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.

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