Caught in the middle on marijuana

While alcohol stands as the most prevalent substance addressed in addiction treatment programs and methamphetamine might have the most vexing effects to combat, marijuana undoubtedly remains the substance most likely to elicit strong emotions in the professional community.

Although it carries a slightly lower risk profile for problem use than alcohol, and a substantially lower risk profile than cocaine or opiates, marijuana brings with it a number of widely held misconceptions, even among regular users who find themselves in treatment for substance use problems. These misconceptions lead to frustration among clinical professionals trying to assist individuals on the road to recovery. Many relate to a historic notion that has been difficult for the public and even the treatment community to shed: that marijuana somehow isn't a dangerous drug of abuse.

“It used to be ‘weird’ to seek treatment for marijuana use,” says Alan J. Budney, PhD, professor of psychiatry at the University of Arkansas for Medical Sciences and a nationally prominent researcher on marijuana's effects on the brain. “People could get laughed at in group for talking about problems with marijuana-they could be made to feel like less of a drug addict.”

Today, the prevalence of treatment clients reporting a primary problem with marijuana has increased substantially. Some of this increase is driven by the higher potency of today's marijuana relative to that used by previous generations, while some results from changes in drug court programs that mandate treatment instead of jail. As marijuana has become a more open topic in individual and group therapy, many professionals may feel torn about the other high-profile discussion subject surrounding marijuana: whether the drug should be legalized and regulated in a manner similar to alcohol.

Concerned that moving beyond the more common decriminalization of personal possession into outright legalization would reinforce the misconception that marijuana can never be dependence-producing, many addiction treatment providers have chosen to refrain from the marijuana policy debate. So in states such as California, where a bill to legalize and tax marijuana has been introduced and where a separate voter initiative on the subject could reach the 2010 election ballot, treatment providers generally find themselves on the sidelines as legalization advocates and law enforcement authorities argue opposite sides of the issue.

“The treatment community as an industry isn't of a single opinion on this,” says Margaret Dooley-Sammuli, Southern California deputy state director for the Drug Policy Alliance, a leading national voice for policy reforms related to marijuana and other illegal drugs. “Many are nervous about it, worried that changes in the laws will be interpreted as stating that marijuana use is ‘OK.’”

What do we know?

Although it has been only about 20 years since discovery of the endogenous cannabinoid system that demonstrated marijuana's activity on the brain, a flood of additional findings means that the field now knows a great deal about marijuana's specific effects.

“In the last 10 years we've defined the withdrawal syndrome,” says Budney, who also serves as a research scientist at the University of Arkansas for Medical Sciences' Center for Addiction Research. “I was as surprised as anybody to see withdrawal so clearly. The data are very clear that some people develop dependence syndrome.”

Problematic use develops in about 9% of all marijuana users, compared to problematic alcohol use rates of 10 to 15% and higher rates for cocaine and opiates, Budney says.

Among the factors that inform the treatment process for problematic marijuana use is the drug's relatively long half-life, which means that the period of immediate and post-acute withdrawal for marijuana is longer than that for alcohol, says Stephen F. Grinstead, a leading treatment consultant and a developer of the patented Addiction-Free Pain Management System. Grinstead adds that research does not appear to demonstrate permanent brain damage resulting from use, since marijuana's harmful effects generally dissipate within 18 to 36 months.

However, Grinstead says, marijuana's common delivery system, smoking, presents significant issues for cardiac and pulmonary health. For this reason, he argues that advocates of the medical use of marijuana should explore alternative modes of delivery. “Europe is way ahead of us on new delivery systems,” he says.

The bulk of Budney's current research on marijuana is focused on characterizing the withdrawal syndrome and exploring potentially useful behavioral treatments. Based on knowledge that the opioid system is involved to some degree when marijuana is smoked, some have suggested that a medication such as naltrexone, which was first indicated for opiate addiction and is now approved for alcohol dependence, might have a role in treating marijuana dependence. But Budney believes it is more likely that effective marijuana treatment will require drugs different from those currently available in pharmacotherapy.

“We're pretty close to having things that might help a little,” says Budney, emphasizing that none should be looked at as potential “cures” and that nothing currently is a candidate for approval to market. Possible marijuana substitutes similar to those for nicotine and opiate dependence constitute a promising area for research, he adds.

In terms of behavioral treatments, Budney says several studies have shown that combining nominal incentives such as gift cards with cognitive-behavioral therapy improves individual treatment outcomes. At an adolescent clinic that Budney operates through a research grant, youths receive gift cards for program compliance while their parents learn how to use incentive-based “contingency management” strategies at home.

Budney says that while marijuana-specific treatment centers have not emerged in the United States, the concept has caught on in Australia.

Push to legalize

Marijuana decriminalization measures have been considered and adopted at the state level for many years. California lawmakers passed such a measure in the 1970s, although Dooley-Sammuli says it often appears that law enforcers forgot about it: She says marijuana possession arrests, particularly among people under 20, have recently soared while other drug arrests declined.

Medical marijuana initiatives born of compassion toward the gravely ill have also become commonplace across the country; Dooley-Sammuli says “the sky has not fallen” since California adopted its medical marijuana initiative in the mid-'90s. But a bill that was introduced in the California legislature by State Rep. Tom Ammiano last February would represent the most dramatic policy shift to date regarding marijuana.

The legislation (Assembly Bill 390), for which committee hearings are expected in January 2010, would tax and regulate marijuana in the same manner as alcohol. Revenues from a per-ounce fee, probably collected at the wholesale level, would be earmarked for drug treatment and education programs, supplemented by a sales tax on marijuana at the retail level. A number of issues in the bill are unclear, including which outlets would be allowed to sell the drug, so revisions to the original bill seem likely.

While Dooley-Sammuli sees the legislation as an important step toward the goal of ending marijuana prohibition, she adds that several questions need to be answered about how the drug would be regulated. She states that regulations must ensure a safe and reliable marketplace, eliminate violence associated with illegal drug trading, and decrease the risk faced by consumers who buy a product that at present has no quality control.

Beyond these hurdles, Ammiano's bill certainly will face strong opposition from those who believe that wider availability of the drug will encourage more individuals to begin using it.

“If marijuana is sold by retail outlets, there will by definition be advertising and sale prices, and it will be more available to users,” Budney says in reference to the arguments that likely will be used. “This will result in more use, and more problems.”

Such concerns could overshadow the significant financial windfall predicted from legal marijuana sales. A California State Board of Equalization report from July indicated that a wholesale fee of $50 per ounce of marijuana, combined with a 9% retail sales tax, would generate an estimated $1.4 billion a year for the cash-strapped state.

Budney is quick to point out that no one really knows how legalization would affect consumption. And, the drug's current illegal status has not profoundly affected its availability to those who seek it. With so much recent enforcement action focused on underage drinking and tobacco use, several of those interviewed for this article point out that it is much easier for the typical high school student to buy marijuana than it is to buy alcohol or cigarettes.

Grinstead says the two sides in the marijuana policy debate tend to take extreme points of view, with one practically denying the risk of harm and the other demonizing any use. Like many addiction treatment professionals, Grinstead sees problematic use, not the substance itself, as the issue of concern. For example, he explains that European authorities who more quickly embraced marijuana's medicinal properties have developed alternative delivery systems that eliminate the noxious effects of smoked marijuana.

While leaders on both sides of the marijuana debate look toward activity at the state level, there seems to be little momentum for substantive action on marijuana policy in Congress. Dooley-Sammuli says that, among drug-related topics, issues such as syringe exchange and the sentencing disparity for crack and powder cocaine offenses appear to have more traction than marijuana policy in Washington right now.

Moreover, statements from the new director of the White House Office of National Drug Control Policy (ONDCP) that have questioned any medicinal value of marijuana appear to signal little appetite for dramatic policy change from within the Obama administration.

Treatment providers' view

Some treatment providers have stayed out of the debate about marijuana's legal status because, to them, it is immaterial whether a client's problems relate to a legal drug or an illegal substance. Most of those interviewed for this article agree that regardless of a primary substance's legal status, clients need objective information about what they use-delivered in a direct but not fear-producing way.

“My experience is that when accurate, realistic facts are presented to clients, especially those they can easily verify, they begin to rethink their position on marijuana,” says Frances Clark-Patterson, PhD, a professional trainer who chairs the Clinical Affairs Committee at NAADAC, The Association for Addiction Professionals. “Of course, for those who are determined to use, it is not going to make any difference what you say-they will find a rebuttal for it. They are not going to hear it until they are ready to.”

Clark-Patterson adds that she likes to incorporate information about brain research related to marijuana, especially when talking to young people. She says that “with today's young people they are more scientifically oriented, so they like that type of information.”

Eileen Ricci, a Phoenix-based counselor with a private treatment agency, believes the characterization of marijuana as a gateway to other drug use tends to be overplayed, and that nicotine is a more likely precursor to the use of other addictive substances. Still, she believes marijuana's effects on the brain argue against its legalization.

Mary R. Woods, CEO of WestBridge Community Services in New Hampshire and a member of the Addiction Professional editorial advisory board, isn't concerned a great deal with how marijuana is addressed in the policy arena.

“The legal issue to me is moot,” Woods says. “Alcohol is legal, and look at the ramifications of alcohol misuse and addiction. I think we do a very poor job as a culture in prevention and education about any substances.”

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For perspectives on how clinicians can address patients' common misconceptions about marijuana, visit https://www.addictionpro.com/norton0709.