The effectiveness of five new treatment protocols was demonstrated by a dramatic reduction of marijuana use among adolescents participating in government trials. The new protocols, announced last month by the Center for Substance Abuse Treatment, decreased the percentage of adolescents reporting any prior-month use of marijuana from 81 percent to 39 percent.

Also released was the "Treatment Episodes Data Set (TEDS): 1993-1998", which revealed that admissions of adolescents (ages 12 to 17) to treatment programs for marijuana abuse increased by a startling 155 percent from 1993 to 1998.

The Center for Substance Abuse Treatment (CSAT) is part of the federal Substance Abuse and Mental Health Services Administration (SAMHSA).

"The dramatic increase in adolescent admissions for treatment of marijuana use shows that marijuana is a dangerous and addictive drug," SAMHSA Administrator Nelba Chavez, Ph.D, told Psychiatric News. "Fortunately, as we saw adolescent marijuana use rise in the early 1990s, we had the foresight to begin developing, four years ago, appropriate and effective treatment models for marijuana dependence."

The Cannabis Youth Treatment Experiment (CYT) was sponsored by CSAT to bring together academic researchers and clinical treatment professionals and develop more effective treatment protocols for youngsters who abuse or are addicted to marijuana.

Michael L. Dennis, Ph.D., senior research psychologist in the research division of Chestnut Health Systems in Bloomington, Ill., was the coordinator of the study. Dennis led the efforts of Chestnut Health Systems, the Alcohol Research Center at the University of Connecticut, Operation PAR in St. Petersburg, Fla., and the Child Guidance Center of the Children’s Hospital of Philadelphia.

"Outpatient treatment is the most common milieu for marijuana treatment," Dennis told Psychiatric News. "But existing programs have yielded mixed results with methodological problems, including short duration of stay, lack of written treatment manuals, and relatively high attrition."

According to Dennis, posttreatment outcomes have ranged from, at best, a 15 percent reduction in marijuana use to, at worst, a 10 percent increase in marijuana use. In addition, relapse rates are averaging 85 percent to 100 percent, depending on the study.

The Cannabis Youth Treatment Experiment was designed to address many of the known methodological problems as well. Five manual-guided treatments were developed by the CYT team, then field tested with more than 600 adolescents who were between the ages of 12 and 18 and reported having used marijuana in the preceding 90 days, reported problems related to marijuana abuse or dependence (for example, social or family difficulties, school/work difficulties, and legal difficulties), and met criteria for outpatient, rather than inpatient, therapy. The goal, according to Dennis, was to determine whether the new protocols could represent real programmatic and policy treatment options.

Overall, treatment outcomes improved dramatically between initiation of the protocol treatment and three and six months later. There were significant increases in the percentage of adolescents reporting no past-month use (from 4 percent to between 13 percent and 34 percent, depending on the protocol) and the percentage reporting no past-month abuse or dependence symptoms (from 19 percent to between 39 percent and 61 percent). The overall rate of any marijuana use dropped by a dramatic 31 percent between three months prior to the start of the study and three months after the protocol began.

CYT clinicians also saw a marked decrease in their patients’ involvement with the criminal justice system, as well as in attention-deficit problems, family and school problems, and illegal activity.

Investigators at all four CYT sites noted differences by type of treatment and problem severity and their interaction, as well as differences in the pattern of the outcomes. In the "Incremental Study Arm," in which clinicians used treatment protocols 1, 2, and 3, in sequence, the brief intervention (protocol 1) yielded significantly larger reductions in substance-related problems with patients exhibiting the lowest level of severity of problems. The more comprehensive treatment (protocol 3) worked better with higher severity patients.

Researchers saw continued improvement in outcomes, and by six months, results using the comprehensive treatment protocol in low-severity participants equaled those with the basic treatment. At six months the comprehensive treatment—as expected, said Dennis—remained the most effective protocol for patients with high severity.

In the "Alternative Arm," comparing protocol 1 with protocols 4 and 5, the brief (1) and individual behavioral therapy protocols (4) were linked with a significant reduction in use as compared with the integrated family therapy approach (5). However, by the six-month follow-up point, all patients had improved further, so that the differences between the three protocols were no longer statistically significant.

"Each of the protocols," said Dennis, "was proven to be effective for the certain populations in which it was studied. Taken as a whole, the real conclusion here is that what made the treatment productive was solid, old-fashioned consistency."

The CYT also looked at the estimated costs of each protocol in an attempt to pair cost-effectiveness of the protocol with its success rate and come up with an overall "best protocol." The average weekly cost of the five outpatient treatments ranged from $105 to $244 per teenager. The cost varied due to several direct factors, for example, number of sessions and weeks of treatment, hours of formal treatment sessions, and treatment retention; and indirect factors, such as cost of living, staff educational level, and caseload variations.

Each of the CYT treatment protocols appeared to be cost-effective when compared with both the average cost ($365/week) of treatment of adolescent marijuana abuse as reported by clinic directors in the National Treatment Improvement Evaluation Study (NTIES).

"So," Dennis told Psychiatric News, "each of these programs would appear to be sustainable under the current levels of funding available. They are all clinically effective, and each protocol is cost-effective."

According to the CYT report, all five of the protocols are starting to differentiate themselves in their effectiveness. "However," said Dennis, "the key is that all five of these treatments are better than current practice." Which treatments are used in practice is likely to vary depending on organizational, staffing, and resource considerations. As such, the CYT team decided not to recommend a specific "best protocol," he said.

"The implications of these findings," said Barry R. McCaffrey, director of the White House Office of National Drug Control Policy, "lies in the statistics that define our young people today." According to National Institute on Drug Abuse figures, marijuana is the illicit "drug of choice," the most common first illicit drug of abuse, among 12- to 17-year-olds in the U.S. (It is second when tobacco is considered.)

"If children reach adulthood," McCaffrey continued, "without using illegal drugs, alcohol, or tobacco, they are very unlikely to develop a chemical dependency later in life. . . ." Providing treatment for America’s chronic drug users is both compassionate public policy and a sound investment."