Treating Cannabis Use Disorder in the Time of Legal Marijuana

Considering marijuana is likely to be legalized everywhere in the U.S. very shortly, those of us focused on dependence medicine and drug use prevention must rethink our approach to marijuana. No longer will marijuana – also known as cannabis – be an illegal drug, on par with other class one drugs such as cocaine or heroin. Cannabis will become increasingly normalized in our society and, similar to alcohol, be useable legally and recreationally by many people. And, just as with alcohol, while not everyone who uses will become dependent, there is a minority of people for whom usage may become a problem, with potentially severe consequences on their quality of life.

We need to view cannabis like we view alcohol – legal, but potentially problematic. Make no mistake, people are becoming addicted to cannabis.

The most recent findings by the 2021 National Survey on Drug Use and Health (NSDUH) make it clear that cannabis is a much bigger problem than most people believe. According to the survey, there were 24 million people in the U.S. in 2021 ages 12 and above who – based on responses about their use of alcohol and other substances and the impact it has on their lives – had a diagnosable drug use disorder. Out of those, 16.3 million could be diagnosed with cannabis use disorder, accounting for over two-thirds of the people who met the criteria for a drug use disorder.

Why we must update our messaging on marijuana

Cannabis use is growing and, with that, so are the number of people who are edging into problematic use. We once spoke of marijuana as a “gateway drug” to the use of harder drugs. That old message is wildly out of touch with what we see in treating patients at Caron: Marijuana has become a problem in and of itself.

There are several reasons for this:

• The dramatically higher potency of today’s cannabis makes it much more likely to cause problems such as lethargy, disengagement, short-term memory problems and even breaks from reality.
• Consistent, daily and ongoing use of cannabis compounds the issues caused by higher potency.
• Marijuana’s interaction with psychiatric maladies is troublesome. While it is unclear whether cannabis makes people more susceptible to psychiatric problems, or vice versa, it is clear that cannabis makes psychiatric maladies worse, rather than better.
• Marijuana’s profound effects on brain development during adolescence and into young adulthood means that every year we can delay someone’s first use of marijuana is a win for their brain development and long-term mental health. This is especially true with high-potency cannabis. The brain is not fully developed until age 25.

Cannabis is psychologically addictive and can be very difficult to quit. One in 10 people who use marijuana becomes addicted to it psychologically. For those who start using it before the age of 18, one in six becomes addicted.

Physical withdrawal symptoms vary in severity depending upon the length of time and how heavily it was used, how it was consumed and its potency. Typically, physical withdrawal doesn't require medication-assisted treatment. However, marijuana is also often contaminated with other substances, such as fentanyl, which can drastically affect withdrawal symptoms.

Warning signs of cannabis dependence

As with alcohol, the social acceptance of cannabis use can make it difficult to spot someone who may be struggling. One of the key red flags is using cannabis – and continuing to use it – despite experiencing consequences.

When someone is addicted to a substance, they navigate their whole life around it. It becomes their central focus, and everything else becomes a means to the end of using the substance. They will actively avoid situations that prevent them from using, like skipping events that won’t allow marijuana or leaving early so they can go home and get high. Their social life shifts, ensuring the people around them won’t challenge their use or will partake in it with them. They struggle to sleep, socialize, work, or even feel hungry without it. They cannot get through a day without thinking about it. The further the symptoms of a cannabis use disorder progress, the more those symptoms will end up touching every part of their life.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM 5), outlines the criteria we use for diagnosing a substance use disorder. There are, of course, physiological symptoms involved in a diagnosis, like craving, withdrawal, and tolerance. Most important from the perspective of marijuana use, however, are factors involving quality of life.

Specifically, does the use of cannabis:

• Get in the way of relationships and the ability to connect with people?
• Get in the way of career, occupation, schooling, or other personally important commitments?
• Make physical and psychological problems worse?

The impact of legal marijuana on treatment

When a substance shifts from illegal to recreational, the paradigm of how we look at it must change. With alcohol, for example, there are times in social settings when not consuming alcohol is seen as strange behavior. We aren’t quite at that level with cannabis, but people increasingly perceive cannabis as a socially acceptable and relatively harmless way to relax. As with alcohol, however, people may have difficulty recognizing the negative impact that marijuana use is having on their lives.

I see this all the time in my own clinical practice. People may be struggling with depression and anxiety, for example, and are working hard to build healthy coping skills to manage their symptoms. Yet they also persist in using cannabis. They wind up spinning their wheels, not making the progress they had hoped. The role of the clinician therefore involves helping patients understand how managing their symptoms using a mood- or mind-altering substance may be counter-productive.

One of the best therapeutic approaches in these circumstances is to use motivational interviewing. Instead of starting with the idea that marijuana is bad, this process helps the patient explore how they benefited from using marijuana, the payoff they got from it and the consequences of their use. This approach meets the patient where they are. The key question for the patient becomes: What does marijuana take away from my quality of life?

Quality of life is the key issue with marijuana use

Educating patient care staff on the cannabis of today

From a patient care standpoint, our understanding of marijuana today is vastly different from what it was just five years ago. In large part, that means educating staff on how long-term, consistent use of high-potency cannabis can change the way a patient presents behaviorally, both while they are using and as they stop.

Protracted withdrawal symptoms after intensive, long-term use might include difficulty with short- and long-term memory, or difficulty with aspect regulation, where someone cannot manage their emotions. People who use marijuana often seem to underreact emotionally, so there is often a rebound effect once usage stops that leads to overreaction – even irrational anger. If somebody has been using marijuana to reduce anxiety-related symptoms, they may have rebound anxiety. Sleep-related issues are also common, with people having difficulty getting to sleep and staying asleep.

It can take a while to work through these symptoms because the body holds onto cannabis in fat cells. It can take up to four weeks for the substance to work out of a person’s system. This affects treatment because patients’ bodies will still be detoxing from cannabis just as they are completing a 28-day program of care and changing their level of care. It’s important to educate patients on the post-acute withdrawal symptoms they may continue to experience for some time to come and the need to stay connected to their aftercare therapy and recovery network.

How our messaging on cannabis needs to change

The legalization of cannabis has led us into a brave new world. Despite the widespread belief that marijuana is safe, there’s a lot we don’t know about cannabis. Let me be clear – it is not safe as it is currently marketed. There hasn’t been enough research to truly understand how cannabis affects the body and mind, largely because until recently Federal law prevented widespread research on it. Clearly, just as with alcohol, there are some people who will have problems with usage. As we make marijuana more widely available, we should also be investing in identifying and helping those who have problems with it.

There are three key messages we need to emphasize in talking about cannabis:

• It interferes with brain development in adolescents. Every year we can delay first use is a win for long-term mental health. Legal usage should be limited to those 21 and older.
• Potency is a game-changer, as is daily use. Using high-potency cannabis products on a frequent, sustained basis increases the risk of negative side effects.
• There are better alternatives than medical marijuana. There is no evidence that shows cannabis makes any psychiatric condition better. In fact, there is a lot of evidence showing it makes them worse.

The most powerful messages are around quality of life, and they are deeply personal questions. What does marijuana take away from your quality of life? Is use preventing you from living the life you wanted? Do you have life goals and important commitments you aren’t following through on because of cannabis use? Again and again, I’ve seen that the answers to these questions can provide the motivation for someone to quit using cannabis and enter recovery. As people see that their values are not matching up with their behaviors, they can begin to evaluate and navigate positive changes. Recovery is about improving quality of life.