How can we optimise treatment of people

who are cannabis dependent?

Tom Freeman
Clinical Psychopharmacology Unit
University College London, UK

Disclosure statement:
I have no conflicts of interest

Outline of talk

EMCDDA (April 2015)

Overview of
current treatment

Strategies for
improvement

CURRENT TREATMENT

What is the problem?

Current treatment

Psychological Approaches

Current treatment
Cannabis specific:
CANDIS

* ** *

Hoch et al. 2011, 2012, 2014

Current treatment
Cannabis specific:
CANDIS

MI resolve ambivalence &

strengthen motivation to change

* ** *

CBT cannabis education,

cognitions-emotions-behaviours, new
coping skills
Psychosocial problem solving (e.g.
unemployment)

MI: Motivational Interviewing; CBT: Cognitive Behavioural Therapy

Current treatment
Cannabis specific:
CANDIS

End treatment: 46.3% abstinent

vs. 17.7% in waiting list

* ** *

6 months: 35.7% abstinent

Hoch et al. 2011, 2012, 2014

Current treatment

General approaches
Based on similar concepts
(e.g. MI/CBT)
Tailored to individual need
All drug groups treated together;
cannabis users are younger with
different problems

Unmet clinical need

EMCDDA (April 2015)

STRATEGIES FOR IMPROVEMENT

1) Increase European investment

Treatment provision
Research funding

2) Refine psychological approaches

MI (1-2 sessions) and CBT (4-14 sessions) beneficial

CM may improve further

Optimum number of
sessions (cost effective?)

Cannabis-specific vs. general approaches?

Cooper et al. (2015) Health Technology Assessment

2) Refine psychological approaches

Control group (drug trial)

2) Refine psychological approaches

Control group (drug trial)

Control group (psychological trial)

2) Refine psychological approaches

Control group (drug trial)

Control group (psychological trial)

Placebo versus nocebo

Move beyond everything works

Consider single- or even double- blinding

3) Find effective pharmacotherapies

Oral THC
withdrawal, maintenance

THC/CBD spray
withdrawal, maintenance

N-acetylcysteine (GLU modulator)

2.4 greater odds of negative urine

Gabapentin (GABA modulator)

use, withdrawal, depression, sleep, problems

Allsop et al. (2014), Gray et al. (2012), Levin et al. (2011), Mason et al. (2012)

3) Find effective pharmacotherapies

Placebo
Dependent on
cannabis &
want to quit

CBD 200mg
CBD 400mg
CBD 800mg
4 weeks

Primary outcome: cannabis use during

treatment

24 weeks

4) Prioritise specific populations

Adolescence: huge clinical need & potentially the most
vulnerable
Co-morbid mental health problems: psychological
interventions are not effective

Cooper et al. (2015) Health Technology Assessment

5) Improve access to treatment

Telephone & computer: small effect across 10 studies
Computer vs. therapist MI/CBT/CM?
Same attendance, retention and cannabis use outcomes

Smartphone: promising area Jan Copeland (symposium on Friday)

Budney et al. (2011), Tait et al. (2013)

6) Dont forget about tobacco

Europe: 78 92%

Australasia: 40 50%

Americas: 7 12%
Hindocha et al. (submitted)

6) Dont forget about tobacco

Is cannabis a gateway for harder drugs?
Reverse gateway: people are exposed to tobacco first by
using cannabis
Tobacco linked to greater cannabis dependence and relapse
Dual abstinence: best outcome

Haney et al. (2010), Hindocha et al. (2015), Patton et al. (2005)

6) Dont forget about tobacco

Harm reduction?
Pipes/bongs/vaporizers may facilitate use without tobacco

12th Aug 2015

Conclusion

Rising clinical need across Europe

Specific/general psychological approaches

How to optimise treatment?

1)

Increase European investment

2)

Refine psychological approaches

3)

Find effective pharmacotherapies

4)

Prioritise specific populations

5)

Improve access to treatment

6)

Dont forget about tobacco

Thanks to collaborators and funders

Celia Morgan, Exeter

Clinical Psychopharmacology Unit, UCL

Adam Winstock, Michael Lynskey,
GDS
KCL

Tailor treatment to individual need

DSM-5 Cannabis Use Disorder
Continue despite problems: psychological/physical
Time spent obtaining, using, recovering
Use more/longer than intended
Tolerance
Craving/strong desire
Give up other activities
Unable to control use or quit
Withdrawal
Failure to meet important obligations
Continue despite problems: social/interpersonal
Use in hazardous situations