REITOX-ACADEMY Berlin, 30. 3. 2007 Eva Hoch, Heike Rohrbacher, René Noack, Jana Henker, Anja Pixa, Targeted Treatment of Cannabis Use Disorders* A project.

Präsentation zum Thema: "REITOX-ACADEMY Berlin, 30. 3. 2007 Eva Hoch, Heike Rohrbacher, René Noack, Jana Henker, Anja Pixa, Targeted Treatment of Cannabis Use Disorders* A project."—  Präsentation transkript:

1 REITOX-ACADEMY Berlin, 30. 3. 2007 Eva Hoch, Heike Rohrbacher, René Noack, Jana Henker, Anja Pixa, Targeted Treatment of Cannabis Use Disorders* A project of the BMBF Addiction Research Network ASAT *funded by German Ministry for Education and Research (Project-Nr. 01EB0440)

2 1.Background: Unmet needs of patients with cannabis use disorders 2.CANDIS – A controlled randomized clinical study for CUD 1.Rational and Aims 2.Methods: Design and assessment instruments 3.Manual and targeted treatment interventions 3.Preliminary study results 4.Summary, conclusion and outlook Overview …

3 Unmet needs (Perkonigg 2002-2007) Epidemiological studies have highlighted that CUD patients reveal the largest degree of unmet needs among all illegal drug use groups. CUD patients have impressively variable problem profiles – different from other illegal substance user groups. Despite CUD patients willingness to change - existing treatment services are neither prepared nor able to provide adequate services. Lack of treatments: Few evidence-based approaches – few randomized-controlled studies for the treatment of cannabis use disorders worldwide Existing approaches incorporate inappropriate elements (cross-cultural- and cross-national appropriateness) and do not match patient needs and problem profiles. Unmet needs of CUD patients – lack of treatments

4 Zimmermann et al. (2004) 1. Background: adults Intervention studies for adults with cannabis use disorders

5 There is limited evidence that interventions may be effective in CUD - In Adults, there is some evidence for the effectiveness of: - Motivational enhancement components (MET) - Cognitive-behavioral components (CBT ) - Psychosocial problem solving skills (PPS) - In children and teenagers: - Multidimensional family therapy (MDFT) There are no data informing us about for what patients, which type of intervention, respectively which intervention components, are effective Ergebnisse und Schlussfolgerungen 1. Background: Conclusion from the literature Zimmermann et al. (2004)

6 2. CANDIS – A controlled randomized clinical study for CUD Rational and aims

7 1.Based on available cross-sectional and longitudinal data about patients needs and expert-rated needs we designed a targeted treatment approach 2.Targets are the patients core problems and the core processes involved in the etiology of CUD 3.Target population is the high-risk age groups for CUD, namely adolescents 16+. 4.Because patients problem profiles were variable – individualized components were considered to be necessary 5.Treatment components should be based as far as possible on established treatment components that have been shown to be effective in previous trials 6.Content, material and structure should adress the needs of our target population Rationale

8 1.To develop a modular treatment manual for cannabis use disorders, adapted to the needs of our target population. 2. To demonstrate that the treatment is effective in comparison to a delayed treatment control (DTC) group. 3.To test whether a targeted (individualized) treatment (TST) produces superior outcomes as compared to the standardized treatment group (ST). Aims of CANDIS Aims of CANDIS-study

9 Methods: design and instruments of CANDIS-study

10 Project Design I. Preparatory phase (2005): Development, pilot testing and revision of two treatment manuals, training of therapists, recruitment of participants. II. Intervention phase (2006/07): Randomized, controlled trial in the area of Greater Dresden with three treatment conditions a) standardized treatment (ST, n=40), b) targeted standardized treatment (TST, n=40), c) and delayed treatment control (DTC n= 40). III. Follow-up phase (2006/07): Assessments after 3 and 6 months to test stability of effects. Design of CANDIS-study

11 „Everybody who wants to rethink, reduce or stop his/her cannabis use!“ Inclusion criteria: 1. Age: >= 16 years 2. Lifetime DSM-IV diagnosis of cannabis abuse or dependence 3. Current regular use (at least 2 days a week) Exclusion criteria: 1. Severe current dependence to alcohol or other illegal drugs (DSM-IV) 2. Current psychotropic medication (e.g. sedatives) 3. Intoxication due to opiates or stimulants 4. Lifetime history of any psychotic disorder 5. Current severe episode of major depression 6. Currently acute suicidal tendency 7. Current panic-agoraphobic disorder (severe) 8. Severe learning disability, brain damage or pervasive developmental disorders 9. Not fluent in german language 10. Current treatment of cannabis-related disorders in other services Wer kann mitmachen? Eligibility criteria for study participation

12 Assessment time and instruments Assessment time: 1. Baseline examination (M-CIDI, cannabis specific instruments) 2.Therapy process assessment (prior and past session 1 to 10) 3.Past-treatment assessment (session 10) 4.Follow-up assessments (3 and 6 months) Baseline examination: CIDI-Module: Mental disorders and syndromes, substance use patterns and substance use disorders BSI: Brief Symptom Inventory (Psychopathology) EuropASI: Psychosocial problems, Addiction Severity Index Questionnaire for cannabis-related problems Etc. Outcome assessments: Regular monitoring of smoking status, relapse, symptoms of craving and withdrawal Drug screenings (Drug-Screen-Card-Multi 7) Motivation check HEISA-16: Confidence in cannabis abstinence SKID-II: Personality disorder inventory BDI: Beck Depression-Inventory Etc.

13 I. Outcome criteria: 1.Complete abstinence from cannabis 2.Reduction (cannabis use) 3. Decrease in ASI total score II. Secondary outcome criteria: 1. Relapse 2. Abstinence from legal and other illegal drugs 3. Decrease in number and severity of mental disorders (M-CIDI) 4. Increase in quality of life and functioning score (EQ5D) Outcome measures and criteria Primary and secondary outcome measures

14 CANDIS-study Manual and interventions

15 1.Motivation Enhancement (Rollnick and Miller (2002) Interventions to stimulate motivation to change 2. Cognitive-Behavioral components (CBT) Psychoeducation Etiology of CUD (biological, psychological and social aspects) Understanding individual cannabis use patterns (functional analysis) Development of an individual change concept and goal-setting Quit day preparation (skills training, stimulus control and enforcement of alternative behaviors) Relapse prevention (strategies to cope with urges, craving and high risk situations) Improve social skills, cannabis refusal skills and social support Management of comorbid mental disorders (anxiety, depression, substance use disorders) 3.Psycho-social Problem Solving Skills D’Zurilla and Goldfried (1971) Identify and solve problems 2.3. Manual and Interventions: Modular CANDIS therapy components

16 Sessions Session 1: Diagnostic feedback & enhancement of motivation to change Session 2: Enhancement of motivation to change Session 3: Understanding cannabis use patterns Session 4: Goal setting and target day preparation Session 5: Debriefing of target day and management of craving Session 6: Relapse prevention Session 7: Psychosocial problem solving I Session 8: Psychosocial problem solving II Session 9: Comorbidity Session 10: Social skill training and treatment termination Individualized treatment 2.3. Manual and Interventions: CANDIS-Manual: 10 individual treatment sessions (à 90 minutes)

17 The Setting – it is definitely not clinical … !-

18 3. Results Patients characteristics and treatment observations

19 1.Screened: N= 165 2.Enrolled and randomized: N=128 3.Eligible for Analysis: 71.9% Status …

20 % 3.1. Results: Treatment referral sources to CANDIS

21 Sex: 74% males Age: 16 - 45 years (range) M: 24.7 years Age of onset of CU: M: 15.7 years Time since first cannabis use: M: 7.6 years Current cannabis dependence (past 4 wks): 63.0% Current cannabis abuse w/o dep. (past 4 wks): 8.7% Occupational situation: 3.1. Results: Demographic data (M-CIDI) (subsample; n = 60)

22 % 3.1. Results: Frequency of pre-treatment cannabis use Minimum: 1 joint Maximum: 40 bongs

23 % 3.1. Results: Comorbid 12-month disorders (M-CIDI)

24 % Pre-treatment therapy goals of patients

25 % Complete abstinence (drug screenings) reduction no changeheavier use 3.2. Results: Program effectiveness (end of treatment) (* n=10 still in treatment or did not complete their post-treatment assessment yet)

26 % Abstinence Reduction no change Heavier use 3.2. Results: 3- Month Results

27 1.CANDIS Manual: public interest and many requests for manual and training, internationally 2.Intervention is well accepted by patients and 3.…. study therapists! 4.The “project”character of the program (setting), limited number of “dense” sessions and short term duration is appealing to young cannabis users. 5.The majority of patients are male, of variable socio-oeconomic background and high ambivalence in motivation to change. 6.Comorbidity with other mental disorders is high -> a subgroup of patients needs also psychotherapeutic treatment. European Monitoring Centre for Drugs and Drug Addiction (2005). Annaul Report 2005: The state of the drugs problem in the European Union and Norway. Printed in Belgium. Rilke, O. Jahresbericht 2003 der ambulanten Suchtkrankenhilfe in Sachsen, Hrsg: Sächsische Landesstelle gegen die Suchtgefahren e. V. Simon, R., Sonntag, D., Bühringer, G. & Kraus, L. (2004). Cannabisbezogene Störungen: Umfang, Behandlungs­bedarf und Behandlungsangebot in Deutschland. Bundesministerium für Gesundheit und Soziale Sicherung. Berlin: Springer. von Sydow, K., Lieb, R., Pfister, H., Höfler, M., Sonntag, H., Wittchen, H.-U. The natural course of cannabis use, abuse and dependence over four years; a longitudinal community study of adolescents and young adults, Drug and Alcohol dependence, 2001, 64, 347-361 Zimmermann, P., Mühlig, S., Sonntag, D., Bühringer, G., Wittchen, H.-U., Review on psychotherapeutic interventions for cannabis disorders, Sucht, 2004, 50(5), 334-342 European Monitoring Centre for Drugs and Drug Addiction (2005). Annaul Report 2005: The state of the drugs problem in the European Union and Norway. Printed in Belgium. Rilke, O. Jahresbericht 2003 der ambulanten Suchtkrankenhilfe in Sachsen, Hrsg: Sächsische Landesstelle gegen die Suchtgefahren e. V. Simon, R., Sonntag, D., Bühringer, G. & Kraus, L. (2004). Cannabisbezogene Störungen: Umfang, Behandlungs­bedarf und Behandlungsangebot in Deutschland. Bundesministerium für Gesundheit und Soziale Sicherung. Berlin: Springer. von Sydow, K., Lieb, R., Pfister, H., Höfler, M., Sonntag, H., Wittchen, H.-U. The natural course of cannabis use, abuse and dependence over four years; a longitudinal community study of adolescents and young adults, Drug and Alcohol dependence, 2001, 64, 347-361 Zimmermann, P., Mühlig, S., Sonntag, D., Bühringer, G., Wittchen, H.-U., Review on psychotherapeutic interventions for cannabis disorders, Sucht, 2004, 50(5), 334-342 European Monitoring Centre for Drugs and Drug Addiction (2005). Annaul Report 2005: The state of the drugs problem in the European Union and Norway. Printed in Belgium. Rilke, O. Jahresbericht 2003 der ambulanten Suchtkrankenhilfe in Sachsen, Hrsg: Sächsische Landesstelle gegen die Suchtgefahren e. V. Simon, R., Sonntag, D., Bühringer, G. & Kraus, L. (2004). Cannabisbezogene Störungen: Umfang, Behandlungs­bedarf und Behandlungsangebot in Deutschland. Bundesministerium für Gesundheit und Soziale Sicherung. Berlin: Springer. von Sydow, K., Lieb, R., Pfister, H., Höfler, M., Sonntag, H., Wittchen, H.-U. The natural course of cannabis use, abuse and dependence over four years; a longitudinal community study of adolescents and young adults, Drug and Alcohol dependence, 2001, 64, 347-361 Zimmermann, P., Mühlig, S., Sonntag, D., Bühringer, G., Wittchen, H.-U., Review on psychotherapeutic interventions for cannabis disorders, Sucht, 2004, 50(5), 334-342 European Monitoring Centre for Drugs and Drug Addiction (2005). Annaul Report 2005: The state of the drugs problem in the European Union and Norway. Printed in Belgium. Rilke, O. Jahresbericht 2003 der ambulanten Suchtkrankenhilfe in Sachsen, Hrsg: Sächsische Landesstelle gegen die Suchtgefahren e. V. Simon, R., Sonntag, D., Bühringer, G. & Kraus, L. (2004). Cannabisbezogene Störungen: Umfang, Behandlungs­bedarf und Behandlungsangebot in Deutschland. Bundesministerium für Gesundheit und Soziale Sicherung. Berlin: Springer. von Sydow, K., Lieb, R., Pfister, H., Höfler, M., Sonntag, H., Wittchen, H.-U. The natural course of cannabis use, abuse and dependence over four years; a longitudinal community study of adolescents and young adults, Drug and Alcohol dependence, 2001, 64, 347-361 Zimmermann, P., Mühlig, S., Sonntag, D., Bühringer, G., Wittchen, H.-U., Review on psychotherapeutic interventions for cannabis disorders, Sucht, 2004, 50(5), 334-342 4. Summary & Conclusion

28 I.Analyses II.Adaptations and improvements III.Transfer and Distribution and Training European Monitoring Centre for Drugs and Drug Addiction (2005). Annaul Report 2005: The state of the drugs problem in the European Union and Norway. Printed in Belgium. Rilke, O. Jahresbericht 2003 der ambulanten Suchtkrankenhilfe in Sachsen, Hrsg: Sächsische Landesstelle gegen die Suchtgefahren e. V. Simon, R., Sonntag, D., Bühringer, G. & Kraus, L. (2004). Cannabisbezogene Störungen: Umfang, Behandlungs­bedarf und Behandlungsangebot in Deutschland. Bundesministerium für Gesundheit und Soziale Sicherung. Berlin: Springer. von Sydow, K., Lieb, R., Pfister, H., Höfler, M., Sonntag, H., Wittchen, H.-U. The natural course of cannabis use, abuse and dependence over four years; a longitudinal community study of adolescents and young adults, Drug and Alcohol dependence, 2001, 64, 347-361 Zimmermann, P., Mühlig, S., Sonntag, D., Bühringer, G., Wittchen, H.-U., Review on psychotherapeutic interventions for cannabis disorders, Sucht, 2004, 50(5), 334-342 European Monitoring Centre for Drugs and Drug Addiction (2005). Annaul Report 2005: The state of the drugs problem in the European Union and Norway. Printed in Belgium. Rilke, O. Jahresbericht 2003 der ambulanten Suchtkrankenhilfe in Sachsen, Hrsg: Sächsische Landesstelle gegen die Suchtgefahren e. V. Simon, R., Sonntag, D., Bühringer, G. & Kraus, L. (2004). Cannabisbezogene Störungen: Umfang, Behandlungs­bedarf und Behandlungsangebot in Deutschland. Bundesministerium für Gesundheit und Soziale Sicherung. Berlin: Springer. von Sydow, K., Lieb, R., Pfister, H., Höfler, M., Sonntag, H., Wittchen, H.-U. The natural course of cannabis use, abuse and dependence over four years; a longitudinal community study of adolescents and young adults, Drug and Alcohol dependence, 2001, 64, 347-361 Zimmermann, P., Mühlig, S., Sonntag, D., Bühringer, G., Wittchen, H.-U., Review on psychotherapeutic interventions for cannabis disorders, Sucht, 2004, 50(5), 334-342 European Monitoring Centre for Drugs and Drug Addiction (2005). Annaul Report 2005: The state of the drugs problem in the European Union and Norway. Printed in Belgium. Rilke, O. Jahresbericht 2003 der ambulanten Suchtkrankenhilfe in Sachsen, Hrsg: Sächsische Landesstelle gegen die Suchtgefahren e. V. Simon, R., Sonntag, D., Bühringer, G. & Kraus, L. (2004). Cannabisbezogene Störungen: Umfang, Behandlungs­bedarf und Behandlungsangebot in Deutschland. Bundesministerium für Gesundheit und Soziale Sicherung. Berlin: Springer. von Sydow, K., Lieb, R., Pfister, H., Höfler, M., Sonntag, H., Wittchen, H.-U. The natural course of cannabis use, abuse and dependence over four years; a longitudinal community study of adolescents and young adults, Drug and Alcohol dependence, 2001, 64, 347-361 Zimmermann, P., Mühlig, S., Sonntag, D., Bühringer, G., Wittchen, H.-U., Review on psychotherapeutic interventions for cannabis disorders, Sucht, 2004, 50(5), 334-342 European Monitoring Centre for Drugs and Drug Addiction (2005). Annaul Report 2005: The state of the drugs problem in the European Union and Norway. Printed in Belgium. Rilke, O. Jahresbericht 2003 der ambulanten Suchtkrankenhilfe in Sachsen, Hrsg: Sächsische Landesstelle gegen die Suchtgefahren e. V. Simon, R., Sonntag, D., Bühringer, G. & Kraus, L. (2004). Cannabisbezogene Störungen: Umfang, Behandlungs­bedarf und Behandlungsangebot in Deutschland. Bundesministerium für Gesundheit und Soziale Sicherung. Berlin: Springer. von Sydow, K., Lieb, R., Pfister, H., Höfler, M., Sonntag, H., Wittchen, H.-U. The natural course of cannabis use, abuse and dependence over four years; a longitudinal community study of adolescents and young adults, Drug and Alcohol dependence, 2001, 64, 347-361 Zimmermann, P., Mühlig, S., Sonntag, D., Bühringer, G., Wittchen, H.-U., Review on psychotherapeutic interventions for cannabis disorders, Sucht, 2004, 50(5), 334-342 Outlook

29 CANDIS-Project Dr. Eva Hoch (PI) Institute for Clinical Psychology and Psychotherapy Technische Universität Dresden Chemnitzer Straße 46 01187 Dresden Email: hoch@psychologie.tu-dresden.de Telefon: ++49 (0)351 463 -36592 Fax: ++49 (0)351 463 -36984 URL: http://psylux.psych.tu-dresden.de URL: http://www.candis-projekt.de Thank you for your attention!