Brent A. Moore

The Time Course and Significance of Cannabis Withdrawal

Withdrawal symptoms following cessation of heavy cannabis (marijuana) use have been reported, yet their time course and clinical importance have not been established. A 50-day outpatient study assessed 18 marijuana users during a 5-day smoking-as-usual phase followed by a 45-day abstinence phase. Parallel assessment of 12 ex-users was obtained. A withdrawal pattern was observed for aggression, anger, anxiety, decreased appetite, decreased body weight, irritability, restlessness, shakiness, sleep problems, and stomach pain. Onset typically occurred between Days 1-3, peak effects between Days 2-6, and most effects lasted 4-14 days. The magnitude and time course of these effects appeared comparable to tobacco and other withdrawal syndromes. These effects likely contribute to the development of dependence and difficulty stopping use. Criteria for cannabis withdrawal are proposed.

Clinical Trial of Abstinence-Based Vouchers and Cognitive-Behavioral Therapy for Cannabis Dependence

Ninety cannabis-dependent adults seeking treatment were randomly assigned to receive cognitive-behavioral therapy, abstinence-based voucher incentives, or their combination. Treatment duration was 14 weeks, and outcomes were assessed for 12 months posttreatment. Findings suggest that (a) abstinence-based vouchers were effective for engendering extended periods of continuous marijuana abstinence during treatment, (b) cognitive-behavioral therapy did not add to this during-treatment effect, and (c) cognitive-behavioral therapy enhanced the posttreatment maintenance of the initial positive effect of vouchers on abstinence. This study extends the literature on cannabis dependence, indicating that a program of abstinence-based vouchers is a potent treatment option. Discussion focuses on the strengths of each intervention, the clinical significance of the findings, and the need to continue efforts toward development of effective interventions.

Respiratory effects of marijuana and tobacco use in a U.S. sample.

OBJECTIVE: Although a number of studies have examined the respiratory impact of marijuana smoking, such studies have generally used convenience samples of marijuana and tobacco users. The current study examined respiratory effects of marijuana and tobacco use in a nationally representative sample while controlling for age, gender, and current asthma.DESIGN: Analysis of the nationally representative third National Health and Nutrition Examination Survey (NHANES III).SETTING: U.S. households.PARTICIPANTS: A total of 6,728 adults age 20 to 59 who completed the drug, tobacco, and health sections of the NHANES III questionnaire in 1988 and 1994. Current marijuana use was defined as self-reported 100+ lifetime use and at least 1 day of use in the past month.MEASUREMENTS AND MAIN RESULTS: Self-reported respiratory symptoms included chronic bronchitis, frequent phlegm, shortness of breath, frequent wheezing, chest sounds without a cold, and pneumonia. A medical exam also provided an overall chest finding and a measure of reduced pulmonary functioning. Marijuana use was associated with respiratory symptoms of chronic bronchitis (P=.02), coughing on most days (P=.001), phlegm production (P=.0005), wheezing (P<.0001), and chest sounds without a cold (P=.02).CONCLUSION: The impact of marijuana smoking on respiratory health has some significant similarities to that of tobacco smoking. Efforts to prevent and reduce marijuana use, such as advising patients to quit and providing referrals for support and assistance, may have substantial public health benefits associated with decreased respiratory health problems.

Long-Term Treatment with Buprenorphine/Naloxone in Primary Care: Results at 2-5 Years

To examine long-term outcomes with primary care office-based buprenorphine/naloxone treatment, we followed 53 opioid-dependent patients who had already demonstrated six months of documented clinical stability for 2-5 years. Primary outcomes were retention, illicit drug use, dose, satisfaction, serum transaminases, and adverse events. Thirty-eight percent of enrolled subjects were retained for two years. Ninety-one percent of urine samples had no evidence of opioid use, and patient satisfaction was high. Serum transaminases remained stable from baseline. No serious adverse events related to treatment occurred. We conclude that select opioid-dependent patients exhibit moderate levels of retention in primary care office-based treatment.

Delay Discounting in Current and Former Marijuana-Dependent Individuals

Studies have found that a variety of drug-dependent groups discount delayed rewards more than matched controls. This study compared delay discounting for a hypothetical

Prevalence of chronic kidney disease in an urban HIV infected population.

1,000 reward among dependent marijuana users, former dependent marijuana users, and matched controls. Discounting of marijuana was also assessed in the currently marijuana-dependent group. No significant differences in discounting were detected among the groups; however, currently dependent users showed a trend to discount money more than the other 2 groups. Within the dependent marijuana group, marijuana was discounted more than money, and discounting for money and marijuana was significantly and positively correlated. Regression analyses indicated that delay discounting was more closely associated with tobacco use than marijuana use. A variety of questionnaires were also administered, including impulsivity questionnaires. Dependent marijuana users scored as significantly more impulsive on the Impulsiveness subscale of the Eysenck Impulsiveness-Venturesomeness-Empathy questionnaire than controls. However, the 3 groups did not significantly differ on several other personality questionnaires, including the Barratt Impulsivity Scale-11. The Stanford Time Perception Inventory Present-Fatalistic subscale was positively correlated with money and marijuana discounting, indicating that a greater sense of powerlessness over the future is related to greater delay discounting. Results suggest that current marijuana dependence may be associated with a trend toward increased delay discounting, but this effect size appears to be smaller for marijuana than for previously examined drugs.

Relapse in outpatient treatment for marijuana dependence.

Background:The prevalence of chronic kidney disease in an HIV-infected population during the highly active antiretroviral era has not been fully evaluated. Methods:A retrospective chart review of HIV-infected patients seen in 2004 was conducted to determine the prevalence of chronic kidney disease (CKD), using the 2004 National Kidney Foundations CKD staging criteria. Glomerular filtration rate (GFR) was calculated, using the Modification of Diet in Renal Disease formula. Univariate analyses were performed comparing individuals with normal kidney function and those with CKD. Multivariate analysis was conducted including all variables with a value of P < 0.1. Results:We found evidence of CKD in 24% of the patients. Forty patients (10%) had stage 1 CKD, 19 patients (4%) stage 2, 29 patients (7%) stage 3, 4 patients (1%) stage 4, and 8 patients (2%) stage 5. Patients with CKD are more likely to be African American (AA), older, have AIDS, lower CD4 counts and higher HIV viral loads. Patients with CKD were also more likely to have hypertension (HTN), diabetes mellitus (DM), or both. Indinavir or tenofovir exposure was associated with CKD. In multivariate analysis HTN, AA race, or HTN and DM were the only significant predictors of CKD. Physicians did not identify CKD in 74% of patients. Renal biopsies were done in 10 patients; 5 had HIV-associated nephropathy. Conclusions:Substantial minorities of HIV-infected patients have CKD. AA race or the presence of HTN or HTN and DM is associated with CKD. Clinicians often do not note the presence of CKD in this population.

Terminal Decontamination of Patient Rooms Using an Automated Mobile UV Light Unit

The current study provides an initial examination of lapse and relapse to marijuana use among 82 individuals who achieved at least 2 weeks of abstinence during outpatient treatment for marijuana dependence. Seventy-one percent used marijuana at least once (i.e., lapsed) within 6 months of initial abstinence, averaging 73 days (SD = 50) till lapsing. Similarly, 71% of those who lapsed, relapsed to heavier use defined as at least 4 days of marijuana use in any 7-day period. Early lapses were more strongly associated with consequent relapse. Previous studies have noted that marijuana-dependent outpatients experience difficulty initiating abstinence from marijuana much as do those dependent on other substances. The present data suggest that these similarities extend to difficulty maintaining abstinence.

Comparison of Fluorescent Marker Systems with 2 Quantitative Methods of Assessing Terminal Cleaning Practices

OBJECTIVE To determine the ability of a mobile UV light unit to reduce bacterial contamination of environmental surfaces in patient rooms. METHODS An automated mobile UV light unit that emits UV-C light was placed in 25 patient rooms after patient discharge and operated using a 1- or 2-stage procedure. Aerobic colony counts were calculated for each of 5 standardized high-touch surfaces in the rooms before and after UV light decontamination (UVLD). Clostridium difficile spore log reductions achieved were determined using a modification of the ASTM (American Society for Testing and Materials) International E2197 quantitative disk carrier test method. In-room ozone concentrations during UVLD were measured. RESULTS For the 1-stage procedure, mean aerobic colony counts for the 5 high-touch surfaces ranged from 10.6 to 98.2 colony-forming units (CFUs) per Dey/Engley (D/E) plate before UVLD and from 0.3 to 24.0 CFUs per D/E plate after UVLD, with significant reductions for all 5 surfaces (all [Formula: see text]). Surfaces in direct line of sight were significantly more likely to yield negative culture results after UVLD than before UVLD (all [Formula: see text]). Mean C. difficile spore log reductions ranged from 1.8 to 2.9. UVLD cycle times ranged from 34.2 to 100.1 minutes. For the 2-stage procedure, mean aerobic colony counts ranged from 10.0 to 89.2 CFUs per D/E plate before UVLD and were 0 CFUs per D/E plate after UVLD, with significant reductions for all 5 high-touch surfaces. UVLD cycle times ranged from 72.1 to 146.3 minutes. In-room ozone concentrations during UVLD ranged from undetectable to 0.012 ppm. CONCLUSIONS The mobile UV-C light unit significantly reduced aerobic colony counts and C. difficile spores on contaminated surfaces in patient rooms.

Development and Consequences of Cannabis Dependence

OBJECTIVE To compare fluorescent markers with aerobic colony counts (ACCs) and an adenosine triphosphate (ATP) bioluminescence assay system for assessing terminal cleaning practices. DESIGN A prospective observational survey. SETTING A 500-bed university-affiliated community teaching hospital. METHODS In a convenience sample of 100 hospital rooms, 5 high-touch surfaces were marked with fluorescent markers before terminal cleaning and checked after cleaning to see whether the marker had been entirely or partially removed. ACC and ATP readings were performed on the same surfaces before and after terminal cleaning. RESULTS Overall, 378 (76%) of 500 surfaces were classified as having been cleaned according to fluorescent markers, compared with 384 (77%) according to ACC criteria and 225 (45%) according to ATP criteria. Of 382 surfaces classified as not clean according to ATP criteria before terminal cleaning, those with the marker removed were significantly more likely than those with the marker partially removed to be classified as clean according to ATP criteria (P = .003). CONCLUSIONS Fluorescent markers are useful in determining how frequently high-touch surfaces are wiped during terminal cleaning. However, contaminated surfaces classified as clean according to fluorescent marker criteria after terminal cleaning were significantly less likely to be classified as clean according to ACC and ATP assays.