Marijuana…Weeding Out Fact
From Fiction
Short and Long Term Treatment Options
John Rodolico, Ph.D
McLean Hospital
Harvard Medical School
Recent Trends in Marijuana Use
Recent Trends in Marijuana Use
Trends:
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Past month MJ amongst teens is up 42% (up from 19% in 2008 to
27% in 2011), which is equivalent to about 4 million teens.
Past year MJ amongst teens is up 26% (up from 31% in 2008 to 39%
in 2011), which is equivalent to about 6 million teens.
Lifetime MJ amongst teens is up 21% (up from 39% in 2008 to 47% in
2011), which is equivalent to about 8 million teens.
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.
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)
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.
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.
Treatment Considerations
How do we tell the difference
between kids who smoke and those
who don’t in a treatment setting?
Kids who don’t smoke pot
Kids who smoke pot
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 WON’T
• This may happen physically but not with overt
motivation
What do we do in Treatment?
Motivational Interviewing and CBT
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
Spirit of Motivational Interviewing
with Adolescents
THE SPIRIT OF
MOTIVATIONAL INTERVIEWING
• COLLABORATION—Counseling involves a partnership
that honors the client’s expertise and perspectives. The
counselor provides an atmosphere that is conducive rather
than coercive to change
• EVOCATION—The resources and motivation for change
are presumed to reside within the client. Intrinsic
motivation for change is enhanced by drawing on the
client’s own perceptions, goals, and values
• AUTONOMY—The counselor affirms the client’s right and
capacity for self-direction and facilitates informed choice
• Patience, Patience, Patience
Fundamental Processes in MI
Engaging
Focusing
Evoking
Planning
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)
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 MI+CBT)
• Strategies include; self monitoring, altering
reinforcement contingencies, skills training
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
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
STEP ONE HISTORY
(Combination of MI +CBT+TSF)
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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
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
Questions and Thank You!