Problematic Marijuana Use (Addiction): Characteristics,

Prevalence, Treatment Outcomes

Alan J. Budney, Ph.D. Dartmouth College, Geisel School of Medicine

alan.j.budney@dartmouth.edu

National Debate on Marijuana,

Cancun, Mexico January 26, 2016

My Background

• Treatment Research for Substance Use

(cannabis) problems for over 25 years

• Lab & Survey Studies: Cannabis Withdrawal

• DSM-5 Substance Use Disorders Workgroup

Goals / Conclusions for Today

1. Characterize cannabis use, misuse, or addiction

- substantial abuse potential and consequences

2. Clinical Epidemiology: Prevalence of Problems

- comparable or greater than other substances

3. Treatment Responsivity

- “efficacious” treatments

- but, like other substances: limited efficacy

4. Importance of dealing with cannabis in ways similar to other substances

Can Cannabis Use Lead to Addiction?

Behavioral and Biological Evidence

• Functions as a reinforcer in the human laboratory

• People meet dependence criteria

• People seek help for marijuana problems

• Cannabinoid system in the brain

• Effects of administration and cessation on the brain are similar to that with other drugs of abuse

• Evidence for a Withdrawal syndrome

• It is difficult for those with problems to quit

Defining Addiction (Problem Use)

Is Cannabis / Marijuana Addictive?

DSM and ICD definitions

Cannabis Use Disorder criteria are not

different from other substances

How Does Cannabis Compare

to Other Types of Dependence?

Cannabis vs. Cocaine

Cannabis Cocaine # of DSM criteria 6.3 (1.8) 7.7 (1.2)*

Continued Use 97% 97%

Cut Down 86% 93%

Larger Amounts 80% 100%*

Excessive time 73% 87%*

Withdrawal 75% 81%

Tolerance 63% 97%*

Reduced Activities 41% 87%*

• indicates significant difference

(Budney et al., 1998)

How Does Cannabis Dependence Compare to Other Types of Dependence?

Treatment seekers meet 4.7 - 5.9 of the 7 DSM-IV

criteria…reflects a lower severity syndrome

The “structure” of cannabis dependence is more similar than different than others

- unidimensional, factor structure

- full range of criterion items are endorsed

- generally less severe Budney (2006)

Cannabis Use Disorder Similar to other SUDs Shmulewitz et al. 2015; Hasin et al. 2013

Review: Multiple International Studies (n > 30), large population-based studies

Cannabis Use Disorder highly similar to other SUDS

- unidimensional construct

- full range of criterion are endorsed

- most prevalent behind alcohol and tobacco

Cannabis Withdrawal

Cannabis Withdrawal demonstrated in:

– Non-human studies (primate, rodent, dog)

– Clinical survey studies

– Human inpatient/outpatient laboratory studies

Budney et al. 2004

True Withdrawal Syndrome (Hughes 1990)

• Reliable abstinence symptoms

• Not Rare

• Onset, with Transient Timecourse

• Pharmacological Specificity

• Clinical Importance

Marijuana Withdrawal Withdrawal Discomfort Score

(Budney et al. 2003)

0

2

4

6

8

10

1-5 1-3 4-6 7-9 10-

12

13-

15

16-

18

19-

21

22-

24

25-

27

28-

30

31-

33

34-

36

37-

39

40-

42

43-

45

Abstinence Days

Severit

y S

core

*

*

* *

*

BL

*

Impact of oral THC (dronabinol)

on Withdrawal Discomfort Score Budney et al, 2007

0

1

2

3

4

5

6

7

Base Placebo Base 10mg Base 30mg

***

**

* diff from base, * diff from 10mg, * diff from 30mg

Cannabis vs. Tobacco Withdrawal (Vandrey et al., 2005; Vandrey et al. 2008, Budney et al., 2009)

Symptom Severity

0

1

2

3

Irritable

Cra

vin

g*

Restle

ssSle

ep D

iffD

epre

ssD

ec A

pp*

Diff C

onc

Aggre

ssA

nger

Str D

ream

sH

eadache

Inc A

pp*

Shakin

ess

Nause

aSto

mach P

ain

Sw

eat*

Withdrawal Checklist Symptoms

Me

an

Rati

ng

(0

-3)

Cannabis Tobacco

Clinical Importance of Cannabis WD

Similar in magnitude and severity to Tobacco Withdrawal

- similar attributions about impact on quitting & relapse

Cannabis users report using cannabis (or other substances) to relieve WD symptoms

Patients complain of WD; indicate it makes quitting difficult

# of WD symptoms predicts dependence severity 1-yr later and WD severity predicts rapid relapse (adolescents)

Cannabis Use Disorder is real, and when it occurs, it looks

much the same as other types of SUDs

NESARC data 2002 vs. 2012 Prevalence of CUD

Hasin et al. (2015)

NESARC data 2002 vs. 2012 Prevalence of CUD among Users

Hasin et al. (2015)

NHSUD 2011 (Wu et al., 2013)

U.S. Treatment Admissions

TEDS Data Set

Cannabis Use Disorder is “common” and it makes up a

substantial proportion of treatment admissions!

How Effective is Treatment?

Published Randomized Trials

Behavioral Treatments (Adults) Stephens, et al. (1994) SS, CBT

Stephens, et al. (2000) MET, CBT

Budney et al. (2000) MET, MET/CBT, MET/CBT/CM

Copeland et al. (2001) MET/CBT

MTPG (2004) MET, MET/CBT

Budney et al. (2006) MET/CBT, CM, MET/CBT/CM

Carroll et al. (2006) MET/CBT, DC, MET/CBT/CM, DC/CM

Kadden et al. (2007) MET/CBT, CM, MET/CBT/CM

Kay-Lambkin (2009, 2011) MET/CBT (computerized)

Budney et al (2011, 2015) MET/CBT/CM (computerized)

Carroll et al (2012, 2013) CBT, CM, CBT/CMabst, CBT/CMhmk

Litt et al. (2013) CaseM, CBT/CMabst, CBT/CMhmk

Hoch et al (2014) CANDIS (MET/CBT/Problem Solving)

Marijuana Treatment Project (2004)

Reduction in Days of MJ Use

0

10

20

30

40

50

60

70

80

4 Months 9 Months 15 Months

% P

art

icip

an

ts A

bst

inen

t

DTC MET MET/CBT

% of Participants Abstinent (90 days)

Add Motivational Incentives to MET/CBT (Budney et al. 2006); replicated in Carroll et al, 2006 and Kadden et al., 2007

Across Studies: Response Rates

at Participant Level (unpublished)

End Tx 6 m FU 12m FU

MET

Abstinent: 9% 10% 13%

Improved: 17% 15%

MET/CBT

Abstinent: 23% 16% 23%

Improved: 30% 25%

MET/CBT/CM

Abstinent: 43% 25-46% 28-37%

CM only

Abstinent: 40% 13-23% 14-17%

Summary of Adult Trials for CUD

- MET, CBT, CM, MET/CBT are efficacious

- Abstinence incentives (CM) enhance outcomes

- Many people do not respond to these treatments

** Still much room for Improvement

Adolescent Treatment Literature

Multiple types of family-based and group / individual

behavioral efficacious interventions (Waldron 2008: review)

Waldron et al. FFT, CBT, combo

Liddle et al. MDFT

Henggeler et al. MST

Dennis et al./Godley et al. MET/CBT, ACRA, FSN

Kaminer et al. MET/CBT

Szapocznik et al. BSFT

Stanger, Budney et al. CM

Cannabis Youth Treatment Study Abstinence at Discharge

(Dennis et al., 2004)

Incentives Enhance During and End of

Treatment Marijuana Abstinence Stanger et al. 2015

45

35 33

69 65

59

72

59

49

0

20

40

60

80

100

>=2 Wks >=4 Wks ETX

MET/CBT MET/CBT/CM MET/CBT/CM/BPT

*

* * *

* *

*

Post Treatment Abstinence

0

20

40

60

80

100

ETX 3 Months 6 Months 12 Months

MET/CBT MET/CBT/CM MET/CBT/CM/BPT

Summary of Teen Trials for CUD/SUD

- Multiple interventions are “efficacious”

- Abstinence incentive (CM) enhance outcomes

- % of teens improved appears lower than that observed

with adults

- Success rates in disadvantaged populations are low

** Still much, much room for Improvement

How Do We Improve?

Behavioral and Neuro-science Provide Targets

- Enhance Delivery Systems / Improve Access

- Endogenous Cannabinoid System; Withdrawal Syndrome

- Genetics

- Impulsivity/Delay Discounting

- Brain Function

- Innovative Incentive Programs

- Concurrent Tobacco Use

- Target Non-responders

- Innovative Use of Technology

Computer-assisted MET/CBT/CM Point Prevalence Abstinence

Budney et al. 2011, 2015

0

10

20

30

40

50

60

ETX 3 mo 6 mo

MET n=16 tMET/CBT/CM n=29 cMET/CBT/CM n=30

P

erce

nta

ge

of

Part

icip

an

ts

Study 2: Cost

0

100

200

300

400

500

600

700

Mea

n C

ost

Per

Pa

rtic

ipa

nt

MET tMET/CBT/CM cMET/CBT/CM

Adaptive Treatments: Current Teen Study Sequential Multiple Assignment Randomized Trial (SMART):

Targets Impulsive Decision Making and Nonresponders

Cannabis Use Disorders are not easily treated. Like for other SUDs, we have efficacious

treatments, but many adults and teens do not respond.

We need to find more effective treatments

and treatment strategies!

CONCLUSIONS

CANNABIS HAS SUBSTANTIAL

ADDICTIVE POTENTIAL!

ADDICTION / PROBLEMATIC USE

• Pharmacology: e.g., impact on brain reward system (dopamine) – dose, route of administration

• Availability / Access

• Cost

• Intrapersonal Factors (emotional/behavioral)

• Environmental Factors / Alternatives

• Societal Norms and Attitudes (perceived risk)

• Biological Vulnerability (genetic / congenital)

Cannabis is more similar than dissimilar to other substances that are considered “substances of abuse”

Like other substances, cannabis is used primarily for its positive (and negative) reinforcing effects

• a subset of those who use cannabis will develop problems

• problems will range from mild to severe

Funding and Support

National Institute on Drug Abuse: – multiple research and training awards

University of Vermont

University of Arkansas for Medical Sciences

Dartmouth College, Geisel School of

Medicine

THANKS!!!! Faculty/Trainees Staff / Therapists Cathy Stanger Patty Costello

Stephanie Fearer Eliza Wessinger

Brent Moore Gray Norton

Ryan Vandrey Leanna Delhey

John Hughes Lee Whetstone

Steve Higgins Doris Ogden

Warren Bickel Jonathan Young

Denise Walker Heath Rocha

Roger Roffman Andrea Meier

Bob Stephens Merrie Vannucci

Pam Brown, Jen VanScoyoc Marlo Lowe

Stacy Ryan Bobby Ward

Amanda Elton / Clint Kilts Sarah Clark

Jody Kamon Nancy Culbertson

Dustin Lee, Jacob Borodovsky Stanley See, Hao Yang

Ben Crosier Nick Tacke, Samantha Auty

James Sargent Jennifer Darsie

Additional Slides

Cannabis Withdrawal Symptoms

1) irritability, anger, or increased aggression

2) nervousness or anxiety

3) sleep difficulty (insomnia)

4) decreased appetite or weight loss

5) restlessness

6) depressed mood

7) at least 1 physical symptom causing significant discomfort (stomach pain, shakiness/tremors, sweating, fever, chills, headache)

NSDUH 2011 (Wu et al., 2013)

Adolescent Treatment Admissions

TEDS Data Set

Admissions x Criminal Justice Involvement

TEDS Data Set