug Abuse (R01DA12471, R01DA15186, and R01DA23526) and in office by the Arkansas Biosciences Found, the major research component of the Arkansas Master Tobacco Settlement.
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