Marijuana Treatment Project

The Center for Substance Abuse Treatment (CSAT), part of the Substance Abuse and Mental Health Services Administration, funded three clinical sites and a Coordinating Center (CC) to design and implement the Marijuana Treatment Project (MTP) in the late 1990s. A major focus of CSAT is rigorous testing of approaches to treat marijuana dependence in both adults and adolescents. MTP studied the efficacy of treatments for adults who are dependent on marijuana. At the time of funding, MTP was one of the largest Knowledge Development and Applications initiatives funded by CSAT. Another was the Cannabis Youth Treatment (CYT) Study, which resulted
in the CYT Series, a five-volume resource that provides unique perspectives on treating adolescents for marijuana use (Godley et al. 2001; Hamilton et al. 2001; Liddle 2002; Sampl and Kadden 2001; Webb et al. 2002). This manual for Brief Marijuana Dependence Counseling (BMDC) is based on the research
protocol used by counselors in MTP. The manual provides guidelines for counselors, social workers, and psychologists in both public and private settings who treat adults dependent on marijuana.

The 10 weekly one-on-one sessions in the BMDC manual offer examples of how a counselor can help a client understand certain topics, keep his or her determination to change, learn new skills, and access needed community supports (exhibit I-1). Stephens and colleagues (2002) describe the MTP rationale, design, and participant characteristics. Findings from MTP are presented in supplemental reading B of section VII.

Me? Hooked on Pot?
Many individuals for whom this intervention was designed often have difficulty accepting that they are dependent on marijuana. The topic is controversial, even for those who walk through a counselor’s door to talk about their marijuana use.
People who become clients in BMDC may have
• Put off actions and decisions to the point of being a burden on family and friends
• Given up personal aspirations
• Had nagging health concerns, such as worries about lung damage
• Made excuses for unfinished tasks or broken promises
• Experienced disapproval from family and friends
• Been involved in the criminal justice system.

Current Findings About Marijuana Use
Marijuana is the most commonly used illicit substance in the United States (Clark et al. 2002; Substance Abuse and Mental Health Services Administration 2003). According to the 2003 National Survey on Drug Use and Health, 14.6 million people ages 12 and older had smoked marijuana in the preceding month (Substance Abuse and Mental Health Services Administration 2004). It is estimated that approximately 4.3 million people used marijuana at levels consistent with abuse or dependence in the past year. Given that it is an illicit substance, any use of marijuana carries with it some significant risks. However, this document focuses on people who use marijuana heavily or are dependent on it. This treatment manual is directed primarily at these
persons but may be useful for other persons with substance abuse or substance use disorders. Studies have demonstrated that tolerance and withdrawal develop with daily use of large doses of marijuana or THC (Haney et al. 1999a; Jones and Benowitz 1976; Kouri and Pope 2000). About 15 percent of people who acknowledge moderate-to-heavy use reported a withdrawal syndrome with symptoms of nervousness, sleep disturbance, and appetite change (Wiesbeck et al. 1996). Many adults who are marijuana dependent report affective (i.e., mood) symptoms and craving
during periods of abstinence when they present for treatment (Budney et al. 1999). The contribution of physical dependence to chronic marijuana use is not yet clear, but the existence of a dependence syndrome is fairly certain. An Epidemiological Catchment Area study conducted in Baltimore found that 6 percent of people who used marijuana met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (American Psychiatric Association 1994), criteria for dependence and 7 percent met DSM-IV criteria for substance abuse (Rosenberg and Anthony 2001). Coffey and colleagues (2002) found that persons who use marijuana more than
once a week are at significant risk for dependence. In the 1990s, the number of people who sought treatment for marijuana dependence more than doubled (Budney et al. 2001). Therefore, a large group of adults who smoke marijuana is dependent and may need and benefit from treatment. Surveys of people using marijuana who are not in treatment consistently show that a majority report impairment of memory, concentration, motivation, self-esteem, interpersonal relationships,
health, employment, or finances related to their heavy marijuana use (Haas and Hendin 1987;

Section I. Introduction
Rainone et al. 1987; Roffman and Barnhart 1987; Solowij 1998). Similar marijuana-related consequences are seen among those seeking treatment for their marijuana use (Budney et al. 1998; Stephens et al. 1994b, 2000). People using marijuana who participated in previous treatment studies averaged more than 10 years of near-daily use and more than six serious attempts to quit (Stephens et al. 1994b, 2000). These individuals had persisted in their use despite multiple forms of impairment (i.e., social, psychological, physical), and most perceived themselves as unable to stop.
During the past decade evidence has emerged that a variety of problems are associated with chronic marijuana use. Although the severity of these problems appears to be less than that of problems caused by other drugs and alcohol, the large number of people using who may have these problems raises the possibility of a significant public health problem. Like those who use other mood-altering substances, many individuals who use marijuana chronically perceive the
problems to be severe enough to warrant treatment. The results of earlier studies on treatments for marijuana problems indicated that some adults
who used marijuana responded well to several types of interventions, such as cognitive behavioral, motivational enhancement, and voucher-based treatments (Budney et al. 2000; Stephens et al. 1994b, 2000). Relapse rates following treatment were similar to those for other drugs of abuse and, as found with other types of substance abuse treatment, improvements in drug use were accompanied by other positive gains, including improvements in dependence symptoms, problems
related to marijuana use, and anxiety symptoms. However, the generalizability of the treatment findings appeared to be limited by the predominantly white, male, and socioeconomically stable (i.e., educated and employed) characteristics of the samples. Therefore, the results of these studies may be limited to this fairly homogeneous group of people who are marijuana users.

Overview of the Marijuana Treatment Project1
CSAT funded MTP to design and conduct a study of the efficacy of treatments for marijuana
dependence, to extend this line of research, and to broaden the applicability of the approach to a
more diverse group than that used in earlier trials (Stephens et al. 1994b, 2000). The treatment
sites were the University of Connecticut School of Medicine, Department of Psychiatry,
Farmington, Connecticut; The Village South, Miami, Florida; and the University of Washington,
School of Social Work, Seattle, Washington. The CC was at the University of Connecticut,
Department of Psychiatry.
The study examined the efficacy of treatments of different durations for a diverse group of adults who
were marijuana dependent. Two treatments—one lasting two sessions, the other nine sessions—
were compared with a delayed treatment control (DTC) condition, in which subjects were offered
treatment 4 months after their baseline assessment. The same counselors delivered treatments of
both durations to avoid confounding the mode of treatment, length of treatment, and counselor
experience. A case management component was incorporated in the longer treatment to help clients
identify and overcome barriers to successful behavior change in their everyday environments. The
hypothesis was the nine-session and two-session interventions would produce outcomes superior to
the DTC in terms of higher abstinence rates and associated negative consequences.