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Treatment of Cannabis-Related Disorders in Europe

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INSIGHTS EN

ISSN 2314-9264
Treatment of
cannabis-related
disorders in
Europe

17
Treatment of
cannabis-related
disorders in
Europe

Authors
Jonathan Schettino, Fabian Leuschner, Lorenz Kasten and Peter Tossmann
(Delphi Institute, Berlin, Germany)
Eva Hoch
(Department of Addiction Research and Addictive Behaviours, Central
Institute of Mental Health, Mannheim, Germany)

EMCDDA project group


Marica Ferri, Bruno Guarita and Roland Simon

17
Legal notice
This publication of the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) is protected by
copyright. The EMCDDA accepts no responsibility for any consequences arising from the use of the data
contained in this document. The contents of this publication do not necessarily reflect the official opinions of the
EMCDDA’s partners, any EU Member State or any agency or institution of the European Union.

Europe Direct is a service to help you find answers to your questions about the European Union.

Freephone number (*): 00 800 6 7 8 9 10 11


(*) The information given is free, as are most calls (though some operators, phone boxes or hotels may
charge you).

More information on the European Union is available on the Internet (http://europa.eu).

Luxembourg: Publications Office of the European Union, 2015


ISBN: 978-92-9168-759-6
doi:10.2810/621856

© European Monitoring Centre for Drugs and Drug Addiction, 2015


Reproduction is authorised provided the source is acknowledged.

Praça Europa 1, Cais do Sodré, 1249-289 Lisbon, Portugal


Tel. +351 211210200
info@emcdda.europa.eu I www.emcdda.europa.eu
twitter.com/emcdda I facebook.com/emcdda
Contents

5 Foreword

7 Executive summary

9 Acknowledgements

11 Introduction

13 CHAPTER 1
Cannabis treatment in context: cannabis use, related problems and
common treatment approaches
13 Cannabis in the European Union: use and problematic use
13 Health consequences of cannabis use
14 Trends in treatment provision for cannabis-related problems
15 Treatment needs and cannabis-related problems
17 Delivery of treatment in Europe
18 Psychosocial approaches used to treat drug-related problems
20 Control conditions

23 CHAPTER 2
Effectiveness of interventions: review of recent research on available treatments
24 Research on treatment for adolescents
30 Research on treatment for adults
35 Research on telephone and online interventions
38 Factors and mechanisms influencing effectiveness
39 Study characteristics
39 Recent findings in perspective

43 CHAPTER 3
Treatment of cannabis use disorders in Europe
43 Treatment availability
49 Selected cannabis-specific treatment programmes in Europe

57 CHAPTER 4
Estimation of unmet treatment needs
58 Specific treatment for specific substances?

61 CHAPTER 5
Conclusions

63 Glossary

65 References
I Foreword
Cannabis is the illicit drug used most widely and most frequently in Europe; for those who
experiment with banned substances in their youth, cannabis is the first, and in many cases
the only, controlled drug they will experience. For most, use will be experimental,
occasional and short-lived — but an important minority of consumers will go on to develop
a long-term attachment to the drug and report periods of sustained and regular use. Over
the last decade, our understanding of the potential problems that can be associated with
the use of cannabis has grown substantially. Acute problems, though rare, can occur even
among naive, occasional and inexperienced users — sometimes sufficiently serious to
require emergency responses — with implications for drug prevention and harm-reduction
activities. It is the chronic use of cannabis, however, that is of particular concern in the
context of the need for drug-treatment interventions — and it is this area which is explored
in detail in this new EMCDDA publication.

A substantive backdrop to this report is that we now see increasing numbers of young
people presenting for, or being referred to, treatment for cannabis-related problems. Until a
few years ago, the majority of those seeking treatment for their drug problems for the first
time in their life were opioid users. However, that has changed, and now the largest group
of first-time treatment entrants is those seeking help for problems related to cannabis use.
Opioid use, it must be noted, still accounts by far for the greater burden on European
drug-treatment services. Cannabis treatment covers a range of therapeutic interventions,
some of which are relatively low-intensity. Nonetheless, it is clear that cannabis use now
represents, and is increasingly recognised as, a major issue for European drug-treatment
services and therefore an area of growing importance for defining what constitutes an
effective and evidence-based approach.

It is, in my view, both timely and appropriate that the EMCDDA is addressing the treatment
of cannabis use disorders when, in many parts of the world, the drug is high on the political
agenda. However, it is important to note that regardless of discussions on the most
appropriate control or regulatory frameworks for this drug, the question of how best to
respond to those individuals who experience problems with their cannabis use remains an
important one. This report is only possible because the evidence base in this area has
grown substantially in recent years and many countries now have considerable experience
of successful engagement with this client group. We are therefore indebted to the
researchers and practitioners whose work is reflected here. Drawing on the research
literature and experiential learning, this publication presents an in-depth and up-to-date
review of what works in treating cannabis use disorders and maps out the geography of
cannabis treatment in Europe.

Looking towards the future, the challenges we will face in this area are not easy to predict.
We have observed seismic shifts in the cannabis market, with unprecedented changes in
the way the drug is produced and distributed. There is also a growing debate on cannabis
control, changes in patterns of use and, to some extent at least, a growing diversity in the
implementation of control and regulatory frameworks used for this drug. Regardless of the
implications of these factors on either the prevalence or patterns of cannabis use we will
see in Europe, we can say, with some confidence, that providing effective treatment for
those with cannabis use disorders is likely to be an objective of growing importance in
European drug policy.

Wolfgang Götz
Director, EMCDDA

5
I Executive summary
I Background
Individuals with cannabis use disorders have historically presented in drug treatment
settings in Europe; however, over the past several years, the numbers seeking treatment
for problems related to cannabis use have increased, both in absolute and relative terms.
In parallel, many countries in Europe have implemented, expanded or modified national
treatment programmes to better serve this population.

This publication aims to provide experts and policymakers with an analysis of the latest
information available on treatment for cannabis use to ensure that they have a firm
foundation for decision-making. More specifically, it provides a review of recent research
on available treatments for adolescent and adult cannabis users. In addition, it describes
and analyses selected cannabis-specific programmes currently offered in the European
Union and provides a brief overview of the availability and type of treatments for
individuals with cannabis use disorders in each EU Member State. Finally, it compares
indicators of treatment needs with estimated provision of treatment.

I Methods and data sources


Materials and research publications from the European Monitoring Centre for Drugs and
Drug Addiction (EMCDDA) were searched to identify all the systematic reviews, narrative
reviews and individual studies (randomised controlled trials and observational studies) on
the effectiveness of treatment for cannabis users (adolescents or adults) published
between 2008 and 2012. Publications in three databases (PubMed, EBSCO and Google
Scholar) were searched for terms related to treatment of cannabis-related disorders.
Exclusion criteria were set for studies focusing only on either alcohol or tobacco.

Data on cannabis-specific treatment programmes in the 28 EU Member States, Turkey and


Norway were obtained from the EMCDDA Annual reports and Statistical bulletins from
2008 to 2012 (EMCDDA 2008–2012a, b) and through an ad hoc data collection with the
support of the EMCDDA’s network of national focal points (the Reitox network).

I Findings
A variety of evidence-based treatments were found to be available for cannabis use
disorders. Compared with standard treatment in place (treatment as usual), these
interventions are more effective in reducing the frequency and quantity of substance use,
as well as the severity of substance use-related problems.

No individual empirically supported treatment emerged as being significantly more


effective than any other empirically supported treatment. However, a combination of
cognitive behavioural therapy (CBT) and motivational interviewing (MI) appeared to be
more cost-effective than other treatment approaches in several studies.

While multidimensional family therapy (MDFT) may have some advantages (e.g. better
treatment adherence) over other treatment approaches for adolescents, a combination of
CBT, MI and contingency management (CM) appears to be the most effective treatment
approach for adults.

7
Treatment of cannabis-related disorders in Europe

Most countries in Europe offer evidence-based treatment programmes for cannabis use
disorders. These follow either a general substance use treatment approach or a cannabis-
specific approach.

Of the 30 European countries surveyed, all bar Sweden provided information on the
provision of cannabis treatment. Fifteen of the countries provide at least one cannabis-
specific treatment programme. In the remaining countries, individuals with cannabis use
disorders are treated in the same programmes as individuals with other substance use
disorders.

Treatment programmes are administered in both outpatient and inpatient settings by a


variety of different service providers, including professionals, para-professionals and
laypeople. The most frequently offered evidence-based cannabis-specific interventions in
Europe are based on MDFT, CBT and MI/MET (motivational enhancement therapy). In
most of the countries offering cannabis-specific treatment, coverage of the affected
population is rated as ‘good’, and experts report that the majority of individuals in need of
treatment for cannabis use disorders have access to treatment. A few countries, however,
have only limited coverage, sometimes despite high overall levels of need. Less is known
about the accessibility of treatment for cannabis use disorders in countries that do not
offer cannabis-specific interventions.

I Conclusions
Although many countries in Europe offer quite effective and comprehensive treatment
programmes for cannabis use disorders, there is still potential for further improvement. In
some cases, no evidence-based treatment for cannabis use disorders is offered; in other
cases, availability may not be sufficient. Collaboration between treatment providers,
general healthcare and the criminal justice system can help to reach people in need
through referrals. While most of those receiving treatment for cannabis-related problems
are treated in outpatient settings, treatment in inpatient settings is also reported by the
majority of countries. Given the young age and often limited level of problems experienced
by many cannabis users, Internet-based interventions are a promising approach which is
already supported by some evidence.

Addressing shortcomings and limitations will help to increase the overall availability and
quality of treatment for cannabis use disorders in Europe, which may reduce the potential
long-term negative effects in this relatively young group of drug users. The high levels of
cannabis use in some parts of Europe, coupled with growing challenges to the drug’s
status as a controlled substance and possible shifts in the social acceptability of the drug,
underline the importance of meeting current treatment needs and remaining vigilant for
future changes.

8
I Acknowledgements
The European Monitoring Centre for Drugs and Drug Addiction wishes to thank the authors
for their work on this publication. In addition, the Centre is grateful to the members of the
EMCDDA Scientific Committee who reviewed the manuscript.

9
I Introduction
In Europe, cannabis is now the drug most often cited as the main reason for seeking help
by those entering drug treatment for the first time in their life. This is a recent development,
reflecting in part an expansion in the provision of treatment for problems related to
cannabis use. It may also reflect the status of cannabis as the most used illicit drug, with
an estimated 14.6 million Europeans aged 15–34 using the drug in the last year and
3 million using it daily or near-daily (EMCDDA, 2014b; Thanki et al., 2012). These
developments have taken place against a backdrop of major change in the European
cannabis market, which has been transformed over the past decade by the spread of
domestic cultivation of the drug, lowering the barriers between producer and consumer;
furthermore, the potency of cannabis products is increasing (EMCDDA, 2012a).

Treatment for cannabis-related problems, in contrast to treatment for problems related to


heroin use, relies primarily on psychosocial approaches combining elements of classical
psychotherapy with social support and care. Various psychological interventions to treat
drug dependence exist, and these may be tailored to the needs of the users of one drug or
they may be provided to users of any drug. With the large numbers entering treatment each
year in Europe, where drug treatment is paid for largely from public funds, effectiveness is a
key consideration for policy. Research into the effectiveness of treatment approaches for
cannabis problems, however, is still relatively new, and when it was last reviewed by the
European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) no conclusive
evidence was found for any specific treatment (Bergmark, 2008). The present publication
includes an updated review of the literature on treatment for cannabis problems, with the
aim of helping policymakers identify the interventions most likely to succeed.

This publication has two principal aims. The first is to examine the evidence base underlying
interventions for cannabis-related problems. Among the main questions addressed are the
following: ‘For what interventions is there evidence of effectiveness?’ and ‘Does the evidence
favour cannabis-specific interventions over general substance use treatment?’ The second aim
is to map the availability and provision of cannabis treatment in Europe, based on information from
the 28 EU Member States, Turkey and Norway. Here, in addition to describing cannabis treatment
programmes, the relationship between treatment needs and treatment provision is addressed.

The first chapter provides the reader with the background information necessary to
understand the rest of the book. The topics covered include the prevalence of cannabis use
in Europe and the social, health and legal consequences of use of the drug. The provision of
treatment for cannabis users is looked at, as is the question of determining treatment need.
In an overview of treatment for cannabis problems in Europe, a distinction is made between
cannabis-specific and general substance use treatment approaches. The main psychosocial
approaches to treating cannabis-related problems in Europe are described here. This chapter
also describes the methods and sources of data used in the study.

In the second chapter, the evidence for the effectiveness of the various interventions is
reviewed, with treatments for adolescents and adults considered separately. This chapter
also reviews the research on telephone and Internet interventions. The chapter closes by
examining the factors and mechanisms that influence effectiveness.

The treatments available in Europe for cannabis-related problems are reviewed in the third
chapter. Information is presented on the treatment options available in each country, with
a particular focus on the major cannabis-specific programmes in Europe. The fourth
chapter looks at the calculation of unmet treatment needs.

The findings of the study are brought together in a final chapter, where the implications for
policy and practice are assessed.

11
1
CHAPTER 1
Cannabis treatment in context:
cannabis use, related problems
and common treatment approaches

I Cannabis in the European Union:


use and problematic use
because of the possibility of under-reporting among
survey participants and the higher probability of frequent
users occurring outside the sampling frame of general
population surveys. About two-thirds of daily or near-daily
Population surveys indicate that cannabis is the most widely users are between 15 and 34 years old and three-quarters
used illicit substance in most European countries. The most are male (EMCDDA, 2013a).
recent estimates suggest that 5 % of adults (15–64 years)
in the European Union, or 18 million adult Europeans, used Cannabis problems are not driven only by the demand
cannabis in the last year; 74 million adult Europeans side; the supply side also plays a crucial role in these
reported having using cannabis at least once in their life developments. Today, in the European Union, cannabis is
(EMCDDA, 2014b). To put Europe into a global context, one predominantly consumed in two different forms: herbal
can refer to the United Nations World drug report 2013 cannabis (marijuana) and cannabis resin (hashish).
(UNODC, 2013), which indicates that annual prevalence of Historically, cannabis resin was the most widely
cannabis use in Europe overall is above the global average consumed cannabis product in western European
but still below that of West and Central Africa (12.4 %), countries (EMCDDA, 2012a). Over the past decade,
North America (10.7 %) and Oceania (10.9 %). However, there has been a major shift across Europe from the use
there is considerable variation within Europe, with annual of cannabis resin to the use of herbal cannabis products,
prevalence rates ranging from 0.3 % in Romania to 9.6 % in partly driven by an increase in domestic production in
Spain. In terms of the demographics of the affected the European Union. Today, herbal cannabis is the most
population, available data indicate that the typical cannabis used cannabis product in Europe overall. Cannabis resin
user in Europe is a young male aged 15 to 24. remains the most widely used cannabis product only in
countries in the south-west and north of Europe. Even in
More than cannabis use as such, problematic use of the these countries, however, its use has declined
drug is highly relevant for the healthcare sector and considerably relative to that of herbal cannabis products.
policymakers. Data on regular use of cannabis, available
from population surveys, can be used as an indicator of In addition to cannabis resin and herbal cannabis,
the prevalence of such problematic patterns of use in the synthetic cannabinoids play a small, but possibly
population. Thanki et al. (2012) provided an overview on increasing, role in consumption. These synthetic
the prevalence of daily or almost daily cannabis use, substances bind to cannabinoid receptors in the central
defined as use on 20 or more days in the month prior to nervous system, producing similar effects to cannabis.
the survey. Results were based on self-reported data from They constitute a relatively new cannabis-like product,
large, probabilistic, nationally representative samples of which is now available in most EU countries, and often less
the general population. The countries included represent controlled than cannabis. Given the often higher potency
more than 83 % of the population of the European Union and chemical differences of these substances, there may
and Norway. In these countries, between 3.5 % and 44 % be specific risks different from those known for cannabis.
of last-month cannabis users reported daily or near-daily
use — an overall proportion of 25 %. The prevalence of
daily or near-daily use in the adult population (15–64
years) ranged from 0.05 % to 2.6 % for these countries, I Health consequences of cannabis use
resulting in an overall rate of 1 %. This equates to 3 million
people who consume cannabis daily or almost daily. Although cannabis has historically been viewed as much
However, this must be considered a minimum estimate less harmful than so-called ‘hard drugs’, such as opioids

13
Treatment of cannabis-related disorders in Europe

and cocaine, the evidence indicates that cannabis may the share of cannabis-dependent users who seek help is
have serious health implications for some users. the lowest for any illicit drug (Stephens et al., 2007).
Perceived barriers to treatment include not being aware
A brief report compiled in 2011 by the US National of treatment options, thinking treatment is unnecessary,
Institute on Drug Abuse (NIDA) lists the main findings of not wanting to stop using cannabis and wanting to avoid
research into the effects of cannabis on humans. the stigma associated with accessing treatment (Gates
Cannabis intoxication can negatively affect short-term et al., 2012).
memory, reduce reaction time and motor coordination,
and impair judgement. Moreover, these cognitive and
neurological impairments associated with cannabis
intoxication could lead to risky behaviour (e.g.
unprotected sex, driving while intoxicated). Consumption
of high doses of cannabis can result in anxiety disorders
I Trends in treatment provision for
cannabis-related problems
and paranoia, or increase the risk of heart attack in
vulnerable individuals. Long-term negative outcomes The widespread use of cannabis across the European
associated with cannabis use include dependence, Union and the increase in the use of the drug over many
poorer achievement-related outcomes, diminished life years is reflected in the high number of cannabis users
satisfaction, upper respiratory problems and increased now seeking treatment. In 2012, 110 000 of those
risk of developing psychosis in vulnerable individuals. enrolling in specialised drug treatment in the European
Cannabis dependence is a mental disorder with a Union reported cannabis as the primary drug for which
distressing, chronic and relapsing nature. treatment was being sought (Table TDI-062 in EMCDDA,
2014a). Cannabis is the second most commonly
In clinical settings, many cannabis users have been reported primary drug in both inpatient (18 % of clients)
described as self-medicating for anxiety and depressive and outpatient (26 % of clients) treatment settings
subclinical syndromes (anxiety, irritability, negative (Tables TDI-050 and TDI-056 in EMCDDA, 2014a). All
mood, physical symptoms and decreased appetite) countries report admitting cannabis users for treatment
(Weinstein et al., 2010). Individuals with cannabis in outpatient settings, and most countries also report
dependence have been found to be six times more likely cannabis users entering treatment in inpatient settings.
to have mood or anxiety disorders than those without Primary cannabis users account for more than 30 % of
cannabis dependence (Stinson et al., 2006). There is treatment entrants in Belgium, Denmark, Germany,
strong evidence from well-controlled prospective France, Cyprus, Hungary, the Netherlands and Poland,
longitudinal studies for an association between for less than 10 % in Bulgaria, Estonia and Malta, and for
cannabis use and increased risk of psychotic disorders between 10 % and 30 % in the remaining EU Member
(Moore et al., 2007), and specific genetic factors are
emerging as plausible explanations for increased risk
among a subgroup of users (van Winkel, 2011; Verweij et FIGURE 1
al., 2010). There is consistent evidence that cannabis use First-time treatment entrants in the European Union by
is correlated with poor clinical outcomes, relapse, primary drug, 2006–12
remission and exacerbation of symptoms across many %
psychiatric disorders (Baker et al., 2010). A more recent
40 Cannabis
study also points towards long-term negative effects for Opioids
intellectual development if the drug is used regularly 35
during adolescence (Meier et al., 2012). Others have
30
pointed out that these associations may not necessarily
be the result of the direct effects of cannabis use 25
Cocaine
(Danovitch and Gorelick, 2012).
20

Although only a small proportion of intensive users may 15


develop cannabis-related health problems, because of Unreported
10 drugs
the non-trivial prevalence of intensive cannabis use Other drugs
within populations large numbers of people may develop 5 Amphetamines
such problems, making it a public health problem of
0
some size (Copeland and Swift, 2009). Compared with
2006 2007 2008 2009 2010 2011 2012
users of other drugs, cannabis users are less likely to
seek help for their drug problems. At an estimated 10 %, Source: EMCDDA (2013c) Figure TDI-1 and EMCDDA (2014a) Table TDI-059.

14
CHAPTER 1  I Cannabis treatment in context: cannabis use, related problems and common treatment approaches

States. The number entering treatment for the first time explained by differences in the prevalence of use. Factors
in their life is commonly used as an indicator of trends in at national level may also influence the numbers entering
treatment demand. Between 2006 and 2012, the treatment. Among these are the following: the proportion
number of cannabis users entering treatment for the first of users developing problematic patterns of use; the
time in their life has increased, whereas first-time perceived risk and harm of cannabis use at population
treatment admissions for heroin and cocaine have level and related policy decisions; differences in funding
declined. Among first-time entrants to drug treatment, of treatment provision; and referrals for treatment from
cannabis is now the primary substance most frequently the criminal justice system. In addition, the availability,
reported (Figure 1). quality and price of cannabis products on the national
market may have indirect effects on treatment needs and
requests. Other factors influencing availability of
treatment include funding mechanisms in the country,

I Treatment needs and


cannabis-related problems
treatment systems and treatment organisation.

How the provision of treatment for cannabis-related


problems relates to treatment needs is an important
The upward trend in the number of cannabis users question for policymakers. Scientific findings have shown
entering drug treatment in Europe is no longer in step the existence of problematic acute and long-term effects
with the trend in prevalence of cannabis use among the of cannabis use. Some of these may be permanent,
general population. After many years of signalling especially in the case of users who are adolescents or
increasing cannabis use, prevalence indicators now children. Cannabis-related problems are correlated with
point to use of the drug having levelled off or, in some other mental health problems, and although causal or
countries, gone into decline. The continued upward trend multiplying effects of the drug often remain unclear, they
in treatment demand may reflect the delay typically cannot be excluded. While a smaller percentage of
observed between the onset of drug use, the cannabis users than users of other illicit drugs, such as
development of harmful patterns of use and associated heroin, seek treatment, the overall high prevalence of use
problems, and referral for treatment. The average results in a considerable number of cases where
cannabis user entering treatment in Europe is 26 years treatment is needed. This has clear implications from a
old and first used the drug at age 16. The overall trends public health perspective. Furthermore, the debate in
may hide differences between different user groups. One some countries about decriminalisation of or changes in
possible scenario is that the prevalence of problem the regulations on cannabis consumption calls for
forms of cannabis use may still be on the increase while reflection on the possible effects on treatment needs.
less problematic patterns of use are decreasing. While the impact that possible changes in the law may
have on the use of cannabis is outside the scope of this
Overall, there is considerable regional variation in the publication, the need for evidence-based interventions for
prevalence of cannabis treatment, which cannot be problematic users will continue.

Methods and sources of data

A search strategy was carried out to identify all relevant systematic reviews, narrative reviews and individual
studies (randomised controlled trials and observational studies) on the effectiveness of treatment for cannabis
users (adolescents or adults) published after 2008. Publications in three databases (PubMed, EBSCO and Google
Scholar) were searched using the following search terms: cannabis, marijuana, treatment, therapy, counselling,
evaluation, efficacy and effectiveness. Publications were selected for further inspection if at least one treatment
approach was evaluated which was also used for treatment of cannabis use disorders, or if the study revealed
relevant information concerning the factors which influence the effectiveness or the acceptability of these
treatments. Studies focusing only on alcohol or tobacco were excluded. The results were summarised and
compared with an earlier work on the same topic published in an EMCDDA monograph (Bergmark, 2008).

Data presented in this report regarding cannabis-specific treatment programmes in Europe were also obtained
from a number of EMCDDA sources, provided either directly or indirectly through the Reitox network, made up of

15
Treatment of cannabis-related disorders in Europe

national focal points in the 28 EU Member States, Turkey and Norway. The sources were as follows: EMCDDA
Annual reports from 2008 to 2012; Reitox national reports to the EMCDDA from 2008 to 2012; Exchange on Drug
Demand Reduction Action (EDDRA) online resources; the cannabis treatment section of Structured
Questionnaire 27 (SQ27); the Cannabis-Specific Treatment National Focal Point Survey (CSTNFPS);
and the Cannabis-Specific Treatment Programme Manager Survey (CSTPMS).

The EMCDDA Annual reports provided a yearly assessment of the drug problem in Europe, containing facts and
figures on drug policy, use, trafficking and treatment in the 28 EU Member States, Turkey and Norway. The 2012
report was the most recent one available when the data for the current publication were collected. In 2013, the
Annual report was succeeded by the European Drug Report.

Each year, Reitox national focal points provide the EMCDDA with a report detailing the drug phenomenon on a
national basis.

The EDDRA online resources contain additional information on cannabis-specific treatment options
(accessible at emcdda.europa.eu/themes/best-practice/examples).

The SQ27 is a routine data collection via a structured questionnaire that was last updated by the EMCDDA in
2011. The structured questionnaire addresses the policies and interventions that EU Member States, Turkey and
Norway have established to provide evidence-based drug treatment; it also gathers information on measures that
countries have taken to achieve and maintain a high quality of treatment service provision. The survey was sent to
each national focal point. Of the 30 national focal points contacted to participate in this survey, 29 completed the
survey (response rate 97 %). The survey included items assessing basic information about cannabis-specific
treatment programmes offered in each country.

The CSTNFPS was a 15-item survey created and administered by the authors of this report in February 2013.
The purpose of this survey was to gather basic data about currently available inpatient and outpatient cannabis-
specific treatment programmes offered in European countries. The survey contained items assessing the
following information: presence of cannabis-specific treatment programmes in the country, name of the
programme, average waiting time for treatment, cost of treatment to participants, percentage of people in need
who receive treatment, presence of cannabis-specific programmes for adolescents, sources of referral for the
available programmes, and additional information regarding national cannabis use disorder treatment
programmes. Of the 30 national focal points contacted to participate in this survey, 19 completed the survey
(response rate 63 %).

The CSTPMS was a six-item survey created and administered by the authors of this report in March 2013. This
survey was sent to managers of cannabis-specific treatment programmes who were identified by national focal
points in the CSTNFPS. The survey contained items assessing the following information: name of the programme,
description of the programme, standard dose of treatment, status of empirical evidence regarding the efficacy or
effectiveness of the programme, and references to studies indicating efficacy or effectiveness. Of the 14
programme managers that were contacted to participate in the survey, nine, representing five countries and 10
different programmes, completed the survey (response rate 64 %). The purpose of this survey was to provide
detailed information on individual cannabis-specific interventions.

The CSTNFPS and the CSTPMS were the primary sources of data used to characterise European cannabis-
specific interventions in this report. For Member States that did not complete one of these surveys, data from one
or more of the following sources were used: online resources, literature review, SQ27.

16
CHAPTER 1  I Cannabis treatment in context: cannabis use, related problems and common treatment approaches

I Delivery of treatment in Europe needs of cannabis users. In addition, group therapy


interventions incorporated into cannabis-specific
Although subsidised national treatment programmes are programmes may be more effective, as group members
common, there is no one treatment or intervention for may benefit from an increased universality of experience
cannabis use problems that is implemented in all in their interactions. In other words, since group
Member States. Indeed, treatment for cannabis-related members in these interventions engage in problematic
problems takes many forms across the European Union. use of the same substance, they may be better able to
Both evidence-based and non-evidence-based relate to each other’s substance-related experiences
treatments are provided in Europe. In addition, treatment and behaviours. Another advantage of cannabis-specific
is offered in individual, group and family sessions and programmes over general substance use treatment
over the Internet. Treatment programmes are programmes may lie in the reduced risk of typically
administered primarily in outpatient settings, although younger, less problematic cannabis users mixing with
also in inpatient settings. Finally, treatment is more problematic, older users of other illicit substances.
administered by a variety of different service providers,
including professionals (e.g. psychiatrists, General substance use treatment programmes may,
psychologists), para-professionals (e.g. trained however, offer some practical advantages over
counsellors with other professional backgrounds) and substance-specific approaches. General substance use
laypeople (e.g. teachers and other individuals who work treatment may be more cost-effective and easier to
closely with at-risk individuals). Given the variety of administer than separate programmes for a variety of
treatment options currently available in the European substances. In addition, many of the demographic
Union, a major goal of the present report is to differences between cannabis users and users of other
characterise the treatment of cannabis use disorders in substances could be addressed by tailoring treatment to
Europe by providing in-depth, up-to-date information specific age groups or target populations, rather than
about the type and availability of treatments. specific substances. Alternatively, general substance
use treatment services could be tailored to individual
Although there is considerable diversity with regard to needs on a case-by-case basis. Finally, in support of
treatment approach for cannabis use disorders in the general substance use treatment approaches,
European Union, all treatment programmes can be epidemiological and clinical literature indicates that the
roughly classified into one of two categories: cannabis- symptoms of cannabis dependence are similar to the
specific treatment and general substance use treatment. symptoms of dependence on other substances (Budney,
Cannabis-specific treatment programmes treat only 2006). Moreover, the reasons given by cannabis users
those individuals with cannabis-related problems. for seeking treatment and the treatment outcomes are
Typically, such programmes use interventions that are similar to those for users of other substances (Dennis et
designed for or tailored to the specific needs of this al., 2002; McRae et al., 2003; Stephens et al., 1993).
population. In contrast, general substance use treatment
programmes treat individuals with cannabis-related EU Member States have taken different approaches to
problems alongside individuals with problems related to addressing cannabis treatment. The normal standard of
other drugs. Treatment is typically administered by the care in the European Union has historically been general
same service providers and involves the use of general, substance use treatment. Thus, general treatment
non-specific substance use or dependence programmes are widely available throughout the
interventions. Although general substance use treatment European Union, whereas only 15 of the 30 countries
has historically been the typical form of care in the reporting to the EMCDDA currently offer treatments that
European Union, the term is not synonymous with are specific to cannabis.
consensus-based treatment as usual. In fact, many
countries offer general substance use treatment Both general and specific approaches to treating
programmes that incorporate evidence-based cannabis-related problems exist and have been applied
interventions. For example, in the United Kingdom, to meet the needs of people with cannabis-related
individuals with cannabis-related problems are offered disorders. The present publication evaluates both types
general substance use treatment programmes that are of intervention. Programmes focused on cannabis
based on cognitive behavioural interventions. problems are relatively recent additions to the array of
drug treatment interventions available in Europe, and
Both substance-specific and general treatment providing for the first time an EU-level overview of this
approaches for cannabis-related problems have class of treatment is one of the main aims of this
advantages and disadvantages. Cannabis-specific publication. In the section ‘Estimation of unmet
programmes are designed to meet the specific service treatment needs’, Chapter 4, which compares indicators

17
Treatment of cannabis-related disorders in Europe

of treatment needs with estimated provision of sure that sessions occur on the clinician
treatment for this target group, general substance use (Godley et al., 2006).
approaches are also included.

I Behavioural family therapy

I Psychosocial approaches used to treat


drug-related problems
Behavioural family therapy (BFT) is aimed at helping
families going through difficulties in their relationships.
This group treatment is learning-based and, thus, applies
cognitive behavioural analysis of the problems presented
The term ‘psychosocial approaches’ covers all forms of by a family. It focuses on changing thought patterns and
structured psychological or social interventions that may overt behaviour (Psychology Dictionary, no date).
be used to treat substance-related problems. In the
studies identified by this review, these approaches
include a variety of different programmes and concepts. I Brief strategic family therapy
Most interventions followed either an individual-centred
approach or a family approach (summarised in Table 1). Brief strategic family therapy (BSFT) is a brief
They differ considerably in their level of detail and intervention used to treat adolescent drug use that
theoretical basis. A more theoretical overview of co-occurs with other problem behaviours. These
addiction and its treatment can be found in Robert co-occurring problem behaviours include conduct
West’s Models of addiction (EMCDDA, 2013b). problems at home and at school, oppositional behaviour,
delinquency, associating with antisocial peers,
The main approaches are listed below, providing aggressive and violent behaviour and risky sexual
information on background, concept and practical behaviour (Szapocznik et al., 2003).
application. It should be noted that the list is incomplete
and the description of interventions is not theory-driven.
Different approaches may share common techniques or I Cognitive behavioural therapy
be applied to the same target population. They
approaches are listed alphabetically, to serve as a type Cognitive behavioural therapy (CBT) is a
of glossary when reading the outcome tables psychotherapeutic treatment modality offered in
(Tables 3–6). individual or group format (Butler et al., 2006). It is
empirically supported as a treatment for substance
use disorders and has been shown to be effective
I Assertive continuing care in studies containing samples of primary cannabis
users.
Assertive continuing care (ACC) is one of several
‘assertive’ interventions available to treat substance In general, CBT involves challenging irrational, negative
use disorders. This approach aims to increase retention thinking styles, which are thought to promote negative
in treatment by placing the responsibility of making affective states, which in turn promote maladaptive

TABLE 1
Interventions for families and individuals
Target group Intervention (acronym)
Family Behavioural family therapy (BFT)
Brief strategic family therapy (BSFT)
Family process-only condition (FAM)
Functional family therapy (FFT)
Multidimensional family therapy (MDFT)
Multisystemic therapy (MST)
Structural ecosystems therapy (SET)
Individuals (adolescents or adults) Assertive continuing care (ACC)
Cognitive behavioural therapy (CBT)
Contingency management (CM)
Drug counselling (DC)
Educational feedback (EF)
Motivational interviewing and motivational enhancement therapy (MI/MET)

18
CHAPTER 1  I Cannabis treatment in context: cannabis use, related problems and common treatment approaches

behaviours, such as problem cannabis use. In addition to I Functional family therapy


helping clients develop new ways of thinking, CBT
interventions promote the development of alternative Functional family therapy (FFT) is a short-term, high-
coping skills and the implementation of behavioural quality intervention programme with an average of 12
strategies for reducing and eliminating problem sessions over a 3- to 4-month period. Services are
behaviours such as illicit drug use. delivered in both clinical and home settings, and can
also be provided in a variety of other settings, including
CBT for substance-related disorders works by means of schools, child welfare facilities, probation and parole
self-control training (e.g. stimulus control techniques), offices/aftercare systems and mental health facilities
social and coping skills training and relapse prevention. (Functional Family Therapy, no date).
When CBT is used to treat problem cannabis use
specifically, initial treatment sessions often involve
developing skills directly related to achieving and I Multidimensional family therapy
maintaining abstinence from cannabis. Later CBT
sessions may focus on topics and skills indirectly related Multidimensional family therapy (MDFT) (Liddle et al.,
to maintaining abstinence. 2001) is a family systems-oriented outpatient
intervention for adolescents and young adults. It is
empirically supported as an effective treatment for
I Contingency management cannabis use disorders. The intervention is designed to
address problem cannabis use at four different levels:
Contingency management (CM) is a type of treatment (1) the adolescent, (2) the adolescent’s parents, (3) the
used in the mental health and substance use fields. adolescent’s family, and (4) the adolescent’s extra-
Patients’ behaviours are rewarded (or, less often, familial network, which includes friends and peers in
punished) in line with treatment objectives and, school, work and leisure settings. The principle
generally, adherence to or failure to adhere to underlying MDFT is that the family is instrumental in
programme rules and regulations or their treatment plan treating problem cannabis use by helping the adolescent
(Griffith et al., 2000). to create new, developmentally adaptive lifestyle
alternatives. Thus, interventions are aimed at improving
family functioning, communication and accountability.
I Drug counselling
Drug counselling (DC), delivered on an individual basis,
addresses the symptoms of the drug addiction and
areas of impaired functioning that are related to it, and
I Motivational interviewing and motivational
enhancement therapy

the content and structure of the client’s ongoing Motivational interviewing (MI) (Miller, 1983; Miller and
recovery programme (Mercer and Woody, 1999). Rollnick, 1991) is a therapeutic intervention typically
offered in an individual therapy format. Since the focus
of MI is to harness an individual’s motivation to engage
I Educational feedback in the treatment process, interventions based on MI are
often employed at the initial phase of substance use
Educational feedback (EF) (as described in Walker et al., treatment to motivate the client to engage in the more
2011) involves two sessions with a counsellor delivering intensive psychosocial treatments, which are skills-
a PowerPoint presentation on current research and facts oriented (e.g. CBT). Motivational enhancement therapy
about cannabis. Based on questions elicited from the (MET) relies heavily on the principles of MI. As these two
participating teenagers, clients are informed about the concepts are strongly interrelated, they will be discussed
effects of cannabis on the body, sexual behaviour and together here and abbreviated as MI/MET.
pregnancy. Further topics could include the legalisation
debate, legal issues, and cannabis and medicine. MI/MET is empirically supported for substance use
disorders and has shown to be effective for both adults
and adolescents. MI/MET combines the
I Family process-only condition transtheoretical model (Prochaska and DiClemente,
1982) with client-centred therapy and self-efficacy. It is
Family process-only condition (FAM) focuses exclusively particularly useful in treating individuals who are
on working with family members to modify within-family ambivalent about personal behavioural change, as is
interactions (Robbins et al., 2008). often the case with those presenting with cannabis use

19
Treatment of cannabis-related disorders in Europe

problems. The primary goal of this treatment approach relationships with his or her peer group and school and
for cannabis use disorders is to explore and resolve with the juvenile justice system. SET is intended to be
ambivalence about cannabis use and facilitate and delivered over 12–16 family therapy sessions (e.g.
engage the client’s intrinsic motivation to change sessions conducted with multiple family members) and
problem behaviour. 12 ecosystemic therapy sessions (e.g. sessions with
family members and individuals from the family’s social
Thus, MI/MET differs from other substance use ecology) (Robbins et al., 2008).
treatments in that its purpose is not to impart
information or skills. In contrast, it emphasises exploring
and reinforcing the client’s intrinsic motivation to engage
in adaptive behaviours and refrain from addictive I Control conditions
behaviours, while simultaneously supporting the client’s
autonomy. Techniques employed by MI/MET therapists Studies on the effectiveness of interventions have to
include asking open-ended questions, providing prove that a change in the behaviour or state of a person
affirmations to the client, listening reflectively and is due to the treatment condition. The general approach
summarising the client’s statements. is to use control conditions for comparison, which do not
include the specific measure under research. In the
studies analysed here, the following interventions have
I Multisystemic therapy been used as controls.

Multisystemic therapy (MST) is an intensive family and


community-based treatment that addresses the I Community service
multiple determinants of serious antisocial behaviour in
chronic, violent or substance-using male or female Community service (CS) is a type of punishment that
juvenile offenders, ages 12 to 17, at high risk of out-of- involves working for the community. CS is used as a
home placement. The multisystemic approach views control condition in some studies.
individuals as nested within a network of interconnected
systems that encompass individual, family and extra-
familial (peer, school, neighbourhood) factors. I Delayed feedback
Intervention may be necessary in any one or a
combination of these systems. Treatment sessions Delayed feedback (DF) is the name given by Walker et
occur primarily with caregivers and other involved al. (2011) to the intervention provided to the
adults to make changes in the youth’s environment that participants assigned to the control arm. Participants in
will in turn result in changes in the youth’s behaviour. the DF condition were not assessed until the 3-month
Individual therapy with the youth is not a routine follow-up.
component of MST. The primary goals of MST
programmes are to decrease rates of antisocial
behaviour and other clinical problems, improve I Delayed treatment control
functioning (e.g. family relations, school performance)
and promote behaviour change in the client’s natural Delayed treatment control (DTC) compares the effect
environment (Episcenter, 2010). of the intervention with no intervention during
this period in the control arm. To motivate subjects
to participate in such studies and for ethical reasons,
I Structural ecosystems therapy the same treatment is then — at a later stage —
provided to the control group. This design cannot
Structural ecosystems therapy (SET) is a manualised control for the effects of positive expectations
family- and ecological-based intervention for adolescent in the control arm.
drug use (Robbins et al., 2003). The within-family
components of SET are (a) joining with family members,
(b) tracking and eliciting family interactions to assess I Intention-to-treat analysis
family relationships, (c) reframing to create a context for
behaviour change to occur, and (d) restructuring Intention-to-treat (ITT) analysis is a quality criterion for
maladaptive family relationships. The ecological studies, whereby the outcome is calculated on the basis
components of SET include assessment of and of those initially assigned to the intervention, whether
intervention in the adolescent’s and family’s they received the intervention or not.

20
CHAPTER 1  I Cannabis treatment in context: cannabis use, related problems and common treatment approaches

I Treatment as usual
Treatment as usual (TAU) is used in experimental
studies as a control condition against which the effects
of an intervention can be compared. Instead of
specifying the treatment, in this case, the (new) form of
treatment being tested is compared with the routine
type of intervention.

21
2
CHAPTER 2  I Effectiveness of interventions: review of recent research on available treatments

CHAPTER 2
Effectiveness of interventions:
review of recent research on
available treatments

Overall, 65 studies were found that fulfilled the and other problem behaviours. Studies generally
inclusion criteria: 26 were reviews, 9 of which included reported following study participants for periods of 1 to
a meta-analysis. The majority (31) of the remaining 39 12 months. Most studies provided information on loss of
individual studies were randomised controlled trials. study participants over time, which is a common
As one meta-analysis and one randomised controlled occurrence in clinical trials. The number of study
study contributed information on effectiveness dropouts was counted and a retention rate calculated.
as well as on factors of influence, the total number Methodologically strong studies included measures of
of studies is smaller than the sum of all subgroups quality assurance, for example using a manual to guide
(see Table 2). the intervention, providing some type of training and
supervision of study counsellors and assessing
The studies were heterogeneous in terms of design. In treatment fidelity using audio or video recordings of the
most of the primary studies, subjects were randomly therapy sessions.
assigned to an active intervention and to a control
condition for comparison. The control condition was None of the 26 reviews identified were published by
either an alternative active intervention, a combination of European research groups; the majority were from the
interventions, treatment as usual or a delayed treatment United States or Australia. Only three of the 39 individual
control. Measures of substance use were provided studies were European ones; these three looked at the
through self-report or a combination of self-report and effectiveness of cannabis-specific brief motivational
biochemical measures of substance use. Baseline enhancement for adolescent cannabis users
measurements were made of study outcome variables (McCambridge et al., 2008) and the efficacy of MDFT for
including abstinence, quantity and frequency of adolescents in the Netherlands (Hendriks et al., 2011)
cannabis use and other substance use, number and and Germany (Tossmann et al., 2012). The two later
severity of use-related problems, DSM-IV (American studies were part of the International Need of Cannabis
Psychiatric Association, 2000) dependence symptoms Treatment (INCANT) collaboration.

TABLE 2
Type and number of studies included in the review
Adolescents Adults Studies on Factors Total
General Cannabis- General Cannabis- tele-interventions influencing
substance specific substance specific effectiveness
use treatment treatment use treatment treatment of treatment
programmes programmes programmes programmes
Meta-analyses 3 1 4  0  1   1 (3 ) 9
Reviews 7 1 1  5  1  2 17
Randomised controlled 4 6 3  5  8   6 (3 ) 31
trials
Quasi-experimental 3 0 0   1 (1)   2 (2 )   2 (2 ) 8
study and observational
studies
Total 17 8 8 11 12 11 65
(1) Pre/post, (2) observational, (3) one study also listed under ‘Adults’.

23
Treatment of cannabis-related disorders in Europe

I Research on treatment for adolescents significant for both groups, but between-group
differences had disappeared. Two further randomised
The literature on the effectiveness of treatment for controlled trials did not find significant treatment effects
adolescents is considerably less developed than the for a school-based MI intervention for adolescent
corresponding literature on adults, but recent empirical cannabis users (McCambridge et al., 2008; Walker et al.,
studies have begun to provide more insight into the 2011). Both of these studies compared the effectiveness
effectiveness of cannabis-specific treatment in this of a single session of MI against drug information and
population. advice in reducing cannabis use.

Overall, the search strategy identified 25 publications on Given that each treatment approach has specific
interventions for adolescent cannabis users. strengths and limitations, clinical researchers have
begun to combine different treatments in efforts to
Eight publications were about cannabis-specific increase overall effectiveness. The most common
treatment for adolescents with cannabis use disorders: approach is a combination of elements designed to
one meta-analysis (Bender et al., 2010), one literature strengthen clients’ motivation to change (MI, MET) and
review (Copeland and Swift, 2009) and six randomised elements targeting thoughts, emotions and behaviours
controlled trials (Hendriks et al., 2011; Martin and that are implicated in substance use (CBT). Researchers
Copeland, 2008; McCambridge et al., 2008; Stanger et have also evaluated whether CM adds to the efficacy of
al., 2009; Tossmann et al., 2012; Walker et al., 2011). combined treatment interventions.

Seventeen publications addressed adolescent cannabis Martin and Copeland (2008) conducted a randomised
users in general substance use treatment programmes. controlled trial examining the effectiveness of a two-
Among these publications, there were three meta- session CBT and MI combination treatment compared
analytical reviews (Baldwin et al., 2012; Jensen et al., with a 3-month delayed treatment control condition in a
2011; Tanner-Smith et al., 2013), seven literature reviews sample of 40 people aged between 14 and 19 years.
(Barnett et al., 2012; Becker and Curry, 2008; Griffin and They found that, compared with the control condition,
Botvin, 2010; Hogue and Liddle, 2009; Macgowan and MI/CBT produced significantly greater reductions in the
Engle, 2010; Rowe, 2012; Waldron and Turner, 2008), frequency of cannabis use per week, the quantity of
three randomised controlled trials (Godley et al., 2011; cannabis used per week and the number of DSM-IV
Liddle et al., 2008; Robbins et al., 2011), one dependence symptoms at the 3-month follow-up.
effectiveness trial (Letourneau et al., 2009), two
observational studies (Lott and Jencius, 2009; Stanger et al. (2009) found that an additional element of
Ramchand et al., 2011) and one quasi-experimental CM improves the efficacy of MET/CBT interventions. In
study (Hunter et al., 2012). the study, 69 adolescents were randomly assigned to
one of two groups, both of which received MET/CBT and
a twice-weekly drug-testing programme. Both groups
I Cannabis-specific treatment for adolescents additionally took part in an incentive programme (i.e. CM
intervention). In the experimental condition, incentives
Interventions targeting the individual were abstinence-based, whereas incentives were
attendance-based in the control group. Results revealed
We identified six randomised controlled trials (involving that cannabis abstinence was significantly greater in the
905 participants) performing various combinations of experimental condition during treatment. After
MI/MET, CBT and CM (Table 3). treatment, cannabis use tended to rise, but at 9 months
it stabilised at a level lower than baseline.
Two studies provide information on MI/MET applied
alone without further treatment elements. Walker et al. The CANDIS study, by Hoch et al. (2012), tested the
(2011) compared MET with an ‘educational feedback effectiveness of a programme for cannabis use disorders
control’ intervention and a delayed feedback control that blends aspects of CBT and MI in a sample of 122
group. The study was conducted on 310 cannabis users participants over the age of 16 years who had been
aged 14 to 19 years old, who were assigned to one of the diagnosed with cannabis dependence. Subgroup
three groups. At the 3-month follow-up, both active analyses showed that teenagers could benefit from the
treatments showed significant reductions in cannabis programme, and abstinence rates at the end of treatment
use, with participants in the motivational enhancement were comparable between them and the adult subgroup
condition showing greater reductions. After 12 months, in the study. More details on the study can be found in
reductions in use and use-related problems were still Table 5, as the study focused on an adult target group.

24
TABLE 3
Adolescents: cannabis-specific treatment
Reference Design Number of Age Target Population Treatment Outcome
participants/ group characteristics
studies (years)
Reviews
Bender et al., Meta-analysis 17 s – Individual, Cannabis use Individual and family-based Individual and family-based treatments have roughly equivalent moderate
2010 family interventions effect sizes in reducing cannabis use.
Copeland and Review – – Individual, Cannabis use CBT, CM, family-based Brief CBT and CM have the strongest empirical support; family-based
Swift, 2009 family interventions interventions may be particularly effective adjunctive treatment options for
adolescents.
Individual studies
Hendriks et RCT 109 p 13–18 Family Cannabis use a. MDFT Adolescents in both treatments showed significant and clinically meaningful
al., 2011 b. CBT reductions in cannabis use from baseline to 1-year follow-up.
Tossmann et RCT 120 p 13–18 Individual Cannabis use a. MDFT Participants in both treatments significantly reduced their cannabis use in the
al., 2012 b. CBT 12-month follow-up. MDFT was significantly more effective than TAU in
reducing cannabis use.
Stanger et al., RCT 69 p 14–18 Individual Marijuana abuse a.  CM, MET/CBT Integrating CM abstinence-based approaches with other empirically based
2009 and dependence b. MET/CBT outpatient interventions provides an alternative and efficacious treatment
model for adolescent substance abuse or dependence.
Hoch et al., RCT 122 p 16–44 Individual Cannabis use a. MET/CBT/problem-solving Subgroup analyses for teenagers found abstinence rates at the end of
2012 training treatment comparable with those for the adult subgroup in the study (for more
b.  DFC information, see Table 5).
Martin and RCT 40 p 14–19 Individual Cannabis use a.  MI/CBT Compared with the control condition, MI/CBT produced significantly greater
Copeland, b.  DFC reductions in the frequency of cannabis use per week, the quantity of
2008 cannabis use per week and the number of DSM-IV dependence symptoms at
the 3-month follow-up.
McCambridge RCT 326 p 16–19 Individual Cannabis use a. MET-1 No differences were found between MET and drug information and advice.
et al., 2008 b.  Information and advice
Walker et al., RCT 310 p 14–19 Individual Cannabis use a. MET Participants in both the MET and EF conditions reported significantly fewer
2011 b. EF days of cannabis use and negative consequences compared with DFC.
c. DFC Reductions in use and problems were sustained at 12 months, but there were
no differences between MET and EF interventions.
Abbreviations: CBT, cognitive behavioural therapy; CM, contingency management; DFC, delayed feedback control; EF, educational feedback; FFT, functional family therapy; MDFT, multidimensional family therapy; MET,
motivational enhancement therapy; MI, motivational interviewing; MST, multisystemic therapy; p, participants; RCT, randomised controlled trial; s, studies; TAU, treatment as usual.
CHAPTER 2  I Effectiveness of interventions: review of recent research on available treatments

25
Treatment of cannabis-related disorders in Europe

Copeland and Swift (2009) concluded that brief CBT al., 2001). Bergmark concluded that the treatment
treatment approaches have the most empirical support; modality has less impact on treatment outcome than the
however, they found that CM (e.g. monetary reward for context in which treatment is delivered and the
abstinence) and family-systems approaches may be individual’s motivation to engage in treatment.
particularly effective adjunctive treatment options for
adolescents.
I General treatment of substance use disorders
Family-based interventions Interventions targeting the individual

Studies examining the effectiveness of family-based Among the reviews addressing treatments for
interventions on cannabis use are scarce. The few adolescent substance use in general, we identified 17
studies available suggest that family-based publications, 7 of which are narrative reviews, including
interventions are effective approaches for treating 143 studies, and 3 are meta-analyses, including 90
cannabis disorders in adolescents. We identified one studies (see Table 4).
meta-analysis of 15 randomised controlled evaluations
of interventions to reduce adolescent cannabis use Findings show that most treatments that aim to reduce
published between 1960 and 2008 (Bender et al., substance use appear to be beneficial for adolescents.
2010), one review (Copeland and Swift, 2009); and two Although Waldron and Turner (2008) found no clear
RCTs involving 229 patients between 13 and 18 years differences in effectiveness between the treatment
of age. approaches, behaviour-based interventions emerged as
‘well-established’ (Waldron and Turner, 2008) or
Hendriks et al. (2011) compared the effectiveness of ‘probably efficacious’ (Macgowan and Engle, 2010), or
MDFT and CBT for treatment of cannabis use disorders showed evidence of immediate superiority (Becker and
in a randomised trial. They found that both interventions Curry, 2008). Motivational interventions were found to
were equally effective in reducing cannabis use in a be ‘promising’ (Macgowan and Engle, 2010), or also
sample of adolescents from the Netherlands. In a showed evidence of immediate superiority (Becker and
German sample, Tossmann et al. (2012) compared the Curry, 2008).
effectiveness of MDFT and an individual therapy
combining elements of CBT and MET in the treatment of Jensen et al. (2011) conducted a meta-analysis (5 471
cannabis use disorders. The results revealed that MDFT participants, 21 studies) to determine the effectiveness
was significantly more effective than CBT in reducing of MI interventions on adolescent substance use. Their
cannabis use. results revealed that MI interventions have a small yet
significant effect on substance use at both post-
These results are consistent with a previous review for treatment and follow-up assessments. These results
the EMCDDA by Bergmark (2008), which reviewed suggest that adolescent substance users treated with MI
results from the Cannabis Youth Treatment Study interventions can make significant gains in treatment
(Dennis et al., 2004), a large (600 participants), and maintain these gains even after treatment has
randomised, multisite trial comparing the effectiveness ended.
of five different cannabis treatment conditions: five
sessions of MET and CBT, 12 sessions of MET and CBT, Barnett et al. (2012) conducted a systematic review of
family support network, the adolescent community 39 studies, conducted between 1998 and 2011,
reinforcement approach and MDFT. The results of the examining the effectiveness of MI on substance use.
study revealed that treatment outcomes were very They found that two-thirds of the studies reported a
similar across sites and conditions; however, a statistically significant reduction in substance use. No
combination of MET and CBT emerged as the most significant differences were found between motivational
cost-effective treatment. In addition, Bergmark (2008) interventions that used feedback and those that did not
found that research concerning the effectiveness of use feedback. In addition, their review included seven
family-based substance use treatment produced mixed randomised controlled trials that focused specifically on
results. While some of the studies included in his review the treatment of cannabis use with MI. Of these seven
found strong support for the effectiveness of family- studies, five found significant effects for the MI
based treatments (Ozechowski and Liddle, 2000; intervention compared with control conditions, including
Prendergast et al., 2002; Stanton and Shadish, 1997; a study that found that MET reduced cannabis use at
Williams and Chang, 2000), others reported post-treatment, 3-month and 12-month follow-up
contradictory findings (Dennis et al., 2004; Waldron et assessments.

26
CHAPTER 2  I Effectiveness of interventions: review of recent research on available treatments

In an observational study, Ramchand et al. (2011) however, family-based interventions were found to be
compared the effectiveness of community-based more effective than comparison treatment conditions.
outpatient treatment and MET combined with five Becker and Curry (2008) found evidence of ‘immediate
sessions of CBT (MET/CBT5) in a sample of 605 superiority’ for ecological family therapy. Waldron and
adolescents (mean age 15.7 years) meeting at least one Turner (2008) regarded MDFT and functional family
of the criteria of abuse or dependence (DSM-IV-TR; therapy as ‘well-established’, and brief strategic family
American Psychiatric Association, 2000). Adolescents therapy, behavioural family therapy and multisystemic
receiving the MET/CBT5 condition exhibited greater therapy as ‘probably efficacious’ models for substance
reductions in substance use frequency, substance use use treatment.
problems and illegal behaviours 12 months after
treatment entry than those allocated to a community- Baldwin et al. (2012) concluded from their meta-analysis
based outpatient treatment. of four studies that family-based interventions (e.g. brief
strategic family therapy, functional family therapy, MDFT,
A second quasi-experimental study by the same or multisystemic therapy) had statistically significant,
research team administered the same CBT/MET but modest, effects compared with alternative
combination treatment in a community practice setting treatments for substance use. Interestingly, the authors
(involving 2 751 adolescents) and replicated the findings observed larger, but insignificant, effects when
from the previous study (Hunter et al., 2012). comparing family-based treatments with no-treatment
Furthermore, under these better-controlled conditions, it control groups. The authors concluded that this counter-
showed that participants receiving MET/CBT5 had intuitive result was likely to have resulted from
better results at the 12-month evaluation than the underpowered analyses of these comparisons. In
control group. addition, the meta-analysis did not have enough power
to determine if different family-based approaches had
Godley, S., et al. (2010) compared a MET/CBT 7-session different levels of effectiveness.
intervention with another outpatient treatment
(Chestnut’s Bloomington outpatient treatment) in a Some recent research has focused on the effects of brief
sample of 320 adolescents. Both interventions strategic family therapy (BSFT) on adolescent
significantly reduced cannabis use over 12 months; substance use. Griffin and Botvin (2010) found in their
however, the MET/CBT combination was more cost- review of effectiveness literature that treatment with
effective. brief strategic family therapy (including eight studies)
produced significant pre–post reductions in cannabis
In community-based treatment studies with samples of use, and other substance use, compared with a no-
polysubstance users, results on the effectiveness of CM treatment control group in one study. However,
were mixed. Lott and Jencius (2009) found that compared with treatment as usual (i.e. standard
adolescents participating in a CM programme had treatment offered at community mental health centres),
significantly lower rates of positive opioid and cocaine brief strategic family therapy was not found to be
urine samples than adolescents treated without CM. significantly more effective in reducing adolescent
However, no significant differences were found for all substance use in a recent individual randomised
other drug classes, including cannabis, although rates controlled trial including 471 adolescents (Robbins et al.,
were trending lower in adolescents treated with CM. 2011).

Multidimensional family therapy (Liddle et al., 2001),


Family-based interventions another family-based treatment approach, has also
received some empirical support. Liddle et al. (2008)
Although studies on the effectiveness of family-based compared the effectiveness of MDFT and a peer group
general substance use treatment interventions on intervention with young teens (mean age 13.7 years) in a
cannabis use are scarce, there is some evidence that the randomised controlled trial recruiting 83 patients. From
family-based intervention is an effective approach for the beginning of treatment until the last follow-up
treating general substance use in adolescents. In assessment at 12 months, MDFT showed superior
particular, we identified two meta-analyses, five reviews effectiveness in reducing substance use frequency and
and one RCT. substance use problems. EMCDDA (2014c) conducted a
systematic review of literature comparing MDFT with
Comparing pre–post effect sizes, Tanner-Smith et al. other treatments for adolescent substance use
(2013) found that adolescents in almost all treatment (including five studies). They concluded that MDFT is an
modalities showed reductions in substance use; empirically supported intervention for substance use

27
28
TABLE 4
Adolescents: general treatment of substance-related disorders
Study Design Number of Age Target Population Treatment Outcome
participants/ (years) characteristics
studies (1)
Reviews
Baldwin et al., Meta-analysis 24 s – Family Substance use BSFT, FFT, MDFT, MST, TAU Family-based interventions had statistically significant, but modest, effects
2012 compared with alternative treatments for substance use. Larger, but
Treatment of cannabis-related disorders in Europe

insignificant, effects were observed when family-based treatments were


compared with no-treatment control groups.
Barnett et al., Review 39 s – Individual Substance use MI 67 % of the reviewed studies reported a statistically significant reduction in
2012 substance use. There were no significant differences found between
motivational interventions that used feedback and those that did not use
feedback.
Becker and Review 31 s – Family Substance use CBT, MI, family-based Ecological family therapy, brief motivational interventions and CBT showed
Curry, 2008 interventions evidence of immediate superiority.
Griffin and Review 8s – Family Substance use BSFT BSFT produced significant pre–post reductions in cannabis use, and other
Botvin, 2010 substance use, compared with a no-treatment control group in one study.
Hogue and Review 14 s – Individual Substance use Family-based interventions Family-based interventions can play a significant role in cannabis-related
Liddle, 2009 disorders.
Jensen et al., Meta-analysis 21 s – Individual Substance use MI MI interventions have a small, but significant, effect on substance use in both
2011 post-treatment and follow-up assessment.
Macgowan Review 34 s M = 19 Individual Substance use Behaviour therapies; MI Behaviour therapies were ‘probably efficacious’, and MI interventions were
and Engle, found to be ‘promising’.
2010
Rowe, 2012 Review – – Family Substance use Family-based interventions Adolescent-focused family-based interventions show the most consistent
and strongest findings in recent studies.
Tanner-Smith Meta-analysis 45 s – Family Substance use Family-based interventions Adolescents in almost all treatment modalities evidenced reductions in
et al., 2013 substance use; however, family-based interventions were found to be more
effective than comparison treatment conditions.
Waldron and Review 17 s – Family Substance use CBT, family-based MDFT, FFT and group CBT emerged as well-established models for
Turner, 2008 interventions substance use treatment.
TABLE 4 (continued)
Study Design Number of Age Target Population Treatment Outcome
participants/ (years) characteristics
studies (1)
Individual studies
Godley et al., RCT 320 p M = 15.9 Individual Substance use a.  CBOP + ACC All interventions significantly reduced cannabis use over 12 months; however,
S., b. CBOP the MET/CBT7 intervention was more cost-effective.
2010 c.  MET/CBT7 + ACC There were no statistically significant findings with regard to the incremental
d. MET/CBT7 effectiveness of ACC following outpatient treatment.
Hunter et al., Quasi- 2 751 p – Individual Substance use a. MET/CBT5 Participants who received MET/CBT5 fared better than comparable
2012 experimental b. TAU participants in the control group on five out of six 12-month outcomes.
study
Letourneau Effectiveness 127 p 11–17 Family Substance use a. MST At the 12-month follow-up, participants in the MST condition exhibited
et al., 2009 trial b. TAU significantly reduced substance use relative to the control group.
Liddle et al., RCT 83 p M = 13.7 Family Substance use a. MDFT MDFT showed superior effectiveness in reducing substance use frequency
2008 b.  Peer group intervention and substance use problems until the last follow-up assessment at 12
months.
Lott and Observational 347 p 12–18 Individual Substance use a. MET/CBT/12-step Adolescents participating in a CM programme had significantly lower rates of
Jencius, study facilitation positive opioid and cocaine urine samples than adolescents treated without
2009 b. MET/CBT/12-step CM. However, no significant differences were found for all other drug classes,
facilitation + CM including cannabis, although rates were trending lower in adolescents treated
with CM.
Ramchand et Observational 605 p M = 15.7 Individual Substance use a. MET/CBT5 Adolescents receiving the MET/CBT5 condition exhibited greater reductions
al., 2011 study b. TAU in substance use frequency, substance use problems and illegal behaviours
12 months after treatment entry compared with a community-based
outpatient treatment.
Robbins et al., RCT 471 p – Family Substance use a. BSFT Compared with TAU, BSFT was not found to be significantly more effective in
2011 b. TAU reducing adolescent substance use.
(1)  Indicated as range or mean age, where available.
Abbreviations: ACC, assertive continuing care; BSFT, brief strategic family therapy; CBOP, Chestnut’s Bloomington outpatient treatment; CBT, cognitive behavioural therapy; CM, contingency management; FFT, functional family
therapy; M, mean; MDFT, multidimensional family therapy; MET, motivational enhancement therapy; MI, motivational interviewing; MST, multisystemic therapy; p, participants; RCT, randomised controlled trial; s, studies; TAU,
treatment as usual.
CHAPTER 2  I Effectiveness of interventions: review of recent research on available treatments

29
Treatment of cannabis-related disorders in Europe

and that it is slightly superior to most other treatments et al., 2012; Barnett et al., 2012; Becker and Curry, 2008;
(e.g. CBT, MET) in terms of treatment adherence and Griffin and Botvin, 2010; Hogue and Liddle, 2009;
long-term maintenance of treatment gains. MDFT also Jensen et al., 2011; Macgowan and Engle, 2010; Rowe,
appeared to be more effective in reducing severity of 2012; Tanner-Smith et al., 2013; Waldron and Turner,
substance use and related problems than CBT; however, 2008). Positive treatment effects were shown for MET
this conclusion was not supported for studies in which (Barnett et al., 2012; Becker and Curry, 2008; Jensen et
participants were being treated for cannabis use al., 2011; Macgowan and Engle, 2010), CBT (Becker and
disorders. Thus, with regard to treatment for problem Curry, 2008; Macgowan and Engle, 2010; Waldron and
cannabis use, MDFT appears to be comparable to other Turner, 2008), CM (Lott and Jencius, 2009) and various
evidence-based treatments. Finally, the authors argued types of family interventions (Baldwin et al., 2012;
that some of the benefits of MDFT may be attributable Becker and Curry, 2008; Griffin and Botvin, 2010; Hogue
to a larger dose of treatment compared with brief and Liddle, 2009; Liddle et al., 2008; Rowe, 2012;
interventions (e.g. MI, MET, CBT). Tanner-Smith et al., 2013; Waldron and Turner, 2008).
Generally, abstinence was a less common outcome than
Multisystemic therapy has been classified as a ‘probably reduction in the frequency of cannabis use.
efficacious’ family-based treatment for substance use
disorders in a review of 17 studies (Waldron and Turner,
2008). Letourneau et al. (2009) compared multisystemic
therapy in a sample of 127 juvenile sex offenders with I Research on treatment for adults
services that are typically provided to this group in the
United States. At the 12-month follow-up, young people A range of behaviour-based treatment options have been
in the multisystemic therapy condition exhibited studied for the treatment of cannabis dependence.
significantly reduced substance use relative to the These include MET and a combination of CBT and CM.
control group. We reviewed the most recent studies on treatment
options for cannabis dependence in adults, including
interventions for those with co-occurring cannabis use
I Conclusions and psychiatric symptoms.

Interventions for adolescents with cannabis use


disorders address young people at early stages of their I Cannabis-specific treatment for adults
cannabis-using careers. They take into account a young
person’s current risk behaviour and his or her general For adults with cannabis use problems, no cannabis-
relationship to drugs, as well as associated physical, specific programmes were found targeting their families.
mental or psychosocial problems. Research on the
efficacy of such interventions is still scarce compared A small number of studies were found that target the
with treatment studies of other child and adolescent adult population of people with cannabis-related
disorders, such as anxiety, attention deficit hyperactivity disorders who also show co-occurring psychiatric
disorder (ADHD) and depression (Gilvarry, 2000; Liddle problems. As this group shows specific needs and may
et al., 2008). Nevertheless, this review of the current differ from others with respect to effectiveness of
literature indicates that the knowledge base for treating interventions, it is presented separately in this section.
children and adolescents with cannabis use problems is
growing, albeit slowly. Among the studies reviewed here,
more attention is given to general substance use Interventions targeting the individual
treatment models that take into account the
developmental stage and special needs of young people, Psychosocial approaches involving CBT, MI/MET or CM
rather than simply generalising (potentially age- were investigated in 10 studies identified through the
inappropriate) adult programmes to this group search strategy. In particular, Weinstein et al. (2010)
(Pumariega et al., 2004). examined whether CBT was effective in treating cannabis
withdrawal syndrome in a sample of 26 individuals
Findings from meta-analyses and RCTs indicate that diagnosed with cannabis dependence. They found that
adolescents with cannabis use problems generally only 20 % of the participants remained abstinent after 6
benefit from various treatment approaches. Aggregated months. The remainder of the participants either relapsed
data from recently published meta-analyses and reviews prior to the 6-month follow-up (30 %) or dropped out of
provide strong evidence for the efficacy of treatments the treatment programme prior to receiving the full
targeting adolescent substance use in general (Baldwin 12-week dose of CBT (50 %).

30
CHAPTER 2  I Effectiveness of interventions: review of recent research on available treatments

In a recent randomised controlled trial examining the


effects of MI on cannabis use specifically, Stein, L., et al.
(2011) found that MI was more effective in reduced
I General treatment of substance use disorders
in adults

cannabis use than an assessment control condition at As with the studies on adolescents, the search strategy
the 3-month follow-up. These effects were not observed, identified a number of studies on substance use
however, at the 6-month follow-up, except for disorders in adults in which cannabis use may be
participants who entered the trial with a desire to involved, although not exclusively (see Table 6).
abstain from cannabis use. This finding suggests that
motivation to abstain from substance use when entering A large body of research exists on the effectiveness of
treatment may moderate treatment efficacy. CBT for the treatment of substance use disorders. To
provide a quantitative summary of this research, Magill
In an attempt to increase the effectiveness of cannabis and Ray (2009) conducted a meta-analysis of 53
use treatment for adults, combinations of various randomised controlled trials examining the effectiveness
treatment approaches have been utilised. Similarly to of CBT in the treatment of adults diagnosed with alcohol
the adolescent literature, the evidence suggests that the or substance use disorders. The authors found a small,
most effective combined treatment for adults is a but statistically significant, effect of treatment. The
combination of CBT, MI and CM. effect of CBT was largest in cannabis studies, but
tended to diminish over time. In addition, gender was
In a randomised controlled clinical trial, Hoch et al. found to be a potential moderating factor, making CBT
(2012) examined the effectiveness of CANDIS, a more effective for women than for men.
treatment programme for cannabis use disorders
combining aspects of CBT and MI. A sample of 122 A meta-analytical review of 34 randomised controlled
patients diagnosed with cannabis dependence was studies of treatments for polysubstance use found that a
randomly assigned to a 10-session CANDIS intervention, combination of CBT and CM is the best approach for
which consisted of MET, CBT and psychosocial problem- treating adult substance use disorders (Dutra et al.,
solving training, or to a delayed treatment group. 2008). However, this finding must be interpreted
Analyses revealed that about half of the active treatment cautiously, as only two studies included in the meta-
group achieved abstinence at post-treatment (49 %) and analysis contained a condition in which a combination
maintained abstinence at the 6-month follow-up (45 %). (CBT/CM) treatment was administered. Yonkers et al.
In addition, compared with the control group, (2012) examined the effectiveness of a CBT/MET
participants in the intervention condition exhibited combination treatment compared with brief advice
significantly lower frequency of cannabis use, addiction about substance use from obstetricians in a sample of
severity, number of disability days and overall level of pregnant women with substance use disorders. No
psychopathology. significant differences were observed between
treatment groups, suggesting that in this population
When the effectiveness of CM, CBT/MET and CBT/ even brief treatments may be effective in reducing
MET/CM was compared with a case management substance use. Consistently with these results, a brief
control condition in a randomised controlled trial, the intervention targeting risky behaviours associated with
CBT/MET/CM condition was found to be associated cannabis use was shown to reduce risky cannabis-
with the highest rates of cannabis abstinence at related behaviour (e.g. driving after cannabis use) in a
follow-up assessment for up to one year (Kadden and sample of college students (Fischer et al., 2013).
Litt, 2011).
There is also a large empirical literature on the
These findings appear to be in contradiction with the effectiveness of MI-oriented approaches for the
outcome of Carroll et al. (2012), which compared the treatment of substance use disorders. Lundahl et al.
effectiveness of four different treatments for cannabis (2010) conducted a meta-analysis of 119 treatment
use (CBT alone, CM for abstinence alone, CBT with CM studies. MI was found to have a consistent small effect
for homework completion, CBT with CM for abstinence) on substance use in general, and cannabis use
on a sample of 127 young adults, 94 % of whom were specifically, compared with weak comparison groups
referred for treatment by the criminal justice system. (e.g. waiting list, written materials, non-specific
Individuals in the combined treatment groups had worse treatment as usual). However, compared with a specific
outcomes (i.e. lower abstinence rates). The authors treatment, no significant effect for MI was observed,
concluded that a combination of cannabis use suggesting that its effects are equivalent to those of
treatments may not be effective in a population of other specific treatments (e.g. CBT, 12-step). The
individuals involved with the criminal justice system. authors concluded that MI may be more cost-effective,

31
32
TABLE 5
Adults: cannabis-specific treatment
Study Design Number of Age Population Treatment Outcome
participants/ (years) characteristics
studies (1)
Reviews
Baker et al., Review 7s – Cannabis use CBT, MI, psychoeducation, An intensive combination of CBT and MI is the most effective treatment for individuals with
2010 and psychosis computer-delivered CBT co-morbid psychotic and mood disorders.
Benyamina Review – – Cannabis use Combinations of CBT, MET, CBT and MET have proven their efficacy in several randomised controlled trials. Brief
et al., 2008 CM therapies have also been associated with good compliance and efficacy. Combinations
with CM have shown improved treatment compliance and reduced cannabis use.
Danovitch Review 37 s – Cannabis use CBT, MET, CM, SEP, MDFT, A combination of CBT, MET and CM is the most effective approach for cannabis treatment;
and Gorelick, 12-step facilitation however, the authors note that data from treatments in randomised trials show that fewer
2012 than 20 % of the participants achieve long-term abstinence.
Treatment of cannabis-related disorders in Europe

Elkashef et Review 16 s – Cannabis use Combinations of CBT, MET, Behavioural therapies are efficacious for facilitating abstinence from cannabis.
al., 2008 CM
Hjorthøj et al., Review 41 s – Cannabis use Combinations of CBT, MI, CM MI alone or CBT alone had no effect on cannabis-related treatment outcomes; however,
2009 and these treatments showed efficacy in reducing the use of other substances.
schizophrenia
Individual studies
Carroll et al., RCT 127 p M = 25.7 Cannabis use a.  CM abstinence When the effectiveness of four different treatments for cannabis use was compared,
2012 b.  CM abstinence/CBT individuals in the combined treatment groups had worse outcomes (i.e. lower abstinence
c.  CBT rates). The authors concluded that combination cannabis use treatments may not be
d.  CBT/CM effective in a population of individuals involved with the criminal justice system.
Fischer et al., RCT 134 p M = 20.4 Cannabis use a.  Cannabis BI A brief intervention targeting risky behaviours associated with cannabis use was shown to
2013 b.  Health BI reduce risky cannabis-related behaviour in a sample of college students.
c.  Both
Hoch et al., RCT 122 p M = 24.1 Cannabis use a. MET/CBT/problem- Half of the active treatment group achieved abstinence at post-treatment and maintained
2012 16–44 solving training abstinence at the 6-month follow-up. In addition, compared with the control group,
b.  DFC participants in the intervention condition exhibited significantly lower frequency of cannabis
use, addiction severity, number of disability days and overall level of psychopathology.
Kadden and RCT 240 p – Cannabis use a.  CM The two CM conditions had superior abstinence outcomes: CM-only had the highest
Litt, 2011 b.  CBT/MET abstinence rates at post-treatment, and the MET/CBT/CM combination had the highest
c.  CBT/MET/CM rates at later follow-ups.
d.  Case management
Stein, M., RCT 332 p 18–24 Cannabis use a.  CBT2 MI was more effective in reducing cannabis use than an assessment control condition at
et al., 2011 b.  Control condition the 3-month follow-up. These effects were not observed, however, at the 6-month follow-up,
unless participants entered the trial with a desire to abstain from cannabis use.
Weinstein Pre–post 26 p M = 33.9 Cannabis use CBT10/MET/relapse Only 20 % of the participants remained abstinent after 6 months. The remainder of
et al., 2010 prevention participants either relapsed prior to the 6-month follow-up or dropped out of the treatment
programme prior to receiving the full 12-week dose of CBT.
(1)  Indicated as range or mean age, where available.
Abbreviations: BI, brief intervention; CBT, cognitive behavioural therapy; CM, contingency management; DFC, delayed feedback control; M, mean; MDFT, multidimensional family therapy; MET, motivational enhancement therapy;
MI, motivational interviewing; p, participants; RCT, randomised controlled trial; s, studies; SEP, supportive-expressive psychotherapy.
All studies target the individual drug user.
CHAPTER 2  I Effectiveness of interventions: review of recent research on available treatments

as it can be administered in less time (e.g. one or two mood disorders, Baker et al. (2010) concluded that
sessions) than is required for other treatment effective cannabis treatment in this population requires
programmes, yet produces comparable effects. longer or more intensive psychological interventions
rather than brief interventions. Specifically, they argued
Smedslund et al. (2011) conducted a meta-analysis of that an intensive combination of CBT and MI is the most
the effectiveness of MI for substance use that included effective treatment approach.
only randomised controlled trials (59 studies; 13 342
participants). The results revealed that the effects on When looking at general treatment, Cleary et al. (2009)
substance use were strongest when MI was compared concluded from their review of psychosocial treatments
with no-treatment control groups. Furthermore, the for individuals with substance use disorders and
effect was stronger at post-intervention and tended to co-morbid severe mental illness that a combination of
attenuate at short- and medium-term follow-up. No CBT and MI was most effective (Table 6). Specifically,
significant effect was found for long-term follow-up. In they found that a combination of these treatments
contrast with the findings from Lundahl et al. (2010), no produced both improvement in mental health and
significant difference of effects was found between MI reduction in substance use. In contrast, MI alone
and treatment as usual. resulted in only short-term reduction in substance use,
and CBT alone did not appear to have a significant effect
The research on the effectiveness of CM shows that it may on measured treatment outcomes.
enhance substance use treatment for adults, in a similar
way to that which has been demonstrated in programmes
targeting adolescent substance use. Stitzer et al. (2010) I Conclusions
conducted an incentive-based abstinence programme in a
large sample of stimulant users (803 participants). In a Generic versus cannabis-specific treatment
multisite randomised trial, participants were randomly programmes for adults
assigned to treatment as usual, with or without a prize
draw incentive programme. Individuals in the incentivised Given the relative dearth of evidence-based cannabis-
condition had a higher retention rate in the treatment specific interventions in the drug research literature and
programme and lower substance use than those in the the considerable heterogeneity of cannabis use disorder
non-incentivised treatment condition. Similar results were patients’ characteristics and treatment needs, the
found in a study of homeless, non-treatment-seeking men diversity of treatment settings, patient populations and
who have sex with men (Reback et al., 2010). In that study, countries where the studies were conducted is very
participants in the CM condition achieved greater welcome and needed. It seems quite likely that there is
reductions in stimulant, alcohol and methamphetamine no ‘one-size-fits-all’ intervention for all these cases.
use than those in the control group. Reductions in
substance use were maintained at the 9- and 12-month Most of the effective general and cannabis-specific
follow-up evaluations. While cannabis use was common interventions reported in the literature are based on the
among study participants, cannabis use did not differ same therapeutic strategies. As no study has
significantly between the CM group and the control group. systematically compared the treatment outcomes (e.g.
willingness to participate and retention in treatment,
abstinence, reduction in cannabis use) of cannabis-
Dual diagnosis specific interventions with those of general substance
use treatments for cannabis users, the question of the
Treatment of patients with dual diagnosis — substance superiority of one approach to the other remains
use and co-occurring psychiatric problems — has been unanswered. Nevertheless, there are signs that ‘keeping
considered in a specific line of investigation. Two reviews treatment specific to cannabis’ can be important in
were identified, which included 48 studies (Table 5). facilitating dependent cannabis users to enter treatment.
Hjorthøj et al. (2009) reviewed the literature on
treatment of cannabis dependence in individuals with
schizophrenia spectrum disorders. They found that MI Dual diagnosis
alone or CBT alone had no effect on cannabis-related
treatment outcomes; however, these treatments showed Individuals with cannabis use and co-morbid psychotic
efficacy in reducing the use of other substances. or affective disorders (Baker et al., 2010; Hjorthøj et al.,
2009) may not benefit sufficiently from MI or CBT alone;
From a review of the literature focusing on cannabis they may need a longer or more intensive
treatment for individuals with co-morbid psychotic and psychotherapeutic treatment, combining MI and CBT

33
34
TABLE 6
Adults: general substance use treatments
Study Design Number of Age (years) Population Treatment Outcome
participants/ (1) characteristics
studies
Reviews
Cleary et al., Review 54 s – Substance use Combinations of CBT, MET, A combination of CBT and MI was most effective. Specifically, the authors found that a
2009 CM combination of these treatments produced both improvement in mental health and
reduction in substance use, whereas MI alone resulted only in short-term reduction in
substance use, and CBT alone did not appear to have a significant effect on measured
treatment outcomes.
Dutra et al., Meta-analysis 34 s M = 34.9 Substance use CM, relapse prevention, CBT, Psychosocial treatments are more efficacious for cannabis use than for polysubstance
Treatment of cannabis-related disorders in Europe

2008 CBT/CM use. A combination of CBT and CM is the best approach for treating adult substance
use disorders.
Lundahl et al., Meta-analysis 119 s – Substance use, MI, MET MI was found to have a consistent small effect on substance use in general, and
2010 behaviour cannabis use specifically, compared with weak comparison groups. However, compared
change with a specific treatment, no significant effect for MI was observed.
Magill and Meta-analysis 53 s – Substance use CBT The effect of CBT was largest in cannabis studies and in studies with a no-treatment
Ray, 2009 control as the comparison condition. In addition, gender was a potential moderating
factor, such that the effect of CBT may be larger for women than for men.
Smedslund Meta-analysis 59 s – Substance use MI, TAU, assessment and Effects on substance use were strongest when MI was compared with no-treatment
et al., 2011 feedback, other active control groups. Furthermore, the effect was stronger at post-intervention and tended to
treatment attenuate at short- and medium-term follow-up. No significant effect was found for
long-term follow-up. No significant difference of effects was found between MI and TAU.
Individual studies
Reback et al., RCT 131 p M = 36.4 Substance use a. Healthy behaviour Participants in the CM condition achieved greater reductions in stimulant, alcohol and
2010 promotion + CM methamphetamine use than those in the control group. Reductions in substance use
b. Healthy behaviour were maintained at the 9- and 12-month follow-up evaluations.
promotion
Stitzer et al., RCT 803 p Methadone Substance use a. TAU/CM Individuals in the CM condition had a better retention rate in the treatment programme
2010 maintenance, b. TAU and reduced substance use further than those in the non-CM treatment condition.
M = 42;
psychosocial
counselling,
M = 36
Yonkers et al., RCT 168 p Age groups: Substance use a. MET/CBT No significant differences were observed between treatment groups in a population of
2012 16–19; b. Brief advice pregnant women.
20–34; ≥ 35
(1)  Indicated as range or mean age , where available.
Abbreviations: CBT, cognitive behavioural therapy; CM, contingency management; M, mean; MET, motivational enhancement therapy; MI, motivational interviewing; p, participants; RCT, randomised controlled trial; s, studies; TAU,
treatment as usual.
CHAPTER 2  I Effectiveness of interventions: review of recent research on available treatments

with standard pharmacotherapy (Baker et al., 2010). a very efficient adjunct to the treatment of adult
However, there is a notable lack of studies addressing substance use disorders, where it helps in fostering
cannabis use disorder patients with schizophrenia retention or improving substance-related treatment
spectrum disorders or anxiety disorders and individuals outcomes (Dutra et al., 2008). Combinations of MET, CBT
with further dual diagnoses (e.g. alcohol use disorders, and CM are also considered the most effective cannabis-
polydrug use, ADHD, personality disorders). Knowledge specific treatment approach (Benyamina et al., 2008;
about how to treat these highly prevalent medical Danovitch and Gorelick, 2012). Both narrative reviews
conditions remains very limited. confirm earlier findings from the systematic Cochrane
review on psychosocial interventions for adults with
primary cannabis use disorders (Denis et al., 2006).
Intervention types
Adults with cannabis use disorders seem to benefit from
As described in the narrative review section of this various intervention types. The strongest and most
report, various empirically supported treatments are enduring treatment effects are found in secondary
available for adults with cannabis use disorders. outcomes such as reductions in the frequency of
Randomised studies have been performed on different cannabis use, the number of dependence symptoms, the
combinations of MET, CBT and CM. One study combined severity of cannabis dependence or the number and
psychosocial problem solving, as developed by D’Zurilla severity of cannabis-related problems (e.g. Danovitch and
and Goldfried (1971), with MET and CBT (Hoch et al., Gorelick, 2012). It has to be noted that moderation and
2012). These efficacy studies were mostly conducted in harm reduction are not accepted as treatment goals by
clinical settings with a limited number of study sites. No many healthcare providers and other stakeholders (e.g.
published studies on family interventions for adults with Hoch et al., 2012). Therefore, response rates, particularly
cannabis use disorders were found. Twelve-step regarding abstinence from cannabis, leave much room for
programmes were absent from the literature on improvement. Questions about the optimal duration,
psychosocial interventions for cannabis dependence, intensity and type of treatment, setting and moderating
unlike that on other substance use disorders. Their factors (e.g. gender, co-morbidity, culture, family
utilisation, long-term efficacy and potential role as an cohesion) need to be further examined in future research.
integrated component of psychosocial interventions for
cannabis dependence have not been examined until
now. Notably, no individual empirically supported
treatment emerged as being significantly more effective
than any other empirically supported treatment.
Because the underpinnings of these therapeutic models
I Research on telephone and online
interventions
are complementary, researchers have focused less on
treatment superiority and more on identifying effective Most recently, new formats for these approaches have
combinations (Danovitch and Gorelick, 2012). been tested. Minimal interventions reported in the
literature include postal (Norberg et al., 2012),
computerised (Budney et al., 2011; Carroll et al., 2009;
Treatment effects Godley, M., et al., 2010; Tossmann et al., 2011) and
telephone-based interventions (Gates et al., 2012).
Aggregated empirical evidence on general substance use These general or cannabis-specific interventions have
treatments indicates that motivational enhancement has the potential to increase access to treatment and lead to
small effects on substance use in adult patient benefits such as reduced substance use, motivation to
populations (Lundahl et al., 2010). Effects were largest at change, retention and increased knowledge about the
post-treatment and when MI was compared with no substance. This can be achieved especially in
treatment (Smedslund et al., 2011). Compared with a uncomplicated cases of substance use and related
specific treatment or treatment as usual, no significant problems (Rooke et al., 2013). However, Hoch et al.
effects were found (Lundahl et al., 2010; Smedslund et al., (2014) argue that tele-interventions cannot completely
2011). All of the systematic reviews and meta-analyses replace a live clinician, as some patients may be
consistently found that a combination of MET and CBT is unwilling to use web-based interventions or need
most effective in reducing the frequency and quantity of personal assistance as a result of complex impairment
substance use, as well as the severity of substance and more severe problems.
use-related problems and mental health problems.
Whereas CM has not always been seen as a practical Here we review research into interventions using
strategy for many clinicians, evidence suggests that CM is telecommunications — Internet, telephone, messaging

35
Treatment of cannabis-related disorders in Europe

services — to reach clients and treat cannabis use Tossmann et al. (2011) conducted a randomised
disorders. The characteristics of the studies included in controlled study evaluating the effectiveness of a
the present analysis can be found in Table 7. 3-month online drug-related information and prevention
programme. Cannabis users seeking web-based
Studies conducted to date have produced promising treatment were recruited to participate in the study and
outcomes in the treatment of numerous behavioural and were assigned to either a waiting list control condition or
psychological disorders. Reviewing 12 studies of the treatment condition. Of the 1 292 subjects included
computer-based interventions for drug use disorders, for in the trial, a total of 206 took part in both the pre-test
example, Moore et al. (2011) found that, compared with and post-test assessments. Participants in the treatment
treatment as usual, computer-based interventions led to condition showed a significantly stronger reduction in
less substance use, higher motivation to change, better cannabis use than those in the control group. In the
retention and greater knowledge of presented per-protocol analyses, moderate to strong effects were
information. found for reduction in the frequency of cannabis use and
the quantity of cannabis consumed. Small to moderate
In the field of substance use disorders, Carroll et al. effects were observed on secondary outcomes (e.g.
(2008) examined whether biweekly access to computer- use-related self-efficacy, anxiety, depression and life
based training adds incremental value to standard CBT satisfaction). The same research group (Jonas et al.,
treatment in an outpatient community setting. The 77 2012) evaluated the effectiveness of a one-session,
participants were randomly assigned to standard online intervention based on MI. Young alcohol and
treatment or standard treatment plus computer-based cannabis users (302 participants) were randomised to
training in CBT (CBT4CBT). The results revealed that either a group that received chat-based MI or a group
participants in the CBT4CBT group had significantly that received feedback on a previous self-test. Intention-
fewer positive urine specimens and exhibited longer to-treat analysis yielded no differences between the
continuous periods of abstinence during treatment. groups. In both groups, there was a significant time-
Carroll et al. (2009) followed up this research with a effect in alcohol use and readiness to change. Another
study examining whether CBT4CBT was more effective approach, using a mobile phone as a medium, was
than treatment as usual over a 6-month period. Results tested by Laursen (2010). Based on qualitative
revealed that, compared with those in the treatment as interviews, she found initial evidence that information on
usual condition, participants in the CBT4CBT condition cannabis use delivered via short message service (SMS)
slightly reduced their substance use over the course of could help young people reduce their consumption of
the study period. The effect remained significant even cannabis.
after controlling for treatment retention, substance use
outcomes and exposure to other treatment during the Interventions for substance use disorders delivered via
follow-up period. telephone have also been shown to be effective. Godley,
M., et al. (2010) examined whether telephone-based
Sinadinovic et al. (2012) examined the effectiveness of an continuing care was as effective as usual continuing care
Internet-based screening and brief intervention (eScreen. in preventing substance use relapse. Participants were
se) on reducing substance use. The 202 participants were randomised into one of the two treatment groups. At the
randomised to either the treatment condition or an 3-month follow-up, participants in the telephone-based
assessment-only control group. Although both groups care group reported significantly fewer substance-
showed a significant decrease in self-reported substance related problems than the face-to-face group; however,
use, the Internet-based treatment group exhibited a significant differences were not found at the 6-month
significantly larger decrease in substance use frequency. follow-up. Gates et al. (2012) expanded on the Godley,
M., et al. (2010) study. In a randomised controlled trial,
Budney et al. (2011) published results of a feasibility they examined the efficacy of a telephone-based
study comparing a computer-delivered version of MET/ cannabis use intervention. The 160 participants were
CBT/CM with a therapist-delivered version. For the randomised to a telephone-based intervention that
non-randomised, 12-week comparison study, 38 adults contained components of CBT and MI or to a delayed
were assigned to either the computer-delivered MET/ treatment control condition. Results revealed that the
CBT/CM or the therapist-delivered MET/CBT/CM. No participants in the treatment condition exhibited greater
significant differences were found between the conditions reductions in dependence symptoms and substance-
in terms of attendance, retention and cannabis use related problems at both follow-up assessments.
outcomes. Although these results are promising, they Furthermore, they reported greater confidence in their
need to be replicated in studies using randomised ability to reduce cannabis use at four weeks and a
controlled designs before firm conclusions can be drawn. greater percentage of abstinent days at 12 weeks.

36
TABLE 7
Characteristics of studies evaluating telephone and online interventions

Study Design Number of Age Population Treatment Outcome


participants/ (years) characteristics
studies (1)
Reviews
Moore et al., Review 12 s M (range) Substance use Computer-based interventions Compared with TAU, computer-based interventions led to less substance use and
2011 = 23–47 for drug use greater motivation to change, better retention and greater knowledge of presented
information.
Tait et al., Meta-analysis 10 s 11–16 and a. Several type of Internet- and Internet- and computer-based interventions appear to be effective in reducing
2013 ≥17 computer-based interventions; cannabis use.
b. No intervention, only
assessment
Individual studies
Arnaud et al., RCT 800 p 16–18 Substance use a. Feedback/MI/advice Arnaud and colleagues have published only a study protocol.
2012 b. Assessment-only control group
Budney et al., Comparison 38 p a. M = 32.7; Cannabis use a. Therapist-delivered MET/CBT/ There were no significant differences between the conditions in terms of attendance,
2011 study SD = 10.5 CM retention and cannabis use outcomes.
b. M = 32.9; b. C omputer-delivered MET/
SD = 8.7 CBT/CM
Carroll et al., RCT 77 p M = 41.6; Substance use a. TAU Participants in the CBT4CBT group had significantly fewer positive urine specimens
2008 SD = 10.2 b. TAU/computer-based training and exhibited longer continuous periods of abstinence during treatment.
in CBT
Carroll et al., RCT 77 p M = 41.6; Substance use a. TAU Compared with TAU, participants in the CBT4CBT condition slightly reduced their
2009 SD = 10.2 b. TAU/computer-based training substance use over the course of the study period.
in CBT
Gates et al., RCT 160 p M = 36.0; Substance use a. Telephone-based MI/CBT Participants in the treatment condition exhibited greater reductions in dependence
2012 SD = 10.1 b. DTC symptoms and substance-related problems at both follow-up assessments.
Godley, M., RCT 104 p M = 31.6; Substance use a. TCC At the 3-month follow-up, participants in the telephone-based care group reported
et al., 2010 range =  b. UCC significantly fewer substance-related problems than did the face-to-face group;
19–56 however, significant differences were not found at the 6-month follow-up.
Jonas et al., RCT 302 p M = 24.2; Cannabis use a. Chat-based MI ITT analysis yielded no differences between the groups. In both groups, there was a
2012 SD = 5.8 b. Feedback on a preceding significant time-effect in alcohol use and readiness to change.
self-test
Laursen, Qualitative 12 p Adolescents Cannabis use Information on cannabis use via Along with other factors, SMS motivated the participants to reduce their level of
2010 interviews SMS cannabis use or to maintain a reduced level.
Sinadinovic RCT 202 p a. M = 33.2 Substance use a. Internet-based screening and Both groups showed a significant reduction in substance use. Participants in the
et al., 2012 b. M = 31.9 brief intervention Internet-based treatment group exhibited a significantly larger reduction in substance
b. Assessment-only control group use frequency.
Tossmann RCT 206 p M = 24.7; Cannabis use a. Online based CBT/MI Participants in the treatment condition showed a significantly greater reduction in cannabis
et al., 2011 SD = 6.8 b. DTC use than those in the control group. Small to moderate effects were observed on secondary
outcomes (e.g. use-related self-efficacy, anxiety, depression, life satisfaction).
(1)  Indicated as range or mean age, where available.
Abbreviations: CBT, cognitive behavioural therapy; CM, contingency management; DTC, delayed treatment control; ITT, intention to treat; M, mean; MET, motivational enhancement therapy; MI, motivational interviewing; p,
CHAPTER 2  I Effectiveness of interventions: review of recent research on available treatments

participants; RCT, randomised controlled trial; s, studies; SD, standard deviation; SMS, short message service; TAU, treatment as usual; TCC, telephone continuing care; UCC, usual continuing care.

37
Treatment of cannabis-related disorders in Europe

Tait et al. (2013) conducted a systematic review of 10 The type of substance used and the type of treatment
randomised controlled studies, which included about provided may not be the only determinants of treatment
4 125 participants aged 11 years or older. The authors success. Rather, there are several moderating factors
concluded that Internet treatment can reduce cannabis that have a profound impact on the effectiveness of
use in the short term. treatment. For instance, Hendriks et al. (2012) found in a
secondary analysis that co-morbid psychiatric problems
moderated the effectiveness of different substance use
I Conclusions treatment modalities. They found that MDFT was more
effective for adolescents with a previous diagnosis of
Telephone and online interventions are still under conduct disorder, oppositional defiant disorder or
investigation. Nevertheless, they can offer a good internalising problems. Participants without these
opportunity for those who are not prepared to seek co-morbid psychiatric conditions benefited much more
treatment in healthcare centres, and especially for from CBT. In addition, Hendriks et al. found evidence that
young people, who are very comfortable with the use of older adolescents (17–18 years old) benefited more from
the Internet and telecommunications. Moreover, the CBT, whereas younger adolescents benefited more from
relatively low costs can be appealing, especially for MDFT. Additionally, Stein, L., et al. (2011) found some
countries that are facing the prospect of providing evidence for moderating effects of depression on the
treatment for large numbers of intensive cannabis effectiveness of treatment for cannabis use among
users. incarcerated adolescents. Their study demonstrated that
MI significantly reduced cannabis use among
incarcerated adolescents, but only in a group with low
depression symptoms. Relaxation training was a more

I Factors and mechanisms influencing


effectiveness
effective approach for adolescents in their sample with
high depression symptoms.

Some research suggests that cultural factors may


In addition to studies investigating the effectiveness of moderate the effectiveness of substance use treatment.
treatment, some researchers have tried to identify the A study comparing the effectiveness of a culturally
determinants of treatment success (see Table 8). adapted version of CBT and standard CBT for substance
use in Latino adolescents found that treatment
Bergmark (2008) cites results that indicated that outcomes were moderated by ethnic identity and
increases in treatment dosage did not produce familism (Burrow-Sanchez and Wrona, 2012).
significantly better treatment outcomes for adolescents. Specifically, their results revealed that Latino
This result is consistent with previous research adolescents with high levels of ethnic identity and
indicating that even brief interventions can influence familism benefited significantly more from the culturally
cannabis use. For example, McCambridge and Strang adapted treatment than Latino adolescents who were
(2005) found that a 1-hour face-to-face MI session low on these cultural variables. In addition, Robbins et al.
significantly reduced weekly frequency of cannabis use (2008) compared the effectiveness of regular BSFT and
compared with a no-treatment group. These findings BSFT enhanced with ecological interventions. Latino
have major real-world implications for the adolescents benefited more from the ecologically
implementation of effective cannabis-treatment enhanced BSFT, but African American adolescents did
protocols, including the potential for reduced cost and not, suggesting that ethnicity may moderate treatment
increased availability of treatment. effectiveness in some cases.

Tanner-Smith et al. (2013) found that longer duration of Family-level factors may also moderate the effectiveness
general substance use treatment was associated with of substance use treatment. In an unpublished study,
smaller improvements. This is in agreement with earlier Mermelstein (2011) examined the influence of family
work that suggests that longer duration of treatment cohesion on substance use severity in adolescents
does not necessarily produce better treatment admitted to a residential substance use treatment
outcomes (Dennis et al., 2004). centre. Results suggested that family cohesion level was
significantly and inversely related to substance use
A brief intervention targeting risky behaviours associated severity. In agreement with these findings, Henderson et
with cannabis use was shown to reduce risky cannabis- al. (2009) found that improved parental monitoring of
related behaviour (e.g. driving after cannabis use) in a the adolescent partially mediated the effect of MDFT on
sample of college students (Fischer et al., 2013). reduced substance use. Perhaps some of the

38
TABLE 8
Characteristics of studies evaluating factors and mechanisms influencing effectiveness of cannabis or substance use treatments
Study Design Number of Age (years) Population Treatment Outcome
participants/ (1) characteristics
studies
Reviews
Baker et al., Review 7s Adults Cannabis use CBT, MI, psychoeducation, An intensive combination of CBT and MI is the most effective treatment for individuals with
2010 computer-delivered CBT co-morbid psychotic and mood disorders. Studies also indicate that effectively treating the
mental health disorder with standard pharmacotherapy may be associated with a
reduction in cannabis use.
Kadden and Review – Adults Substance use Self-efficacy is an important mediator of the effectiveness of substance use treatment. In
Litt, 2011 addition, self-efficacy may serve as a moderator of treatment effectiveness, such that
individuals who are high in self-efficacy exhibit better treatment outcomes.
Magill and Meta-analysis 53 s Adults Substance use CBT CBT was most efficacious with cannabis users. Effects were larger with women than with
Ray, 2009 men.
Individual studies
Burrow- RCT 35 p M = 15.5; Substance use a. CBT Latino adolescents with high levels of ethnic identity and familism benefited significantly
Sanchez and SD = 1.3; b. Culturally more from the culturally adapted treatment than Latino adolescents who were low on
Wrona, 2012 range = 13–18 accommodated CBT these cultural variables.
Garner et al., Predictor 295 p M = 15.5; Substance use Adolescents reporting higher levels of therapeutic alliance also reported higher levels of
2008 analysis SD = 1.3 social support and greater problem recognition and had more reasons for quitting.
Moreover, therapists tended to report a higher level of therapeutic alliance with older
adolescents, suggesting that adolescent age may serve as an additional factor moderating
treatment effectiveness.
Henderson et RCT 83 p M= 13.7; Substance use a. MDFT Improved parental monitoring of the adolescent partially mediated the effect of MDFT on
al., 2009 SD = 1.1; b. Peer group reduced substance use.
range = 11–15 intervention
Hendriks et RCT 109 p range = 13–18; Cannabis use a. MDFT Co-morbid psychiatric problems moderated the effectiveness of different substance use
al., 2012 a. M = 16.6; b. CBT treatment modalities. MDFT was more effective for adolescents with a previous diagnosis
SD = 1.3 of conduct disorder, oppositional defiant disorder or internalising problems. Participants
b. M = 16.9; without these co-morbid psychiatric conditions benefited much more from CBT. In
SD = 1.2 addition, older adolescents (17–18 years old) benefited more from CBT, whereas younger
adolescents benefited more from MDFT.
Mermelstein, Observational 139 p M = 16.2 Substance use a. Families admitted to a Results suggested that family cohesion level was significantly and inversely related to
2011 study residential substance substance use severity.
use treatment centre
b. Non-clinical
comparison sample
Robbins et al., RCT 190 p M = 15.8; Substance use a. SET Latino adolescents benefited more from the ecologically enhanced BSFT than from a
2008 SD = 1.2; b. FAM regular version of BSFT. African American adolescents did not, suggesting that ethnicity
range = 12–17 c. C S may moderate treatment effectiveness in some cases.
Stein, M., et RCT 332 p M = 20.5; Cannabis use a. MI Individuals with a high initial desire to refrain from substance use have more successful
al., 2011 SD = 1.8; b. Assessment-only treatment outcomes.
18–24
Stein, L., et al., RCT 162 p M = 17.1; Alcohol and a. MI MI significantly reduced cannabis use among the participants, but only in a group with low
2011 SD = 1.1; cannabis use b. Relaxation training depression symptoms. Relaxation training was a more effective approach for adolescents
range = 14–19 with high depression symptoms.
(1)  Indicated as range or mean age, where available.
Abbreviations: BSFT, brief strategic family therapy; CBT, cognitive behavioural therapy; CS, community service; FAM, family process-only condition; MDFT, multidimensional family therapy; M, mean; MI, motivational interviewing;
CHAPTER 2  I Effectiveness of interventions: review of recent research on available treatments

p, participants; RCT, randomised controlled trial; s, studies; SD, standard deviation; SET, structural ecosystems therapy.

39
Treatment of cannabis-related disorders in Europe

effectiveness of family-based treatments for substance methods and the formats used. Type of intervention and
use disorders is because these treatments also address treatment intensity (i.e. number and frequency of
family-level factors that can moderate the effectiveness therapy sessions) varied largely, too. In most studies, the
of treatment. patients were randomly assigned to an active
intervention and to a comparison. The latter was either
Therapeutic alliance serves as a major factor influencing an alternative active intervention or combination of
the effectiveness of treatment in a variety of domains interventions, treatment as usual or a delayed treatment
(Martin et al., 2000) and, therefore, is likely to play a key control. Measures of substance use were provided
role in determining the effectiveness of substance use through self-report or self-report combined with
treatment. Garner et al. (2008) examined whether biochemical measures of substance use. Outcome
therapeutic alliance influenced the effectiveness of variables measured at baseline and assessed at follow-
substance use treatment. They found that adolescents up included, for example, abstinence, quantity and
reporting higher levels of therapeutic alliance also frequency of cannabis use and other substance use,
reported higher levels of social support and greater number and severity of use-related problems, DSM-IV
problem recognition and had more reasons for quitting. dependence symptoms and other problem behaviours.
Moreover, they found that therapists tended to report a Studies generally reported following study participants
higher level of therapeutic alliance with older for periods of between 1 and 12 months. Most studies
adolescents, suggesting that adolescent age may serve provided information on loss of study participants over
as an additional factor moderating treatment time, which is a common occurrence in clinical trials. The
effectiveness. number of study dropouts was counted and a retention
rate was calculated. Methodologically strong studies
Kadden and Litt (2011) reviewed literature examining included measures of quality assurance, for example
whether increases in self-efficacy mediate the using a manual to guide the intervention, providing
association between substance use treatment and training and supervision of study counsellors, and
successful treatment outcomes. The results of their assessing treatment fidelity using audio or video
review indicate that self-efficacy is an important recordings of the therapy sessions.
mediator of the effectiveness of substance use
treatment. In addition, their results revealed that
self-efficacy may serve as a moderator of treatment
effectiveness, such that individuals who are high in I Recent findings in perspective
self-efficacy exhibit better treatment outcomes.
The results of this review are in line with findings
Stein, M., et al. (2011) found that initial desire to quit previously published by the EMCDDA (Bergmark, 2008).
may be an important predictor or moderator of All of the studies included in Bergmark’s review were
treatment outcome, regardless of the specific consistent in that they found that cannabis dependence
substance use treatment that is utilised, such that treatment, regardless of modality, was more likely to
individuals with a high initial desire to refrain from result in abstinence than no treatment (Budney et al.,
substance use are more likely to have a successful 2000, 2006; Carroll et al., 2006; Copeland et al., 2001;
treatment outcome. Marijuana Treatment Project Research Group, 2004;
Stephens et al., 2000). It remained unclear, however,
Finally, the effectiveness of treatment may be moderated whether the relative effectiveness of the treatment
by characteristics of the population being treated, such depended more on the type of treatment offered or the
as gender (Magill and Ray, 2009), involvement in the duration of the treatment. The Marijuana Treatment
criminal justice system (Carroll et al., 2012) and co- Project Research Group (2004) found some evidence
morbid psychopathology (Baker et al., 2010). Therefore, suggesting that brief interventions were somewhat less
it is important to be aware of factors that may influence effective than longer interventions; however, more
treatment, in order to find the best match between research is needed in this area before firm conclusions
patient and treatment approach. can be reached.

Bergmark (2008) also reviewed several studies


comparing the effectiveness of different treatment
I Study characteristics modalities. The treatments that were reviewed included
MET, CBT, CM and combinations of these approaches.
The studies identified and included in this review were Based on his review, Bergmark concluded that a
heterogeneous in terms of their research designs and combination of MI interventions, behavioural and

40
CHAPTER 2  I Effectiveness of interventions: review of recent research on available treatments

cognitive coping skills, and incentives was the most randomised trials: less than 20 % of those treated for
effective approach to treatment (Budney et al., 2000; cannabis-related problems achieved long-term
Budney et al., 2006). abstinence.

Bergmark found that a combination of motivational To date, no medication has been found to be broadly
interventions, behavioural and cognitive coping skills, effective in the treatment of cannabis use disorders,
and incentives was most effective in the treatment of although a number of pharmacological approaches are
cannabis use disorders for adults. Benyamina et al. being pursued (Danovitch and Gorelick, 2012).
(2008) and Elkashef et al. (2008) supported this Psychosocial interventions, mainly focusing on
position. Still, it is worth highlighting the conclusion of psychotherapeutic approaches, are therefore the only
Danovitch and Gorelick (2012) from their review of type of treatment available for this target group.

41
3
CHAPTER 3
Treatment of cannabis use disorders
in Europe

The options available for treating individuals with FIGURE 2


cannabis use problems vary widely across the European Existence of specialised treatment programmes
Union. For example, the Netherlands reports one of the for cannabis users in European countries
most comprehensive cannabis-specific treatment
systems, offering two inpatient and two outpatient General substance
treatment only
programmes specialising in the treatment of cannabis- Cannabis-specific
related problems. These programmes are provided free treatment is available

of charge and available to the majority of those in need


of treatment. In the United Kingdom, cannabis-specific
treatment programmes are not provided, but
considerable resources are devoted to treating
individuals with cannabis use disorders through general
substance use programmes, which may be tailored to
individual needs on a case-by-case basis. This chapter
brings together information from these countries and 28
others to present, in the first part, an overview on the
approaches to treating cannabis use disorders across
Europe, providing the most recent information on the
programmes available in each country. In the second
part, selected cannabis-specific programmes offered in
European countries are described. Source: SQ27 dataset (section on specific cannabis treatment), 2011;
Cannabis-Specific Treatment National Focal Point Survey (CSTNFPS),
2013.

I Treatment availability In both 2011 and 2013, countries were asked to provide
expert assessments of the coverage of treatment relative
I The European picture to needs — that is, the proportion of those in need
estimated to have access to treatment (see Table 9 for
Information on the type of treatment offered to those rating scale). In the 2011 survey, of the 18 countries
with cannabis-related problems was gathered in 2011 reporting provision of cannabis-specific treatment, 8
and 2013. In 2011, out of the 30 countries affiliated to reported that treatment coverage was rare or limited and
the EMCDDA, 17 reported the provision of substance- 10 reported extensive or full treatment coverage. Five
specific treatment for cannabis-related problems. This countries stated that they were planning to implement
information was updated in 2013 by a survey of national cannabis-specific treatment approaches by 2014.
focal points (CSTNFPS) conducted by the authors of this
report. When the information provided through this The main focus of this overview is cannabis-specific
survey is combined with the 2011 data, it emerges that treatment. Where no specific intervention was reported,
cannabis-specific treatment programmes are available in information is provided on how generalised substance
15 countries (Figure 2). As more than one-third of the use services cater for the needs of those with cannabis
Member States did not provide updated information in problems.
the 2013 survey, it is not possible to make a definitive
statement on whether the number of European countries
offering cannabis-specific programmes had increased or
decreased since 2011 (Table 9).

43
Treatment of cannabis-related disorders in Europe

TABLE 9
Availability of cannabis-specific treatment (CST) in European countries
Country CST available CST coverage (1) Implementation of Type of treatment offered
CST planned (2)
Belgium Yes Full n.a. CBT, MDFT, MI
Bulgaria (3) No n.a. Yes n.a.
Czech Republic (3) Yes Rare n.a. –
Denmark Yes Full n.a. CBT
Germany Yes Extensive n.a. CANDIS, CAN Stop, Quit the Shit, Realize It!, MDFT
Estonia No n.a. Yes n.a.
Ireland (3) No n.a. No n.a.
Greece Yes Full n.a. –
Spain No n.a. – n.a.
France No n.a. No n.a.
Croatia (3) Yes Full n.a. –
Italy (3) Yes Extensive n.a. –
Cyprus No n.a. Yes n.a.
Latvia No n.a. No n.a.
Lithuania (3) Yes Extensive n.a. –
Luxembourg (3) Yes Extensive n.a. CANDIS
Hungary No n.a. Yes n.a.
Malta No n.a. – n.a.
Netherlands Yes Extensive n.a. MDFT, CBT
Austria (4) Yes – n.a. CANDIS
Poland Yes Rare n.a. CANDIS (5)
Portugal Yes Limited n.a. –
Romania (3) Yes Limited n.a. –
Slovenia No n.a. – n.a.
Slovakia Yes Full n.a. CBT, MI
Finland No n.a. – n.a.
Sweden (4) Yes Extensive n.a.
United Kingdom No n.a. – n.a.
Turkey (3) No n.a. – n.a.
Norway (3) Yes Limited n.a. Out of the Fog
(1) Expert rating. Rating scale: full: nearly all people in need of help would obtain it; extensive, a majority but not nearly all of them would obtain it; limited,
more than a few but not a majority of them would obtain it; rare, just a few of them would obtain it.
(2) Implementation of specific cannabis treatment is planned within the next three years.
(3)  No information for 2013 or later.
(4)  Information from national focal point, 2014.
(5)  Personal communication, Hoch, 2014.
Abbreviations: CBT, cognitive behavioural therapy; MDFT, multidimensional family therapy; MI, motivational interviewing; n.a., not applicable; –, no information
available.
Source: SQ27 dataset (section on cannabis-specific treatment), 2011; Cannabis-Specific Treatment National Focal Point Survey (CSTNFPS), 2013.
For further information see the EMCDDA Annual report 2012, pp. 42–43, and the 2012 Statistical bulletin (available at emcdda.europa.eu/stats12).

I Country descriptions Belgium

The most recent information available on treatment Belgium provides cannabis-specific treatment through
for cannabis use disorders in each of the 28 EU the Cannabis Clinic. Adolescents with cannabis use
Member States, Turkey and Norway is presented problems are offered MDFT, and adults with cannabis
in this section. use problems are offered CBT, MI and group therapy.
National coverage of the affected population is rated as
comprehensive, as nearly all individuals in need of
treatment are estimated to have access to a cannabis-
specific treatment programme. Treatment is
administered in an outpatient setting.

44
CHAPTER 3  I Treatment of cannabis use disorders in Europe

For more information about the Cannabis Clinic, visit the programmes for adolescents with cannabis use
website chu-brugmann.be/fr/med/psy/cannabis.asp problems. These programmes include CANDIS, Quit
the Shit, Realize It, MDFT and CAN Stop. The available
programmes use a range of modalities, including
Bulgaria individual therapy, group therapy, systems therapy and
Internet-based counselling. All cannabis-specific
According to the most recent available data, cannabis- interventions in Germany are offered on an outpatient
specific treatment programmes are not offered in Bulgaria. basis. The majority of individuals in need of treatment
Individuals with cannabis use problems typically receive for cannabis use disorders in Germany are estimated to
psychosocial treatment that is tailored to their individual have access to treatment through a cannabis-specific
symptoms and needs. The majority of patients with programme.
cannabis use problems are treated via non-governmental
organisations, public and private clinics, in outpatient More information about cannabis-specific programmes
settings and through Internet-based consultations. offered in Germany can be found on the following
websites:

Czech Republic n 


C ANDIS: candis-projekt.de
n 
Realize It: realize-it.org
The Czech Republic reports the existence of a cannabis- n 
Quit the Shit: quit-the-shit.net
specific treatment programme. However, no additional n 
C AN Stop: canstop.med.uni-rostock.de
information is available about the type of treatment
provided or the settings in which treatment is
administered. In the Czech Republic, coverage of the Estonia
affected population is rated as very limited, as only a
small percentage of individuals in need of treatment for Estonia does not offer cannabis-specific treatment
cannabis use problems are estimated to have access to programmes. Nevertheless, general substance use
cannabis-specific treatment. treatment is available to all those who wish to receive
treatment for problems related to cannabis use.
Treatment for cannabis use disorders is typically
Denmark provided in psychiatric hospitals through individual
substance use treatment plans.
Cannabis-specific treatment programmes are available
throughout Denmark. While most large municipalities
offer one, the nature of the programme offered differs Ireland
from municipality to municipality. Cannabis treatment
programmes offered in Denmark are seldom manual- Ireland does not offer cannabis-specific treatment
based, predetermined cannabis programmes; rather, the programmes. Individuals with cannabis use problems
treatment programmes are based on a variety of receive psychological outpatient interventions in the
cognitive behavioural and psychoeducational techniques context of the general substance use treatment system.
adjusted to the particular group of clients receiving No additional information is available on the types of
treatment. Admission to cannabis-specific treatment in interventions offered.
Denmark is open only to those who cite cannabis as their
principal drug of use. The majority of the available
programmes are based on individual counselling and Greece
psychotherapy. Special programmes are also offered for
adolescents with cannabis use disorders. Coverage of Greece offers a family systems cannabis-specific
the affected population in Denmark is rated as extensive, treatment programme through the ATRAPOS early
as the majority of those who are in need of treatment are intervention programme. The programme draws
estimated to have access to it. interventions from MDFT and multisystemic therapy and
is targeted specifically at adolescents and young adults.
In addition, 11 other treatment programmes offered in
Germany the country mainly treat problem cannabis users;
however, these programmes are not cannabis-specific.
Germany offers a variety of cannabis-specific All available programmes are offered on an outpatient
treatment programmes, including specialised basis.

45
Treatment of cannabis-related disorders in Europe

More information about the ATRAPOS programme can through the programme. Coverage of treatment for
be found on the website okana.gr cannabis-related problems is rated as comprehensive,
as nearly all those in need are estimated to have access
to treatment. In addition, substance use treatments are
Spain available that are targeted specifically at adolescents,
including those with cannabis-related problems.
Cannabis-specific treatment programmes are not
offered in Spain. Most of the substance use treatment More information about treatment for cannabis-related
programmes follow a ‘patient type’ approach as opposed problems in France can be found on the website
to a ‘substance’ approach. Nevertheless, individuals with drogues.gouv.fr/etre-aide/lieux-daccueil/
cannabis use problems who require professional support consultations-jeunes-consommateurs/
or treatment can receive free, government-subsidised
treatment, in both inpatient and outpatient settings.
Spain offers three treatment programmes, described Croatia
below.
Croatia reported offering a cannabis-specific treatment
The Abuse/Addiction Treatment Programme for Adults is programme in 2011. Updated information on the status
administered in drug addiction centres in Madrid. The of this programme is not available. The most recent
intervention uses biopsychosocial interventions and is estimate indicates that nearly all those in need have
provided by a multidisciplinary team. Treatment is access to treatment for cannabis use. Treatment is
administered in both individual and group formats. A provided via counselling centres specialising in the
substantial proportion of those treated through this treatment of cannabis users.
programme use cannabis as their primary drug.

The Abuse/Addiction Treatment Programme for Young Italy


People is targeted at individuals younger than 25 years
old. This treatment programme is also administered in Italy offers cannabis-specific treatment programmes, but
drug addiction centres in Madrid. Adolescents and no information is available on the type of treatment
young adults with substance use problems are treated offered or the setting in which treatment is typically
by a specialised team according to a specific treatment administered. The most recent estimate indicates that
protocol. In 2012, 84 % of the 14- to 18-year-olds and the majority of those in need of treatment for cannabis
66 % of the 19- to 24-year-olds who received treatment use problems in Italy have access to cannabis-specific
through this programme reported cannabis as their treatment programmes.
primary drug.

The Prevention Programme is aimed at users who have Cyprus


been penalised by the criminal justice system for drug
use or possession. The programme is designed to Cyprus does not offer a cannabis-specific treatment
prevent the development of dependency in casual users. programme. In Cyprus, individuals with cannabis use
In 2012, 81 % of those referred to the programme had problems are treated in outpatient facilities that primarily
been penalised for a cannabis-related offence. provide psychosocial treatments. Treatment for cannabis
users is mainly provided by public agencies specialising
in adolescent drug treatment, as well as by private
France clinics and non-governmental organisations.

France does not offer cannabis-specific treatment


programmes. However, the Consultations Jeunes Latvia
Consommateurs programme was initially introduced as
a prevention programme for cannabis users. The scope In Latvia, cannabis-specific treatment programmes are
of the treatment programme was expanded in 2008 to not available. According to the most recent data,
include all illicit substances used by adolescents and treatment for individuals with cannabis use problems is
young adults. So, while these centres are no longer seen provided in outpatient settings and involves
as cannabis-specific programmes in France, this psychosocial interventions. Additional information on
substance continues to be the most common primary the specific nature of the psychosocial interventions is
illicit substance among individuals receiving treatment not available.

46
CHAPTER 3  I Treatment of cannabis use disorders in Europe

Lithuania programmes are estimated to be accessible to the


majority of individuals in need of treatment.
Lithuania offers cannabis-specific treatment
programmes that involve counselling, detoxification, More information about cannabis-specific programmes
psychosocial interventions and rehabilitation. The offered in the Netherlands can be found on the following
majority of those in need of treatment for cannabis use websites:
problems are estimated to have access to treatment. No
additional information is available on the specific types CBT and MDFT: brijder.nl/Verslaving/zorgprogramma/
of treatment programmes that are offered or the settings hulp-voor-jongeren,intensieve-gezinsbehandeling
in which treatment is administered.
Mistral: brijder.nl/Service/contact/locaties-zuid-holland

Luxembourg Bauhuus: vnn.nl/advies-hulp/jongeren/opname-in-een-


kliniek/bauhuus/
Luxembourg offers cannabis-specific treatment
programmes, which also include CANDIS (Hoch,
personal communication, 10 November 2014). Coverage Austria
of the affected population is rated as extensive, as the
majority of those in need of treatment for cannabis use In November 2013, CANDIS became the first cannabis-
problems are estimated to have access to treatment. No specific treatment programme to operate in Austria.
additional information is available on the specific types Primary cannabis users are often treated in the general
of treatment programmes that are offered or the settings substance use treatment services. This is particularly the
in which treatment is administered. case in outpatient settings and has been increasingly
observed in inpatient settings. For example, about 90 %
of the participants in the Konsumreduktionsgruppen, a
Hungary general substance use support group offered by Checkit!
in Vienna, are cannabis users. In fact, when this service
In Hungary, cannabis-specific treatment programmes was initially implemented, the focus was on cannabis.
are not available. Those with problems related to Since then, however, the Konsumreduktionsgruppen has
cannabis use, as well as individuals with problems extended its services to adolescents and young adults
related to other substances, are treated by public service who use other substances.
providers, non-governmental organisations and
commercial services providing general outpatient and
inpatient substance use treatment. Treatment includes Poland
medically assisted interventions and psychosocial
interventions. Poland offers CANDIS as a cannabis-specific treatment.
This programme is provided on an outpatient basis at
healthcare centres and clinics throughout the country.
Malta Although 60 drug experts have been trained in this
programme and 30 services throughout the country
Malta does not offer cannabis-specific treatment provide it, the coverage of the affected population is rated
programmes. No additional information is available on as limited, as only a small percentage of those in need of
treatment for cannabis use problems in this country. treatment for cannabis problems are estimated to have
access to treatment. There are no treatment options
available that are tailored specifically to adolescents with
Netherlands cannabis use disorders. From January 2014, the
programme has accepted adolescents as well as adults,
The Netherlands has one of the most comprehensive and the number of trained experts has increased to 110
cannabis-specific treatment systems in the European (Hoch, personal communication, 10 November 2014).
Union. The country offers a variety of cannabis-specific
programmes in both inpatient and outpatient settings.
Outpatient options include CBT and MDFT (for Portugal
adolescents and young adults). Inpatient cannabis-
specific treatment is offered through the Mistral and Portugal offers cannabis-specific treatment programmes
Bauhuus clinical programmes. These treatment within a public network of prevention, treatment and

47
Treatment of cannabis-related disorders in Europe

rehabilitation centres (called CRIs, centres for integrated Finland


responses). CRIs are accessible throughout the country,
providing a nationwide network of coverage for drug Finland does not offer cannabis-specific treatment
addiction interventions. Each CRI develops an programmes. Specialised treatment for those with
intervention for at-risk cannabis users who do not yet substance use problems include outpatient care
meet the criteria for abuse or dependence. Interventions (A-Clinics, youth centres), short-term inpatient care
are based on a targeted prevention framework, which (detoxification units), longer-term rehabilitative care
includes psychoeducation, counselling and social skills (rehabilitation units), support services (day clinics,
training. Referral for more intensive treatment will occur if housing services and subsidised housing) and peer
it is judged to be necessary. The PIAC programme support activities. In addition to the units providing
administered at a CRI in Oporto is an example of a specialised services for those with substance use
programme that treats cannabis abuse and dependence. problems, increasing numbers are treated within primary
The interventions typically involve psychotherapy and only social and healthcare services, including social welfare
seldom require a combination of psychopharmacotherapy offices, child welfare services, mental health clinics,
and psychotherapy. If psychiatric co-morbidity is present, health centre clinics, hospitals and psychiatric hospitals.
it is addressed in specialised CRI units. The CRI at UD-C The Finnish system emphasises that substance use
Taipas in Lisbon is an example of this type of intervention. treatment alone is often insufficient and that the
individual in treatment should receive assistance in
solving problems related to income, living situation and
Romania employment.

The most recent available data indicate that Romania


offers cannabis-specific treatment programmes; Sweden
however, coverage of the affected population is rated as
very limited, as only a small percentage of those in need No information is available regarding the availability
of treatment are estimated to receive treatment through of treatment for cannabis use problems
the available programmes. No additional information is in Sweden.
available on the types of treatments offered and the
settings in which treatment is administered in Romania.
United Kingdom

Slovenia The United Kingdom adheres to an inclusive view of


substance use treatment and has implemented services
Slovenia does not offer cannabis-specific treatment that are tailored to individual needs. Thus, there are only
programmes. Treatment for individuals with cannabis a few cannabis-specific services or groups, and these
use problems is provided by non-governmental services are often part of a larger substance use
organisations and public health institutions. No treatment service. Most interventions for treating
additional information is available about treatment cannabis-related problems are provided as part of the
options for cannabis-related problems in this country. wider substance use treatment system. The mainstay of
treatment is evidence-based psychosocial
interventions. The United Kingdom also has young
Slovakia people’s substance misuse services, which are
commissioned and delivered separately from adult
Slovakia provides cannabis-specific treatment substance use treatment. The majority of adolescents
programmes in both outpatient and inpatient settings. and young adults accessing specialist drug and alcohol
The cannabis-specific programmes in Slovakia are based interventions have problems with alcohol (37 %) or
on CBT and MET interventions. Coverage of the affected cannabis (53 %). Treatment for young adults and
population is rated as comprehensive, as nearly all adolescents often involves psychosocial, harm
individuals in need of treatment are estimated to have reduction and family interventions, rather than
access to treatment. Special programmes do not exist treatment for addiction, which is required by most of the
for adolescents with cannabis use problems. adults but only some of the young people referred for
treatment for cannabis use.
More information about the treatment of cannabis use
disorders in Slovakia can be found on the website More information about the treatment of cannabis use
cpldz.sk/ disorders in the United Kingdom can be found in the UK

48
CHAPTER 3  I Treatment of cannabis use disorders in Europe

clinical guidelines (National Treatment Agency for


Substance Misuse, 2007). I Selected cannabis-specific treatment
programmes in Europe

Turkey A number of programmes have been developed in


Europe specifically to treat people with cannabis-related
Turkey does not offer cannabis-specific treatment disorders. For a better understanding of the concepts
programmes. Available data indicate that those with behind these programmes and to provide, where
cannabis use problems receive detoxification treatment possible well-evaluated, examples of such programmes,
followed by psychosocial treatments. No additional this chapter examines some of them in more detail.
information is available on the treatment of those with While it is not intended to give a comprehensive
cannabis-related problems in Turkey. description of all available cannabis-specific
interventions in Europe, the major cannabis-specific
treatment programmes currently existing in Europe are
Norway included here.

Norway offers a cannabis-specific treatment programme, An overview of selected programmes is presented at the
Ut av taka (Out of the Fog). The programme has two target end of the section, listing the European countries where
populations: (1) adolescents and young adults with these interventions have been implemented (Table 10).
cannabis-related problems and (2) employees in urban
districts whose day-to-day work involves contact with
affected young people. The programme is a group-oriented I Realize It
outpatient treatment. Coverage is rated as limited,
however, as only a few of those in need of treatment are Realize It is a cannabis-specific treatment programme
estimated to have access to the programme. for adolescents and young adults aged between 15 and

Realize It

Individual session I: Introduction to treatment programme, create a self-monitoring diary, define individual goals
regarding cannabis use (within the programme period), define specific goal to be accomplished by the next session.

Individual session II: Two modules:


n Evaluate progress towards goal 1
  n Problem solving
 
n Define goal 2
  n Reduce cannabis consumption
 
Individual session III: Self-control strategies:
n Evaluate progress towards goal 2
  n Identify risky situations
 
n Define goal 3
  n Develop coping strategies
 
Individual session IV: n O vercome stressful situations
 
n Evaluate progress towards goal 3
  n Plan a cannabis-free spare time activity
 
n Define goal 4
 

Individual session V: Evaluate progress towards goal 4 and overall treatment goal.

Group sessions: Group sessions are focused on increasing awareness of risky situations and the development of
coping strategies. The counsellor serves as a moderator of group discussions. Group sessions last two hours, take
place on a weekly basis and contain between three and six participants. Participants are strongly encouraged to
attend at least one group session during the course of treatment.

Source: Realize It overview obtained from the Realize It programme manager on 27 June 2013.

49
Treatment of cannabis-related disorders in Europe

30 years. The programme includes five individual CANDIS is currently offered in Germany, Austria,
sessions and at least one group session. Individuals who Luxembourg, Poland and Switzerland. In Germany, CANDIS
exhibit signs of problematic alcohol use or limited is administered by psychologists, psychiatrists and social
problem-solving skills have the option of participating in workers. The programme is primarily provided in outpatient
a 3-session alcohol reduction module, a 3-session settings, but is sometimes offered in inpatient settings in
problem-solving skills module or both. Thus, the typical Germany. In Poland, CANDIS is conducted by addiction
dose of treatment ranges from 6 to 12 sessions. The therapy specialists in outpatient facilities.
individual sessions are based on the principles of brief
solution-focused therapy (Berg and Miller, 2000).
Individuals in treatment learn how to define individual Conceptual elements of CANDIS
behavioural goals with regard to their problem cannabis
use. In addition, a major objective of the treatment Motivational enhancement therapy (MET)
programme is to help clients develop self-regulation and Miller and Rollnick (2002)
n 

self-control skills. For instance, clients learn how to Interventions to stimulate motivation to change
n 

identify successful strategies for limiting cannabis use


by examining their entries in a drug diary. The group Cognitive behavioural therapy (CBT)
session provides individuals in treatment with an Aetiology of cannabis use disorder (biological,
n 

opportunity to share their successful strategies with psychological, social aspects)


others. Communication between the counsellor and Understanding cannabis use patterns (functional analysis)
n 

clients in both the individual and group sessions relies Development of an individual change concept and goal
n 

heavily on the principles of MI. At present, this setting


programme is available only in Germany, where it is Quit day preparation (skills training, stimulus control
n 

offered in outpatient drug-counselling centres and is and enforcement of alternative behaviours)


administered by social workers. Relapse prevention (strategies to cope with urges,
n 

craving and high-risk situations)


Improve social skills, cannabis refusal skills and social
n 

support
Management of co-morbid mental disorders (anxiety,
n 

depression, substance use disorders)

Psychosocial problem-solving training (PPT)


D’Zurilla and Goldfried (1971)
n 

Identify and solve problems


n 

More information about Realize It can be found on the Standard sessions in CANDIS
website: realize-it.org
Session 1: Diagnostic feedback and enhancement of
n 

motivation to change
I CANDIS Session 2: Enhancement of motivation to change
n 

Session 3: Understanding cannabis use patterns


n 

CANDIS (Hoch et al., 2012) is an outpatient intervention for Session 4: Goal setting and target day preparation
n 

adolescents (over 16 years old) and adults that was created Session 5: Debriefing of target day and management
n 

specifically to treat cannabis use disorders. The of craving


programme is empirically supported in the treatment of Session 6: Relapse prevention
n 

problem cannabis use. This intervention is offered only in Session 7: Psychosocial problem solving
n 

an individual therapy format and the standard dose of Session 8: Psychosocial problem solving
n 

treatment is 10 sessions, spanning a period of 8 to 12 Session 9: Co-morbidity


n 

weeks. CANDIS consists of three programme modules: (1) Session 10: Social skills training and treatment
n 

MET, (2) CBT and (3) psychosocial problem-solving training termination


(PPT). The aim of the programme may be either total
Source: Hoch et al. (2011)
abstinence from cannabis or reduction in cannabis use.
Treatments, such as CANDIS, which combine aspects of
CBT and MI have been shown in empirical research to be For more information about CANDIS in Germany and
efficacious treatments for cannabis use disorders. Poland see candis-projekt.de

50
CHAPTER 3  I Treatment of cannabis use disorders in Europe

I CAN Stop techniques. CAN Stop is conducted by laypeople, that is,


individuals from a broad range of professional
CAN Stop is an intervention for adolescent backgrounds who have experience working with the
and early adult cannabis users (aged target group and who have attended a one-day training
14–21 years) offered throughout Germany. seminar. CAN Stop was specifically developed in such a
The CAN Stop programme consists of way that it could be easily implemented in various
eight 90-minute group treatment sessions. Group size contexts. It is currently offered in inpatient and outpatient
typically ranges from 6 to 12 clients. The treatment medical settings, juvenile detention facilities and
programme primarily uses CBT and MI interventions and substance use treatment settings.

CAN Stop: treatment overview (1)

Session 1: You CAN Stop!


Participants are introduced to the Can Stop group training model. The trainer informs participants about the
schedule and the group rules. Following a ‘get to know each other’ exercise, participants begin to build up an
atmosphere of trust. Then, the diary in which participants will document their cannabis consumption is explained
with the help of examples. In the second part of the session, participants are asked to reflect on the disadvantages
and advantages of consuming cannabis.

Session 2: Knowledge is power!


Participants receive psychoeducation on the consequences of cannabis consumption for the brain and general
health. Subsequently, participants complete a 15-question quiz addressing topics relating to cannabis
consumption including origin, active ingredients, addiction, impact on health, detectability, psychosis and legal
matters. With the help of illustrations and diagrams, processes in the brain are explained. Furthermore,
participants learn the criteria of addiction and rate their own status on a scale from ‘non-problematic’ to ‘misuse’
or ‘addiction’.

Session 3: Find your strengths!


Diary entries are evaluated and discussed. First, achievements in reducing cannabis consumption are reinforced.
The main focus in this session is identifying individual strengths and resources that can help change cannabis
consumption behaviour. The aim is to promote positive self-perception and strengthen participants’ self-confidence.

Session 4: Express your emotions!


The role of emotions in cannabis consumption is discussed, as emotions often trigger consumption. Participants
are instructed to think about how typical consumption situations are associated with their emotional state. In the
second part of the session, participants work together in the group to develop alternative coping strategies for
dealing with these emotions.

Session 5: Doesn’t everyone get stoned?


The fifth and sixth sessions focus on the topic ‘Cannabis and peers’. In Session 5, the perceived norms of
participants’ own consumption are contrasted with peer norms. Subsequently, the participants’ own social
environment is discussed. Participants then reflect specifically on the interaction between the peer group and
consumption behaviour. Acquaintances and friends who are abstinent are praised and cannabis-independent
interests are reinforced. With the help of the group, concrete steps to reconnect with abstinent contacts or friends
are developed.

Session 6: Just say No!


The main focus of the sixth session is tempting social situations and the refusal of cannabis use in these
situations. On the basis of their diary entries, participants are instructed to identify typical individual (social)

51
Treatment of cannabis-related disorders in Europe

situations that are tempting. The aim is to increase awareness of situations where there is an increased risk of
consumption. On this basis, strategies are developed to help participants cope with such situations and to enable
them to avoid cannabis use.

Session 7: Relapse prevention


The aim of the seventh session is to identify individual signs or predictors of relapse and to find strategies to
prevent relapse. Using their diaries, participants explore their individual consumption and risk situations and
group them into different risk categories in accordance with Marlatt’s risk classification system. Finally, they rank
their risk situations. With the help of a role-play exercise and the ‘angel-devil-dialogue’ metaphor, associations
between cognitions and cannabis consumption are discussed. Playful cognitive and behaviour strategies are
developed to avoid future risky situations.

Session 8: Emergency and goodbye


In the eighth session, the aim is to consolidate what has been learnt so far. Furthermore, an emergency plan is
developed. The difference between a ‘slip’ and a full relapse is explained. The participants search for possible
reinforcers for abstinence and connect their programme goals (e.g. abstinence or reduction) with a concrete
symbol. Finally, participants create an individual ‘emergency kit’ in the form of a matchbox that contains helpful
cognitions. The programme closes with the presentation of an individual certificate to each participant.

Source: CAN Stop treatment overview obtained from CAN Stop programme manager on 27 June 2013.

More information about CAN Stop can be found on the website canstop.med.uni-rostock.de

(1) Translated from German.

I Out of the Fog Much of the effort involved in Out of the Fog is directed
towards training personnel and working together with city
The Out of the Fog (Ut av tåka) cannabis-specific wards in Oslo to enable them, in the longer term, to run
intervention is designed to target two groups: (1) these courses on their own and offer them to young
adolescents and young adults (aged 15–25 years) who people in their ward. Some city wards have run groups in
are motivated to stop using cannabis and (2) first-line cooperation with Out of the Fog. The wards are also given
employees (e.g. teachers, mentors, social workers) in guidance, and there is cooperation on follow-up. The
urban districts who come into contact with these project is also working on making the ‘quit smoking hash’
individuals on a daily basis. The programme emphasises course and method better known and on developing the
the integral role played by multisystemic support in methodology. In total, 98 people were followed up through
reducing cannabis use. the project in the first half of 2012. This is more than in the
whole of 2011, when the total number was 64.
The Out of the Fog ‘quit smoking hash’ course in Oslo
involves intersectoral cooperation and aims to develop Similar courses aimed at weaning people off cannabis are
local competence and methods, based on experiences also held in several other Norwegian towns and cities.
from Sweden and Denmark. The initiative has helped Such courses may reach young people who would not
professionals to offer young people in their city ward an otherwise seek help for their drug problems. Increased
opportunity to quit smoking cannabis, both through focus on and knowledge about cannabis use problems in
groups and individually. Young people are reached social and healthcare services will enable more young
earlier than they were before. people to seek help for their problems at an earlier stage
(see the 2012 Reitox national report for Norway).

52
CHAPTER 3  I Treatment of cannabis use disorders in Europe

I Quit the Shit the programme, the admission phase begins. This phase
involves an initial 50-minute online chat with a
Quit the Shit (Tossmann et al., 2011) is an Internet-based counsellor. The objective of this chat is to clarify the
counselling programme that takes place over a 50-day client’s substance use situation, determine cannabis use
period. The programme targets adolescents and young goals and identify coping strategies. After admission, the
adults, and the interventions used in the programme are online diary is activated. Clients record all relevant
based on solution-focused therapy. Thus, interventions aspects of their cannabis use in an online diary for the
are geared towards helping the client to establish next 50 days. During this period, clients receive written
effective self-control and self-regulation skills. Quit the feedback once a week from their counsellor. The
Shit is administered by trained counsellors over email feedback relates to cannabis use levels, the
and through online chat. The programme is free and, psychosocial situation of the participant and the
since it is offered online, can be used anonymously. The counselling process. On completion of the 50-day online
programme consists of four consecutive phases: (1) diary phase, the counsellor conducts a termination chat
registration, (2) admission chat, (3) online diary and with the client. The objective of this chat is to review
feedback, and (4) termination chat. The registration progress towards the client’s cannabis use goals,
phase involves gathering personal information from the identify which individual strategies were most effective
client that is relevant to substance use counselling and in reducing cannabis use and determine whether further
programme evaluation. After the client has registered for professional help is required.

Screening: evaluate stage of change (transtheoretical model), obtain sociodemographic data, evaluate for
cannabis use or dependence (DSM-IV), determine patterns of cannabis consumption

One-on-one chat: Six modules:


n Introduction to treatment programme, creation of
  Identify disadvantages and advantages of consuming
 
n

cannabis use diary, definition of individual goals cannabis.


(within the programme period). Identify risky situations.
 
n

50-day diary: C ome up with alternative (drug-free) activities.


 
n

n Self-monitoring.
  Write farewell letter to substance.
 
n

n Document consumption patterns.


  Develop and implement problem-solving skills.
 
n

n Daily summary .
  Identify personal strengths and resources.
 
n

Read weekly written feedback:


 
n

Motivation enhancement.
 
n

Develop coping strategies.


 
n

Final chat evaluating progress towards treatment goals and providing referral if necessary

Source: Quit the Shit treatment programme overview obtained from the Quit the Shit treatment programme
manager on 27 June 2013.

More information about Quit the Shit can be found on the website quit-the-shit.net

53
54
TABLE 10
Overview of selected European cannabis-specific treatment programmes
Treatment name Country provided Target population Treatment Treatment providers Treatment Evidence- Additional notes
format setting based?
ATRAPOS Greece Adolescents, young adults Individual, group Unknown Unknown Unknown Family-oriented interventions (e.g. family
Treatment of cannabis-related disorders in Europe

(< 25 years old) members can attend therapy groups)


CANDIS Austria, Germany, Adolescents (> 16 years Individual Psychologists, psychiatrists, social Outpatient Yes Interventions based on CBT and MI
Luxembourg, old), adults workers, addiction therapy
Poland specialists
CAN Stop Germany Adolescents, young adults Group Laypeople with experience with Inpatient, Unknown
(< 22 years old) target group outpatient
CBT Belgium, Denmark, Adults, adolescents Individual, group Psychologists, psychiatrists, Outpatient, Yes Inpatient therapy only offered in Slovakia
Netherlands, trained therapists inpatient
Slovakia
MDFT Belgium, Germany, Adolescents, young adults Family-systems, Psychologists, psychiatric nurses, Outpatient, Yes Inpatient therapy only offered in the
Netherlands (< 25 years old) multisystemic trained therapists inpatient Netherlands
MI/MET Slovakia, Belgium Adults, adolescents Individual, group Psychologists, psychiatrists Outpatient, Yes
inpatient
Out of the Fog Norway Adolescents, young adults Unknown Laypeople with experience with Unknown Unknown
(< 25 years old) target group
Quit the Shit Germany Adolescents, young adults Individual Trained counsellors Online, Yes Interventions based on solution-focused
telemedicine therapy
Realize It! Germany Adolescents, young adults Individual, group Social workers Outpatient Yes Interventions based on solution-focused
(< 30 years old) therapy and MI
Abbreviations: CBT, cognitive behavioural therapy; MDFT, multidimensional family therapy; MET, motivational enhancement therapy; MI, motivational interviewing.
4
CHAPTER 4
Estimation of unmet treatment needs

The last chapter showed how European countries vary in treated in outpatient settings. Second, those entering
the way they handle treatment needs for cannabis- inpatient treatment are often referred from outpatient
related problems. Some focus on special programmes services, raising the possibility of double-counting and
and approaches whereas others use a more generic thereby overestimating the overall numbers entering
system of treatment provision, which can be adapted to treatment for cannabis problems.
needs at an individual level. The extent to which
treatment needs are met by any of these treatment As treatment monitoring in many countries covers only
offers is an important question. In this chapter, estimates parts of the drug treatment system, a correction factor
of treatment provision — taking into account both for under-coverage (as reported by the national focal
specific and generic approaches — per country are points) was used to calculate the total number of treated
presented and discussed in relation to indicators of cases.
treatment needs.
The resulting numbers are presented in Figure 3. The
This approach has to be seen as a first attempt to ratio of treated cases per daily or near-daily user is
compare needs and provision of treatment for cannabis- understood as a rough indicator of the coverage of
related problems at a European level. In the absence of a treatment needs for those with cannabis-related
European instrument to assess the treatment needs of problems.
this clientele, a proxy indicator is used. Studies have
shown a high correlation between regular, especially Considerable variation exists between countries in the
daily, use of cannabis and cannabis-related disorders. ratio between the number of treated cases with
This permits ‘daily or near-daily use’ prevalence to be cannabis as the primary drug and the number of daily or
used as a proxy for problematic cannabis use. It is near-daily cannabis users. Seven out of the 15 countries
assumed that those using the drug daily or almost daily
would be the target group for cannabis treatment. While FIGURE 3
acknowledging that not all individuals using the drug on Treated cannabis cases per 100 daily or near-daily
a daily or near-daily basis would be in need of or would users
benefit from cannabis treatment, the size of this group Latvia
can serve as a crude estimate of possible treatment Germany
needs. Norway
Denmark
For each country, a national estimate was calculated Belgium
from (1) the prevalence of cannabis use in the last United Kingdom
month, as measured in the most recent national surveys, Austria
and (2) the percentage of daily or near-daily users Ireland
among this group, as reported by national focal points to Finland
the EMCDDA in a separate study (EMCDDA, 2012b). France
Czech Republic
Treatment provision was calculated on the basis of Spain
reports of clients who had been in specialised drug Portugal
treatment in Europe who cited cannabis as their primary Italy
drug. This information is collected through the treatment Lithuania
demand indicator (TDI) for each calendar year. Only
outpatient treatment numbers were used in the 0 5 10 15 20 25 30 35

calculations for two reasons. First, the majority of Treated per 100 daily or near-daily users

reported admissions for primary cannabis problems to NB: Treatment data for Denmark, Portugal, Sweden and the United
specialised drug treatment facilities in Europe are Kingdom refer to 2011; data for other countries refer to 2012.

57
Treatment of cannabis-related disorders in Europe

FIGURE 4
Ratio between annual number of cases treated for cannabis use problems per 100 daily or near-daily users and
prevalence of daily or near-daily cannabis use
2.5
Spain
Daily or
near-daily
use in 2.0
general
population
(%) Italy

1.5 France

1.0
Belgium
Portugal
Ireland United Denmark
0.5 Kingdom
Czech Republic Germany
Norway
Finland Austria

0.0 Lithuania
0 3 6 9 12

Number in treatment per 100 daily or near-daily users

NB: Dashed lines represent average values. Latvia, with a daily use of 0.7 % and 34.2 in treatment per 100 daily users, is off-scale and is not plotted on the
graph.

for which such detailed data are available report only a very limited proportion of the population in need
between 5 and 10 treatment cases per 100 daily or of treatment. In these countries, and in others with only
near-daily users. This is equivalent to 1 person receiving limited treatment availability, additional resources could
treatment for each 10 to 20 daily users in a given year. be devoted to programmes aimed at increasing the
Latvia has a still higher value, which reflects the very low accessibility of quality treatments for those with
prevalence of daily cannabis use assessed in the cannabis-related problems.
country. Some other countries have extremely low ratios
of around or below 1 per 100.

By adding the level of prevalence to this analysis, it is


possible to provide national policymakers with an
indication of how cannabis treatment in their country
I Specific treatment for specific
substances?
stands both in relation to potential needs and in
relation to other European countries. As Figure 4 Looking at treatment offered for cannabis-related
shows, a high prevalence of daily or near-daily use in problems throughout Europe, two approaches are
the population does not always coincide with a high evident: (1) cannabis-specific treatment, which is
level of treatment provision. Two examples of this are targeted at a specific age group (adolescents or young
Spain and Portugal. In these countries, which present a adults) and the risks and harms associated with the use
rather high prevalence of daily or near-daily cannabis of the drug, and (2) general substance use treatment,
use, the ratio of treatment cases to daily or near-daily which is tailored to the individual needs of the cannabis
users is very low compared with the European user seeking treatment. In terms of treatment
average. organisation and settings, general approaches may
appear to have certain disadvantages. Treating users of
Although the majority of the countries report that drug different drugs together may lead to mixing of older and
treatment is provided to most or all of those asking for it, younger users, more marginalised and problematic users
there are still several European countries in which and well-integrated users, which is unwanted both by
available cannabis use treatment programmes cover public health services and by drug users. By offering only

58
CHAPTER 4  I Estimation of unmet treatment needs

standard treatment facilities and approaches, services profiles and user groups. The discussion on the
may not attract all of the cannabis users who could treatment of drug problems related to new psychoactive
benefit from this type of treatment. substances has just started. What lessons can be learnt
from the past 10 years’ discussion on treatment for
However, comparing the evidence for specific and cannabis use for this target group of ‘recreational users’?
generic interventions, there seems to be no firm basis for First, it is important to gather more information on the
a conclusion in favour of cannabis-specific treatment: users. More knowledge about their consumption
both approaches have shown similar levels of effect. This patterns, other drugs used and drug-related physical,
is not unexpected, as both types of intervention are built mental and social harms is required to understand the
on the same psychotherapeutic and educational possible treatment needs of this specific group of users.
approaches, which have shown their efficiency As with the treatment of those dependent on alcohol,
frequently under different conditions: MI, MET and CBT nicotine or cannabis, and based on the evidence
for adults, with some additions based on family systems available for patients with substance use disorders, it is
theory and therapy for younger people. very likely that combinations of MET, CBT, CM and
family-based interventions will be effective for this target
While cannabis is by far most the prevalent illicit drug in group. General treatment approaches may already exist
Europe, it is not the only one. There are many other in many treatment services, where staff are trained and
substances in use, often changing, with unclear risk sufficiently experienced in these approaches.

59
5
CHAPTER 5  I Conclusions

CHAPTER 5
Conclusions

The observation of Bergmark (2008) that for cannabis possibly high levels of need, have reported relatively low
use disorders all treatments appear to work still seems levels of treatment provision, which may indicate the
apt. Our review of the literature published since 2008 existence of unmet treatment needs.
found no conclusive evidence for the superiority of any
specific treatment to others. Treatment context and the Although the bulk of cannabis problems are treated in
individual’s choice in entering treatment are more outpatient settings, primary cannabis users nevertheless
important determinants of outcome than treatment account for almost one in every five of those entering
modality. The evidence does not show that specialised inpatient drug treatment. Whereas about half of the
cannabis use treatment offers cannabis users better countries offer cannabis-specific outpatient
outcomes than general substance use treatment — both interventions, cannabis-specific residential treatment
approaches can work. These findings are reassuring options are offered only in the Netherlands and Slovakia.
given that the options available for treating cannabis- Demand for inpatient treatment for cannabis problems is
related problems vary widely across the European Union. likely to increase in the future, if the overall demand for
cannabis treatment continues to rise.
Despite the cooperation of experts in almost all EU
countries, the picture of cannabis treatment that Internet-based interventions present a promising area
emerges is incomplete. For many of the treatment for further development, as they can reach a much
options provided in Europe, especially the general broader group of cannabis users, which may benefit
substance use approaches, at best only limited from preventative and treatment interventions.
information is available. In contrast, detailed information
is available for most of the cannabis-specific Closely related to the issue of rising demand for
programmes covered by this study: all of those are treatment are the legal issues associated with cannabis
based on therapeutic strategies with the highest use and treatment. A substantial proportion of those
evidence for effectiveness — although only four of these presenting with cannabis use problems in Europe are
programmes have been tested for efficacy. referred by the criminal justice system. Changes in
criminal justice referral practices and the emphasis on
Questions can be raised about how the available rehabilitation and treatment over punishment and
evidence may inform the treatment of cannabis use correction will continue to have an impact on who is
problems in European countries. Recent research on referred for treatment, who receives treatment and,
moderators for treatment effectiveness show that ultimately, the availability of treatment in Europe.
‘culture’ may be a relevant factor in determining the Depending on policy, rates of referrals for treatment
failure or success of an intervention (Burrow-Sanchez could increase or decrease regardless of actual changes
and Wrona, 2012; Robbins et al., 2008). The evidence in the prevalence of cannabis-related problems. Issues
base, however, is largely made up of published treatment relating to the legal status of cannabis have the potential
studies carried out in the United States or Australia. To to affect criminal justice referral policy and practice, and
what extent are published evidence-based CBT perhaps even the nature of treatment for cannabis
programmes transferable to diverse European treatment problems. For example, decriminalisation of cannabis
settings? Are cultural adaptations of these approaches could lead to treatment programmes setting moderation
needed? These are research questions that ought to be of cannabis use, rather than complete abstinence, as a
addressed. treatment goal.

Comparing indicators of treatment needs and treatment Other directions for the future growth of treatment
provision, the overall situation in Europe looks positive. provision in Europe include the implementation of
In most countries, there seems to be an adequate level adolescent-specific drug use treatment in more
of treatment provision in relation to needs. However, countries and a growth of multisystemic therapies to
some of the countries with quite high levels of use, and treat this population. From the data analysed in this

61
Treatment of cannabis-related disorders in Europe

study, it appears that programmes designed specifically heterogeneous group of clients (e.g. co-morbidity, gender,
for adolescents exist in only half of the countries that referral from the criminal justice system). More effective
offer cannabis-specific treatment; the data do not reveal approaches to early interventions and secondary
how many of the other countries offer treatment prevention are needed for children, teenagers and young
programmes targeted at adolescents. As adolescents adults. Moreover, further work is need on improving
account for a large proportion of those with problematic treatment for specific groups of users, including those
cannabis use in the European Union, meeting the needs with dual diagnoses, prisoners, female and pregnant
of this population will depend on more countries offering cannabis abusers and certain groups of elderly cannabis
adolescent-specific treatments, such as family and abusers. The function of prolonged cannabis-associated
multisystemic therapy. neurocognitive deficits in the treatment process (and their
reversibility) needs to be examined, as does the
The low rates of treatment seeking, retention and effectiveness of cognitive remediation therapy in this
continuous abstinence (which is still the primary group of patients. Research into new and effective
treatment goal of treatment providers and health pharmacological approaches to treatment of cannabis
insurance companies in many EU countries) associated dependence is still under way and much needed. Finally,
with cannabis treatment may suggest that there is the questions of treatment organisation and differential
considerable room for improvement in the interventions. indication (‘which patient benefits most from an
intervention, delivered by which type of health
As well as the development of new therapeutic strategies, professional in which setting?’), and the need for
a diversification of existing approaches is needed, education, training and case-related supervision for
tailoring treatment to the characteristics and needs of this treatment providers, need to be addressed.

62
I Glossary
Cannabis: a plant-based substance containing tetrahydrocannabinol (THC), a
psychoactive substance. In Europe, it is typically marketed in two forms: herbal cannabis
or ‘marijuana’ and cannabis resin or ‘hashish’. Cannabis is a controlled substance
throughout the European Union.

Cannabis-specific treatment: a treatment whose target population is limited to individuals


with cannabis use disorders.

Cannabis use disorders: this term refers to either cannabis abuse or cannabis
dependence. Both of these disorders are characterised by problematic cannabis use (i.e.
cannabis use that causes distress, dysfunction or both in the user’s life). Cannabis
dependence is indicative of a more problematic pattern of use than cannabis abuse. Full
descriptions of both of these disorders, including symptoms and associated features, can
be found in the Diagnostic and statistical manual of mental disorders, 4th edition, text
revision (American Psychiatric Association, 2000).

General substance use treatment: a treatment whose target population is individuals with
substance use disorders. Thus, treatment is not targeted at users of one specific
substance.

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71
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TD-XD-14-017-EN-N
About the EMCDDA

The European Monitoring Centre for Drugs and


Drug Addiction (EMCDDA) is the central source and
confirmed authority on drug-related issues in Europe.
For over 20 years, it has been collecting, analysing and
disseminating scientifically sound information on drugs
and drug addiction and their consequences, providing
its audiences with an evidence-based picture of the
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the EMCDDA is one of the decentralised agencies of
the European Union.

About this series

EMCDDA Insights are topic-based reports that bring


together current research and study findings on a
particular issue in the drugs field. This publication
reviews the interventions used in the treatment of
cannabis disorders and maps out the geography
of cannabis treatment in Europe.

doi:10.2810/621856

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