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P00: frame around

P01: olicognography

P02: addictions




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Tobacco and Cannabis

Basic Olicognograph: Teens Spirit Care

(nfm - not from me: extracts from reference articles)

Marijuana - Cannabis dependence as experienced in clinical populations appears very similar to other substance dependence disorders, although it is likely to be less severe. Adults seeking treatment for marijuana - cannabis abuse or dependence average more than 10 years of near-daily use and more than 6 serious attempts at quitting. They continue to smoke the drug despite social, psychological, and physical impairments, commonly citing consequences such as relationship and family problems, guilt associated with use of the drug, financial difficulties, low energy and selfesteem, dissatisfaction with productivity levels, sleep and memory problems, and low life satisfaction

Approximately half of the individuals who enter treatment for marijuana use are under 25 years of age. These patients report a distinctive profile of associated problems, perhaps due to their age and involvement in other risky behaviors. Adolescents who smoke marijuana are at enhanced risk of adverse health and psychosocial consequences, including sexually transmitted diseases and pregnancy, early school dropout, delinquency, legal problems, and lowered educational and occupational aspirations.

Observe that a large proportion of adolescent will quit smoking cannabis by themselves. Care not to increase the possible conflict or afraid parents. Behavioral treatments, such as motivational enhancement therapy (MET), cognitive-behavioral.therapy (CBT), and contingency management (CM), as well as family-based treatments have been carefully evaluated and have shown promise. Outpatient treatments for cannabis - marijuana abuse among adolescents have recently received increasing attention.

Adults outpatient treatments can reduce marijuana consumption and engender abstinence. The most commonly tested interventions are adaptations of interventions initially developed to treat alcohol or cocaine dependence, in particular MET and CBT (also known as coping skills training). The cumulative findings indicate that (1) each of these interventions represents a reasonable and efficacious treatment approach; (2) the combination of MET and CBT is probably more potent than MET alone; and (3) an intervention that integrates all 3 approaches—MET, CBT, and CM—is most likely to produce positive outcomes, especially as measured by rates of abstinence from cannabis - marijuana, particularly for engendering longer periods of abstinence. Recognizing that many people overcome dependence only after multiple treatment exposures.

Most information on marijuana-cannabis treatment efficacy among young people derives from trials that have included users of various drugs and have not focused specifically on marijuana use. Nevertheless, most patients in these studies has begun to emerge, family support network intervention. The CBT interventions studied have been similar to those studied for adults in scope and duration. Specific forms of family-based treatment that have been tested include functional family therapy, multidimensional family therapy (MDFT), multisystemic therapy, family support network intervention, multisystemic therapy, and brief strategic family therapy.

Among the clinical features that distinguish marijuana-cannabis dependence are the drug’s relatively mild withdrawal effects and marijuana users’ frequent desire to pursue a goal of reducing—rather than abstaining from—use. But marijuana is also the most common “other drug” used by those seeking treatment for stimulant or opiate dependence. Many individuals who enter treatment for heroin/opiate dependence or cocaine dependence do not consider their marijuana use problematic. In the cocaine clinic, where many patients do not endorse a goal of stopping marijuana use, the clinician must decide how best to approach this issue without adversely affecting treatment for cocaine dependence. Studies demonstrate how systematic approaches to secondary marijuana abuse can be implemented without having significant adverse effects on treatment for primary opiate or cocaine abuse.

Studies established a neurobiological basis for a marijuana withdrawal syndrome via an endogenous cannabinoid system in the central nervous system; (2) established the reliability, validity, and time course of withdrawal syndrome; and (3) demonstrated the potential clinical importance of the withdrawal syndrome. The marijuana withdrawal syndrome resembles those associated with other drugs, particularly tobacco. Patients experience irritability, anger, depression, difficulty sleeping, craving, and decreased appetite.

Like users of other drugs of abuse, regular marijuana-cannabis users have a higher rate of tobacco use than the general population; approximately 50 percent of heavy cannabis users also smoke tobacco. Moreover, many adolescents and, to a lesser extent, adults use tobacco and marijuana together, either mixing the substances, smoking blunts (hollowed out cigars filled with marijuana), or smoking one immediately after the other.

Smoking tobacco doubles the risk of death in every age group. One third of deaths, because of tobacco, occur before age 65. Smokers who quit — at any age — reduce their risk of tobacco-related disease and prolong their lives. Each cigarette smoked shortens a smoker’s life by 11 minutes. Smokers lose, on average, 14 years of life. A pregnant woman who smokes is exposing her fetus to dozens of harmful chemicals. In the case of pregnancy, the risk to the fetus is high, and voluntary counseling is indicated.

Nicotine addiction is a chronic disease, and relapse after initially successful treatment is common (often more than 70% relapse). Persistent efforts are required, but proven techniques for brief counseling are quick and can easily be integrated into a busy practice. 3 questions must first be answered: 1) Does the patient smoke? 2) Does the patient want to quit? 3) Is the patient addicted?

Quitting smoking is effective on cardiac, coronary and lung performance; as well as cancer risk reduction. Brief counseling is effective and should obtain patient’s acceptance of a quit date. There is a strong dose-response relationship in effective counseling consisting of 4 or more sessions, each at least 10 minutes long. Subsequent counseling can be individual, group, or by telephone. “Reactive” and single-session counseling is less effective than “proactive” counseling, in which the counselor arranges repeated sessions to interact with the patient and follow progress.

Conditions that complicate treatment are: 1) Weight grain; 2) Concurrent psychiatric or substance abuse problem; 3) Pregnancy; 4) Adolescence; 5) Relapse.

Several types of nicotine replacement therapy (NRT) have been approved for use by smokers who want to quit: nicotine gum, nicotine patch, nicotine oral inhaler, and nicotine nasal spray. In recommended doses, it is safe to use NRT in patients with stable heart disease. Most pregnant smokers can quit without medication, but NRT is safer than continued smoking. Sustained-release bupropion (buproprion SR), an antidepressant, is effective for smokers who want to quit. The most important contraindication is a history of seizures. Interactions between bupropion SR and other psychotropic drugs can produce serious adverse effects, so a psychiatrist should see other psychotropic medications. For strongly-addicted smokers, bupropion SR is commonly prescribed in combination with one or even two kinds of nicotine replacement (e.g., bupropion SR plus a patch, plus gum to supplement the patch). Bupropion SR appears to increase quit rates even more among women. Other drugs are known to be effective for nicotine like clonidine. Other drugs, including other antidepressants, have not been shown to increase quit rates; nor has acupuncture or hypnosis.

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