Cart
Courses: 0

Total: $00.00

Marijuana – Substance and Treatment Back to Course Index

maraleaf

MARIJUANA

Substance and Treatment

 

INTRODUCTION

 

Marijuana is an ancient drug of abuse and became a problem in the United States in the early 1960s.  It has continued to present a significant threat to users into the 21st century.  There are many myths, misconceptions, misinformation and mistakes about marijuana.  It may be unfortunate that marijuana is not as sensational a drug as LSD or PCP so that it might sway public opinion away from use.  As a matter of fact, it seldom makes headlines or TV news but its influence and effects are insidious and malignant, nonetheless.

 

The primary psychoactive ingredient in marijuana is delta-9-tetrahydrocannabinol, or THC.  images-2When marijuana is smoked approximately half of the THC is absorbed whereas only 5 to 10 percent is absorbed when it is taken orally.  It has a biphasic pattern in the plasma with high levels initially, which rapidly disappear due to high lipid solubility and the gradual slow release form the lipid stores.  The half-life of THC in the body is about seven days (seven days from intake, one-half of the amount stored is eliminated).  The organs of the body with high lipid concentration tend to concentrate the THC and slowly excrete it, requiring approximately four half-lives or 30 days for complete elimination.

 

Tolerance develops rapidly and the smoking of three joints a week can easily lead to an increase in the amount used in an effort to maintain the desired results.  Dependence may be categorized as being either psychological or physical.  There is considerable data that indicates the use of marijuana results in psychological dependence.  Evidence is also accumulating that a low-grade physical dependence can also occur, but due to the long half-life and gradual excretion, acute signs and symptoms of withdrawal, similar to narcotics, barbiturates or alcohol are not seen.

 

Marijuana is derived from the cannabis plant (cannabinoids) and chemically similar synthetic compounds.  When the leaves, tops, and stems of the plant are cut, dried and rolled into cigarettes, the product is generally called marijuana or bhang.  Hashish is the dried, resinous exudates that seep from the tops and undersides of the cannabis leaves; hashish oil is a concentrated distillate of hashish.  In recent years, another high-potency form of cannabis, sensimilla, has been produced in Asia, Hawaii, and California.  Cannabinoids are usually smoked, but they may be taken orally, usually mixed with tea or food.   The cannabinoid that has been identified as primarily responsible for the psychoactive effects of cannabis is, as mentioned earlier, delta-9-tetrahydrocannabinol (also known as THC, or delta-9-THC), a substance that is rarely available in a pure form.  The cannabinoids have diverse effects in the brain, prominent among which are actions on CB1 and CB2 cannabinoid receptors that are found throughout the central nervous system.

 

The THC content of the marijuana that is generally available varies greatly.  The THC content of illicit marijuana has increased significantly since the late 1960s from an average of approximately 1%-5% to as much as 10% to 15%.  Synthetic delta-9-THC has been used for certain general medical conditions (e.g., for nausea and vomiting caused by chemotherapy, for anorexia and weight loss in individuals with acquired immunodeficiency syndrome [AIDS]).

 

The DSM contains criteria sets for the diagnosis of substance related disorders.  The general criteria is applicable to all drugs will be presented first followed by specific criteria for cannabis dependence, abuse and intoxication.

 


GENERAL CRITERIA (ALL SUBSTANCES)

 

Substance Dependence:

 

The essential feature of Substance Dependence is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues use of the substance despite significant substance-related problems.  In essence, it is a pattern of repeated self-administration that can result in tolerance, withdrawal, and compulsive drug-taking behavior.  The criteria for substance dependence is a maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

(1)              tolerance, as defined by either of the following:

(a)             a need for markedly increased amounts of the substance to

achieve intoxication or desired effect

(b)             markedly diminished effect with continued use of the same amount of the substance

(2)             withdrawal as manifested by either of the following:

(a)       the characteristics withdrawal syndrome for the substance (b)    the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms

(3)              the substance is often taken in larger amounts or over a longer period than was intended

(4)              there is a persistent desire or unsuccessful efforts to cut down or control substance use

(5)              a great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects

(6)             important social, occupational, or recreational activities are given up or reduced because of substance use

(7)            the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by substance use (e.g., current marijuana use despite recognition of marijuana-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption)

             

Substance Abuse:

 

The essential feature of Substance Abuse is a maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to the repeated use of the substance.  In order for an abuse criterion to be met, the substance-related problem must have occurred repeatedly during the same 12-month period or been persistent. There may be repeated failure to fulfill major role obligations, repeated use in situations in which it is physically hazardous, multiple legal problems, and recurrent social and interpersonal problems.  Unlike the criteria for Substance Dependence, the criteria for Substance Abuse does not include tolerance, withdrawal, or a pattern of compulsive use and instead include only the harmful consequences of repeated used.  The criteria for Substance Abuse is:

 

A.     a maladaptive pattern or substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:

(1)  recurrent substance use resulting in a failure to fulfill major role obligations at            work, school or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)

(2)   recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)

(3)   recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)

(4)    continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences or intoxication, physical fights)

 

B.     The symptoms have never met the criteria for substance Dependence

for this class of substance.

 


CANNABIS-RELATED DISORDERS

 

Cannabis Dependence:

 

Individuals with Cannabis Dependence have a compulsive use and associated problems.  Tolerance to most of the effects of cannabis has been reported in individuals who use cannabis chronically.  There have also been some reports of withdrawal symptoms, but their clinical significance is uncertain.  There is some evidence that a majority of chronic users of cannabinoids report histories of tolerance or withdrawal and that these individuals evidence more severe images-4drug-related problems overall.  Individuals with Cannabis Dependence may use very potent cannabis throughout the day over a period of months or years, and they may spend several hours a day acquiring and using the substance.  This often interferes with family, school, work, or recreational activities.  Individuals with Cannabis Dependence may also persist in their use despite knowledge of physical problems (e.g., chronic cough related to smoking) or psychological problems (e.g., excessive sedation and a decrease in goal-oriented activities resulting from repeated use of high doses).  

 

Cannabis Abuse:

 

Periodic cannabis use and intoxication can interfere with performance at work or school and may be physically hazardous in situations such as driving a car.  Legal problems may occur as a consequence of arrests for cannabis possession.  There may be arguments with spouses or parents over the possession of cannabis in the home or its use in the presence of children.  When psychological or physical problems are associated with cannabis in the context of compulsive use, a diagnosis of cannabis Dependence, rather that Cannabis Abuse, should be considered.

 

Cannabis Intoxication:

 

The essential feature of Cannabis Intoxication is the presence of clinically significant maladaptive behavioral or psychological changes that develop during, or shortly after, cannabis use.  Intoxication typically begins with a high feeling followed by symptoms that include euphoria with inappropriate laughter and grandiosity, sedation, lethargy, impairment in short-term memory, difficulty carrying out complex mental processes, impaired judgment, distorted sensory perceptions, impaired motor performance and the sensation that time is passing slowly.  Occasionally, anxiety (which can be severe), dysphoria, or social withdrawal occurs.  These psychoactive effects are accompanied by two or more of the following signs, developing within 2 hours of cannabis use:  conjunctival injection, increased appetite, dry mouth, and tachycardia.  The symptoms must not be due to a general medical condition and are not better accounted for by another mental disorder.

 

Intoxication develops within minutes if the cannabis is smoked, but may take a few hours to develop if ingested orally.  The strong effects may last for three to four hours, the duration being somewhat longer when the substance is ingested orally.  The magnitude of the behavioral and physiological changes depends on the dose, the method of administration and the individual characteristics of the person using the substance, such as rate of absorption, tolerance and sensitivity to the effects of the substance.  Because most cannabinoids, including delta-9-THC, are fat soluble, the effects of cannabis or hashish may occasionally persist or reoccur for 12-24 hours due to a slow release of psychoactive substances from fatty tissue or to enterohepatic circulation.

 


THE ESSENCE OF ADDICTION

 

Dr. Alan I Leshner, PhD., Director, National Institute of Drug Abuse, provided the following insight into drug addiction.  This article is of value as we  frame concepts and applications surrounding the addiction process.  He states: The word addiction calls up many different images and strong emotions.  But what are we reacting to?  Too often we focus on the wrong aspects of addiction so our efforts to deal with this difficult issue can be badly misguided.  Any discussion about psychoactive drugs, particularly drugs like nicotine and marijuana, inevitable moves to the question but is it really addicting?   The conversation then shifts to the so-called types of addiction whether the drug is physically or psychologically addicting.  The issue revolves around whether or not dramatic physical withdrawal symptoms occur when an individual stops taking the drug, what we in the field call physical dependence.

 

The assumption that follows then is that the more dramatic the physical symptoms, the more serious or dangerous the drug must be.  Indeed, people always seem relieved to hear that a substance just produces psychological addiction, or has only minimal physical withdrawal symptoms.  Then they discount the dangers.  They are wrong.  Marijuana is a case in point images-3and I will come back to it shortly

 

Defining addiction Twenty years of scientific research, coupled with even longer clinical experience, has taught us that focusing on this physical vs. psychological distinction is off the mark, and a distraction from the real issue.  From both clinical and policy perspectives, it does not matter much what physical withdrawal symptoms occur.  Other aspects of addiction are far more important.  Physical dependence is not that important because, first, even the florid withdrawal symptoms of heroin and alcohol addiction can be managed with appropriate medications.  Therefore, physical withdrawal symptoms should not be at the core of our concern about these substances.

 

Second, and more important, many of the most addicting and dangerous drugs do not even produce very severe physical symptoms upon withdrawal. Crack cocaine and methamphetamine are clear examples.  Both are highly addicting, but stopping their use produces very few physical withdrawal symptoms, certainly nothing liked the physical symptoms of alcohol or heroin withdrawal.

 

What does matter tremendously is whether or not a drug causes what we now know to be the essence of addiction:  uncontrollable, compulsive drug seeking and use, even in the face of negative health and social consequences.  This is the crux of how many professional organizations all define addiction, and how we all should use the term.  It is really only this expression of addiction uncontrollable, compulsive craving, seeking and use of drugs that matters to the addict and to his or her family, and that should matter to society as a whole.  These are the elements responsible for the massive health and social problems caused by drug addiction.

 

Essence of Addiction Drug craving and the other compulsive behaviors are the essence of addiction.  They are extremely difficult to control, much more difficult than any physical dependence.  They are principal target symptoms for most drug treatment programs.  For an addict, there is no motivation more powerful than drug craving.

 

Rethinking Addiction focusing on addiction as compulsive, uncontrollable drug use should help clarify everyones perception of nature of addiction and of potentially addicting drugs.  For the addict and the clinician, this more accurate definition forces the focus of treatment away from simply managing physical withdrawal symptoms and toward dealing with the more meaningful, and powerful, concept of uncontrollable drug seeking use.  The task of treatment is to regain control over drug craving, seeking and use.

 

Rethinking addiction also affects which drugs we worry about and the nature of our concerns.  The message from modern science is that in deciding which drugs are addicting and require what kind of societal attention, we should focus primarily on whether taking them causes uncontrollable drug seeking and use.  One important example is the use of opiates, like morphine to treat cancer pain.  In most circumstances, opiates are addicting.  However, when administered for pain, although morphine treatment can produce physical dependence which now can be easily managed after stopping use it typically does not cause compulsive, uncontrollable morphine seeking and use, addiction as defined here.  This is why so many cancer physicians find it acceptable to prescribe opiates for cancer pain.

 

An opposite example is marijuana, and whether it is addicting.  There are some signs of physical dependence of withdrawal in heavy users, and withdrawal has been demonstrated in studies on animals.  But what matters much more is that every year more than 100,000 people, most of them adolescents, seek treatment for their inability to control their marijuana use.  They suffer from compulsive, uncontrollable marijuana craving, seeking and use.  That makes it addicting, certainly for a large number of people.

Treating Addiction:  Follow The Science It is important to emphasize that addiction, as defined here, can be treated, both behaviorally and, in some cases, with medications, but it is not simple.  We have a range of effective addiction treatments in our clinical toolbox although admittedly not enough.  This is why we continue to invest in research, to improve existing treatments and to develop new approaches to help people deal with their compulsive drug use.

 

Our national attitudes and the ways we deal with addiction and addicting drugs should follow the science and reflect the new, modern understanding of what matters in addiction.  We certainly will do a better job of serving everyone affected by addiction  – addicts, their families and their communities if we focus on what really matters to them.  As a society, the success of our efforts to deal with the drug problem depends on an accurate understanding of the problem.

 


ADDICTION PROCESS

The addiction process is presented to help the clinician and the drug user to better understand the why behind their use and abuse of drugs.  The hope is that the better this process is understood, the more effective counseling and other treatment modalities can be toward helping the user to achieve a drug-free life.  It is imperative that clinicians in the field of addictions understand the cognitive, behavioral and physical aspects of drug use.  The objectives are for the clinician involved with treatment to recognize the special needs of this sub-population and design treatment modalities aimed at their specific needs.  For example, as it is beneficial for an insulin dependent diabetic to be educated on all aspects of diabetes, it is equally important for the problematic marijuana user to be educated on all aspects of marijuana use including impulse control, distorted cognitive ability and the consequences of poor decision-making.

  

Figure 1 depicts a typical addiction process and identifies the major functional blocks of the process.  The essence of this process is that if an individual has a flawed or permissive value/belief system (based upon his or her perceptions of events, teachings and influences of his family, friends, peers and other during his or her early life) it leads to that individual having a distorted cognitive ability.  That, in turn, enables an individual to continue to use and will ultimately result in unmanageability of his or her life (if the cycle is not disrupted).  The following paragraphs describe each block and how it impacts the users life.

Mar1

VALUE/BELIEF SYSTEM

An individuals value/belief system reflects his/her perception of self and represents values, judgments and myths that he/she believes to be true.  A persons value/belief system is fairly well established by an early age and is refined and honed as lifes experiences make us into the person we are at any given time in our lives.   It is the major control and decision-making guide and helps us to chose between right and wrong and things we do versus things we dont do.  Our value/belief system influences our thinking and decision making throughout our lives.  Most individuals have a value/belief system about:

 

              Religion

              Alcohol and other drugs (marijuana)

              Sexuality

              Race

               Careers

              Age

              Peer pressure/fitting in

              Time management

              Social involvement

              Community involvement

              Family roles

A clinician should explore a clients value/belief system to better understand what they believe about various topics including topics related to drug use.  An area I like to explore with clients is the environment they were exposed to during their early life.  For example, I want to determine if their parents or caregivers had a permissive attitude toward drugs.  I also want to know what type neighborhood they lived in and what was the norm regarding use of alcohol and other drugs.  Other questions might include:

 

  •               Were you exposed to limits or restrictions as a youth?
  •               Did your parents use alcohol or marijuana?
  •                Were you allowed to drink or use other drugs with your parents?
  •               At what age did you start to drink or smoke?;
  •               Was their a permissive attitude toward alcohol and other drugs in your home/neighborhood?
  •                Did you have a detailed schedule as a youth?
  •               Did your parents involve themselves with your friends?
  •               Did your parents monitor your activities?

 

 Obviously, exposure to a permissive attitude/environment will enable a young person to form a positive image of most activities and/or to establish a distorted mental picture of specific activity (such as use of alcohol and/or marijuana).   To give an example of how our belief/values work in the life of a marijuana user, lets suppose a person forms a concept of a problem user as one who dropped out of school and is unemployed.  Now, lets suppose this individual is a compulsive user but does not meet his or her pre-programmed characteristics of how they perceive an addict to be or act.  In this case, the individual would test his situation against his value/belief system and would conclude he or she does not have a drug problem.  The cycle is repeated until there is a match between his/her behavior and his/her pre-programmed belief/value system about drug use.  It should also be noted that an individuals belief system about drug use may change in response to his or her own experiences and influences from clinicians and other treatment modalities.  The cycle may also be disrupted by other factors (generally a crisis) in the users life.


DISTORTED COGNITIVE ABILITY

A flawed or permissive value/belief system results in a distorted cognitive ability that, in turn, results in illogical and impaired thinking; consequently, the affected individual continues to make high-risk decisions for themselves.  With respect to use of drugs, it results in compulsive, uncontrolled drug craving, seeking and use.  It follows that an individual is unable to comprehend the reality, consequences or truth about events/actions/activities.  When an individual cannot see the reality or truth about things, the distorted cognitive activity is generally referred to as denial.  The most common forms of denial are:

              Rationalizing:  Making excuses for marijuana use.  Example, Im restless and it helps me sleep;  all of my friends use more than me.

              Minimizing:    Indicating his/her use is less serious than it really is.  Example: Sure I smoke a joint occasionally, but not that much; I only use on week ends, real users use every day.

              Blaming:        I use marijuana because;  everyone else does.  The user admits involvement but the responsibility for it lies with some else.

An important challenge facing most compulsive users it to break thrugh denial and accept the reality of their situation; consequently, the greatest challenge in counseling situations is to help the individual through this process.  This generally takes patience, professionalism, research, and a willingness to face adversity. The client must adjust to a changing lifestyle and adapt new coping strategies and new ways to divert himself or herself away from his or her former lifestyle.   Learning new concepts is usually met with rsistance, as most individuals dont want to change and will only change in response to pain or other strong motivator.   Distorted cognitive activity or impaired thoughts mask the reality of most situations, and truth (in many cases) ceases to exist.  A marijuana user who finds themself in a quagmire can gain insight as to their preconception (thinking) regarding excessive use by answering and analyzing the following questions:

              Most frequently used form of denial (with respect to marijuana use) is: __________ (rationalizing, minimizing, blaming or others).

              Most frequently processed impaired thought:  ____________________________________________________

              Im not a problem user because: ____________________________________________________

If an individual becomes emotionally stressed when asked these types of questions, it is a strong indication that the individual is in denial regarding their involvement with marijuana and they are in need of professional help. The key to any cognitive change is that the individual be open and honest and willing to accept that change is needed.  If they have a good attitude, it is easier for them to accept the perils associated with compulsive use.  The net is that people can change but in most cases the change must be initiated at the cognitive level.  If one is in denial regarding a problem there is very little that anyone else can do to help that individual.

 


CYCLE OF USE

 

The cycle of use is an outcome of an individual continuing to live with distorted cognitive functioning. This on-going activity results in addiction (again, compulsive, uncontrolled drug craving, seeking and use).  This lifestyle is problematic and typically follows a well-established pattern (Reference Individual Addiction Cycle).  At this phase of use, his or her drug related choices begins to disrupt normal activities with family, work, school and social and community.  His or her use is increasing in importance to where it is masking most other activity/relationships.  It generally results in behavioral problems or unmanageability of ones life.


UNMANAGEABILITY

As the use continues, the individual begins to encounter the negative consequences of his/her behavior.  In general, the consequences causes pain (psychological or physiological) that, when severe enough, may increase his or her willingness to accept help.  The hypothesis is that deeply imbedded in human nature is the tendency to resist all change until we finally experience pain and then we may stop to look at the cause of the pain.  This process may manifest itself in any of the following:

  •           Physical (health problems, increased risk taking)
  •           Social problems (family, work, school, community)
  •           Emotional (feelings of guilt, shame or depression)
  •           Spiritual (low self esteem, feeling empty, isolated)
  •           Financial (heavy debt load; inability to manage)

Another self-analysis assignment is for an individual to identify the negative consequences as a result of his/her marijuana use.  This exercise is generally done over several counseling sessions and ultimately will lead the individual to accept responsibility for their decisions (related to marijuana use). 

INDIVIDUAL ADDICTION CYCLE

Figure 2 depicts an individual addiction cycle for a marijuana user and identifies the major blocks associated with the cycle.   Most clinicians believe that all addictions fit into a cycle and that it starts with a cognitive process related to the event (thinking about or preoccupation with the activity).

 
mara2

PREOCCUPATION

 

Preoccupy is defined as to absorb wholly the mind or attention of or occupy beforehand or before another. It can be viewed as a locked in mind state, where the main focus is on obtaining his or her drug of choice.  Some individuals are so focused they appear to be in a somnolent state (as of deep hypnosis) where the individual may have limited sensory and motor contact with his or her surroundings and subsequent lack of recall. Most somnolent states vary in intensity, duration and frequency.  The initial onset may be mild but generally get more intense as time passes without satisfying the impulse.   The intensity of the state also varies depending on how long the individual has been a drug user as all individuals are creatures of habit and we program ourselves to expect resolution within a predetermined timeframe or the mind will increase the desire to satisfy the impulse.   An approach to understanding this phase of use is to ask the user a series of questions such as:

 

  •           What thoughts did you focus on when you initially began use marijuana?
  •           Was your intent to be accepted by your peers?
  •           Was your objective to prove your manhood or womanhood?
  •           Did you use as an act of rebellion?
  •           What role did peers play in your decision to experiment?
  •           How did the focus items change as the compulsion to use increased?
  •           What are your thoughts like at present?
  •           What do you think regarding using again?
  •           How often do you think about using?

 

Remember that it takes time to break old habits and to re-program our minds to desire different things.   Also, remember the urge to continue or use will be very strong when an individual initially stops.  Its also safe to say that everyone thinks about resuming again, and individuals must be resilient in their efforts to break the cycle.  This exercise is intended as a tool that will help the individual to become familiar with how his/her mind works and the thought processes prior to previous relapses.   Again, the mind wants to continue to do those things that bring pleasure.  Consequently, a big shopping spree or  hanging out with former using buddies are positive events in our minds and we want to repeat them.  Consequently, there is a strong drive to set aside or dismiss concepts that would limit us doing what we want to do.  I have often stated in-group sessions that using is an extremely selfish action.  It basically says I will do what I want to do without any consideration for my health, family or other considerations.  Unfortunately, we all know there is the negative side to compulsive use, but our mind is quick to “set aside” those thoughts when the other (positive) thoughts are being processed. As healthy, normal humans, it is always a good idea to keep the rewards versus consequences balanced in our minds.  I often use the phrase, when one makes the decision (for example, to get high on marijuana) they also accept the consequences.  Sometimes good happens, but most of the time bad and sometimes catastrophic event can occur.


HABITS/RITUAL

The second part of the individualized addiction cycle is a set of habits that typically lead to marijuana use.  Some counselors may refer to this as ritualistic or as a person being on autopilot where the behavior is almost fully automatic and, once initiated, the activities are generally done without thinking.  The preceding cycle (Figure 1) discusses preoccupation, which is thought without action (it may lead to action), whereas this cycle addresses a set of habits (ritual) that are typically completed without thought.

A using ritual is the behavior that leads to marijuana use.  For example, it may be as simple as an urge to get together with old friends (former using buddies) or thinking about an event that previously include drug use (concert).  It may also be triggered by an argument with a spouse; loss of a job or other catastrophic events or it could be as insignificant as driving through a neighborhood where his or her former supplier lived.  In any event, it is something that triggers a thought in our minds that initiates a chain of events that leads to using.  This is another view of compulsivity.  Its also important to note that when a ritual is initiated, it is very difficult to stop the process.  For a compulsive marijuana user, it is virtually impossible without professional help.

Another assignment for the addicted individual is to describe what keys their use. List and analyze the activities and behaviors leading to use.  The objective is that the better we understand what motivates an individual; the easier it is to interrupt the cycle.  The second part of the exercise is to identify what could be done to disrupt the process.   This may be as simple as planning an evening of entertainment at home with the family.  Whatever the case may be, the better one understands themselves, the easier it is to manage their lives and to make better decisions.


COMPULSIVITY
      

The third block of Figure 2 is compulsivity.  Compulsive actions are related to an irresistible impulse to perform an irrational act.  In essence, the user has an impulse control problem and/or is susceptible to relapse. Consequently, compulsivioty is characterized as continued use of the substance despite significant substance-related problems.  Some clinicians refer to this phase as when the user begins to experience the consequences of his use.  Also, most users are aware of their need to stop using and have made several unsuccessful attempts to stop.  This tendency leads to a look at relapse where the clinician and user attempt to identify what triggered the action (resumption of use) and how he or she may avoid that activity in the future.  The clinician must always be mindful that when the user resumes use, he or she expects to experience euphoria.  Unfortunately, the opposite emotions, of fear, hopelessness and helplessness, shame, guilt, depression and despair are often encountered.  One must remember that our minds retain the positive memorizes and have a tendency to set aside the negative ones.   Consequently, the individual thinks he/she will experience a high, when, in fact, he/she has been deceived by his/her own mind.  I think one of the root causes of severe depression is when the individual is expecting an unrealistic outcome and finally realizes he/she has to deal with a set of negative consequences.


DESPAIR

Despair is the end result of addiction and is where  feeling of hopelessness abound.  This block represents the consequences of compulsive use (negative impact on family, work, society, health) and the user generally has feelings of shame and guilt following episodes of use.   However, the addicted individuals mind attempts to soften his/her despair by processing thoughts such as I will never use again; things will be different in the future.  The effect of this mental defense mechanism is to alleviate the bad feeling as quickly as possible by processing the neutralizing thoughts.  So, instead of facing the addiction, the individuals mind has found another way to deny the addiction.  Consequently, the cycle continues.

 


WHY DO PEOPLE USE MARIJUANA

 

Adolescences begin to use marijuana due to curiosity and a desire to fit into a social group (peer pressure).  Certainly, an adolescent that has already begun to smoke cigarettes and/or to use alcohol is at a higher risk for marijuana use.

 

images-2Research suggests that the use of alcohol and/or other drugs by other family members is a risk factor as to whether children start using drugs.  Parents, grandparents, older siblings, other relatives and caregivers are all models for children to copy and follow.  I personally like to expand the model concept to everyone who is an authority figure or in a position to influence a childs life.  Too often parents blindly trust teachers, youth camps, sports figures others with their children without taking the time to research the individuals involved to ensure a safe and drug free environment.

   


DOES MARIJUANA USE LEAD TO USE WITH OTHER DRUGS

 

Marijuana was identified as a gate-way drug several years ago.  This theory has now been substantiated by long-term studies of high school students and their patterns of drug use.  This pattern shows that very few young people use other drugs without first trying marijuana, alcohol or tobacco.  The present trend is that only a few high school students use cocaine; however, the risk of doing so is much greater for youths who have tried marijuana than for those who have never tried it.

 


IMPACT OF MARIJUANA USE ON SCHOOL, WORK AND SOCIAL LIFE

 

The following trends have been observed for heavy marijuana users versus their non-using counterparts:

 

          Lower grades and are less likely to graduate.  This difference is more pronounced in math and science than in social studies and courses like music and art.  It appears that some students lack the drive or desire to remain focused sufficiently long to solve difficult problems, whereas it may very well increase their interest in non-technical studies.  It should be noted that this is a generalized trend and specific individuals may be able to excel in math and science and use marijuana.

          Experience increased personality disorders such as depression, anxiety, fear, impaired judgment, distorted sensory perceptions, difficulty in carrying out complex mental processes, and impaired motor performance.  Some user experience unusual anti-social behaviors and a rebellious attitude.

          Research has indicated an adverse impact on memory and retention that can last for days or weeks after the acute effects of the drug subside.  For example a study of over 100 college students found that among heavy users of marijuana (smoked at least 27 of the preceding 30 days) their critical skills related to attention, memory, and learning were significantly impaired even after they had not used the drug for at least 24 hours.  A follow-up to the initial study showed that a group of long-term heavy users ability to recall words from a list was impaired 1 week following cessation of marijuana use, but returned to normal by 4 weeks.  The implication is that even after long-term heavy use, if an individual quits, some if not most of his or her cognitive abilities may be recovered.

 


IS MARIJUANA ADDICTIVE

 

The 2003 National survey on Drug Use and Health estimates that over 20 million Americans aged 12 and older were classifieds with problematic use of marijuana.  Long-term use can lad to compulsive use that may interfere with family, school, work, and recreational activates. In 2002, approximately 15 percent of people entering drug treatment programs reported marijuana as their primary drug of choice.

 

Withdrawal symptoms (that may vary from very mild to moderate) along with cravings can make it hard for long-term marijuana smokers to stop using the drug.  Individuals trying to quit report irritability, difficulty sleeping, and anxiety.  Some individuals also display increased aggression on psychological tests, peaking approximately one week after they last used the drug. 

 

Research also indicates that early use of marijuana can increase the likelihood of a lifetime of subsequent drug problems.  Data from over 200 fraternal and identical twin pairs, who differed on whether or not they used marijuana before the age of 17, indicated that those who had used marijuana early had elevated rates of other drug use and drug problems lager, compared with their twins, who did not use marijuana before age 17.  This shows the importance of primary prevention by showing that early drug initiation is associated with increased risk of later drug problems, and it provides more evidence for why prevention marijuana experimentation during adolescence could have an impact on preventing addiction.     

 

 


PREVENTION/TREATMENT

 

Stand-alone marijuana treatment modalities are rare as many who use marijuana do so in combination with other drugs such as alcohol and cocaine.  However, due to the number of long-term heavy users it may become necessary for substance abuse counselors to focus more on marijuana.  Some progress is already being made in this endeavor.  For example, a study of adult marijuana users found comparable benefits from a 14-session cognitive-behavioral group counseling and a 2-session individual counseling sessions (this amount of counseling is similar to American Society of Addictive Medicine, Level 1).  This counseling includes motivational interviewing and advice on ways to reduce marijuana use.   This study included people mostly in their early thirties who had smoked marijuana daily for over 10 years.  By increasing patients awareness of what riggers their marijuana use (e.g., cycle of marijuana use) the counselors can help the patients devise avoidance strategies.  Marijuana use and related problems (school, work, family) as well as psychological problems decreased for at least one year after treatment.  Approximately 30 percent of former users were drug- free the last 3-month follow-up-period.

 

No medications are now available to treat marijuana abuse; however, there are medications to help moderate the withdrawal symptoms.  Also, recent discoveries about the workings of he THC receptors have raised the possibility that scientists may eventually develop medications that will block THCs intoxicating effects. Such medication might be used to prevent relapse to marijuana use and abuse by reducing or eliminating its appeal. 

 

Probably the greatest challenge facing recovering marijuana addicts (and the substance abuse counselors who work with the patients) is to avoid relapse.  This CEU will present a prevention technique developed by Marlott and Gordon in 1995.  They described a comprehensive relapse prevention technique for alcohol and other drug addicts.  This treatment application will also work for problematic use of the marijuana.   They suggested an approach where high-risk situations were assessed and then coping strategies were developed for each situation.  The following factors were analyzed for each situation:

 

          Self-Efficacy:  The individuals perception of his/her ability to cope with situations.

          Expectations:  What is the consequence to the user of a specific behavior?

          Attribute:  Why an individual exhibits a specific behavior.

           Decision-Making:  Methodology used when the individual chooses a specific action.

 

Once this analysis is complete, Marlatt and Gordon suggest the following intervention strategies:

 

          Self-monitoring:   Maintaining a log of urges/needs to use marijuana.  Additional information such as intensity of urge and coping strategy employed may also be documented.

          Direct observation:         The individual rates the degree of temptation due to various situations.  The individual may respond to an imaginary past episode or a fantasy about a past episode and then describe what he/she may have done differently to avoid future encounters.

          Coping Skills:      This analytical tool is used to document the clients ability to cope once a high-risk behavior is encountered.  This helps the individual to identify strengths and weaknesses and helps the client focus on areas that need improvement.

          Decision Matrix:  The matrix is used to document the consequences of a specific decision or action.  It may be used to gather immediate, as well as delayed consequences and can document both positive and negative outcomes.

          Behavioral Commitment:           This tool is intended to establish limits on drug use (if any).  It is also a commitment to seek help at the first episode of use, to prevent a full-scale return to using.

          Reminder Questions:      They are used to key specific avoidance actions in the event of a strong urge.

 

It follows that a primary goal of any prevention program is to enable the individual to cope with future, inevitable urges to use marijuana.  The initial step is to identify the coping strategies that can be used in high-risk situations.  It is also important to discuss an implementation plan for how these skills will be used.  Some have referred to this process as setting up a self-management program.  According to Ricky George (1990), The goals of self-management programs are to teach the individual how to anticipate and cope with the problem of relapse.  This approach generally combines behavioral skills training, cognitive interventions and lifestyle changes to help the individual modify their behavior.

 

The most frequently applied prevention method is the cognitive-behavioral approach.  The primary feature of this approach is that it acknowledges the individual may have had little or no control over becoming a compulsive user but has total responsibility for management of his/her recovery.

 


Recovery Model

 

This model is based on the concept that recovery is a process that requires the mastery of emotional, psychological, and social and recovery related tasks.  These tasks, which become increasingly more challenging, are the foundation for recovery.  Recovery is defined as the ongoing process of improving ones level of functioning while striving to remain drug-free.  A brief overview of a recovery process follows:

 

          Pre-treatment phase:      The individual experiences or becomes aware of:

o       Unpleasant consequences associated with drug use (family problems, loss of friends, loss of job, loss of freedom);

o        Loss of control of their life; and emotional pain (may motivate individual to decide to enter treatment).

           Initial stabilization:

o        Stop use of marijuana; avoid former using buddies;

o        Professionally managed coping and emotional strategies (to ease the discontent associated with urges to resume using);

o        Help with controlling impulsive behavior (counseling)

 

Phase 1:        Recovery (Getting Started)

 

          Helps individual to accept and comprehend the addiction process

          Identify use triggers:  Develop a plan to avoid and control impulses.

          Learn problem solving, stress management, and anger management skills.

          Accept personal responsibility for self (choices, decisions, behaviors, and consequences);

          Express feelings. 

 

Phase 2:        Recovery (Early)

 

          Accepts need for recovery

          Accepts responsibility for management of marijuana use

          Begins to develop a drug-free self-image

          Acknowledges the need for lifestyle changes; new friends

          Adjusts to non-use behavior apply new problem solving skills as needed

          May struggle with peer and family issues as drug-free lifestyle is demonstrated

          Improved self-image.

 

Phase 3 (Middle)

          Changed behavior and cognitive awareness aligned with new self-concept.

          Accepts responsibility for own recovery.

          Recognizes and embraces success of recovery.

          Incorporates problem-solving skills into new lifestyle.

          Comfortable with lifestyle changes.

          Continues to struggle with peer and family issues.

          Learns to balance and control life.

 

Phase 4 (Advanced)

 

          Focus on learning coping skills to help deal with peers and family

          Increases scope of life; starts to fulfill potential.

          Develops balance and takes control of life.

          Develops independence from the treatment program develops self-initiative.

          Accepts identity as a recovering individual.

 

After Care

 

          Positive experiences fuel personal growth.

          Focus on total person (activities, spiritual growth and independence).

 

Keys to Avoid A Return to Problematic marijuana use:

 

          High Activity Level: An idle mind often wanders in the wrong direction.

          Generate To Do lists to guide daily activities.

          Goal setting to acknowledge and reward success.

          Individual reward system:           Work toward a specific individualized reward.  For example, new car, trip, clothes.

          Plan pleasurable activities:        Hobbies, travel, reading, etc.

          Plan self-improvement activities: Items that will help the individual feel good about themselves.

o       Exercise/ active lifestyle

o       Nutrition program

o       Rest/relaxation time

o       Manage stress

          Think positive.

          Avoidance of high risk situations and activities

o       Events that previously led to use;

o       Avoid people/functions whos focus in on drug use.

          Avoid things that have triggered previous relapses.

          Develop mind-management techniques:         Block negative thought processes.  The mind always leads the physical act (i.e., an individual thinks positive regarding an activity before they do the activity).  Consequently, if we could train our minds to detect wrong thinking (about drug use), then we could alter or disrupt those thoughts and focus on different things or thought processes to avoid actually using.

          Avoid over confident feelings, such as, I am in control and I have this problem licked.  Generally, overconfidence leads to high-risk behavior and poor decision-making.

          Avoid out-of-balance emotional states.  Either feeling too good (overconfident) or too bad (depression) can lead to resumption of use.

          Forgetting or rationalizing away the pain and anguish of the former lifestyle.  Our minds will sometimes focus only on the pleasurable aspects of a former activity and completely mask (or forget) the negative consequences.  At times, individuals are convinced that returning to a former lifestyle would be wonderful (feeling, emotions, etc.)  Also, when they actually return to that lifestyle, they become deeply depressed as the reality of their actual use is realized.  The mind is a wonderful thing, but it too must be monitored and trained and one must realize that the mind can be misleading in some cases.

          Think positive; act positive, surround yourself with positive people.   Remember the little engine that said, I think I can.