Eating Disorders: Common & Sometimes Deadly

Eating Disorders have been on the rise, especially among men, minority groups, and the LGBTQ community (Swanson et al., 2011). However, young adult women are at the highest high risk for eating disorders...a staggering 25% to 40% will experience eating problems (Schwitzer et al., 2001).

0.9% of the population will experience Anorexia Nervosa, 1.5% will experience Bulimia Nervosa, and 3.5% of women and 2.5% of men will experience Binge Eating Disorder. Treatment is critical, as eating disorders can be unhealthy or worse: they can be deadly. They are chronic, meaning they don't often disappear on their own, and have high rates of remission (Crow et al., 2009).

The American Psychiatric Association's Practice Guidelines (2006) for therapists recommend Cognitive-Behavioral Therapy (CBT) for all eating disorders. However, Fairburn et al., (1993) suggest Dialectical Behavioral Therapy (DBT) for Binge Eating, and family-based therapy for Anorexia Nervosa.

If you suspect that a loved-one has an eating disorder, consult a psychotherapist, and a local eating disorder support group. Nobody should struggle with these common and dangerous disorders alone.

References:

Swanson, S.A., Crow, S.J., LeGrange, D., Swendsen, J., Merikangas, K.R. (2011). Prevalance and correlates of eating disorders in adolescents. Archives of General Psychiatry, 68, 714-123

Crow, S.J., Peterson, C.B., Swanson, S.A., Raymond, N.C., Specker, S., Eckert, E.D., Mitchell, J.E. (2009). Increased mortality in bulimia nervosa and other eating disorders. American Journal of Psychiatry, 166, 1342-1346

American Psychiatric Association (APA). (2006). Practice guidelines: Treatment of patients with eating disorders (3rd ed.). Retreived from: www.psychaitryonline.com

Fairburn, C.G., Marcus, M.D., Wilson, G.T. (1993). Cognitive-Behavioral Therapy for binge eating disorder and bulimia nervosa: A comprehensive treatment manual. In: Binge Eating: Nature, assessment, and treatment (pp. 361-404). New York, NY: Guilford Press.

When Luck Has Run Out: Signs of Gambling Addiction

Pathological gambling is defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-1V, 1994) as: persistent and recurrent maladaptive gambling behavior" (p. 618) which disrupts personal, family, or vocational pursuits. This condition effects 1.8% of adults.

Pathological gambling is classed as an impulse control disorder. Like substance abuse, 30-40% of gamblers report mild withdrawal characterized by: irritability, agitation, concentration difficulties and even somatic complaints (Wray & Dickerson, 1981). "Substance use disorders and pathological gambling share similarities in terms of diagnostic criteria, epidemiology, and clinical course" (Petry, 2002). And like substance abusers, pathological gamblers jeopardize work, social, and family responsibilities to gamble. Up to 60% of pathological gamblers commit illegal acts to support their gambling, much as the addicted do (Rosenthal & Lorenz, 1992). Additionally, "Comorbidity of gambling and substance abuse is high" (Spunt et al., 1998). This means many gamblers also have a substance abuse disorder.

In treatment of pathological gambling, Gambler's Anonymous (GA) was modeled after Alcoholics Anonymous and is the most commonly used intervention among pathological gamblers. Combining group GA with individual psychotherapy seems to be the most efficacious treatment of all (Petry, 2002). The majority of gamblers were able to maintain abstinence when they participated in both of these interventions. In other studies, 70% of gamblers responded favorably to Cognitive-Behavioral Therapy (individual talk therapy).

In one study (Petry, 2002), Naltrexone was reported to block urges or endorphins released during gambling, thus reducing the "gambler's high." A combination of group therapy (GA), individual psychotherapy (CBT), and psychopharmacology  such as Naltrexone, or other impulse-control medications, have been shown effective for treating gambling addiction.

If you have a loved-one struggling with gambling, contact a psychotherapist or psychiatrist, and your local Gambler's Anonymous for support. Odds are good your loved-one will get the help they need!

References:

American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (DSM-1V).  American Psychiatric Association, Arlington, VA

Wray, L., Dickerson, M.G. (1981). Cessation of high frequency gambling and "withdrawl" symptoms. British Journal of Addiction, 76, 401-405

Petry, N.M. (2002). How Treatments for Pathological Gambling Can Be Informed by Treatments for Substance buse Disorders. Experimental and Clinical Psychopharmacology, Vol. 10, No. 3, p. 184-192

Rosenthal, R.J., Lorenz, V.C. (1992). The pathological gambler as criminal offender. Clinical Forensic Psychiatry, 15, 647-660

Spunt, Dupont, LeSieur, Liberty, & Hunt. (1998). Pathological gambling and substance misuse: A review of the literature. Substance Use and Misuse, 33, 2535-256.

Tangled in The Web: When Does Internet Porn Become an Addiction?

Internet porn is the largest internet commerce (Jaychandran, 2006). Signs of internet porn addiction are typically:

1. Large amounts of time spent in chat rooms or engaging in cyber-sex
2. Preoccupation with using the internet to find sexual activities
3. Anonymity online
4. Expectation of future online sexual encounters
5. Participant moves from cybersex to phone sex, and sometimes to real-life meetings
6. Hides online activities from others
7. Masturbation while online
8. Feeling guilt or shame
9. Less interested in real sex partners, prefer cybersex as primary sexual gratification.

The majority of problems caused by sex addiction happen because it interferes with marital or partner relationships (Greenfield, & Orzack, 2002). Partners frequently feel hurt, betrayed, rejected, abandoned, devastated, jealous, angry, and experience a loss of self-esteem. The majority of partners feel that online affairs are just as painful as live affairs (Young, 2008).

Cooper (1998) suggests three factors that contribute to porn addiction: accessibility, affordability, and anonymity. "Individuals who suffer from low self-esteem, who feel lonely, restless, or withdrawn can use cybersex to feel better about themselves and their circumstances (Young, 2008).
Young (2008) states that internet sex addiction follows progressive stages:
1. Discovery
2. Experimentation
3. Escalation of habit
4. Compulsive use
5. Hopelessness.

If you think a loved-one may be dealing with a porn or sexual addiction, contact a psychotherapist for support. Also, I recommend this book: "Tangled in the Web" (2001) by K.S. Young.


References:

Jaytrandran, C.R. (2006). Porn rules net revenue charts. The Economic Times, Sept. 2003

Greenfield, D., Orzach, M. (2002). The electric bedroom: Clinical assessment of online sexual problems and Internet-enabled sexual behavior. In Sex and Internet: A guidebook for clincians (p. 129-145). New York: Brunner-Routledge

Young, K.S. (2008). Internet Sex Addiction: Risk Factors, Stages of Development, and Treatment. American behavioral Scientist, 52-21. Sage Publications

Cooper, A. (1998). Sexuality and the Internet: Surfing into the new millenium. CyberPsychology & Behavior, 1, 187-193

A Soldier's Story: Depression, Addiction and Trauma-Treatment for Comorbidities

                                                                   Abstract

This article will present a clinical plan created to treat Major Depressive Disorder, Addiction and Trauma. It will address etiology of the disorders which the client is presenting and explain how depression and addiction are correlated to the life history of the client. I will select a number of formal instruments for use in assessing depression, substance abuse, and suicidal ideation. Further, I will customize treatment strategies and my therapeutic method for the client. Lastly, plans for developing and maintaining a therapeutic relationship with the client will be discussed.

    This is not a simple case of Major Depression, Addictive Disorder, Post-Traumatic Stress Disorder, or Suicidal Ideation. Instead, the following is a description of a soldier-returned-home who is experiencing all of the above, due to the war zone he served in. In order to provide a comprehensive treatment plan for depression, this client’s history, thought patterns, and drinking patterns will need to be assessed. For soldiers returning home,“Depression screening has increased. Treatment often includes administration of SSRI or other classes of anti-depressant” (Konstantinidis, Martiny, Beck, & Kaspar, 2011). When enough stress is placed on an individual who has a generic propensity to develop mental illness, referred to as the Diathesis-Stress-Coping Model (Lazarus & Folkman, 1984), mental illness can be kindled by the stress into a flame of symptoms. When enough unpleasant symptoms are experienced, “self-medicating” with alcohol is a common defense tactic of military personnel, whether active or retired from duty. “Previous work suggests that veterans of the U.S. armed forces have a relatively high prevalence of alcohol misuse and other psychiatric disorders” (Heslin, Stein, Dobalian, Simon, Lanto, Yano, & Rubenstein, 2013). In this case, my client is a male, 45, who recently returned from a war zone, and is reporting depression and suicidal ideation, has been drinking heavily to cope, and feels isolated. This is not a safe combination, especially since the client has been trained in combat and likely has a firearm handy. Therefore, I want to intervene immediately with a customized treatment plan.

    The first order of business is to gain rapport with the client, then to conduct a clinical interview, and follow this with formal assessments to ascertain his level of symptomology. I would use the revised version of the Beck Depression Inventory (BDI-11, 1996), as it is aligned closest with the DSM-1V-TR (APA, 2000), and because it is the most recent form of the instrument. I would administer the screening inventory, and then discuss the results of the screening with the client.

    The SAD Person's Scale (Patterson, Dohn, Bird, & Patterson, 1983) suggests the following risk factors for suicide:
1. Depression and hopelessness
2. Men are more likely to commit suicide than women
3. Alcohol and drug abuse increase risk
4. System support loss
5. No significant other.

    A formal suicide assessment tool could aid in determining if this client should be advised to seek immediate hospitalization, or to return for further counseling. I would choose either of the following suicide assessment tools:
1. The Beck Scale for Suicidal Ideation (BSS), (1991-1993). BSS is a 21-item self-report instrument for adults. Due to its time efficacy, this scale is recommended for novice clinicians for detecting suicidal ideation in the psychiatric, psychological, and allied heath fields (Hanes, & Steward, Mental Measurements and Tests, Yearbook 13).
2. Adult Suicidal Ideation Questionnaire, (Reynolds, 1987-1991). This assessment is a self-report for adults comprised of 25 questions, and takes approximately 10 minutes to administer. It measures suicidal ideation to rate the frequency of suicidal thoughts in the past month. This assessment is useful with clients who are reticent to divulge symptoms.

    Further, this client has admitted abuse of alcohol, so an alcohol screening assessment is indicated. I would administer the Substance Abuse Subtle Screening Inventory-3 (SASSI-3, 2013), and also seek to psychoeducate the client on the effects of alcohol abuse including tolerance, withdrawal, and treatment effectiveness and benefits. I would inquire about the client's family: what relationship does he have with them? "Addiction is a family disease because of the seriousness of its effects on family members and family functioning. Just as the person needs support, education, and counseling, so too does the family" (Center For Substance Abuse Treatment, 1995).

    If the client scored high on the Beck Scale, I may advise he be taken to the hospital for treatment for depression and suicidal thoughts. I would collaboratively create a safety plan for the client to follow. If the client scores high for suicide, I would rather err on the side of too much intervention than too little, as 98% of people who die of suicide were diagnosed with depression (International Association for the Prevention of Suicide, 1999), and because he knows how to use a weapon and likely has a gun at home. If he declines to go to the hospital, I would contract with him to refrain from suicide attempts until our next appointment. I would also give this client the necessary referrals to hospitals as well as a local crisis line, and discuss with him any concerns he might have about gaining support from family and friends, and what type veteran facilities he may use for future psychiatric care.

    In order to customize this depression treatment plan, since the client witnessed trauma while in combat, I would investigate combat-related Post-Traumatic Stress Disorder (PTSD) as a diagnosis. “Forms of cognitive-behavioral therapy (CBT) currently have the most evidence for efficacy” (Veterans Affairs/Dept. of Defense, 2010). Utilizing CBT as the therapeutic modality, I may also elect to apply systematic desensitization therapy, which, “Pairs the implementation of relaxation techniques with hierarchical exposure to the aversive stimulus” (Nolen-Hoeksema, 2011).

     Issues to consider when approaching termination of therapy include: Will the client’s VA Hospital pay for his psychopharmaceuticals and physician visits? Does the VA offer post-service treatment for PTSD? Will the client have adequate social/familial support, and group therapeutic support for his drinking? I would ask if the client feels he needs a monthly check-in with me until he finds the support he needs. Due to the serious nature of his diagnosis and lack of social and other therapeutic support, I am responsible to offer to him follow-up counseling if he feels he could benefit by it. This way he knows there is an open door: he can return to therapy in case his depression worsens, if the PTSD symptoms are not subsiding, and if he is not able to maintain sobriety.

    Last but certainly not least this client may require treatment of major depression and PTSD with psychopharmaceuticals. A referral to his medical doctor or VA Hospital to discuss medical intervention is crucial in order to stop the suicidal thoughts.

References:

Konstantinidis, A., Martiny, K., Beck, P., Kaspar, S. (2011). A comparison of the Major Depression Inventory (MDI) and the Beck depression Inventory (BDI) in severely depressed patients. International Journal of Psychiatry in Clinical Practice, Vol. 15 (1), p. 56-61. Informa Healthcare.   

Lazarus, R. S., Folkman, S. (1984). Stress, appraisal, and coping. New York, NY: Springhill.

Heslin, K. C., Stein, J.A., Dobalian, A., Simon, B., Lanto, A. B., Yano, E. M., Rubenstein, L.V., (2013). Alcohol problems as a risk factor for post disaster depressed mood among U.S. veterans. Psychology of Addictive Behaviors, Vol 27 (1), pp. 207-213. Publisher: US: American Psychological Association.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-1V-TR) (2000). American Psychiatric Association, Arlington, VA.

Patterson, W., Dohn, H., Bird, J., & Patterson, G. (1983). Evaluation of suicide patients: The SAD PERSONS scale. Psychosomatics, 24, 343–349.

Beck, A.T., Steer, R.A. (1991-1993). Beck Scale for Suicidal Ideation. Pearson, San Antonio, TX.

Hanes, K.R., Stewart, J.R. (1991-1993). Review. Beck Scale for Suicidal Ideation. Mental Measurements Yearbook and Tests in Print. Yearbook 3, Psychological Assessment Resources, Inc., Lutz, FL.

Reynolds, W.M. (1987-1991). Adult Suicidal Ideation Questionnaire. Mental Measurements Yearbook and Tests in Print, Yearbook 12, Psychological Assessment Resources, Inc., Lutz, FL.

SASSI Institute. (2013). Specialized Populations. Retrieved from: www.sassi.com/news/index.html.

Center for Substance Abuse Treatment. (1995). Detoxification from Alcohol and Other Drugs. Treatment Improvement Protocol (TIP) Series, No. 19. Rockville, MD.

International Association for the Prevention of Suicide. (1999). Retrieved from: http://www.iasp.info/

Veterans Affairs/Department of Defense (VA/DoD). (2010). Clinical practice guideline:

Management of post-traumatic stress. Retrieved from:

http://www.healthquality.va.gov/Post_Traumatic_Stress_Disorder_PTSD.asp

Nolen-Hoeksema, S. (2011). Abnormal Psychology. Fifth Edition. McGraw-Hill, New York, NY.

Marajuana: The Forbidden Medication by Nina Bingham

Abstract


This article will include a brief overview of the highlights of the clinically significant findings of
research literature on the subject of Cannabis Dependence and treatment. It will review the history of Cannabis use and contemporary use of Cannabis. It will identify an assessment instrument and therapeutic treatment methods. Brief legal and ethical questions regarding Cannabis use will be presented. Finally, I will discuss the importance of the topic of Cannabis research to the field of addiction treatment.

    Cannabis (marijuana) has been used for centuries in many societies medicinally. It was introduced by Dr. William D. Shaghnessy in 1839 to Europe. “Marijuana was admitted to the U.S.Pharmacopoeia in 1850. In 1936 the Federal Bureau of Narcotics advocated for prohibiting its use, which congress passed in 1937 against the advice of the American Medical Association” (Grinspoon, & Bakalar, 1993). In 2012, SAMHSA estimated that 41% of the U.S. population aged 12 and over have used the drug. Today, physicians recommend cannabis for chronic pain, chemotherapy and AIDS patients. “A broader medical literature documenting the therapeutic properties of endogenous cannabinoids has developed, suggesting cannabis has therapeutic potential for a variety of conditions. However, further research on the application of cannabis for medical purposes has been blocked by the Drug Enforcement Administration (Zeese, 1999). Due to the opposition between physicians and the federal government, passage of state laws permitting medical marijuana has been in force since 1996. “Ironically, this trend towards increasing therapeutic usage is bringing marijuana back to the position it held in the U.S. in 1937” (Giringer, 2012).    While marijuana is the most popular illicit drug in the U.S. and Europe among adults and youth (SAMHSA, 1999), it is underrepresented in drug literature compared with “harder” drugs (Hallstone, 2002). Thus, “To gain maximum therapeutic potential across a growing range of conditions for which medical marijuana is being recommended, more systematic research is needed” (Reinerman et al., 2011).

    In 1953 Howard Becker proposed a “social-process” theory stating that drug use is a learned behavior, and not a moral defect (Hallstone, 2002). Since that time,  researchers traced drug use to socio-economic stressors. These social-environmental theories suggest that individuals use substances to reduce or control negative affect (Shrier et al, 2012). However, Bovasso (2001) proposes a different motivator for using marijuana when he states, “Studies have not found evidence that cannabis use develops from self-medicating negative affect.” Instead, Bovasso (2001) asserts that positive affect enhancement dominates reasons to use marijuana, whereas negative affect reduction (coping) tends to be the primary reason for tobacco and alcohol use” (Lee et al., 2007; Thornton et al., 2011). Shrier et al. (2012) also have suggested that young people endorse “enhancement motives.”  It seems these studies suggest that marijuana isn’t being smoked to chase away depression or anxiety, but to socialize with others, and is a socially-enhancing drug (Osbourne, & Fogel, 2008). While cannabis may enhance social interactions, what is it doing to the brain, and what are the side-effects of a marijuana high? “Like other intoxicant drugs cannabis causes profound changes in a variety of higher brain functions” (Iverson, 2000). “Many studies have shown significant effects on short-term memory, particularly when tests were used that depend heavily on attention” (Abel, 1971; Mendelson et al., 1976). Specifically, “Performance on a variety of tests of cognitive function is impaired by the drug but by comparison to alcohol; the effects of cannabis are subtle” (Iverson, 2000). Do genetics play a role in drug use?

     “As is true for adolescents and young adults who use marijuana,most young people who use alcohol are not physiologically dependent on the substance and generally use in social settings (Shrier et al, 2012). Additionally, genetic vulnerability to drug dependence has been shown in twin studies for alcohol, tobacco and cannabis (Kendler, 1998). “Behavior genetics studies suggest another common causal explanation of the association between cannabis and other illicit drug use, namely a shared genetic vulnerability to develop dependence on a range of different drugs” (Hall, & Lynskey, 2005). So while early and frequent use of illicit drugs is vulnerability for later marijuana dependence, genetics also plays a role. While, “The majority of marijuana users are not physiologically dependent” (Anthony et al, 1994), marijuana is known as a “gateway” drug, because it has been said to lead to more serious drug use (Hall, Lynskey, 2005).

    During the 1970s-1980s almost all adolescents who had tried cocaine and heroin had first tried alcohol tobacco and marijuana. Moreover, 84% of regular cannabis users reported using another illicit drug (Kaplan, Martin, & Robbins, 1984). However, “One factor in these patterns needs to be stressed: cannabis use per se is not a strong predictor of the use of other drugs. It is the early initiation and regular use of illicit drugs…There is a reasonably strong association between regular and early cannabis use and other illicit drug use” (Hall, & Lynskey, 2005). Ferguson and Horwood (1997) found a strong relationship between the frequency of use by age 16 and development of problem with cannabis, alcohol or other substances by age 18. These studies lead to the conclusion that prevention campaigns targeted at teens and young adults would be advantageous. “If cannabis use causally contributes to the increased use of other illicit drugs then we should, in principle, be able to reduce the use of illicit drugs by delaying or preventing adolescent cannabis use” (DuPont, 1984). An initial step in the recovery process is to assess clients for cannabis dependence.

       The Marijuana Craving Questionnaire (MCQ) (Singleton et al., 2002) is an effective assessment for cannabis dependency. Researchers found that marijuana cravings increase as a function of marijuana urges (Lundahl, & Johanson, 2011), which were precipitated by cue reactivity (Drummond et al., 1995). Craving is a central symptom of drug abuse and precipitates relapse (O’Brien et. al., 1998; Lowman et al., 2000), so assessing the severity of the cravings is crucial to accurate diagnosis. Craving has also been identified as a symptom of both cannabis dependence (Coffee et al, 2002) and cannabis withdrawal (Budney et al., 2004). Cannabis withdrawal is also a clinically significant symptom, because it causes functional impairment in normal daily activities, as well as relapse to cannabis use (Allsop et al., 2012). The DSM-1V-TR (APA, 2000) requires that a mental health diagnosis, “Causes significant distress or impairment in social, occupational, or other important areas of functioning” (p. 358). “Many regard cannabis as a “soft” drug and question whether one can become truly dependent on cannabis. Nevertheless, the DSM-1V (1994) included a diagnostic category for cannabis dependence” (Weinstein et al., 2010). In 1994, Anthony et al. reported that 46% of people interviewed had used cannabis, and of these, 9% of users had become dependent. Yet Shrier et al. (2012) reported, “Although youth in this study used marijuana frequently, they had desire for the drug in only 54% of the waking moments sampled.” Yet in a different study of adolescents, young adults, and adults seeking treatment, “82%-93% reported experiencing craving for the drug” (Budney, Novy, & Hughes, 1999; Cornelius et al., 2008). It is important for clinicians to distinguish cannabis use from addiction. When treating cannabis dependency, which methods are considered best-practice?

    While there are effective treatments for marijuana dependency, only 10% of individuals who are dependent will seek treatment (Agosti, & Levin, 2004). Additionally, “The majority of marijuana-dependent individuals who enter treatment have difficulty achieving and maintaining abstinence from cannabis partly due to Cannabis Withdrawal Syndrome” (Weinstein et al., 2010). Symptoms of this syndrome include: anxiety, irritability, negative moods, decreased appetite and physical symptoms (Weinstein et al., 2010), but Kouri and Pope (2000) reported anger, nervousness, restlessness, shakiness, sleeping difficulties, stomach pain, strange dreams, sweating and weight loss. “The strongest predictor of functional impairment to daily activities from cannabis withdrawal was the severity of the cannabis withdrawal symptoms” (Allsop et al, 2012). Though marijuana dependency has been treated with 12-step programs (such as Marijuana Anonymous), the efficacy of these programs are not proven (Weinstein et al., 2010). However, when Cognitive-Behavioral Therapy (CBT) is applied to cannabis dependence, it has been proven effective (Inaba, & Cohen, 2007). Specifically, CBT which includes relapse prevention, coping skills therapy and motivational interviewing have been proven efficacious. Also, anti-depressant medication (SSRIs) can reduce the negative symptoms of anxiety, depression and physical discomfort during cannabis withdrawal and has been a successful intervention. CBT for cannabis dependence typically lasts 6 to 12 sessions (Copeland et al., 2001). What ethical and legal questions are important to consider in the discussion about cannabis use?

    “Those who are in favor of legalization tend to ignore the negative health effects of cannabis use. Those who are against legalization ignore the fact that legal substances such as alcohol and tobacco also have bad health effects” (Caulkins et al., 2012). Because nowhere in the world is marijuana legalized, it is difficult to understand about the consequences of legalization (Pudney, 2010). We know there are both positive and negative consequences of use: “A survey of young cannabis users (Athas, & Blanchard, 1997) reported the benefits of relaxation and stress relief, increased insight, and euphoria. 21% of the users also reported impaired memory, paranoia, and laziness.”  However, when marijuana is taken in excessive dosage, acute toxic psychosis can develop (also known as “Marijuana Psychosis”). There is a anger of overdose on cannabis just as an individual might get alcohol poisoning from drinking too much. This can lead to hospitalization, and patients display schizophrenic-like delusions (Iverson, 2003). Adler & Adler (1996) proved that young marijuana smokers are unable to recognize the psychoactive effects of the drug, which means they are vulnerable to overdose. Why is cannabis use an important subject in the field of addiction treatment?

   Since cannabis is the most popular illicit drug, it is important that clinicians are educated in cannabis use, dependency and overdose, so they can psychoeducate their patients, and help them to make informed decisions regarding use. There are both barriers and facilitators to receiving treatment that are crucial for healthcare providers to understand: “Because of the underrepresentation of individuals with cannabis-related problems, it is vital to further identify barriers to treatment seeking and facilities of entry into treatment” (Gates et al., 2012). “Because there are no pharmacological programs or CBT programs widely promoted (for cannabis use), many cannabis-dependent individuals assume there is no effective intervention available” (Gates et al, 2010). Treatment also may not be sought because most users find it unnecessary: “A 1-year follow-up study reported that while one in five had markedly decreased their use, the majority had done so without entering treatment” (Swift, Hall, & Tesson, 2001). Gates et al. (2012) found facilitators to treatment were: (1) Improving treatment information available, (2) separate substance abuse services specific for cannabis abuse, (3) availability of telephone counseling, (4) making treatment admitting procedures easier. Thus, “Results confirmed previous research highlighting that the typical cannabis user believes treatment for cannabis use to be unnecessary, would not be ready to stop using and would feel stigmatized when accessing treatment” (Gates et al., 2012). In summary, more research is needed to enable clinicians and the public to understand both the positive and negative effects of cannabis use.

References:

Grinspoon, L., Bakalar, J.B. (1993). Marajuana: The Forbidden Medication. New Haven, CT: Yale University Press.

SAMHSA, Office of Applied Studies. (2010). Results from the 2008 National Survey on drug Use and Health. Rockville, MD.

Zeese, K.B. (1999). History of medical marijuana policy in US. International Journal of drug Policy, 10: 319-28.

Giringer, D. (2012). Practical experience with legalized cannibus. Addiction, Vol. 107 (5), pp. 875-876.

SAMHSA. (1999). National Household Survey of drug Abuse: Population Estimates 1998. Substance Abuse and Mental Health Services Administration.

Hallstone, M. (2002). Updating Howard Becker’s theory of using marijuana for pleasure. Contemporary Drug Problems: An interdisciplinary Quarterly, Vol. 29 4), pp. 821-845.

Reinarman, C., Nunberg, H., Lanthier, F., Neddleston, T. (2011). Who are medical marijuana patients? Journal of Psychoactive drugs, vol. 43 (2), pp. 128-135.

Shrier, L.A., Walls, C.E., Kendall, A.D., Blood, E.A. (2012). A context of desire to use marijuana: momentary assessment of young people who frequently use marijuana. Psychology of Addictive Behavior, Vol. 26 (4), pp. 821-829.

Bossavo, G.B. (2001). Cannabis use as a risk factor for depressive symptoms. American Journal of Psychiatry, 158, 2033-2037.

Lee, C.M., Neighbors, C., Woods, B.A. (2007). Marajuana motives: Young adults reasons for using marijuana. Addictive behaviors, 32, 1384-1394.

Hall, W.D., Lynskey, M. (2005). Is cannibus a gateway drug? Testing hypothesis about the relationship between cannabis use and the use of other illicit drugs. Drug and Alcohol Review, Vol. 24 (1), pp. 39-48.

Thornton, L.K., Baker, A.L., Lewin, T.J., Kay-Lambkin, F.J., Kavanagh, D., Richmond, R., Johnson, M. P. (2011). Reasons for substance use among people with mental disorders. Addictive Behaviors, 37, 427-434.

Abel, E.L. (1971). Marijuana and memory: acquisition retrieval? Science, 173: 1038-1041.

Mendelson, J.H., Babor, T.F., Kuehule, J.C.  (1976). Behavioral and biological aspects of marijuana use. Ann NY Academy of Science, 282: 186-210.

Osbourne, G.B.,  Fogel, C. (2008). Understanding the motivations for recreational marijuana use among adult Canadians. Substance Use and Misuse, 43, 539-572.

Kendler, K.S. (1998). Cannibus use, abuse, and dependence in a population-based sample of female twins. American Journal of Psychiatry, 155 (8): 1016-1022.

Hall, W.D., Lynskey, M. (2005). Is cannabis a gateway drug? Testing hypothesis about the relationship between cannabis use and the use of other illicit drugs. Drug and Alcohol Review, Vol. 24 (1), pp. 39-48.

Anthony, J.C., Warner, L.A., Kessler, R.C. (1994). Comparative epidemiology of dependence opn tobacco, alcohol, controlled substances, and inhalants: Basic findings from the National Comorbidity Survey. Experimental and Clinical Psychopharmacology, 2, 244-268.

Ferguson, D.M., Horwood, L.J. (1997). Early onset and psychosocial adjustment in young adults. Addiction, 92 (3): 279-296.

DuPont, R.L. (1984). Getting tough on gateway drugs: A guide for the family. Washington, DC: American Psychiatric Press.

Singleton, E.G., Trotman, A.J., Zavahir, M., Taylor, R.C., Heishman, S.J. (2002). Determination of the reliability and validity of the Marijuana Craving Questionnaire. Experimental and Clinical Psychopharmacology, 10, 47-53.

Lundahl, L.H., Johanson, C-E. (2011). Cue-induced craving for marijuana in cannabis-dependent adults. Experimental and Clinical Psychopharmacology, Vol. 19 (3), pp. 224-230.

Drummond, D.C., Tiffany, S.T., Glautier, S., Remington, B. (1995). Cue exposure in understanding and treating addictive behaviors. Addictive Behaviors: Cue Exposure Theory and Practice, p. 1-17. Oxford, England: Wiley.

O’Brien, C.P., Childress, A.R., Ehrman, R., Robbins, S.J. (1998). Conditioning factors in drug use: Can they explain compulsion? Journal of Psychopharmacology, 12, 15-22.

Lowman,C., Hunt, W.P., Litten, R.Z., Drummond, D.C. (2000). Research perspectives on alcohol cravings-An overview. Addiction, 95, 545-554.

Coffee, C., Carlin, J.B., Degenhardt, L. Lynskey, M., Sanci, L., Patton, G.C. (2002). Cannabis dependence in young adults. Addiction, 97, 187-194.

Budney, A.J., Hughes, J.R., Moore, B.A., Vandrey, R. (2004). Review of the validity and significance of cannabis withdrawal syndrome. American Journal of Psychiatry, 161, 1967-1977.

Allsop, D.J., Copeland,J., Norberg, M.M., Shanlin, F., Molnar, A., Lewis, J., Budney, A.J. (2012). Quantifying the clinical significance of cannabis withdrawal. PLoSONE, Vol. 7 (9), ARTID e44864.

American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (DSM-1V-TR). American Psychiatric Association, Arlington, VA.

Budney, A.J., Novy, P.L., Hughes, J.R. (1999). Marijuana withdrawal among adults seeking treatment for marijuana dependence. Addiction, 94, 1311-1322.

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