Cannabis Use Treatment in Adolescents

1. Cannabis Use Treatment in Adolescents Kara Bagot, MD Assistant Professor of Psychiatry University of California, San Diego AMSP 2018

2. Defining Key Terms • Cannabis (CB) – plant used for a high • Marijuana – dried pieces of CB plant • Hashish (hash) – resin from CB flower • Synthetic CB - chemicals sprayed on plant • Concentrates – high potency hash AMSP 2018

3. Rates of Cannabis Use • ~ 4 million Americans ≥12 years with repeated CB problems • ~ 2% develop CUD within 2 years after onset of use • Adolescent use • Prevalence in high school seniors ~ 35% • Most commonly used illicit substance • 30% of 12th graders report CB harmful AMSP 2018

4. CB is Not Benign • Impacts brain development • Impairs cognition • ↓ Academic performance • ↑ Risk of other substance use • Treatment exists AMSP 2018

5. This Lecture Covers • CB background • CB-related effects and CUD • Screening for CUD • Treating CUD AMSP 2018

6. This Lecture Covers • CB background • Neurobiology • Methods of Use • CB-related problems and CUD • Screening for CUD • Treating CUD AMSP 2018

7. Key Definitions • Receptor • Cell surface region responding to chemical • Agonist • Substance that binds a receptor  effect • Antagonist • Substance that binds a receptor  no effect • Neurotransmitter (NT) • Brain-released chemical that causes an effect AMSP 2018

8. CB1 Receptor • In brain and spinal cord • ↑↑ CB1 receptors in memory areas • e.g. prefrontal cortex, amygdala • Responsible for: • ↓Excitatory & ↑inhibitory NT • Mediating effects of CB on brain AMSP 2018

9. CB Components • Delta-9-tetrahydrocannibinol (∆9-THC) • Partial CB1 agonist • Major CB psychoactive part • ↑ing THC potency • Cannabidiol (CBD) • Low CB1 affinity • CB1 antagonist-like • Potential medicinal effects AMSP 2018

10. Smoking • Pipe - tube w/ bowl to draw smoke into mouth • Rolling paper (joint) • Blunt – hollowed cigar w/ CB inside • Bong or bubbler – pipe w/ water in bowl • Hookah - pipe w/ flexible tube drawing smoke via H20 • Standard “dose” is 1 mg THC AMSP 2018

11. Hashish • CB plant extract w/ concentrated THC • Forms psychoactive resins • Usually smoked in a pipe • Standard “dose” is 10 mg THC AMSP 2018

12. Edibles • Examples: cookies, brownies, candies • Concentrated hash oil w/ high THC • Standard “dose” 10 mg THC AMSP 2018

13. Concentrates • Ex. Earwax/wax, dabs, shatter, honeycomb • Dabs: high-grade hash • Wax: soft, opaque oils • Extraction from CB via solvents (e.g. butane) • Standard “dose” is 40 mg THC AMSP 2018

14. Synthetics • Ex. Spice, K2, fake weed, herbal incense… • Manufactured in labs • Synthetic CB1 agonists • Sprayed onto marijuana or plant material • Plant material typically smoked AMSP 2018

15. Onset and Length of Action • Action onset varies by route • Smoked/Vape • Effects w/in sec • Typical duration = 1-3 hrs • Oral • Effects w/in 30 min-2 hrs • Typical duration = 4-10 hrs AMSP 2018

16. This Lecture Covers • CB background • Case – Typical presentation • Meet Kylie • CB-related effects and CUD • Screening for CUD • Treating CUD AMSP 2018

17. Kylie • 14 year old female • Use progressed over 2 years • Started smoking CB at age 12 with older siblings • Began monthly, progressed to weekend use • Progressed to daily use over summer vacation AMSP 2018

18. This Lecture Covers • CB background • CB-related effects and CUD • The good, the bad and the brain • Diagnostic & Statistical Manual (DSM)-V • Screening for CUD • Treating CUD AMSP 2018

19. Actions on the Brain & Behavior • ↑↑ CB1 receptors in… • Prefrontal cortex – decision-making, planning, inhibition • Ventral tegmental area – reward, motivation, cognition • Nucleus accumbens – reward, euphoria, craving • Hippocampus – learning, memory, stress • Basal ganglia – movement • Cerebellum – coordination AMSP 2018

20. Short-Term Pleasurable Effects • Euphoria • ↓ Anxiety • ↑ Relaxation • Reward/enjoyment • ∆ Sensory perception • Time slows down • Brighter colors • ∆ Shapes & space AMSP 2018

21. Adverse Behavioral Effects • ↓ Motivation, drive & focus • ↓ Grades • ↓ Strive to succeed at work or school • ↑ appetite  ↑ weight • Paranoia • Hearing voices they think are real • Complex plan to harm you • May mimic a psychotic disorder AMSP 2018

22. Adverse Cognitive Effects • Cannot think quickly • Impaired judgment & decision making • ↓ Motor performance & coordination • ↓ Inhibition/ ↑ Impulsivity • ↓ Attention/Concentration • ↓ Ability to hold, manipulate & store memories AMSP 2018

23. Problems Can Combine into a Cannabis Use Disorder • DSM-V • Same criteria for all substances • CUD  Ø Tx  heavy use & problems AMSP 2018

24. Cannabis Use Disorder Larger amounts used Much time spent Attempts cut down Neglecting major roles Important activities ↓ Interpersonal probs Physical/psych probs Hazardous use Craving • 2+ of 11 symptoms (in same yr) • Tolerance (defined by either) • ↑ amounts for same effect • ↓ effect with same amount • Withdrawal (defined by either) • Withdrawal syndrome • Take drug to ↓ withdrawal AMSP 2018

25. Check-In with Kylie • Isolating + irritable + unable to enjoy life w/out CB • Grades are worse fall term • Parents very concerned  fights • Plans to smoke weekends, but uses all week AMSP 2017

26. This Lecture Covers • CB background • CB-related problems and CUD • Screening for CUD • Behavioral • Biological • Treating CUD AMSP 2018

27. CAGE • Developed for alcohol but works for CB • C: Ever felt you needed to Cut down on CB? • A: Been Annoyed by others criticizing your CB use? • G: Ever felt Guilty about your CB use? • E: Eye-opener? • Score 2+ = potential problems • Doesn’t Dx CUD AMSP 2018

28. CRAFFT • C: Car driver (someone/yourself) high/using CB? • R: Use to Relax, like self more, or fit in? • A: Use drugs while you are Alone? • F: Forget things done while using CB? • F: Family/Friends say: you should ↓ CB use? • T: Get in Trouble while you using CB? • “No” to C, R, A then stop • “Yes” to any C, R, A continue to F, F, T AMSP 2018

29. Toxicological Screening • Urine • Detect CB ~ 5-7 days • Chronic users +/- ↑ body fat ~ 3-4 weeks • Hair • Most recent 1.5 in of growth • Detect past ~90 days CB use • Saliva • Detection level • 0.2ng/mL  12hrs • 0.5ng/mL  72hrs AMSP 2018

30. This Lecture Covers • CB background • CB-related problems and CUD • Screening for CUD • Treating CUD • Behavioral • Pharmacologic AMSP 2018

31. Treatment • Stages of treatment • ↑Motivation • Detoxification • Rehabilitation • Steps to ↓use or relapse AMSP 2018

32. SBIRT • Screen - assess CB severity & identify Tx • Brief Intervention - ↑ problem awareness/∆ motivation • Referral to Tx - substance use-specific Tx • K: CB use  neg school & family impact AMSP 2018

33. SBIRT - Brief Intervention • Confirm concern re question responses • Ask re barriers to quit & relapse risk factors • Discuss personal responsibility for consequences • Non-judgmental advice & benefits of quitting • Discuss Tx options • Encouragement & support • Solicit commitment to goals • Provide education & resources AMSP 2018

34. Cannabis Withdrawal • Day 1: insomnia, irritability, ↓focus, anxiety • 2-3: HA, craving, sweating/chills, ↓appetite, N/V • 4-14: depression, craving • 15+: ↑depression, ↑anxiety, insomnia AMSP 2017

35. Detoxification • ↓Withdrawal sx severity & minimize relapse • Core of Tx is education & reassurance • Preliminary evidence demonstrates some help AMSP 2018

36. Talk Therapies in Rehabilitation • Core is changing attitudes and behaviors • Several Types • Motivational Enhancement Therapy (MET) • Cognitive Behavioral Therapy (CBT) • Contingency Management (CM) • Adolesc. Community Reinforcement Approach • Family Therapies AMSP 2018

37. Motivational Enhancement Therapy (MET) • ↓ Ambivalence & ↑commitment to change • Discuss positives & negatives of CB use • Focus on negatives of use & problems AMSP 2018

38. Cognitive Behavioral Therapy (CBT) • Cognitive changes: • Pt Recognizes responsiblity for actions • Use & problems can change • Ptis major person to suffer consequences • Change often requires help • Behavior changes: • Develop skills for relapse prevention • Learn to control mind & behaviors • Manage high-risk situations AMSP 2018

39. Contingency Management (CM) • (+) Reinforcement to ∆ behavior • Vouchers, prizes, privileges or $$$ • Adjunctive Tx AMSP 2018

40. Adolescent Community Reinforcement(ACRA) • CBT + collaborative community support + CM • Three types of clinical sessions: • Adolescent alone • Parents/caregivers alone • Family • Goals: • ↑ Communication skills • Problem-solving • Prosocial activities AMSP 2018

41. Family-Based Therapies • ↑ Parenting skills • ↑ Parental monitoring • ↑ Limit setting • ↑ Emotional attachment with parents • ↑ Communication skills • ↓ Family conflict AMSP 2018

42. Pharmacotherapy • N-acetylcysteine (NAC) • ↑ cessation when added to CM & behavioral tx • Gabapentin • ↓ Withdrawal and craving • ↑ Tx retention • Topiramate • Poor tolerability • ↑ Depression, anxiety • ↓ Coordination, balance, weight • Questionable efficacy re: • ↓ Grams of CB smoked/day • Ø abstinence, ↓ days use, or urine CB testing AMSP 2018

43. Does Rehabilitation Work? • Hard to measure w/out double-blind studies • Intensity of use may naturally ↑ & ↓over time • Most drug problems have spontaneous remissions • Some evidence of effects of CUD Tx • K: Referred to 3 mo outpt family therapy • ↑(+)social activity ↓ CB using peers  ↑ functioning AMSP 2018

44. This Lecture Covered • 1. CB background • Neurobiology • Methods of Use • 2. CB problems & CUD • Good, bad & brain • DSM-V • 3. Screening for CUD • Behavioral • Biological • 4. Treating CUD • Behavioral • Pharmacologic AMSP 2018

45. Take Home Points • ∆9-THC causes psychoactive effects • CUD can lead to significant problems • Screening is essential for treatment • Several treatments for CUD exist AMSP 2018

46. Questions???? AMSP 2018