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Caught in the middle on marijuana

September 1, 2009
by Gary A. Enos, Editor
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Concerned about effects on treatment, many addiction professionals avoid the heated marijuana policy debate

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.