Recovery Month Conference - Ventura County...
Transcript of Recovery Month Conference - Ventura County...
Christian Thurstone, M.D.Associate Professor of PsychiatryUniversity of Colorado Denver
September 19, 2012
Marijuana: The Blunt Truth
Recovery Month Conference
Trends in use Why adolescent MJ use mattersPrevention and Treatment
Trends
Son, if you’re going to smoke pot, let me know so that
I can get you a “green card.”
Thanks, dad.
Please don’t tell your mother
Change in adolescent past month MJ use in Los Angeles
0
5
10
15
20
25
30
22.5%
Youth Risk Behavior Survey, 2012
%22.2% 18.1
%
21.4% 19.3
%
22.4%
Limitations of CDC data
Does not include teens not in school
Still awaiting data on availability, norms, attitudes
No statistically significant changes
School Expulsions for Drugs - CO
0
2
4
6
8
10
1276
7
53
4
75
3
#
http://www.cde.state.co.us/cdereval/rv2011sdiincidents.htm
0
2
4
6
8
10
12
Year
# of + DREs for THC
Drugged Driving
300 304335
429
391
599
0
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4
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8
10
12
Year
# fatalities with driver +
for THC
Drugged Driving
2729
39
41
47
Teens in substance tx (N=80)
“Have you ever obtained MJ from someone with a MMJ license?”
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25
50
75
100
N = 38/8049%
N = 42/8051%
Thurstone et al.,
“Have you ever obtained MJ from someone with a MMJ license?”
Primary Care Sample (N=66)
0
25
50
75
100
N = 12/6618%
N = 44/6682%
VariableUsed
someone’s MMJn=122
Not used someone’s MMJ
n=42p-value
Male (%) 80.3% 64.3% 0.035
# days of MJ use in past 6 months
102.7 days 81.6 days 0.047
# MJ use d/o sx’s 5.52 3.29 0.0005
Salomonsen-Sautel et al., 2012
N = 137 Yes or unsure No
Is MJ safe for children < 13 yrs?
11.7% 88.3%
Is MJ safe for teens 13-18 yrs?
38.2% 61.8%
Is MJ safe for pregnant women?
27.9% 72.1%
Shuman et al., 2012
Hall and Degenhardt, 2009; NSDUH, 2011
Epidemiology Marijuana and the adolescent brain
17% who try MJ before 18 years develop abuse/dep, compared to 4% for >18 yrs
58% of new users are <18 years
67% of teens substance tx admits are for MJ
20% of all substance tx admits are for MJ
40% of all MJ substance tx admits are teens
Hall and Degenhardt, 2009; NSDUH, 2011
Adolescent exposure to MJ may be toxic to brain development
Age
Functional Development
Limbic system
Prefrontal system
Adolescence
Casey et al., 2008
Adolescent MJ use increases the odds of other ilicit substance use 2-3 times by young
adulthood
Agrawal et al., 2004; Fergusson et al., 2000; Fergusson et al., 2005; Grau et
al., 2007; Kandel et al., 1986; Lessem et al., 2006; Lynskey et al., 2003; Mayet
et al., 2011; van Ours et al., 2003; Yamaguchi and Kandel, 1984
Adolescent MJ use is toxic to adolescent brain development: psychosis
7 cohorts confirm adolescent exposure to MJ predicts psychosis (OR=0.72-3.0)
The risk is dose-dependent
Risk is not accounted for by intoxication effect, reverse-causation or confounds
Andreasson et al., 1987; Arseneault et al., 2002; Fergusson et al., 2003; Henquet
et al., 2005; Tien et al., 1990; van Os et al., 2002; Wiles et al., 2006
Adolescent MJ use may be toxic to adolescent brain development: cognition
Those using MJ before 17 compared to after have:
↓VIQ (103.5 vs 115.6, p<0.001) (Pope et al., 2003)
↓ verbal fluency (# of objects in a category named) (Pope et
al., 2003)
• ↓ word recall in 30 minutes (Pope et al., 2003)
• ↓ visual scanning ability (but not divided attention, working memory, flexibility) (Ehrenreich et al., 1999)
• ↓ visual scanning reaction time (but not for the other measures) (Ehrenreich et al., 1999)
• ↑ ↓difficulty learning, remembering and focus at age 27 with MJ expsure between 14-22 yrs (Brook et al., 2008)
• ↓ Whole brain volume, % cortical gray matter (Wilson et al.,
2000)
• ↑ CBF (Wilson et al., 2000)
Animal Studies - adolescent exposure is toxic to brain development
Domain Outcome
Motivation ↓
Social interaction ↑ anxiety
Memory ↓ short-term recognition
Attention ↓ filtering of unnecessary stimuli
Hippocampus ↓ ↓neurons, synaptic density
Jager and Ramsey, 2008, Rubino et al., 2009
Dunedin StudyN=1,037
0 3818 21 26 327 9 11
13
WISC-R{
Cannabis dependence
Cannabis >3X/wk
At age 38, WAIS-IV and
Attention and Memory
Meier et al., 2012
Dunedin Study
Meier et al., 2012
•Results:• ↓Cannabis dependence predicted in IQ
•↓ was dose-dependent
•Decline in IQ accounted for by adolescent onset users
• ↓Cessation of use at age 38 did not change in IQ
•↓ in all four indices of IQ: working memory, processing speed, perceptual reasoning, verbal comprehension
•Friends/family noticed significantly more memory/attention problems
Dunedin Study
Meier et al., 2012
• ↓ in IQ not accounted for by:
•past 24 hour cannabis use
•past week cannabis use
•tobacco dependence
•alcohol dependence
•other substance dependence
•schizophrenia
Fergusson et al., 2010
Adolescent MJ use predicts less educational achievement
Teens using MJ for the first time after 18 years (or never) compared to those using by 15 years are:
• 3.6 times more likely to get a HS degree
• 2.3 times more likely to enroll in college
• 3.7 times more likely to get a college degree
MJ and School
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-17%
-5%-3%
Fergusson et al., 2010
Adolescent MJ use predicts aggression
⇒ ↑Low dose THC (0.1 mg/kg) aggression (Taylor et al., 1976)
• ⇒ ↓High dose THC (0.25-0.4 mg/kg) aggression (Salzman
et al., 1976)
• ⇒ ↑Marijuana withdrawal aggression on days 3, 7 but baseline on day 28 (Kouri et al., 1999)
Adolescent MJ use and HIV, STD, teen pregnancy
early onset sex (mean=13.1 years)
↑ lifetime partners (mean=6.2)
↓ condom use (55% report sometimes or never)
↑ rates of STD’s (14%)
Adolescent MJ use is associated with:
Among 656 Denver teens on probation at 12-month f/u:
freq. of MJ use predicts STD diagnosis
# of dep. sx’s predicts non-condom use in last 6 months
Bellis et al., 2008; Brodbeck et al., 2006; Crosby et al., 2003; Guo et al., 2005; Hendershot et
al., 2010; Malow et al., 2001; Mertz et al., 2000; Shrier et al., 1997; Wu et al., 2009; Yan et al.,
2007
Marketing1966: “We do not favor smoking by young people.” - J. Cullman,
president Philip Morris
2009: “We have made a significant effort ... to connect only to
adult smokers.” spokesperson for Philip Morris
1991: 31% of 3-year-olds and 91% of 6-year-olds match Joe
Camel with a picture of a cigarette - Fischer et al., 1991
2012: “...despite claims from cigarette manufacturers...,the evidence is sufficient to conclude that marketing efforts...by tobacco companies show a consistent dose-response relationship in the initiation and progression of tobacco use among young people.” U.S. Surgeon general
Conclusions Some indicators of teen MJ use increasing but more data needed
Teens have easy access to MMJ
Teens are especially vulnerable to the effects of MJ
Difficult to protect youth in a legalized, regulated environment
UN Rights of a Child: “State parties shall take all appropriate measures...to protect children from the illicit use of
narcotic drugs and psychotropic substances...”
www.DrThurstone.com
Christian Thurstone, M.D.Associate Professor of PsychiatryUniversity of Colorado Denver
September 19, 2012
Marijuana: Treatment Update
Recovery Month Conference
Treatment
Conduct d/o 53%
ADHD 38%
GAD 23%
MDD 18%
PTSD or acute stress d/o 14%
Past-year assault 66%
Suicidal acts/thoughts 9%
Dennis et al., 2004
Treatment
Condition Treatment
SUD Family therapy, CBT
Conduct d/o Family therapy, CBT
ADHD Medications, CBT
GAD CBT
MDD CBT
PTSD or acute stress d/o CBT
Integrated MH/Substance tx
Contingency management
Case managementCBT
Continuing care
ENCOMPASS
New Treatment Research
Study Methods Results
Riggs et al., 2011
303 13-18 yo’s with ADHD and SUD
OROS/PBO + CBT for 16 weeks
OROS>PBO for ADHD
OROS had more - UDS (3.8 v 2.8)
Riggs et al., 2007
126 12-19 yo’s with MDD, CD and SUD
FLX/PBO + CBT for 16 weeks
FLX>PBO for MDD
⇒MDD remission SUD response
New Treatment Research
Study Methods Results
Stanger et al., 2009
69 14-18 yo’s in tx for MJ
MI/CBT +/- CM for 14 wks
CM>no CM DURING tx
Ramo et al., 2005
90 teens followed for 6 months after inpt tx
88% relapsed in 6 mo’s, MJ involved in 58% of relapses
Waldron and Turner, 2008
Review of 17 RCT’s since 1998 for adolescent substance tx
FT≈CBTMaintained ES at f/u:CBT: 10/12FT: 6/13
Earlier Intervention
•Before court-involvement
•Primary care
•School-based
•Treating substance misuse
NAC
Patients: 116 15-21 yo’sMethods: 8 weeks, NAC/PBO 1200mg bid + CMResults: 41% v 27% negative UDS, p=NS, well-tolerated, OR=2.4 of - UDSLimitations: 8 weeks, 40% drop-out
Gray et al., 2012
Gabapentin
50 adults in tx for cannabis dependence for 12 weeks
Gabapentin (1200 mg/day) v placebo
Gabapentin had greater decrease in grams and days per week (5 days to 0.75 for gabapentin or 1 for PBO) and
urine THC levels
Mason et al., 2012
Summary
MI/CBT
Need to increase accessibility
Need to provide continuing care
Need to provide integrated treatment
www.DrThurstone.com