Double Trouble: Tobacco And Marijuana, Treatment Development

1. Double Trouble: Tobacco And Marijuana, Treatment Development Alan J. Budney, Ph.D. Addiction and Health Research Department of Psychiatry Geisel School of Medicine at Dartmouth 2014 Norris Cotton Cancer Center Comprehensive Thoracic Oncology Program Retreat May 22, 2014

2. Disclosures Research supported by NIH (NIDA) • NIDA R01-DA032243 • (Targeting Tobacco and Cessation During Treatment for Cannabis Use Disorders) • NIDA R01-DA012471 • (Treatment of Adolescent Marijuana Use) • NIDA T32-DA037202 • (Science of Co-Occurring Disorders) - Limited Consultation with GW Pharmaceuticals/Otsuka(2011) - Participation in Pharmaceutical Company Trials (1995-2004)

3. Outline • Prevalence of cannabis (marijuana) use and problematic use • Prevalence of and concerns with co-use of tobacco and marijuana • Clinical approaches to treatment • Current pilot study • Discussion

4. Past Month Illicit Drug Use among Persons Aged 12 or Older: 2012 SAMHSA, 2013

5. Dependence or Abuse on Specific Drugs in the Past Year Among Persons 12 or Older, (2012) SAMHSA, 2013

6. Substances for Which Most Recent Treatment Was Received in the Past Year (Aged 12 or Older) SAMHSA, 2013

7. Marijuana and Tobacco Co-Use SAMHSA, 2013 Approximately 50% of adults in treatment for cannabis use disorders (CUD) report concurrent tobacco use

8. Patterns of Co-Use • Tobacco use onset has typically preceded marijuana use; but not always and some indication that this trend is changing • Smoked together (blunts, spliffs, vapor pens or pipes) • Chasing: smoke a cigarette immediately after marijuana • Separately: smoke marijuana, use tobacco as usual, no intentional mixing

9. The Future??

10. Mechanisms Underlying Co-Use? • Common and reciprocal genetic pathways to co-use • Evidence from twin studies suggests heritability • CNR1 polymorphism associated with nicotine dependence • Pharmacological interactions (increase reinforcing effects) • Endocannabinoid system is involved in the reinforcing effects of nicotine • Marijuana users report tobacco use enhances the marijuana high

11. Mechanisms Underlying Co-Use? • Common route of administration • both substances typically inhaled by smoking (vaporizing) • may increase learned associations between substances through conditioned smoking cues signaling availability of reinforcement from the other substance • Understanding neurobiological or behavioral mechanisms underlying co-use may improve treatments

12. Concerns of Co-Use - Social, psychological, and physical impairments related to use - Substantial public-health costs due to tobacco-related illnesses and death - Targeting only cannabis still leaves the substantial negative-health related consequences of tobacco use - Co-use Impacts Treatment Outcomes - Use of one can negatively impact quit rates for the other - Tobacco smoking is a predictor of poor outcomes for those in treatment for cannabis use disorders - Cannabis use among tobacco smokers predicts continued long term tobacco use

13. Cannabis and Respiratory System and Cancer RiskGates et al. (2014) • Why should we be concerned • Cannabis smoke contains similar array of carcinogens to tobacco smoke (e.g. increased tar, ammonia, hydrogen cyanide) • Smoking topography: prolonged and deep inhalation • 5-fold increase in carboxyhemoglobin • 4-fold increase in tar inhaled; 30% more retention in lower airway • Quantity, frequency, and duration of use are associated with respiratory problems • A lot we don’t know: dose effects, impact of different cannabinoids (e.g., CBD) • Data are not clear that it has additive effects to tobacco

14. Cannabis and Respiratory System and Cancer Risk • Bronchial dynamics (acute effect: bronchodialator) • Results in airway inflammation and infection • Increased bronchitis and seeking of Rx for respiratory illness • Higher frequency cough, sputem production, and wheezing • Equivocal data on COPD and related indicatior (FEV, FCV) and Emphysema (sparse literature) • Lung Cancer • Some support for a link between cannabis use and cancer risk, but • Suggest link between use and premalignant cancer • Link to development of lung cancer remains weak • Link to “heavy” use more positive

15. Treatment for Cannabis Use Disorder • Effective behavioral treatments for CUD: • Gold Standard: Combination of Cognitive Behavioral Therapy (CBT)and Contingency Management (CM) TypicalProgram - 12 Weeks - Weekly Counseling Sessions - Abstinence-based Incentives

16. Motivational Incentives (CM) Improve Outcome Budney et al. (2006)

17. Computer-Assisted Treatment Percentage of Participants Budney et al. (in prep)

18. What about Tobacco in this Population? • Tobacco users (50%) have poorer outcomes • Almost none quit tobacco during treatment • Negative health consequences of tobacco use Suggested that targeting tobacco use might be an option for increasing treatment success and reducing harm from tobacco

19. Potential Approaches to Combining Interventions • Approaches for integrating treatments • sequential(cannabis treatment first, then offer treatment for tobacco) • simultaneous (treat both at the same time)

20. Tobacco Intervention • Combination behavioral counseling (computer-assisted) and pharmacotherapy • NRT was chosen over other pharmacotherapies for tobacco two reasons: • vareniclineand bupropion have side effects profiles that may increase symptoms of cannabis withdrawal • NRT is available without a prescription; easier to access We provide Patch, Gum, Lozenges

21. NIDA R01 • Aims • develop and pilot test a treatment program providing an intervention for tobacco during treatment for CUD • conduct an initial randomized trial

22. Cannabis MET/CBT Computer Modules • Modules 1 and 2 (MET) • an interactive review of a personalized feedback report • goal-setting exercises, including setting a quit date • Modules 3–8 (CBT) • developing an effective social support system, • understanding use patterns, • coping with craving, managing thoughts about using, • problem solving, • refusal skills, • coping with lapses, • managing moods, • assertiveness skills, • lifestyle goal-setting exercise. • The last module encourages participants to revisit helpful computer modules, and to remotely access the relapse prevention module in the future.

23. Tobacco Intervention 5 computer modules (10-30 min each) • personalized assessment - Stop Tabac(Etter, 2009) • Psychoeducation: co-use of cannabis and tobacco • NRT education and instruction; • planning for change/setting a quit date; • reduction strategies

25. Sample of a cumulative progress graph (i.e. cumulative weeks negative cannabis urine screens)

31. Stop Tobacco: Personalized Feedback Report

32. Email Messages Intended to motivate and provide specific instructions based upon responses to the personalized questionnaire

36. Participants • Inclusion Criteria: • adult (> 18 years old) cannabis users seeking treatment for cannabis who also smoke tobacco regularly • meet DSM-IV diagnosis for cannabis abuse or dependence • at least some interest in quitting tobacco (> 2 on a 5 pt scale)

37. Participant Demographics

38. Pilot Study Hypotheses • 90% would complete the first tobacco module. • >40% would set tobacco smoking quit dates and initiate NRT. • Tobacco quit attempts: >35% would make at least one tobacco quit attempt (>24 hrs); >25–30% would achieve two weeks of continuous abstinence; >15–25% would be tobacco abstinent during the final 4–6 weeks. • <10% would report adverse effects of NRT that led to discontinuation. • >35–40% would achieve >4 weeks of documented continuous cannabis abstinence during treatment.

39. Summary of Outcomes • 12 out of 14 participants completed at least one tobacco module (mean = 2.2 modules). • 3 out of 14 participants set a quit date, and 8 out of 14 initiated NRT. • Tobacco quit attempts: 10 of 14 made at least one quit attempt lasting at least 24 hrs, 5 made quit attempts lasting at least two weeks, 1 was tobacco abstinent for the final four weeks of treatment. • No participant discontinued NRT use due to adverse effects. • 6 out of 14 participants achieved >4 weeks of documented continuous cannabis abstinence (mean = 9.5 weeks)

40. Cannabis and Tobacco Outcomes

41. Cannabis and Tobacco Outcomes

42. Cannabis and Tobacco Outcomes

43. Summary • Preliminary fidnings from the pilot: • the tobacco intervention is not adversely impacting cannabis outcomes; • the majority participated in the tobacco intervention and showed substantial interest in quitting or reducing • sustained tobacco quit rates are lower than anticipated, but participants are reducing use and attempting to quit tobacco

44. Alternative Strategies • Decision Support System Task (Mary Brunette, M.D.) • web-based interactive assessment • Subsequent incentive program for tobacco abstinence • Add an 8-week incentive program targeting both for those who quit cannabis but not tobacco • Increase utilization of Stop Tabac (i.e. encourage use of supportive emails, setting a quit date) • Additional pharmacological options (i.e. varenicline, buproprion)

45. Final Comments • Marijuana use is likely to increase • Higher potency marijuana will be used • Combined nicotine/tobacco/cannabis products will be developed and marketed • May become gateway for tobacco / nicotine • Vaporizers / e-cigs e-pens / will have impact on prevalence of use and co-use....consequences are unclear • How all this will impact your field.....IDK

46. Acknowledgements Clinic Staff Members • Kathy Marshall, M.S. • Gray Norton, B.A. • Stanley See, B.S. • Hao Yang, B.S. • William Pelham III Co-Investigators • Dustin Lee, Ph.D. • Catherine Stanger, Ph.D. • Mary Brunette, M.D. • John Hughes, M.D. • Jean-Francois Etter, Ph.D. Funding: National Institute on Drug Abuse: R01 DA032243

47. Thank you for your attention!Questions?