“Its first effect is sudden, violent, uncontrollable laughter; then come dangerous hallucinations… followed by emotional disturbances, the total inability to direct thoughts, the loss of all power to resist physical emotions… leading finally to acts of shocking violence… ending often in incurable insanity.”
America has changed a lot since those introductory words from Reefer Madness greeted the theater audiences in 1940. In the past several years, marijuana has enjoyed rapid increased societal and legal acceptance. As of 2017, eight states have legalized marijuana for recreational use and 29 allowing medicinal use; just over one in five (21%) Americans lives in a state where marijuana is legal. Marijuana is going mainstream.
People now frequently view marijuana as separate from other ‘harder’ drugs and alcohol. It is true that physical effects, withdrawal syndrome, and average dependence severity from marijuana use are less significant compared to other drugs of abuse. Decreasing numbers of people, especially adolescents, perceive significant risks to be associated with regular marijuana use.
But increased societal acceptance of marijuana doesn’t change the fact that, for some, quitting marijuana is just as difficult as quitting other ‘hard’ drugs. The percentage of those who benefit from treatment and the reasons for wanting to quit are similar across marijuana and other drugs. The reality is that marijuana affects different people different ways; some stop with ease while others suffer a much mightier compulsion.
So what does heavy marijuana use really look like? The most well known picture of someone who is ‘high’ is giddiness, anxiety, and bad short term memory coupled with bloodshot eyes and hunger. High doses can cause panic attacks, paranoia, and even hallucinations. The negative effects of THC (delta-9-tetrahydrocannabinol, the main psychoactive compound in marijuana) on memory, attention, and learning are measurable for several days after single use. This means getting high daily or even every other day doesn’t give the brain time to recover. THC also decreases dopamine concentration in circuits controlling motivation. In the long term, it can cause “amotivational syndrome”, where patients suffer reduced drive and impaired concentration.
Causes and Risk Factors
One and a half percent of U.S. adults (4.3 million) meet criteria for Cannabis Use Disorder, making it the most widely used illicit substance in the country. Nine percent of individuals who try marijuana will develop a use disorder, but that number nearly doubles to 17% for people who start using before the age of 18. Furthermore, people who smoke marijuana daily have a 25-50% risk of developing cannabis use disorder.
Individuals with Social Anxiety Disorder (SAD) in adolescence to early adulthood are at 6.5 times greater risk of developing a problem with marijuana within 10 years. Depression as well as use of alcohol and tobacco in teenage years increases risk of marijuana use as well. Worryingly, there is a significant overlap between Cannabis Use Disorder and Schizophrenia. At least 27% of Schizophrenia patients will struggle with marijuana issues at some point in their lives.
Adolescents with disrupted family lives, behavioral problems, poor supervision by parents, and strained relationships with their mothers (especially for males) are more likely to start smoking marijuana early and develop a use disorder. Although being surrounded by peers who smoke marijuana does not put young people at higher risk of starting to use cannabis, it does predict progression to heavier use for those who already do. Kids with a poor relationship with school, such as low grades, truancy, and negative outlook on their own education, are also at higher risk.
Different roles for nature and nurture
Comparisons between identical and fraternal twins show that, while environment predicts the vast majority of marijuana use in adolescence, genetics have an increasing influence on marijuana use with older age. Environmental factors, such as peer group, family life, and school life, tend to predict whether individuals will begin smoking marijuana, whereas genetics accounts for the severity of Cannabis Use Disorder.
Diagnosing Cannabis Use Disorder
A plant in many forms
Marijuana takes on a wide variety of appearances from the raw plant material (the plant’s flower) and hashish (a waxy concentrate) to the anti-nausea prescription medications Marinol (dronabinol) and Cesamet (nabilone). In recent years, synthetic marijuana brands, such as K2 and Spice, have appeared to try to cheat drug screens. Marijuana is most commonly smoked (from a pipe, water pipe/’bong’, or rolled cigarette/’joint’), but can also be vaporized (a device heats it to release the THC which is then inhaled in vapor form) or mixed with food.
The concentration of the primary psychoactive substance, THC, varies widely across different forms of marijuana and has increased four-fold over the past 20 years. Furthermore, the synthetic modifications of THC are potentially hundreds of times more powerful than naturally occurring THC.
Diagnosis requires at least two symptoms over the course of one year. People with Cannabis Use Disorder may:
- Smoke increasing amounts or smoke for longer than originally intended
- Want or try to cut down but can’t
- Spend inordinate amounts of time finding, using, and recovering from using marijuana
- Have a strong drive to continue using
- Have problems in major life domains, such as education, work, and home life because of marijuana
- Continue to smoke even in the face of social and relationship problems
- Sacrifice hobbies, jobs, and relationships to use marijuana
- Risk their physical well-being to continue to smoke marijuana
- Continue to use marijuana in the face of direct physical and mental health consequences
- Develop tolerance to marijuana, needing increased amounts to achieve the same ‘high’
- Experience a characteristic withdrawal (irritability, anxiety, disrupted sleep, decreased appetite, low mood, uneasiness, abdominal pain, tremors, sweating, fever, headache), often smoking more to dull the symptoms.
Increasing numbers of symptoms determines the severity of the disorder. Four or five symptoms qualify as a moderate case; it’s a severe case if there’s six symptoms or more. Patients are in early remission if they have had none of those criteria for at least three months and not more than one year. Late remission extends beyond one year.
Treating Cannabis Use Disorder
Options for therapy
The available research on psychological treatment for Cannabis Use Disorder supports various combinations of Cognitive Behavioral Therapy (CBT), Motivational Interviewing (MI), and Contingency Management (CM), but which one is superior is unclear.
In CBT, marijuana users examine settings that put them at risk for using and work with therapists to monitor and cope with urges. In weekly sessions over 3-4 months, patients learn strategies to deal with tempting situations. If time is a factor, MI is a brief intervention where clinicians use open-ended questions to lead patients to their own conclusions regarding the pros and cons of their marijuana use. CM, in which patients receive monetary rewards for sobriety and treatment compliance, is most effective as an adjunct to CBT and MI. This combination results in significantly increased treatment adherence and fewer relapses when compared to any other combination of therapies. Though rates of complete abstinence following treatment tend to be low (around 15%) these are considered to be the most effective treatments available because they do significantly reduce the amount of daily cannabis use, dependence severity, and problems from cannabis use on follow up.
Marijuana Anonymous (MA), an adaptation of the 12-step program Alcoholics Anonymous, offers patients an understanding support network in lieu of other treatment settings where the seriousness of Cannabis Use Disorder may be minimized by patients who use other drugs. A large study with military veterans showed that increased MA attendance predicted significantly higher probabilities of maintaining sobriety and restarting sobriety after relapse up to five years following initial treatment.
A few medication resources
There are no existing Food and Drug Administration-approved medications for Cannabis Use Disorder. In two small studies, the THC-related medications Marinol and Cesamet showed some promise in mitigating withdrawal and, specifically with Cesamet, in reducing relapse. In one study, Neurontin (gabapentin), an anti-epileptic, reduced cannabis use and withdrawal severity. Combining daily N-acetylcysteine (a dietary supplement) with CM doubled the probability of patients remaining sober compared to CM with placebo in an 8 week trial.
Managing Cannabis Use Disorder
Physical health impacts
Frequent marijuana use is not without health consequences, with chronic users often developing respiratory infections and chronic bronchitis. Synthetic marijuana, which is much, much more potent, has resulted in thousands of emergency room visits for paranoia, anxiety, panic attacks, hallucinations, agitation, and seizures and has even been linked to some deaths.
Dangers of early use
Use by adolescents is especially concerning because heavy, regular marijuana use beginning in teen years results in an irreversible decrease in IQ. Regular marijuana smokers have decreased probability of finishing high school and college and generally are less satisfied with their academic and professional status. Animal studies with adolescent rats exposed to marijuana show that THC changes how the hippocampus (the area of the brain that encodes long term memory) handles information and causes problems in memory formation. In fact, children of women who used marijuana during pregnancy often have difficulties with cognition, memory, and attention.
Gateway drug or just easy to get?
Marijuana has traditionally been labeled a “gateway drug” because its use often comes before the use of other drugs. A study of over 200 twin sets showed that individuals who began using marijuana before age 18 were 6.5 times more likely to eventually use other drugs like cocaine and heroin compared to their siblings who didn’t use marijuana as adolescents. However, it is difficult to prove that a later decision to use “harder” drugs was influenced by the previous use of marijuana. Furthermore, alcohol and nicotine are also used early at similar rates just like marijuana. A more modern conception is that people who are innately prone to use drugs will start with ones that are easy to get and eventually move on to others. The most important message is that early use predicts use disorders, and early intervention is the key to effective treatment.
The question of medical marijuana
Neither the American Medical Association, the Food and Drug Administration, nor the National Council on Alcoholism and Drug Dependence endorse the sale of medical marijuana (not including the FDA-approved medications dronabinol and nabilone). Unlike almost all other pharmaceuticals, medical marijuana has not undergone rigorous testing, and products sold at dispensaries may be unreliably labeled or have inconsistent doses. Lack of research leaves physicians who endorse medical marijuana cards for their patients with little direction to give regarding use. Given this lack of oversight, simply having a medical marijuana card does not provide a free-rein pass for marijuana use and can provide a stumbling block for accurately diagnosing a use disorder.