Reaching nontreatment-seeking cannabis users: Testing an extended marijuana check-up intervention.

Some adult cannabis users report negative consequences of use but do not seek treatment. Nonjudgmental, brief interventions incorporating motivational interviewing techniques may be able to reach users who otherwise would not seek treatment and increase their motivation to change use. Previous studies have shown brief interventions with this population are efficacious in reducing use, but the absolute amount of change has not clearly translated into meaningful reductions in associated negative consequences. The current study used a marijuana check-up (MCU) model to attract nontreatment-seeking adults who used cannabis at levels that may have caused negative consequences. The study randomly assigned participants to 2-session (n = 93) and 6-session (n = 93) versions of the intervention and followed them for 12 months. The study designed the extended 6-session condition to build on the efficacy of the previously tested 2-session intervention. The study hypothesized that the opportunity to continue to consider the consequences of cannabis use would have the greatest impact on those who were in earlier stages of readiness for change. We used cognitive behavioral techniques to assist with change efforts when indicated. Results showed significant reductions in the frequency and daily duration of cannabis use at all follow-ups in both intervention conditions. The extended 6-session condition produced greater change only on a measure of the number of periods of the day in which cannabis was used. Reductions in dependence symptoms and problems related to cannabis use occurred in both conditions, but there was no effect of intervention condition. Participants who were less ready to make changes at the outset decreased use and negative consequences the least. Results suggested that some benefit of the extended session format of the check-up in reducing daily use, but the lack of a corresponding reduction in consequences suggested that the original 2-session MCU may be more cost effective.

Treating cannabis use disorder: Exploring a treatment as needed model with 34-month follow-up.

Research has demonstrated that motivational enhancement (MET) and cognitive behavioral therapy (CBT) are some of the most effective interventions for adults with cannabis use disorder (CUD). As few as two sessions of combined MET and CBT has produced abstinence and reductions in cannabis use greater than delayed treatment controls. Despite their efficacy, outcomes in previous studies yielded abstinence rates from cannabis in the range of 20-30% at follow-ups of 6 to 12 months, and CUD remained a chronic condition for many. Additional models of providing treatment "as needed" (PRN), rather than as a single fixed-dose, are necessary to meet the different needs of adults with CUD and reengage those who do not respond to treatment initially or who relapse later. In the current study, 87 adults who met DSM-IV criteria for cannabis dependence were randomly assigned to receive either a fixed-dose of nine sessions of MET/CBT or to a PRN condition that provided a smaller initial dose of treatment, but allowed repeated access to treatment for 28 months. Cannabis use and associated problems were assessed every six months throughout a 34-month period. More than one-third of participants in the PRN condition accessed additional treatment episodes, but the total number of treatment sessions that participants utilized was comparable across conditions. Both treatments yielded significant reductions in cannabis use and associated problems at each follow-up. Contrary to hypotheses, the PRN condition did not yield better outcomes at the longer-term follow-ups. The fixed-dose condition produced greater rates of abstinence at the first follow-up, but otherwise there were no between group differences in outcomes. Future studies should test active approaches to reengaging participants with treatment when initial outcomes are less than optimal.

The Implications of Cannabis Policy Changes in Washington on Adolescent Perception of Risk, Norms, Attitudes, and Substance Use.

There is increasing interest in the effect of legalization (particularly recreational legalization) of cannabis on prevalence of use and related problems. However, there is no consensus about the impact of policy change on cannabis use, particularly among adolescents. Legalization may increase adolescent use through mediating factors such as perceived risk and normative beliefs regarding the use of cannabis. Washington State enacted Initiative 502 on December 2012, which legalized and taxed recreational cannabis for adults aged ⩾21 years. This paper used data from a randomized, controlled intervention trial for cannabis-using adolescents that was recruiting participants in Seattle before and after the policy change to evaluate the following goals: assess differences in substance use, problems, and symptomatology pre- and post-policy change; evaluate several proposed risk factors that may be associated with such differences; and describe participants' understanding of the law and how this understanding may relate to rates of use. Analyses revealed no significant differences pre- to post-policy in rate of substance use. However, there were significant post-policy increases in problems and use disorder symptoms. Despite these differences, there were no significant increases in norms, attitudes, or perceptions of risk. Participants were able to answer most questions regarding policy changes correctly, indicating a good understanding of the policy. Results provided no evidence that policy change influenced heavy-using adolescents' rates of use nor the proposed risk factors associated with problematic use patterns.

Changing social norms: The impact of normative feedback included in motivational enhancement therapy on cannabis outcomes among heavy-using adolescents.

INTRODUCTION: Heavy cannabis use is a problematic behavior, particularly among some adolescents. Adolescents are particularly prone to social influence. As such, injunctive norms (perceptions of others' approval of cannabis use) and descriptive norms (perception of frequency of others' cannabis use) influence cannabis behavior. Given that norms are not always accurate, motivational enhancement therapy aims to reduce cannabis use through normative feedback and correction of normative misconceptions. The purpose of this study was to evaluate the relationships between perceived norms (descriptive and injunctive) and cannabis-related outcomes (use, cannabis-related problems, and cannabis use disorder symptoms) in a heavy cannabis-using adolescent population receiving motivational enhancement therapy. METHODS: Heavy cannabis-using individuals (n=252, 68% male, mean age 13.38, 59% Caucasian) were recruited from six Seattle high schools for a motivational enhancement therapy-based intervention involving normative feedback. RESULTS: Participants perceived higher rates of cannabis use among close friends than other same age teens and reported a higher perception of approval for cannabis use from close friends as compared to perceived approval of other same aged peers. Personal approval and the perceived approval of other same age teens were reduced following the intervention but there was no evidence of change in normative perceptions for close friends following the normative feedback interventions. Changes in normative perceptions were related to decreases in cannabis use and -related outcomes. CONCLUSIONS: Results suggest the importance of normative feedback in changing behavior in adolescent cannabis users, but also highlight the ongoing influence of close friends.

Psychometric assessment of the marijuana adolescent problem inventory.

Cannabis is one of the most commonly used psychoactive substances among adolescents in the United States. Adolescent cannabis use has multiple consequences including academic, health, and psychiatric problems. The Marijuana Adolescent Problem Inventory (MAPI) is a 23-item scale adapted from the Rutgers Alcohol Problem Index and used in the current literature to assess cannabis use problem severity. Psychometric testing for the MAPI has yet to be reported. The current investigation assessed the psychometric characteristics of the MAPI with cannabis-using adolescents (n=727) from school and outpatient settings who enrolled in five separate randomized clinical trials focused on treatment of substance use. Findings suggested that the MAPI is internally consistent and reliable. Factor structure analyses suggested that the MAPI measures one latent construct, with no differences in factor structure between the outpatient and school settings, supporting a one-factor model. External validity of the MAPI was also demonstrated as evidenced by significant relations with concurrent diagnosis of cannabis dependence and abuse, longitudinal frequency of cannabis use, and mean times used per day. Overall, this initial test of the psychometric characteristics of the MAPI suggests that it can be considered a reliable and valid measure of problems associated with cannabis use among adolescents. Future work is now needed to replicate these findings by testing the psychometric properties of the MAPI in more diverse samples and developing a short version to be used as a brief assessment tool.

Mobile contingency management as an adjunctive treatment for co-morbid cannabis use disorder and cigarette smoking.

INTRODUCTION: Cannabis is the most widely used illicit drug in the U.S. with 19.8 million current users. Population-based data indicate that almost all cannabis users (90%) have a lifetime history of tobacco smoking and the majority (74%) currently smoke tobacco. Among cannabis users, smoking tobacco is associated with increased frequency of cannabis use, increased morbidity, and poorer cannabis cessation outcomes. There is a lack of research, however, focused on addressing cessation of both substances simultaneously. The purpose of the current pilot study was to evaluate the feasibility and acceptability of a multi-component tobacco/cannabis abstinence treatment. METHODS: Five participants completed Abstinence Reinforcement Therapy, an intervention that included five sessions of cognitive-behavioral telephone counseling for tobacco/cannabis, pharmacotherapy for smoking cessation, and five weeks of mobile contingency management to remain abstinent from tobacco and cannabis. RESULTS: Feasibility of recruitment, retention and treatment completion was high. Satisfaction with the treatment was also high. CONCLUSION: Results support the feasibility and acceptability of this approach with dual cannabis and tobacco users and suggest that further research examining the efficacy of this approach is warranted.

Augmenting brief interventions for adolescent marijuana users: The impact of motivational check-ins.

OBJECTIVE: Brief interventions for adolescent marijuana users offered in schools reach users who would not otherwise present for treatment. The current study builds on previous trials of a school-based, 2-session motivational enhancement therapy (MET) intervention by adding periodic, brief motivational check-ins to reinforce gains and bolster motivation. METHOD: Adolescent participants were randomly assigned to a motivational check-in (MCI; n = 128) or assessment-only check-in (ACI; n = 124) comparison condition. Both conditions received 2 sessions of MET. Participants in the MCI condition then attended 3 MET-based check-in sessions at 4, 7, and 10 months after baseline, whereas the ACI condition participants attended assessment-only check-ins at the same time points. Optional cognitive behavior therapy (CBT) sessions were available as needed for 12 months from baseline in both conditions. RESULTS: Outcomes were assessed at 6, 9, 12, and 15 months after baseline. Participants (59% Caucasian; 68% male; mean age = 15.84) reported using marijuana on an average of 37 of the last 60 days, and 70% met diagnostic criteria for a marijuana use disorder. Both conditions were associated with reduced use and negative consequences that were sustained throughout the 15 months of follow-up. The MCI condition resulted in greater reductions at the 6 months follow-up, but differences between conditions were not found at later follow-ups, and MCI participation did not increase engagement in CBT as predicted. CONCLUSIONS: Results replicated the efficacy of the brief intervention for adolescent marijuana use and provided mixed evidence on the utility of adding repeated check-in sessions. (PsycINFO Database Record

Change in motives among frequent cannabis-using adolescents: Predicting treatment outcomes.

BACKGROUND: Heavy cannabis use has been associated with negative outcomes, particularly among individuals who begin use in adolescence. Motives for cannabis use can predict frequency of use and negative use-related problems. The purpose of the current study was to assess change in motives following a motivational enhancement therapy (MET) and cognitive behavioral therapy (CBT) intervention for adolescent users and assess whether change in motives was associated with change in use and self-reported problems negative consequences. METHODS: Participants (n=252) were non-treatment seeking high school student cannabis users. All participants received two sessions of MET and had check-ins scheduled at 4, 7, and 10 months. Participants were randomized to either a motivational check-in condition or an assessment-only check-in. Participants in both conditions had the option of attending additional CBT sessions. Cannabis use frequency, negative consequences, and motives were assessed at baseline and at 6, 9, 12, and 15 month follow-ups. RESULTS: There were significant reductions in motives for use following the intervention and reductions in a subset of motives significantly and uniquely predicted change in problematic outcomes beyond current cannabis use frequency. Change in motives was significantly higher among those who utilized the optional CBT sessions. CONCLUSIONS: This study demonstrates that motives can change over the course of treatment and that this change in motives is associated with reductions in use and problematic outcomes. Targeting specific motives in future interventions may improve treatment outcomes.

A preliminary evaluation of synthetic cannabinoid use among adolescent cannabis users: Characteristics and treatment outcomes.

Little is known regarding the use of synthetic cannabinoids (SC), particularly use among adolescent substance users who may be at higher risk. The present exploratory study seeks to describe SC use and subjective effects among cannabis-using adolescents as well as compare the characteristics of cannabis users who do and do not use SC. Exploratory analyses evaluated cannabis treatment outcomes among SC users and non-users. Participants enrolled in a randomized, controlled intervention for cannabis-using high school students aged 14-19 (N=252) completed questionnaires regarding their use of SC and other substances. Those who used SC in the past 60days reported subjective effects of SC, consequences, and SC use disorder symptoms. Baseline characteristics, alcohol and other drug use, and treatment outcomes of SC users were compared to participants who never tried SC. Within this sample 29% had tried SC, and 6% used SC recently. Although most reported use at a relatively low rate, 43% of recent SC users reported SC use-disorder symptoms. Positive and negative subjective effects of SC were endorsed, with positive subjective effects reported more often. SC use was associated with more cannabis use, but not more alcohol or other (non-SC and non-cannabis) drug use. SC users did not differ from non-users on cannabis treatment outcomes. This exploratory study described SC use, and compared characteristics and treatment outcomes among SC users and non-users. Negative subjective effects of SC were reported as occurring less often, but SC use was associated with use disorder psychopathology. SC use was associated with more problematic cannabis use at baseline, but was not associated with use of other substances or differences in treatment outcome.

Motivational pathways from antecedents of alcohol use to consequences: a structural model of using alcohol to cope with negative affect.

BACKGROUND: Drinking among college-aged individuals can be problematic. The motivational model of use, which examines various cognitive factors, personal characteristics, and environmental factors, can provide a greater understanding of what contributes toward the decision to drink in these young adults. OBJECTIVES: The current study evaluates proposed paths from risk factors for alcohol use, motives for drinking, and subsequent outcomes of alcohol use, drawing from seminal research on the motivational model and drinking motives. METHODS: This model was tested in a sample of 303 undergraduate drinkers (77.9% female, mean age = 19.8 years), and evaluated the potential impact of gender and pattern of use. RESULTS: Results indicate that expectancies, maladaptive coping, and negative affect personality styles are associated with coping motives for drinking, and that coping motives are significantly related to problems associated with use. These results are similar for males and females, and among heavy and lighter drinkers. CONCLUSION: Findings support the role of the coping motive in problematic outcomes associated with drinking and suggest that expectancies, negative affect personality styles, maladaptive coping, and drinking motives are potential targets of prevention and intervention.

Motives for marijuana use among heavy-using high school students: An analysis of structure and utility of the Comprehensive Marijuana Motives Questionnaire.

Motives for marijuana use are important predictors of problematic outcomes associated with marijuana use. Most measures, to date, were developed by adapting alcohol motives measures. However, the Comprehensive Marijuana Motives Questionnaire (CMMQ) was created using a bottom-up approach to evaluate twelve distinct motives for use. The CMMQ was developed and validated in a normative college population. As such, no known study has evaluated the factor structure and utility of the CMMQ in a heavy-using, high school student population. The current study utilized a sample of 252 heavy marijuana-using high school students recruited for a combination motivational enhancement/cognitive behavioral intervention. Results from baseline measures indicated that the factor structure of the CMMQ was maintained in this population. Results from multiple regression analyses revealed distinct relationships with measures of negative consequences of use, including indices of marijuana use, marijuana-related problems, self-efficacy, and internalizing and externalizing symptoms. In particular, the Coping motive was associated with several negative outcomes, which is consistent with previous marijuana and alcohol motives literature. Results suggest that the CMMQ may be useful in assessing marijuana motives among heavy marijuana-using adolescents.

The impact of motives-related feedback on drinking to cope among college students.

Motives for alcohol use are associated with distinct antecedents and consequences. Drinking alcohol to cope with negative affect is consistently associated with the most problematic patterns of use. Interventions targeting drinking to cope are needed. This randomized controlled treatment trial is an initial attempt to evaluate the impact of a brief coping motive-specific personalized feedback intervention on motives and problematic outcomes associated with drinking. The study randomized 170 participants to receive either a brief Standard Feedback Condition (SFC; n=83) or a Motives Feedback Condition (MFC; n=87) that added education and feedback on drinking to cope as well as alternative coping strategies. Significant reductions in drinking to cope with anxiety and with depression were greater in the MFC at the 2-month follow-up. Significant reductions in drinking and negative consequences were observed but did not differ significantly by condition. Indirect tests showed that the MFC, relative to SFC, was associated with outcomes of drinking and negative consequences through change in drinking to cope with depression. Moderation analyses revealed that there were no differential outcomes according to baseline level of coping. This study is a promising new direction in motives research, providing support for brief personalized feedback interventions incorporating motives-related feedback.

The relationship between general causality orientation and treatment outcome among marijuana-dependent adults.

General causality orientations are motivational styles that are indicative of a person's belief about personal change and their motivation to change. The purpose of the current study was to investigate whether causality orientations were associated with marijuana treatment outcomes in a sample of marijuana-dependent individuals. A total of 74 participants (66% male) were recruited from the Seattle, Washington area and randomly assigned to receive a combination of motivational enhancement and cognitive behavioral therapy or the combination treatment plus additional "check-up" sessions. Follow-up assessments evaluated frequency of use, use-related problems, and marijuana use disorder symptoms through 9months. Causality orientations were relatively stable over time. Posttreatment Autonomy orientations were associated with lower frequency of use and Controlled orientations were associated with a reduction in use, problems, and marijuana use disorder symptoms. Autonomy and Controlled orientations were associated with readiness to change. Results suggest that both autonomous and controlled orientations have implications for response to treatment; perhaps for different reasons. Causality orientations may be a promising avenue of research to predict treatment response and outcome.

Maintenance Check-ups Following Treatment for Cannabis Dependence.

Substance use disorders, including cannabis use disorders and associated negative consequences, are best considered chronic and in need of continuing care. In contrast, most treatment efficacy studies evaluate a fixed number of intervention sessions at a single point in time. The present study evaluated the efficacy of posttreatment maintenance check-ups (MCUs) in maintaining and improving outcomes following nine sessions of motivational enhancement treatment/cognitive behavioral treatment (MET/CBT). Adults dependent on cannabis (n=74) were randomly assigned to the MCU or a no check-up (NCU) condition and followed up at 3- and 9-months. MCU sessions occurred 1 and 4months following the completion of the base treatment. Additional MET/CBT sessions were available to participants throughout the follow-up period. The MCUs specifically encouraged treatment re-entry for those showing ongoing signs of disorder. Participants in the MCU condition reported significantly greater abstinent rates at both follow-ups and were using on fewer days at the 3-month but not the 9-month follow-up. Contrary to hypotheses, MCU participants did not attend more additional treatment and differences in rates of cannabis use emerged prior to the first MCU session. Future research with longer follow-up periods and longer monitoring of outcomes is needed to fully evaluate the utility of MCUs or other forms of continuing care.

Changing motives for use: outcomes from a cognitive-behavioral intervention for marijuana-dependent adults.

BACKGROUND: Motives for use have been identified as important predictors of substance use and related problems; however, little is known about how motives for use change following an intervention and how this change may impact future substance use behaviors. The present study sought to describe change in motives following an intervention for marijuana-dependent adults. Furthermore, investigators examined change in motives as a predictor of treatment outcome. METHOD: The study randomized 74 adults to one of two conditions: both of which received 9-sessions base treatment of cognitive behavioral therapy and motivational enhancement therapy and had access to additional sessions of cognitive behavioral treatment on an as-needed basis. The experimental condition received two additional "check-ups" during the course of follow-up. RESULTS: Significant decreases in reported frequency of motives used were observed following treatment. Changes in Expansion and Coping were associated with differential treatment outcomes. Decreases in Expansion were associated with poorer treatment outcome, while decreases in Coping were associated with better treatment outcome. CONCLUSIONS: The relationship between expansion motives and outcomes was paradoxical. Although there were some inconsistencies in the findings, the results regarding the coping motive were consistent with hypotheses and may have important implications for treatment.

Protective behavioral strategies mediate problem-focused coping and alcohol use in college students.

OBJECTIVE: Protective behavioral strategies have emerged as a construct protective against alcohol use. The current study examines the theoretical associations among general coping styles, protective behavioral strategies, drinking to cope motives, and alcohol use in college students. METHOD: Analyses of fully latent variables were conducted using structural equation modeling in a sample of 327 college students. RESULTS: Protective behavioral strategies partially mediated the association between problem-focused coping and alcohol use. Behaviorally oriented problem-focused coping strategies accounted for the positive relationship between problem-focused coping and protective behavioral strategies whereas cognitively oriented problem-focused coping strategies were associated with less use of protective behavioral strategies and increased alcohol use. CONCLUSIONS: This is the first study to find that protective behavioral strategies are more likely to be used by college students who endorse using a problem-focused coping style, especially if they tend to use behaviorally oriented problem-focused coping strategies. These findings extend the literature on protective behavioral strategies and indicate that students less likely to use problem-focused coping skills to deal with stress in general may need additional interventions to increase their use of protective behavioral strategies.

Situational determinants of use and treatment outcomes in marijuana dependent adults.

Research and theory strongly support the importance of situational determinants of substance use as targets for intervention, but few studies have systematically examined situational use characteristics in marijuana dependent adults. The present study describes situational use of marijuana in a population of 87 marijuana dependent adults and reports relationships with outcomes of treatment. Use in negative affective situations was independently associated with psychological distress, maladaptive coping strategies, lower self-efficacy, and poorer outcomes post-treatment. The findings were consistent with research on using drugs to cope with negative affect providing evidence of convergence between two different methods of assessing high risk situations for substance use. The results support continued emphasis on coping with negative affect as a target in treatments for marijuana dependence.

Contracting, prompting and reinforcing substance use disorder continuing care.

The contracting, prompting and reinforcing (CPR) aftercare intervention has improved treatment adherence and outcomes in a number of clinical trials. In multisite randomized clinical trial 92 graduates of two intensive substance use disorder programs who received CPR were compared to 91 who received standard treatment (STX). The CPR group evidenced increased frequency of aftercare group therapy attendance and near significant findings suggested that more CPR than STX participants completed 3 months (76 vs. 64%), 6 months (48 vs. 35%), and 9 months (35 vs. 22%) of aftercare. However, the groups did not differ on the majority of attendance measures and had similar abstinence rates at the 3-month (67% CPR vs. 71% STX), 6-month (52% CPR vs. 51% STX), and 12-month (the primary outcome measure; 48% CPR vs. 49% STX) follow-up points. Exploratory analyses suggest that CPR might be more effective among participants not required to attend aftercare. The incremental capital and labor cost of CPR compared to STX was $98.25 per participant.

Social norms and self-efficacy among heavy using adolescent marijuana smokers.

Adolescence is a time in which individuals are particularly likely to engage in health-risk behaviors, with marijuana being the most prevalent illicit drug used. Perceptions of others' use (i.e., norms) have previously been found to be related to increased marijuana use. Additionally, low refusal self-efficacy has been associated with increased marijuana consumption. This cross-sectional study examined the effects of normative perceptions and self-efficacy on negative marijuana outcomes for a heavy using adolescent population. A structural equation model was tested and supported such that significant indirect paths were present from descriptive norms to marijuana outcomes through self-efficacy. Implications for prevention and intervention with heavy using adolescent marijuana users are discussed.

Motives for cannabis use in high-risk adolescent users.

The present investigation examined the relationships between motives for cannabis use and negative consequences associated with cannabis use following a brief intervention. The sample consisted of 205 adolescent cannabis users (66.3% male), who were recruited in high schools and randomly assigned to a brief two-session motivational enhancement therapy (MET) or an educational feedback control (EFC). Results supported the hypothesis that using cannabis to cope with negative affect would predict the number of problems and dependence symptoms related to cannabis use, after controlling for age, gender, years and frequency of cannabis use, and internalizing and externalizing behavior problems. Significant interactions between internalizing behavior problems and the coping motive showed that using to cope was associated with a higher number of cannabis dependence symptoms among adolescents reporting lower levels internalizing behavior problems. Findings support the potential utility of conducting further research to explore the coping motive as an important indicator of problematic cannabis use.