Cannabis Use Treatment in Adolescents

Kara S. Bagot, MD

Alcohol Medical Scholars Program

2018

 

I. Introduction:

   A. Defining key terms

      1. Cannabis (CB) – plant used for a high

      2. Marijuana – dried pieces of CB plant

      3. Hashish (hash) – resin from CB flower

      4. Synthetic CB – chemicals sprayed on plant

      5. Concentrates – high potency hash

   B. Rates of CB use in general

      1. ~4 million Americans  ≥12 years with repeated CB problems

      2. ~2% develop CUD  within 2 years after onset of use

      3. Adolescent Use

         a. Prevalence in high school seniors ~ 35%

         b. Most commonly used illicit substance

         c. Few perceive harm - only ~30% of 12th graders report marijuana use as harmful

   C. CB is not benign

      1. Impacts brain development

      2. Impairs cognition

      3. ↓ Academic performance

      4.  ↑ risk of other substance use    

      5. However, treatment exists

   D. This lecture covers…

      1.  Background on CB and pharmacology

      2. CB-related effects and CUD

      3. Screening for CUD

      4. Treating CUD

II. CB background – Neurobiology & Methods of Use

   A. Key Definitions

      1. Receptor – region on cell surface that responds to a chemical or substance

      2. Agonist – substance that binds a receptor and causes an effect

      3. Antagonist – substance that binds a receptor and causes no effect

      4. Neurotransmitter – a chemical released by the brain that causes an effect

    B. CB1 receptor  

      1. In the brain and spinal cord

      2.  ↑↑ CB1 receptors in memory brain areas (e.g., amygdala & prefrontal cortex)

      3.  Responsible for

         a. Excitatory and inhibitory neurotransmitters

         b. Mediating the effects of CB on the brain

   C. CB Components

      1. Delta-9-tetrahydrocannibinol (∆9-THC)

         a. Partial agonist at CB1 receptor

         b. Major psychoactive component of CB

         c. THC potency increasing in CB over the years

            1’. USA 1995ΰ 2014: ↑THC/potency 3x (4% ΰ 12%)

            2’. Europe & Australia: ↑THC/potency 3x (4% ΰ 15%)

      2. Cannabidiol (CBD):

         a. Low affinity for CB1 receptor;

         b. Acts like antagonist at CB1 receptor

         c. Potential medicinal effects

   D. Methods of use

      1. Smoking

            a. Pipe - tube with bowl at end to draw smoke into mouth

            b. Rolling paper (joint)           

            c. Blunt – hollowed cigar with CB inside

            d. Bong or bubbler – pipe with water in bowl

            e. Hookah - pipe with flexible tube to draw smoke through water

            f. Standard “dose” is 1 mg THC             

      2. Hashish

         a. Extract of the CB plant with concentrated THC

         b. Forms psychoactive resins

         c. Usually smoked in a pipe

         d. Standard “dose” is 10 mg THC

      3. Edibles

              a. Examples include cookies, brownies, candies

              b. Made with concentrated hash oil with high THC content              

              c. Standard “dose” is 10 mg THC

      4. Concentrates

               a. Examples include wax, earwax, dabs, shatter, honeycomb

                      1’ Dabs: various forms of high-grade hash

                      2’ Wax: softer, opaque oils that have lost transparency after solvent extraction

               b. Extraction from CB via solvents (e.g. butane)

                c. Standard “dose” is 40 mg THC

      5. Synthetics

         a. Examples include Spice, K2, fake weed, herbal incense

         b. Manufactured in labs

         c. Synthetic CB1 agonists 

         d. Sprayed onto marijuana or plant material

         e. Plant material typically smoked

   E. Onset and length of Action

      1. Onset of action varies by route of administration

         a. Smoked/Vape

            1’. Experience effects within seconds

            2’. Typical duration = 1-3 hours

         b. Oral

            1’. Experience effects within 30 min-2 hours

            2’. Typical duration = 4-10 hours

III . Case – Meet Kylie

   A. 14 year old female

   B. Use progressed over 2 years

     1. Started smoking cannabis age 12 with older siblings

     2. Began using every month, progressed to weekend use

     3. Progressed to daily use over summer vacation

IV. CB-related effects and CUD

   A. Actions on the Brain & Behavior

      1. High density of CB1 receptors in these brain regions:

      2. Prefrontal cortex – decision-making, planning, inhibition

      3. Ventral tegmental area -  reward, motivation, cognition

      4. Nucleus accumbens – reward, euphoria, craving

      5. Hippocampus – learning, memory, stress    

      6. Basal ganglia – movement

      7. Cerebellum – coordination

   B. Short-term pleasurable effects

      1. Euphoria

      2. ↓ Anxiety

      3. Feeling reward/enjoyment

      4. Altered sensory perception

          a. Feel time slow down

          b. Brighter colors

          c. Experience change in shapes and space

     C. Adverse behavioral effects         

      1. ↓ Motivation, drive & focus

         a. ↓ Grades

         b. Strive to succeed at work or school       

      2. Appetite ΰ weight

      3. Paranoia

         a. Hearing voices they think are real

         b. Believing is a complex plan to injure or kill you

          c. Resembles a psychotic disorder but usually temporary and recover with abstinence

    D. Adverse cognitive effects

      1. Cognitive slowing/cannot think quickly

      2. Impaired judgment & decision making

      3. ↓ Motor performance & coordination

      4. ↓ Inhibition/↑Impulsivity

      5. ↓ Attention/Concentration

      6. ↓ Ability to hold, manipulate & store memories

    E. Problems can combine into a cannabis use disorder

      1. Diagnostic and statistical manual (DSM-5) used to diagnose

      2. Used same criteria as for all substance use disorders

      3. Diagnosis if not treated ↑s risk for future heavier use and problems

    F. Cannabis Use Disorder

      1. A syndrome of 2+ of 11 potential problems in same 12 months re: CB, including:

      2. Tolerance (defined by either)

         a. ↑ Amounts for same effect

         b. ↓ Effect with same amount

      3. Withdrawal (defined by either)

         a. Withdrawal syndrome (discussed below)               

         b. Take drug to ↓ withdrawal

      4. Larger amounts than intended or more time using than planned

      5. Much time spent using or recovering

      6. Repeated attempts cut down

      7. Neglecting major roles

      8. Important activities ↓

      9. Continued use despite related interpersonal problems

      10. Continued use despite related physical/psych problems

      11. Use in hazardous situations (e.g., driving when high)

      12. Craving

   G. Check-in with Kylie

      1. Has been isolating more; feels more irritable and unable to enjoy life without being high

      2. Grades are worse fall term

      3. Parents very concerned – causing fights

      4. Says she will only smoke on weekends, then ends up smoking during the week

VI. Screening for CUD – behavioral & biological

   A. CAGE

      1. Developed for alcohol but works for CB

         a. C: Ever felt you needed to Cut down on CB ?

         b. A: Have people Annoyed you by criticizing your CB use?

         c. G: Ever felt Guilty about your CB use?

         d. E: Ever felt you needed CB first thing in the morning (Eye-opener) to steady your nerves?

         e. Score 2+ = potential problems

         f. Doesn’t diagnose CUD

   B. CRAFFT

      1. Have you ever ridden in a Car driven by someone (incl yourself) who was high or using CB?

      2. R: Do you ever use CB to Relax, feel better about yourself, or fit in?

      3. A: Do you ever use drugs while you are Alone?

      4. F: Do you ever Forget things you did while using CB?

      5. F: Do your family/Friends ever tell you that you should cut down on your CB use?

      6. T: have you gotten into Trouble while you were using CB?

       7. “No” to C, R, A questions then stop

       8. “Yes” to any or all C, R, A questions then continue to F, F, T

   C. Toxicological Screening

      1. Urine

         a. Can detect CB  ~ 5-7 days after last use

         b. Chronic users or those with ↑ body fat can detect CB ~ 3-4 weeks after last use

      2. Hair

         a. Most recent 1.5 in of growth

         b. Can detect past ~90 days CB use

      3. Saliva

         a. Detection level

            1’. low levelsΰ 12h

            2’. 0.5ng/mL ΰ 72h

VII. Treatment of CUD – behavioral & pharmacologic

   A. Stages of treatment

      1. Motivation

      2. Detoxification

      3. Rehabilitation

         a. Steps to use or relapse to CUD

   B. SBIRT

      1.  Screen - assess CB use severity & identify appropriate treatment

      2. Brief Intervention - awareness of problematic CB use & motivation to change

      3. Referral to Treatment - substance use-specific intervention

     4. Kylie – CB use has led to negative impact on school & family

C. SBIRT-Brief intervention

      1. Confirm your concern with patient's responses to screening questions.

      2. Ask patient's perception, barriers to quitting, and relapse risk factors.

      3. Discuss personal responsibility for consequences of substance use.

      4. Provide non-judgmental advice & discuss benefits of quitting.

      5. Discuss treatment options.

      6. Encouragement & support. Solicit commitment to goals.

      7. Provide patient education & resources.

D. CB withdrawal

      1. Day 1: insomnia, irritability, difficulty focusing, anxiety

      2. Days 2-3: headache, craving, sweating/chills, appetite loss/stomach cramps, nausea, relapse

      3. Days 4-14: depression, craving

      4. Days 15+: depression, anxiety, insomnia

   E. Detoxification

      1. ↓ Withdrawal symptom severity and minimize relapse

      2. Core of Rx is education and reassurance

      3. Preliminary evidence demonstrates some help

   F. Talk based therapies in rehabilitation

      1. Core is changing attitudes and behaviors

      2. Motivational Enhancement Therapy (MET)

      3. Cognitive Behavioral Therapy (CBT)

      4. Contingency management (CM)

      5. Adolescent Community Reinforcement Approach (ACRA)

      6. Family therapies

   G. Motivational Enhancement Therapy (MET)

      1. Ambivalence and commitment to change

      2. Discuss positives and negatives of CB use

      3. Focus on negatives of use and problems

   H. Cognitive Behavioral Therapy (CBT)

      1. Cognitive changes include:

         a. Recognizing patient is responsible for own actions

         b. Use and problems can change

         c. Patient is major person to suffer consequences

         d. Change often requires help

      2. Behavior changes include:

         a. Develop skills for relapse prevention

         b. Learn to control mind and behaviors

         c. Manage high-risk situations            

   I. Contingency management (CM)

      1. Positive reinforcement to change behavior

      2. Can take the form of vouchers, opportunity to win prizes, privileges or money

      3. Used as adjunctive treatment

   J. Adolescent Community Reinforcement Approach (ACRA)

      1. Combination of CBT + collaborative community support + CM

      2. Three types of clinical sessions:

         a. Adolescent alone

         b. Parents/caregivers alone

         c. Family

      3. Goals:

         a. ↑ Communication skills

         b. Problem-solving

         c. Participation in positive social activities

   K. Family-based therapies

      1. ↑ Parenting skills

      2. ↑ Parental monitoring

      3. ↑ Limit setting

      4. ↑ Emotional attachment with parents

      5.  ↑ Communication skills

      6. ↓ Family conflict

   L. Pharmacotherapy

      1. N-acetylcysteine (NAC)

         a. Enhance cessation outcomes when added to contingency management and behavioral tx

      2. Gabapentin

         a. ↓ Withdrawal and craving

         b. ↑ Treatment retention

     3. Topiramate

         a. Poor tolerability

            A’. ↑ Depression, anxiety

            B’.  Coordination/balance difficulty, paresthesia, weight loss

         b. Questionable efficacy re:

            A’. Reduction in the number of grams of CB smoked per day

            B’.  Not associated with abstinence, days of CB use, or urine CB testing

  M. Does rehabilitation work for CUD

     1. Hard to measure without double-blind studies

     2. Intensity of use naturally and over time

     3. Most drug problems for adolescents have spontaneous remissions

     4. Some evidence of potential significant effects of CUD treatment

     5. Kylie: Was referred to 3 months of outpatient family therapy

         a. Led to ↑ prosocial activities, ↓ association with CB-using peers & ↑ psychosocial functioning

VIII. Conclusions

   A. Take home points

      1. ∆9-THC causes psychoactive effects

      2. CUD can lead to significant problems

      3. Screening is essential for treatment

      4. Several treatments for CUD exist