Summary

Opioid addiction is, in many ways, a physical problem as well as a psychological and behavioral problem. Addicts become physically addicted to opiates and, in the later stages of addiction, become preoccupied with relieving the physical symptoms of withdrawal. They become highly attuned to the bodily signals that withdrawal is coming. Heroin addicts spend most of their waking life procuring, using, and withdrawing from heroin—three times a day, seven days a week, fifty-two weeks a year—for years.

The medications used to treat opioid abuse are powerful agents that interrupt this cycle. Although medications alone rarely cure an addiction, they are critically important to breaking the cycle of preoccupation with opioid use and enabling addicts to benefit from comprehensive drug-abuse treatment.

(See also: Coerced Treatment for Substance Offenders; Ibogaine; Opioid Dependence; Opioid Complications and Withdrawal; Pregnancy and Drug Dependence; Substance Abuse and AIDS; Treatment Types)

BIBLIOGRAPHY

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Greenstein, R. A., Arndt, I. C., McLellan, A. T., O'Brien, C. P., & Evans, B. (1984). Naltrexone: a clinical perspective. Journal of Clinical Psychiatry, 45(9 Pt 2), 25-28.

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O'Brien, C. P., Childress, A. R., McLellan, A. T., Ternes, J., & EHRMAN, R. N. (1984). Use of naltrexone to extinguish opioid-conditioned responses. Journal of Clinical Psychiatry, 45 (9 Pt 2), 53-56.

Substance Abuse and Mental Health Services Administration (SAMHSA). (1999). 1998 National Household Survey on Drug Abuse. Washington, DC: U.S. Department of Health and Human Services.

WILSON, B. A., SHANNON, M. T., & Stang, C. L. (Eds.) (1995). Nurses Drug Guide, 3rd ed. Norwalk, CT: Appleton & Lange.

Marc Rosen Revised by Rebecca J. Frey

Marijuana, An Overview Although marijuana is the most widely used illicit drug in the U.S., fairly little is known about how to effectively treat individuals who become dependent on this drug. Increasingly, however, the findings of controlled trials designed to evaluate the effectiveness of alternative counseling approaches are appearing in the literature. Additionally, recently acquired knowledge about the actions of a marijuana-like compound that occurs naturally in the brain will enhance our understanding of the nature of marijuana dependence and possibly set the stage for the development of pharmacological interventions.

Prevalence of Marijuana Dependence. The most widely used illicit substance in the U.S., it is estimated that seventy-two million people have ever used the drug and eleven million are doing so currently (i.e., at least once in the past month). Nearly seven million reported using marijuana weekly or more often in 1998, and approximately two million individuals begin use of marijuana each year (SAMHSA, 1999).

Epidemiological studies conducted in the last two decades permit an estimation of the prevalence of marijuana dependence in the United States. In the 1980s, the Epidemiological Catchment Area (ECA) study involved in-person interviews with 20,000 Americans in five urban areas (Anthony & Helzer, 1991). The study's purpose was to determine the prevalence of psychiatric symptoms for forty major psychiatric diagnoses including drug abuse and dependence. Based on the criteria for the marijuana dependence diagnosis utilized in that study (indications of tolerance or withdrawal plus pathological use or impaired social functioning lasting for at least one month), 4.4 percent of adults were found to have been dependent on marijuana at some point in their lives. About a decade later, interviews conducted with over 8,000 individuals for the National Comorbidity Study led to a very similar estimate that 4.2 percent of the general U.S. population meet the diagnostic criteria of marijuana dependence (Anthony, Warner, & Kessler,

For those who have used marijuana at least once, the relative probability of ever becoming dependent on the substance is estimated at 9 percent (Anthony, Warner, & Kessler, 1994). This risk level appears modest when compared with risk estimates of dependence for those who've used other substances at least once (tobacco-32%; alcohol-15%; cocaine-17%; heroin-23%). However, among individuals who have smoked marijuana more frequently, the risk of developing dependence is higher. Among those who've used it five or more times, the risk of dependence is 17 percent (Hall, Johnston, & Donnelly, 1999). For daily or near daily users, the risk may be as high as one in three (Kandel & Davies, 1992).

Treatment Approaches with Marijuana-Dependent Adults. A series of controlled trials con ducted since the mid-1980s have focused on evaluating interventions for marijuana-dependent adults. Stephens and Roffman (1994), in a 19861989 study funded by the National Institute on Drug Abuse, compared the effectiveness of a 10-session cognitive-behavioral group intervention with a 10-session social support group discussion condition. The cognitive-behavioral treatment focused on strengthening the participant's skills in effectively coping with relapse vulnerabilities. The social support treatment emphasized the use of group support for change. The participants were 212 marijuana smokers who averaged over ten years of near daily marijuana use. Following the completion of treatment and for the next 2.5 years in which participants were periodically reassessed, there were no significant differences between conditions in terms of outcomes (abstinence rates, days of marijuana use, problems related to use). During the final two weeks of counseling, 63 percent of the total sample reported being abstinent. While only 14 percent were continuously abstinent after one year, 36 percent had achieved improvement (i.e., either abstinence or reduction to 50 percent or less of the baseline use level and no reported marijuana-related problems) at that point. At 30 months post-treatment, 28 percent reported abstinence for the past 90 days. Thus, both counseling approaches were modestly effective in helping a significant portion of participants either achieve abstinence or improvement. These findings called into question the hypothesized superiority of a cognitive-behavioral approach with marijuana-dependent adults and argued for additional research on treatment approaches.

In a second NIDA-funded study conducted by Stephens and Roffman (1989-1994) with 291 adult daily marijuana smokers, a three-group design permitted the comparison of two active treatments with a delayed treatment control condition (Stephens, Roffman, & Curtin, in press). One of the active treatments involved 14 cognitive-behavioral skills training group sessions over a four-month period, emphasizing both the enhancement of coping capacities in dealing with situations presenting high risk of relapse and the provision of additional time for the building of group cohesion and mutual support. The second active treatment involved two individual motivational enhancement counseling sessions delivered over a one month period. The latter approach appeared promising inas much as a growing literature in the addiction treatment field was supporting the effectiveness of short-term interventions (Bien, Miller, & Tonigan, 1993), utilizing motivational interviewing strategies (Miller & Rollnick, 1991), designed to strengthen the individual's readiness to change (e.g., providing participants normative comparison data concerning their marijuana use patterns). The first session in this condition involved the counselor reviewing with the participant a written Personal Feedback Report generated from data collected during the study's baseline assessments. The counselor used this review as an opportunity to seek elaboration from the participant when expressions of motivation were elicited, to reinforce and strengthen efficacy for change, and to offer support in goal-setting and selecting strategies for behavior change. One month later, the second session afforded the opportunity to review efforts and coping skills utilized in the interim period. In both conditions, participants had the option of involving a supporter. Following treatment, there was no evidence of significant differences between the two active treatments in terms of abstinence rates, days of marijuana use, severity of problems, or number of dependence symptoms. At the 16-month assessment, 29 percent of group counseling participants and 28 percent of individual counseling participants reported having been abstinent for the past 90 days. Both active treatments produced substantial reductions in marijuana use relative to the delayed treatment control condition. The results of this study suggest that minimal interventions may be more cost-effective than extended group counseling efforts for this population.

The third study, funded by the Center for Substance Abuse Treatment (1996-2000) and conducted in three sites, also employed a three-group design with a delayed treatment control condition (Donaldson, 1998). One of the active treatments involved nine individual counseling sessions delivered over a 12-week period, with the initial sessions focusing on motivational enhancement and the later content emphasizing cognitive-behavioral skills training and, as needed, case management. The other active treatment involved two individual motivational enhancement therapy sessions delivered over a one-month period. (This condition replicated the brief intervention in the above-reported study conducted by Stephens and Roffman). At the 9-month follow-up, both active treatments produced outcomes superior to the 4-month delayed treatment control condition. Further, the 9-session intervention produced significantly greater reductions in marijuana use and associated negative consequences compared to the 2-session intervention. Abstinence rates at the 4- and 9-month follow-ups for the 9-session intervention were 23 percent and 13 percent, respectively. These differences between the two active treatments were apparent as early as 4 weeks into the treatment period and were sustained throughout the first nine months of follow-up. As was the case in the two studies discussed above, the findings of the CSAT-funded research point to modest efficacy of counseling interventions with marijuana-dependent adults. More positive outcomes from the 2-ses-sion motivational enhancement intervention were found in the Stephens and Roffman (in press) study than in the CSAT-funded investigation.

In a study funded by NIDA, Budney and colleagues randomly assigned sixty marijuana-dependent adults to one of three 14-week treatments: motivational enhancement, motivational enhancement plus coping skills training, or motivational enhancement plus coping skills training plus voucher-based incentives (Budney, Higgins, Radonovich, et al., in press). In the latter condition, participants who were drug abstinent— documented with twice-weekly urinalysis screening—received vouchers that were exchangeable for retail items (e.g., movie passes, sporting equipment, educational classes, etc.). The value of each voucher increased with consecutively negative specimens. Conversely, the occurrence of a can-nabinoid-positive urine specimen or failure to submit a sample led to a reduction of each voucher's value to its initial level. Participants in the voucher-based incentive condition were more likely to achieve periods of documented continuous abstinence from marijuana during treatment than were participants in the other two conditions. Additionally, a greater percentage of participants in the voucher-based condition (35%) were abstinent at the end of treatment than was the case in the skills training (10%) or motivational enhancement (5%) conditions. The absence of long-term post-treatment assessment data limits comparisons of this study's outcomes with those from the other trials discussed above. However, based on their earlier research with voucher-based incentives in treating cocaine-dependency, the authors are hopeful that future studies will demonstrate successful long-term outcomes in marijuana-dependent participants who achieve and maintain abstinence during treatment.

In reviewing the above work, it appears that some participants who sought treatment have been substantially aided in either quitting or cutting back. However, it is also apparent that the majority of those treated in the these studies reported above did not achieve their initial goal of durably abstaining from marijuana. Given the evidence of the drug's dependence potential and adverse health consequences (Hall, Johnston, & Donnelly, 1999), continuing development and testing of marijuana dependence interventions is clearly warranted.

Support Groups. Marijuana Anonymous groups, a self-help fellowship based on the principles and traditions of Alcoholics Anonymous, exist in a number of states and internationally. In addition to in-person meetings, MA sessions are also held on-line. The organization's web site address is: www.marijuana-anonymous.org, and its toll-free telephone number is 800-766-7669.

User Characteristics Predictive of Treatment Success. Stephens, Wertz, and Roffman (1993) reported predictors of successful outcomes in their first marijuana treatment trial. Higher levels of pretreatment marijuana use predicted higher use levels following treatment. Indicators of lower socioeconomic status predicted more reports of problems associated with marijuana use post-treatment. Finally, individuals who prior to treatment indicated greater self-efficacy for avoiding use had more successful post-treatment outcomes.

Reaching the Non-Treatment-Seeking Heavy Marijuana Smoker. With funding from NIDA (1997 through 2000), Stephens and Roffman are conducting a clinical trial (''The Marijuana Check-Up' ) with 188 non-treatment-seeking adult marijuana smokers who have been randomly assigned to a motivational enhancement intervention (The Personal Feedback Session), a marijuana educational intervention (The Multimedia Feedback Session), or a brief waiting period. This study is adapted from a brief intervention (''The Drinker's Check-Up'') in the alcoholism field (Miller & Sovereign, 1989).

In conducting The Marijuana Check-Up, a variety of recruitment strategies were used to attract participants, including posters, radio and newspaper ads, and outreach at various community events

(Stephens, et al., 1998). Project publicity targeted adults over the age of 18 who used marijuana and had concerns or were interested in obtaining information. These strategies highlighted the objective, non-judgmental, and confidential approach of the study. All announcements emphasized that the MCU was not a treatment program. Those who inquired were told that although this program did not offer counseling for persons who wanted to quit or reduce their use, it would likely be useful in helping an individual better assess their experiences with marijuana.

The first MCU session involved a structured interview that included an assessment of the individual's use patterns, perceived benefits and adverse consequences associated with both continued use and reductions or cessation of use, and self-efficacy in accomplishing cessation. In the second session, feedback to the client from the initial assessment was largely normative and risk-related in nature. Utilizing motivational interviewing skills, the therapist elicited the client's views concerning benefits and costs associated with both his or her current marijuana use pattern, as well as various pathways of change. When appropriate, the discussion turned to goal-setting for reduction or cessation of use and the identification of useful behavior change strategies.

Based on the finding that 64 percent of participants met diagnostic criteria for cannabis dependence and, of those who did not, 89.4 percent met criteria for cannabis abuse (American Psychiatric Association, 1994), it was evident that the check-up modality offered a useful method for reaching the non-treatment-seeking heavy marijuana user. Upon joining the study, fewer than a third had resolved to quit or cut back on their use. They were using marijuana on more than 80 percent of the days prior to the interventions and typically getting high two or more times per day.

The check-up modality may also show promise in affecting behavior change. While the study is still ongoing, preliminary analyses of outcomes indicated that participants in the motivational enhancement condition (the personal feedback session) were more likely to both reduce the amount of marijuana smoked per day and the number of days of use than were those in the educational or waitlist control conditions.

Marijuana Withdrawal. A mild syndrome of withdrawal from marijuana has been reported, with symptoms that may include: restlessness, irritability, mild agitation, insomnia, decreased appetite, sleep EEG disturbance, anxiety, stomach pain, nausea, runny nose, sweating, and cramping (Budney, Novy, & Hughes, 1999; Crowley, Macdonald, Whitmore, et al., 1998; Haney, Ward, Comer, et al., 1999; Jones, Benowitz, & Bachman, 1976). Commonly, these symptoms lessen within a week to 10 days.

The Future of Marijuana Interventions. Currently underway or recently completed controlled trials testing various models of marijuana dependence treatment with adults and adolescents will undoubtedly contribute new information to what is currently known. The ''leading edge'' of such studies include counseling interventions in which contingency management components, variations in motivational enhancement strategies, brief and extended cognitive-behavioral therapies, treatments involving family members, and alternative dosages and distributions of counseling episodes are being evaluated.

The treatment of marijuana dependence may also ultimately be informed by knowledge of human biology. As an example, there is some evidence for the role of genetics in determining whether the marijuana user will become dependent. In a study of more than 8,000 male twins, genes were shown to influence whether a person finds the effects of marijuana use pleasant (Lyons, Toomey, Meyer, et al., 1997). Comparable findings were demonstrated for females (Kendler & Prescott, 1998). While factors in an individual's social environment clearly influence whether he or she ever tries marijuana, becoming a heavy user or abuser may be more determined by genetically transmitted individual differences, perhaps involving the brain's reward system. Research in this area may eventually identify individual risk factors for marijuana dependence that people can use in making decisions about their own use of this drug.

Finally, considerable evidence for a biological basis to marijuana dependence has accumulated since the identification of a specific cannabinoid receptor in the brain (Devane, Dysarz, Johnson, et al., 1988) and the discovery of anandamide, a compound that binds to and activates the same receptor sites in the brain as delta-9-tetrahydrocannabinol (THC), the active ingredient in marijuana. (Devane, Hanus, Breuer, et al., 1992). Subsequently, researchers discovered a cannabinoid an tagonist, a compound that blocks anandamide action in the brain (Rinaldi-Carmona, Barth, Heaulme, et al., 1994). Taken together, these discoveries have made it possible to systematically study the effects of chronic exposure to marijuana. With greater understanding of the cannabinoid neurochemical system's physiology, the potential for developing and testing pharmacological interventions for marijuana dependence is advanced.

BIBLIOGRAPHY

American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). ANTHONY, J. C., & HELZER, J. E. (1991). Syndromes of drug abuse and dependence. In L. N. ROBINS & D. A. REGIER (Eds.), Psychiatric Disorders in America (pp. 116-154). New York: Free Press. Anthony, J. C., Warner, L. A., & Kessler, R. C. (1994). Comparative epidemiology of dependence on tobacco, alcohol, controlled substances, and inhalants: Basic findings from the National Comorbidity Survey. Experimental and Clinical Psychopharmaco-logy, 2, 244-268. Bien, T. H., Miller, W. R., & Tonigan, S. (1993). Brief interventions for alcohol problems: A review. Addiction, 88, 315-336. Budney, A. J., Higgins, S. T., Radonovich, K. J., et al. (in press). Adding voucher-based incentives to coping-skills and motivational enhancement improves outcomes during treatment for marijuana dependence. Journal of Consulting and Clinical Psychology.

Budney, A. J., Novy, P. L., & Hughes, J. R. (1999). Marijuana withdrawal among adults seeking treatment for marijuana dependence. Addiction, 94, 1311-1322.

Crowley, T. J., Macdonald, M. J., Whitmore, E. A., et AL. (1998). Cannabis dependence, withdrawal, and reinforcing effects among adolescents with conduct symptoms and substance use disorders. Drug and Alcohol Dependence, 50, 27-37. Devane, W. A., Dysarz, F. A., Johnson, M. R., et al. (1988). Determination and characterization of a cannabinoid receptor in rat brain. Molecular Pharmacology, 34, 605-613. Devane, W. A., Hanus, L., Breuer, A., et al. (1992). Isolation and structure of a brain constituent that binds to the cannabinoid receptor. Science, 258, 1946-1949.

Donaldson, J. (Chair) (1998, November). Treatment of marijuana dependence: Recent advances in clinical epidemiology and health services research. Symposium conducted at the annual meeting of the American Public Health Association, Washington, D.C.

Hall, W., Johnston, L., & Donnelly, N. (1999). Epidemiology of cannabis use and its consequences. In H. Kalant, W. A. Corrigall, W. Hall, et al. (Eds.), The Health Effects of Cannabis (pp. 71-125). Toronto: Addiction Research Foundation.

Haney, M., Ward, A. S., Comer, S. D., et al. (1999). Abstinence symptoms following smoked marijuana in humans. Psychopharmacology, 141, 395-404.

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Kandel, D. C., & Davies, M. (1992). Progression to regular marijuana involvement: Phenomenology and risk factors for near daily use. In M. GLANTZ & R. Pickens (Eds.), Vulnerability to Drug Abuse (pp. 211-253). Washington, D.C.: American Psychological Association.

KENDLER, K. S., & PRESCOTT, C. A. (1998). Cannabis use, abuse, and dependence in a population-based sample of female twins. American Journal of Psychiatry, 155, 1016.

Lyons, M. J., Toomey, R., Meyer, J. M., et al. (1997). How do genes influence marijuana use? The role of subjective effects. Addiction, 92, 409-417.

Miller, W. R. (1983). Motivational interviewing with problem drinkers. Behavioural Psychotherapy, 11, 144-172.

Miller, W. R., & Rollnick, S. (1991). Motivational Interviewing: Preparing People to Change Addictive Behavior. New York: Guilford Press.

Miller, W. R., & Sovereign, R. G. (1989). The checkup: A model for early intervention in addictive behaviors. In T. Loberg, W. R. Miller, P. E. Nathan, et AL. (Eds.), Addictive Behaviors: Prevention and Early Intervention (pp. 87-101). Amsterdam: Sweta & Zeitlinger.

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Roger A. Roffman Robert S. Stephens

Polydrug Abuse, An Overview Polydrug abuse (also called multiple-drug abuse) refers to the recurring use of three or more categories of Psychoactive substances. It is a pattern of substance abuse that is most commonly associated with illegal drug use and youth. Most polydrug users also smoke Tobacco, but Nicotine has only recently begun to be recognized as a drug of abuse to be addressed with polydrug users.

While the term Polydrug User is usually reserved for people with a rather varied and nonspecific pattern of drug use, many drug users who have a preferred (a primary) drug of abuse are also polydrug users. In fact, it is uncommon for users of any illicit drug to restrict their substance use to only the one drug. For example, an individual may be a regular Cocaine user but also use Alcohol, Tranquilizers, and Marijuana.

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