Cannabis-Marijuana: Addiction,Treatment and Recovery

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1 2006 Cannabis-Marijuana: Addiction,Treatment and Recovery Published By Caron Treatment Centers 1

2 About Caron Treatment Centers Table of Contents Caron Treatment Centers is a leading provider of addiction treatment services in the fight against chemical dependency. Caron uses a comprehensive treatment approach incorporating spirituality, the family, and current medical/psychological interventions to help those affected by addiction begin a life of recovery. Since its founding in 1957, Caron has pioneered the concept of residential codependency treatment, and currently offers expertise in treatment services for adults, young adults and adolescents. These services include: early intervention, medical evaluation and detoxification, primary and extended residential treatment, relapse treatment, outpatient treatment and family education. Caron has responded to the continued demand for addiction treatment services by offering facilities in Wernersville, Pennsylvania, and Boca Raton, Florida. Caron also has regional offices in New York City and Philadelphia. Caron s mission is to provide an enlightened, caring treatment community in which all those affected by alcoholism or other drug addiction may begin a new life. 5 Forward 6 Introduction: Addiction, Treatment & Recovery 6 What is Marijuana? 6 Marijuana s Actions and Effects 7 Cannabis Abuse and Addiction 7 Symptoms of Addiction 8 Consequences of Cannabis Abuse and Addiction 9 Medical Consequences 9 Cognitive Impairment 9 Psychiatric Consequences 10 Social Development 10 Marijuana: A Gateway Drug? 11 Risks for Cannabis Addiction 11 Early and Heavy Marijuana Use 12 Marijuana and Nicotine 13 Gender Differences 13 Social Influences 14 Attitudes Toward Marijuana Use 15 Psychiatric Vulnerability 16 Treatment and Recovery 16 Seeking Treatment 16 Evidence-based Treatment for Adolescents 17 Evidence-based Treatment for Adults 17 Treatment Works! 19 Marijuana Dependence and Treatment at Caron 20 References

3 Forward Hoover Adger, Jr., MD, MPH, MBA Professor of Pediatrics Johns Hopkins School of Medicine M Marijuana is the most commonly used illegal substance in the United States. Its use is associated with educational underachievement, reduced workplace productivity, motor vehicle accidents, and increased risk of use of other substances. While current surveys document a steady decline since 1991 in the use of marijuana among youth, current rates are still almost thirty percent higher than the nadir that we experienced, in the early 1990 s, in the United States. Even more concerning is the recent decline in perceived risk and disapproval of use of marijuana by our youngest individuals which may suggest a change in the direction of recent progress that has been made in this area. Over the past two decades, scientists have further substantiated the adverse effects associated with the use of this drug. Cannabis-Marijuana: Addiction, Treatment and Recovery, provides a thorough review of what is known about the drug, the associated consequences, and the evidence related to treatment and recovery. In addition, data from the Caron treatment and recovery experience further documents and supports the emerging science related to treatment for cannabis dependence. The report does an excellent job of presenting an upto-date synthesis of information related to the adverse health effects of cannabis abuse and addiction. Topics addressed include: medical consequences, cognitive impairment, psychiatric consequences and the impact of cannabis use on social development. The data that are presented highlight the recent concerns that have been raised regarding impairment in short term memory; the potential role of cannabis in injuries and motor vehicle accidents; chronic bronchial inflammatory changes and evidence suggesting a causal role of cannabis smoking in upper airway cancers in young adults. It also shows new information suggesting a substantial involvement of cannabis use in various psychiatric disorders including: schizophrenia; depression; anxiety or panic disorders; and behavioral disorders in young people; a causal link to poor psychosocial outcomes among adolescents; and new data supporting earlier evidence that maternal use of cannabis during pregnancy may lead to subtle but significant developmental problems in offspring. Important information is provided on risk factors for addiction, marijuana and tobacco use, and gender differences. This information is anchored by a discussion of treatment and recovery and evidence in support of treatment. This is a well written and well researched article that provides an impressive overview of the topic area and should help the reader to have a much better understanding of the most commonly used illicit drug in the world, cannabis. 5

4 6 Marijuana: Addiction,Treatment, and Recovery P Pot, herb, weed, grass, ganja, hash and dope are some of the many names for the most widely used illicit drug in the world cannabis. The hemp plant, cannabis sativa, produces two of the most commonly used illicit drugs marijuana and hashish. Marijuana is a dried mix of flowers, stems, seeds, and leaves of the hemp plant. Hashish is the more resinous and concentrated form of the hemp plant. Marijuana, hashish, and other forms of cannabis are potent substances that alter mood, perceptions, and sensations. They also can become addictive and harmful. This report describes the many aspects of cannabis use, including the extent of its use, its psychoactive and addictive properties, consequences of prolonged use, risk factors for addiction, and treatment and recovery from cannabis use disorders. Although marijuana is one type of cannabis, this report will use marijuana for any type of cannabis use, and will use cannabis for cannabis disorders, such as abuse and addiction. What Is Marijuana? Marijuana is the most widely used illicit drug in the United States, and over 50% of Americans report they have had an opportunity to use the drug. 1 Given the easy access to marijuana, most people who have the opportunity to try it, do so. In 2004, approximately 14.6 million Americans used marijuana compared to only 2 million Americans who used cocaine and less than 200,000 who used heroin. Additionally, over 25 million Americans had histories of marijuana use. 2 Over 2 million Americans begin to experiment with marijuana each year, and approximately 1.3 million of these new users are adolescents. 2 The Monitoring the Future studies (sponsored by the National Institute on Drug Abuse and conducted by the University of Michigan), which track student drug use, have found that marijuana use among high school students rose sharply in the mid 1990s to the late 1990s. Then its use began to decline slightly among middle school and high school students. 3 Currently, almost half of high school seniors report they have used marijuana at least one time, and almost 6% use it daily. 3 Marijuana did not attain its current popularity until the 1960s. While only 2% of teenagers born between 1930 to 1940 have used the drug, approximately half of the teenagers born between 1956 to 1965 have used it. 4 Since marijuana s peak use in the 1960s, new users of marijuana have become younger and younger. In the 1960s and early 1970s, most users tried marijuana for the first time when they were over 18 years of age. However, in the mid to late 1970s, most new users were older adolescents, and since then most users tend to start marijuana use in early to mid adolescence. 5 More alarming was the rapid increase in daily use of marijuana among teens. By 1978 one in nine high school seniors (over 10%) reported they were using marijuana for at least 20 days a month. 3 Marijuana s Actions and Effects Marijuana, hashish, and other forms of cannabis get their psychoactive properties from delta-9-tetrahydrocannabinol (THC), a potent chemical found in cannabis. THC is found in all parts of the hemp plant, but is most concentrated in the flowering tops of the plants and is least concentrated in the stems and seeds. Thus, the THC potency of marijuana tends to range from.5% to 14% depending upon the parts of the plant used, growing conditions, and the plant s genetic properties. Hashish, which is produced by extracting and drying resin from the plant s flowers, also varies in concentration of THC, although THC can be as high as 20%. 6 Years of cultivation and plant breeding have increased THC potency dramatically. In one decade between 1992 and 2002, the potency of THC confiscated by law enforcement increased from 3% to 5%, an overall increase of 66%. 7 The actions of THC and other cannabinoid chemicals are complex and are not completely understood. 6 THC is only one of more than 60 unique chemicals found in cannabis. When THC is isolated from the other cannabinoids, its effects can differ from the effects produced when cannabis is consumed intact. In our brains, THC connects to specific nerve cells on sites called cannabinoid receptors. These receptors are found in parts of the brain that regulate movement, coordination, and cognitive processes such as learning, memory, judgment, perception, and concentration. The cannabinoid receptors usually are regulated by endogenous cannabinoids that are naturally found in our brains and have very similar chemical structures to THC. When marijuana is used, THC overstimulates the cannabinoid receptors and disrupts the normal connections between the receptors and our brain s natural endogenous cannabinoids. THC usually is ingested by smoking it in handmade cigarettes, water pipes, or regular pipes, and by consuming it in food or drink. Recently, marijuana rolled in cigar wrappers called blunts has become popular. Marijuana is used alone or in combination with other drugs, nicotine, and alcohol. When smoked, THC passes from the lungs to the bloodstream and is carried to the brain, as well as other areas in our bodies. Smoking marijuana results in higher levels of THC in the blood. The effects are experienced within 10 minutes of smoking and last from one to three hours. Absorption into the bloodstream is much slower when THC is consumed by mouth-within about one-half to one hour-although the effects last as long as four or five hours. 6 THC is easily stored in fat cells, and its slow release explains why traces of THC can be detected in chronic users for a week or much longer after consumption. Immediate effects of THC ingestion include rapid heartbeat, relaxation, enlargement of the bronchial passages, and expansion of blood vessels in the eyes. 6 People also report an altered state of consciousness and mild euphoria as THC activates the brain s reward system. Users tend to experience pleasant sensations, colors, and sounds that become more intense, while perceptions of time and spatial awareness become distorted. Motor skills and reaction time also are impaired. Feelings of hunger and thirst become pronounced, and people often experience dry mouth. Following the initial euphoria, users can become tired or depressed, occasionally feel anxious or distrustful, or experience panic. Cannabis Abuse and Addiction Cannabis abuse and dependence are psychiatric terms used to classify users by their severity of use and levels of impairment. 8 Abuse refers to repeated instances of use, or recurring use, in hazardous situations, such as driving or operating machinery, despite significant social impairment such as poor work or scholastic performance, legal problems, and interpersonal problems. Dependence is the psychiatric diagnostic term used to describe the condition of severe impairment due to chronic drug abuse. This report refers to dependence by its more commonly accepted term addiction. Dependence can be a confusing term because it is often thought of only in terms of physical dependence, such as a person s tolerance for the drug and the person s withdrawal symptoms when the drug is discontinued. A person can become dependent on (addicted to) a drug, including marijuana, without showing signs of physical dependence. Physical dependence often occurs during proper medical use of certain medications, when other signs of drug dependence do not develop. Cannabis addiction results from continued use, and the addiction produces a number of negative behaviors. Addiction is characterized by increases in the frequency of use and/or amount of cannabis used, a preoccupation with use-related activities, and an inability to cut down or control use despite persistent physical, psychological, or social problems caused or acerbated by its use. Physiological changes also can occur that affect how people respond to cannabis, such as tolerance to its effects and withdrawal symptoms upon cessation. Cannabis is recognized as a substance that can produce addiction. It is estimated that almost 10% of people who have ever used marijuana will develop an addiction. 9 Approximately 1% of the American population is estimated to meet diagnostic criteria for cannabis addiction, including 2.6% of adolescents and 3.5% of young adults, aged 18 to 25 years. 5 Among American adults, rates of cannabis abuse and addiction have increased from 18% at the beginning of the 1990s to over 35% in the early 2000s. 7 Cannabis addiction is also an issue for adolescents, and the risk of them becoming addicted increases significantly in later adolescence and early adulthood. A recent study in Colorado found that a slightly higher proportion of adolescents were diagnosed with cannabis addiction (4.3%) over alcoholism (3.5%), even though alcohol is more easily obtained than marijuana and more often abused. 10 The high rates of cannabis addiction can be seen in the prevalence of younger patients who are admitted to Caron for cannabis treatment. From January 2000 through June 2005, almost 1,000 patients were admitted to Caron s residential treatment program for cannabis addiction. 11 As shown in Figure 1, over half of these patients were under 30 years of age. Figure 1. Number of patients admitted to Caron for cannabis addiction, Years (n=404) 56 and Older (n=49) Under 16 Years (n=30) Years (n=218) Years (n=284) Symptoms of Addiction Two physiological characteristics of addiction are tolerance to cannabis and withdrawal symptoms following abrupt cessation of use. Tolerance occurs when a person s response to a drug decreases so that larger doses of the drug are required to achieve the same effect. Tolerance is due to decreased sensitivity to the drug as the result of repeated exposure. Both biological processes and learning are believed to cause 7

5 tolerance. Because tolerance limits the effects of the drug, people generally experience withdrawal symptoms when they do not increase the amount of drug needed to counteract the effects of tolerance. Thus, the development of tolerance generally leads to higher levels of consumption of the drug to obtain the acute effects of euphoria and to avoid negative withdrawal symptoms. Marijuana appears to affect the brain in ways that are similar to other drugs, such as opiates, nicotine, and cocaine, and tolerance to the drug can develop with chronic heavy use. Tolerance to the effects of marijuana is thought to be influenced by the amount and chronicity of use, and the individual differences in people s biological sensitivity to marijuana. Tolerance is less common in cannabis addiction than in other drug addictions, such as addiction to alcohol and heroin. Adolescents appear likely to develop tolerance even though they use marijuana less frequently than adults. 12 Animal and clinical studies have also identified a withdrawal response. 13 Abrupt cessation of chronic moderate to large Figure 2. Aspects of marijuana cravings at admission Compulsivity Emotionality Expectancy Craving Factors Purposefulness choice long after withdrawal symptoms have subsided. People with cannabis addiction who do not show signs of physical dependence through tolerance or withdrawal symptoms can still have cravings when they are abstinent from marijuana. For Craving Levels Medical Consequences A number of harmful medical problems can be caused by chronic heavy marijuana use. Because marijuana is usually smoked, it is not surprising that even light use can cause respiratory problems, such as heavy coughing, irritation, and stinging of the nose and throat. Frequent chest illnesses, chronic bronchitis, and the risk of lung infections can occur from more severe use. Marijuana smoke also can be related to the development of cancer of the respiratory tract and lungs because the smoke contains irritants and carcinogens. 20 Marijuana smoke contains between 50% to 70% more cancer-causing agents than tobacco smoke. Because marijuana smokers inhale deeply and hold their breath for a long time, they have increased exposure to the carcinogens. There is some evidence from human and animal studies that THC, the active component in marijuana, can impair the immune system and increase the risk of cancer. 9 In addition, people are more prone to heart attacks shortly after In addition, even occasional use of marijuana can be dangerous. Marijuana intoxication impairs attention, judgment, coordination, short-term memory, and balance and can increase the likelihood of accidents. In fact, up to 11% of fatal accident victims test positive for marijuana. 20 Almost onequarter of adolescents admitted to hospital emergency rooms used marijuana. 5 The National Highway Traffic Safety Administration found that a moderate amount of marijuana is sufficient to impair driving performance, and the combined effects of marijuana and alcohol are much greater than for either drug alone. 20 Psychiatric Consequences High doses of, or the use of very potent marijuana can trigger symptoms of panic, anxiety, psychosis, and depressed mood. 25 These symptoms generally subside as the psychoactive effects of the marijuana wear off. Marijuana does not appear to cause psychiatric illnesses, doses of marijuana can produce withdrawal symptoms. 9 Commonly reported cannabis withdrawal symptoms include decreased appetite and weight loss, irritability, nervousness or anxiety, anger and aggressive behavior, restlessness, and sleep disturbance with strange dreams. Some less commonly reported symptoms include depressed mood, stomach pain, chills, shakiness, and sweating. 14 Cannabis withdrawal symptoms usually begin less than one day after stopping marijuana use, and may produce significant discomfort lasting for one to four weeks. 15 Withdrawal symptoms can be more severe for people with psychiatric problems. 14 Cravings for marijuana are reported by many users after cessation. 16 Cravings are a complex phenomenon with subjective, behavioral, and physiological aspects. Cravings can be experienced differently depending upon the person s perceptions, physical state, or environment. Different types of cravings include a compulsive uncontrollable need to use the drug, the anticipation of relief from unpleasant emotions or from withdrawal symptoms, the expectation of positive outcomes, or a state of purposeful planning to use the drug. 17 To learn more about cravings in cannabis addiction, we surveyed a sample of 64 patients at Caron who reported marijuana abuse in the month prior to admission, and resurveyed them during the week prior to discharge. 18 At admission, we asked patients about their total level of cravings, and categorized cravings into four types: compulsive use, emotional relief, positive expectations, and purposefulness of plans to use marijuana. 17 As you can see in Figure 2, on average, patients experienced moderate levels of each type of craving prior to treatment. Although cravings often occur when a person has stopped drug use, cravings are not symptoms of withdrawal. People in recovery from drug addiction frequently experience cravings for their drug of example, by the end of treatment, the severity of three types of cravings emotional relief, positive expectations, and purposefulness significantly reduced for most patients at Caron, as did cravings overall. However, the uncontrollable compulsive aspect of craving remained high for some patients throughout treatment. The sense of an uncontrollable need to use marijuana can persist for a long time following withdrawal and treatment. People who are not strongly motivated to use drug refusal skills that are learned in treatment can be vulnerable to relapse. Tolerance, withdrawal, and cravings all contribute to the uncontrollable and compulsive drug seeking and using behaviors that are at the heart of addiction. A large sample of Australian young adults revealed that the most commonly experienced symptoms of cannabis addiction were a persistent desire for marijuana, followed closely by uncontrolled use and withdrawal symptoms. 19 These behaviors make it very difficult for people to abstain successfully from marijuana. Consequences of Cannabis Abuse and Addiction Chronic long-term use of marijuana can lead to a number of harmful consequences. Persistent use has been shown to be harmful physically to users and to fetal development in pregnant users. Heavy marijuana use also impairs cognitive functioning. Prolonged and heavy use is related to the development of a number of psychiatric problems, including anxiety, depression, and schizophrenia. Marijuana use also is linked to impediments to social development, such as involvement in risky sexual behaviors, poor academic performance, and an increase in delinquency, crime, and violent behavior. Although the verdict is still out regarding marijuana s role as a gateway drug, we do know that early use of marijuana puts young people at risk for involvement with other drugs. smoking marijuana than at other times because smoking marijuana raises blood pressure and heart rate and at the same time reduces the oxygen-carrying capacity of the blood. 21 Chronic marijuana use also appears to increase the risk of stroke. 9 Pregnant women who use marijuana also can jeopardize fetal development. Smoking marijuana during pregnancy is associated with lower birth weight and shorter gestation periods. Babies and young children born to women who smoke marijuana during pregnancy often have more behavioral problems (such as not paying attention and impulsive behavior 22 ) than other children who were not exposed to marijuana before birth. Cognitive difficulties of marijuanaexposed children include impaired learning and memory skills. Cognitive Impairment Heavy marijuana use can impair short-term memory, attention, and coordination of movement. These cognitive impairments tend to decrease with abstinence. However, the negative effects of marijuana on the brain can persist for heavy users. At 28 days following cessation of marijuana use, a sample of former users were given a battery of neurocognitive tests to assess their cognitive functioning. 23 The heavy daily users tended to show higher levels of impairment than the light users on tests measuring memory, reasoning, visual perception, and motor skills. Also, as people grow older, they naturally lose nerve cells in the area of the brain responsible for short-term memory the hippocampus. The hippocampus has many cannabinoid nerve cells, and long-term exposure to marijuana can quicken agerelated memory loss. 20 A recent study found that people who averaged 24 years of regular marijuana use performed much poorer on tests of memory and attention than people who averaged 10 years of use, or people who never used marijuana. 24 although it may precipitate a psychiatric episode in persons who are predisposed to psychiatric illness. However, despite this possibility, over 12% of American adults who have tried marijuana suffer from a serious mental illness. 26 People who begin to use marijuana in childhood are twice as likely to have a serious mental illness, compared to people who first try marijuana as young adults. 26 As shown in Figure 3, almost 80% of patients who abuse marijuana experienced symptoms of depression and/or anxiety in the month prior to admission at Caron. 18 Schizophrenia is a serious chronic mental illness that affects about 1% of the population. It is characterized by symptoms such as hearing voices not heard by others, believing other people have special powers over you, and disorganized speech and behavior. 8 The relationship between marijuana use and schizophrenia is well documented. Young people diagnosed with cannabis dependence have rates of psychotic symptoms that are over twice the rates of young people who are not cannabis dependent. 27 Figure 3. Patients with symptoms of depression and anxiety Depression Neither Anxiety Depression and Anxiety 8 9

6 However, the nature of the relationship has been controversial and we do not know if schizophrenia leads to marijuana use, if marijuana use causes schizophrenia, if both conditions are Marijuana also has been found to have a negative impact on school performance. Early adolescent marijuana use decreases the likelihood of graduating from high school, 29 and is Figure 5. History of violent behavior Male Female account for marijuana use leading to harder drug use. Second, an interaction between environment and genetic vulnerability could explain why drug use generally progresses from initial marijuana caused by something else, or if the relationship is more complex. A review of studies on the relationship between schizophrenia and marijuana concluded that marijuana use doubles the risk of developing schizophrenia, increases risk as greater amounts or potency of marijuana are used, and results in a higher risk for vulnerable people with a predisposition to schizophrenia. 28 Social Development Regular or heavy marijuana use is associated with a range of social difficulties in adolescence and young adulthood. Young marijuana users are at risk for other detrimental health behaviors and for poor academic performance. People who abuse or who become dependent on marijuana are at risk for delinquency and crime, and heavy use can trigger violent behavior. Marijuana use is associated with unprotected sexual intercourse, especially in adolescents. For example, a survey of a large inner-city sample of students found that early adolescent marijuana use increased the risk five years later of having multiple sexual partners and not always using condoms. 29 Unprotected sexual behavior puts people at high risk for HIV and AIDS, hepatitis C, and other sexually transmitted diseases. Females are at risk for unplanned pregnancy. As shown in Figure 4, the risk of unprotected sex continues into adulthood for the 64 patients studied at Caron who were admitted for marijuana abuse and dependence. 18 Over 90% of adolescent and adult patients reported prior sexual intercourse. Surprisingly, the adolescent patients reported less risky sexual behaviors than did the adults, although no statistical differences in use of drugs and alcohol with sex and use of condoms were found between the groups. Half of the Caron patients reported they first engaged in sexual intercourse before they were 16 years old, and approximately 50% had at least six sexual partners in their lifetimes. Figure 4. Risky sexual behaviors Sexual Intercourse Drugs, Alcohol & Sex Condoms & Sex Adolescent Adult Percent of patients associated with problems at school. Regular and heavy marijuana use also is associated with juvenile delinquency, crime, and violent behavior. A study 30 that followed over 1,000 New Zealanders for their first 21 years of life found that young people who reported at least weekly marijuana use had an increased risk of engaging in violent crimes and in crimes against property. Marijuana use also might promote interpersonal violence, and a number of studies have found strong relationships between marijuana use and violence. A major review of the scientific literature on marijuana and interpersonal violence 21 found that marijuana use is very common among men who are violent toward their intimate partners. However, the review also states that scientifically controlled laboratory studies of violence and marijuana are inconclusive. Moore and Stuart, the authors of the review, concluded that marijuana use can trigger violent behavior in a number of ways. 21 First, marijuana intoxication causes cognitive impairments that can decrease the ability of a person to understand complex interpersonal conflictual interactions, and can increase the likelihood of aggressive responses to conflict. Also, intoxication increases heart rate, panic reactions, and paranoid feelings associated with violent behavior. Second, withdrawal also can produce irritability and anger that can lead to aggressive behavior. Patients in treatment at Caron for cannabis abuse and dependence generally reported high levels of violent behavior. 18 As shown in Figure 5, similar percentages of male and female patients reported violent behavior in the month prior to admission and within their lifetime. Most people who are intoxicated with, or in withdrawal from, marijuana do not become violent, and many people become violent when they are not under the influence of marijuana. Violent behavior can be related to personal histories of violence, temperament, psychiatric disorders, the immediate setting, and a sense of threat, 21 and not necessarily related to intoxication or withdrawal. Marijuana: A Gateway Drug? Gateway drug is a term used to describe a drug that is supposed to lead to the abuse of other more dangerous drugs. The gateway drug effect is based on the premise that something intrinsic to the gateway drug, such as the way it affects the brain, produces long-lasting changes that cause progression to the abuse of more dangerous and addictive drugs. Tobacco and alcohol are gateway drugs to marijuana use, and underage use of Violent Behavior Past Month Lifetime these legal substances predicts an addiction to cannabis. Adolescents who drink alcohol at least once a week are more likely than others to initiate marijuana use. 36 Marijuana has long been considered a gateway drug leading to the initiation of, abuse of, and addiction to drugs such as heroin and cocaine. However, the designation of marijuana as a gateway drug is still controversial. Scientists who support marijuana as a gateway to harder drug use point to three types of evidence. 31 First, marijuana users tend to have much higher risks for progression to other drug use than people who do not use marijuana, and the younger people are when they begin to use marijuana, the more likely they will progress to other drugs. This observation could support the premise that marijuana produces changes in a person s brain that promote further drug use. Second, adolescents rarely begin to use drugs such as cocaine and heroin before they use marijuana. Instead, adolescents usually progress from marijuana use to the use of harder drugs. Proponents of the gateway drug theory of marijuana hypothesize that brain changes caused by chronic marijuana use make users vulnerable to further drug use. Third, there is a strong relationship between the frequency of marijuana use and the risk of addiction to other drugs. Chronic and heavy users of marijuana are more likely to progress to harder drugs than are light and infrequent users, lending support to the hypothesis that marijuana produces changes in the brain that can lead to other drug abuse and addiction. However, the evidence of a gateway effect can be explained differently to support a common-factor theory of how marijuana and initiation to other drug use are related. 31 Under the commonfactor theory, marijuana addiction and addiction to harder drugs are hypothesized to be due to a combination of genetic predisposition (an underlying tendency) toward drug use and environmental influences. The common-factor theory counters the gateway effect in the following ways. First, underlying genetic vulnerability to addiction in general not brain changes caused by the marijuana could Percent of patients use to harder drugs. It is easier for adolescents to obtain marijuana over other drugs, and adolescents generally believe it is acceptable to use marijuana. Some adolescents who are vulnerable to drug addiction progress to harder drugs as they enter a drug subculture that offers more opportunities to try harder drugs. Third, increased availability and the acceptability of hard drug use by chronic marijuana users could explain why chronic and heavy users of marijuana are more likely to progress to harder drugs than are light and infrequent users. Neither the marijuana gateway effect nor the common-factor theory disproves the other. Both theories can explain the phenomenon of progression from initial marijuana use to addiction to harder drugs such as cocaine and heroin. Social environments in which marijuana is easily accessible and acceptable to young people could lead to early initiation of marijuana use that becomes chronic for vulnerable individuals. Chronic marijuana use could produce brain changes that lead to vulnerability to other drugs. Likewise, a predisposition to drug addiction could lead young marijuana users to become chronic users who are more likely to experience these brain changes. Regardless of whether or not marijuana is shown to be the active agent that causes future addiction to harder drugs, we do know that the use of marijuana introduces young people to a drug subculture that provides access to marijuana and promotes the use of other drugs. Risks for Cannabis Addiction Most people who develop addictions have a number of risk factors. These risk factors include early and heavy abuse of marijuana; use of nicotine; male gender; social influences and relationships with other people who use drugs and alcohol; attitudes toward drug use; and psychiatric vulnerability. Risk factors have a cumulative effect and addiction generally does not occur without warning signs. Early and Heavy Marijuana Abuse A powerful risk factor for cannabis addiction is early initiation to marijuana. The younger the person is when he or she first tries marijuana, the more likely he or she is to become addicted to it. A long-term study found that students who began using marijuana in elementary school were four times as likely to use the drug in middle school than students who did not initiate use in childhood. 32 In addition, early initiation to marijuana is related to a number of other negative consequences. First use of marijuana at an early age increases the risk of becoming delinquent, engaging in sexual 10 11

7 risk behaviors, using other illicit drugs, having friends who also exhibit deviant behavior, and not graduating from high school. 29 Figure 7. Tobacco and marijuana use Figure 8. Mixing nicotine and marijuana in blunts Figure 9. Gender differences in cannabis addiction admissions Male Female Early initiation into marijuana use can increase the risk of developing an addiction to cannabis because people who begin to use marijuana at young ages also are likely to use it in a compulsive way and become out of control more frequently than users of alcohol. 33 For example, one study 33 found that even oncea-week use predicted later development of cannabis addiction. Adolescents seem to develop the symptoms of addiction to cannabis at a lower frequency and amount of use than do adults. 34 As shown in Figure 6, patients admitted to Caron for cannabis addiction, report a high frequency of use. 18 Over three-quarters of these patients reported using marijuana 14 or more days in the month prior to admission, and over half reported daily use. Figure 6. Frequency of marijuana use in month prior to admission Less than 7 Days Lifetime Tobacco Use Daily Tobacco Use Always Smoke Tobacco and Marijuana quarters of these patients report they always smoke tobacco when they smoke marijuana. It is possible that the higher rates of tobacco use found in our residential sample reflect higher levels of psychosocial problems Percent of patients Sometimes Often Always Rarely Never Frequency of nicotine use does not seem to be related to later cannabis dependence. Instead, nicotine use appears to be related to a social environment that promotes underage use of legal substances 33 and to adult use of nicotine. Adolescents whose fathers smoke tobacco are at greater risk than other Age Group Under The higher prevalence of male marijuana use appears to be related to opportunities to try the drug. Male adolescents appear to have more opportunities to be introduced to marijuana than do female adolescents. 1 However, given the opportunity to use the drug, females seem just as likely as Percent of Cannabis Admissions than those found in outpatient populations. A survey of cannabis- adolescents to begin to use marijuana. 43 males to try it. Interestingly, females are more likely to become 28 or More Days 7-11 Days Days addicted patients admitted to outpatient treatment found that tobacco smokers had higher psychiatric severity, a greater number of legal problems, lower education levels, and lower incomes than non-tobacco smokers. 39 Tobacco smoking also was related to earlier age of initiation to marijuana and greater alcohol severity. Marijuana and nicotine use generally are combined by alternating Marijuana also could be a gateway to nicotine use, especially for people who smoke blunts. Marijuana use also reinforces nicotine use because both substances are inhaled by taking smoke into the lungs. Smoking either substance (or both together in a blunt) can become a trigger to use the other one. Thus, continued use of one substance can make it more difficult to abstain from using addicted at lower levels of use than are males. 34 Females also are more likely to use tobacco prior to their introduction to marijuana, while males are more likely to precede marijuana use with alcohol. 42 In fact, female adolescents are more likely to develop an addiction to nicotine, compared to male adolescents who are more likely to become puffs of cigarettes and joints (marijuana cigarettes). Recently, in the other one. Marijuana users can experience greater difficulty addicted to alcohol and cannabis. Delaying marijuana use might not be sufficient to reduce the the United States, the use of blunts have become popular quitting nicotine than nonusers. In fact, a number of marijuana negative consequences of use. One study found that adolescents who started marijuana use after the age of 13, but who steadily increased their use throughout adolescence and young adulthood, were more likely to use other illicit drugs than adolescents who started marijuana use younger than 13, but who did not increase their use over time. 35 High frequency use could be due to social and psychological reinforcers of drugtaking behavior and to the addictive properties of the drug itself. Marijuana and Nicotine People who smoke tobacco are more likely to use marijuana than those who do not smoke tobacco, 37 and nicotine use often precedes marijuana use. However, recent research suggests that marijuana also might serve as a gateway to tobacco use. 38 Either way, smoking both substances increases health risks and can lead to greater rates of addiction to nicotine and marijuana. Surveys of cannabis-addicted patients in outpatient treatment have found that approximately 50% of the patients also smoke tobacco. 39 As shown in Figure 7, patients in treatment for a marijuana disorder at Caron have much higher rates of marijuana and nicotine use. 18 Over 95% of the patients reported they have used a tobacco product in their lifetime, and over 80% smoke cigarettes on a daily basis. In addition, more than three- among some groups of marijuana users. Blunts are tobacco leaves or cigar wrappers filled with marijuana. Gutted-out cigars also are used to contain marijuana. Other drugs, such as heroin, cocaine, PCP, methamphetamine, and embalming fluid, also can be added to blunts to achieve different effects. The use of blunts has been related to increases in emergency room and drug treatment admissions. 40 Male adolescents are more likely to use blunts than females, and blunt use also is associated with poor scholastic achievement, belonging to a single-parent family, nonwhite race, and use of both cigarettes and cigars. 41 Although use of blunts has become more common, it probably is not the most common method of using marijuana. As seen in Figure 8, very few Caron patients report they always mix tobacco and marijuana in a blunt. 18 In fact, over two-thirds of Caron patients either rarely or never mix tobacco and marijuana. As mentioned above, tobacco use often is a precursor of marijuana use and can be a risk factor for cannabis addiction. The earlier children begin to use legal substances such as tobacco and alcohol, the more likely they will turn to illicit drugs such as marijuana. Older adolescents who began smoking tobacco before the age of 13 are more than three times as likely to have used marijuana than those who did not smoke. 42 users who have been interviewed about their nicotine use report they have tried to quit tobacco but were not able to stop its use. 44 Gender Differences Modest gender differences have been found in the initiation to, and heavy use of, marijuana. In general, males and females are more alike than different in their use of marijuana. However, surveys have found that males appear slightly more likely to use marijuana than females, and more likely to develop an addiction to it. While over 7% of male high school seniors reported using marijuana on a daily basis in 2004, only 3% of female seniors reported daily use. 3 As shown in Figure 9, gender interacts with age in patients admitted for cannabis addiction at Caron. 11 From 2000 to mid 2005, almost 62% of patients admitted for cannabis addiction were male. However, gender differences do not appear until young adulthood, when Caron generally admits a higher proportion of male cannabis-addicted patients than female patients. Although slightly more young adolescent, middleaged, and older females are admitted for cannabis addiction than males in those age groups, gender differences are not as pronounced as for the younger adult group. Social Influences Early initiation and heavy use of marijuana, and the use of nicotine, alcohol, and other drugs are strongly related to social influences. These influencing factors include families, friends, and scholastic performance. Most of us begin our lives within a family unit that can vary from a single-parent to a multigenerational extended family unit. The people who raise us from birth through young adulthood have a profound and lasting influence on our development. Parents can influence future marijuana use and can become a protection against abusive drug use. For example, children who identify with their parents and who experience a strong family bond are less likely to begin to use marijuana than are those who do not emulate their parents. 43 On the other hand, parental drug and alcohol use and family conflict predict marijuana use. 43,45,46 Parents who set, monitor, and enforce reasonable rules and limitations also tend to protect their children against early initiation to marijuana. In addition, the family value of religious attendance also serves as a protective factor against early marijuana initiation. Siblings, one s sisters and brothers, also are important influences. Sibling alcohol use also predicts marijuana initiation

8 Peers are our contemporaries and usually are defined as people who are similar to us. Peers make up the friendship networks of adolescents. A hallmark of adolescence is the do not hold part-time jobs or who work fewer hours. 51 Students who work can have extra money to spend on drugs. They also could be less committed to school and spend less time on frequently expect positive consequences, such as feelings of relaxation, mind expansion, and social enjoyment. 54 Furthermore, the belief that marijuana will produce relief from negative moods Figure 12. History of psychiatric distress importance of peer culture or the values and expectations of friends. Although parents remain important throughout life, peers become more important to adolescents and often overtake parental values as people mature. Peer culture has been found to be an especially important schoolwork. As shown in Figure 10, less than 10% of the adolescents in treatment at Caron for cannabis disorders report they do not work, and almost 20% work more than 20 hours a week. An underlying theme of commitment including lack of commitment unites the social predictors of cannabis tends to be associated with cannabis addiction. 55 As shown in Figure 11, the highest average score on the Marijuana Motives Measure 56 (on a scale from 1-25) for Caron patients is the motive to use marijuana for enjoyment and to get high. 18 The other motives for using marijuana appear to be factor in adolescent initiation to marijuana use and the development of cannabis addiction. Adolescents are strongly influenced by the attitude and behaviors of their friends regarding drug use. Adolescents with friends who use marijuana and who have positive attitudes toward marijuana are more likely to initiate use themselves. 47 Characteristics of these peer groups also include other deviant behaviors such as underage alcohol and tobacco use and delinquency. Adolescents choose their peer groups and friends. Most likely, adolescents who are susceptible to cannabis abuse select peer groups that have favorable attitudes toward the drug and use it. Friends, however, remain a strong influence on a person s marijuana use. The negative attitudes of one s friends toward marijuana use strongly influence a person s likelihood to stop marijuana use. 48 One of the major tasks of early recovery is the development of sober and abstinent friends and peer groups. On the other hand, peers are a major source of marijuana, especially for adolescents. Over 80% of adolescents obtain their marijuana from a friend, either for free or purchase. 49 Initiation to marijuana use also is predicted by poor academic performance. Adolescents who earn grades of C or lower have twice the risk of starting marijuana use in the next year compared to those whose grades are higher. 50 In addition to poor academic performance, school-related predictors include truancy and school dropout. Interestingly, part-time employment during high school also is associated with marijuana use. Students who work between 26 to 31 hours a week are more likely to use marijuana than those who Figure 10. Adolescent employment status Hours/Week Hours/Week Irregular Hours Unemployed addiction. 52 People who become addicted to cannabis are less committed to family, religion, and school than others. They also show a higher commitment to deviant peer groups. Attitudes Toward Marijuana Use Attitudes toward marijuana and the availability of marijuana are important predictors of subsequent marijuana use. A person who approves of marijuana use and who has easy access to the drug is much more likely to use it than a person who disapproves of marijuana or who is unable to obtain it. From 1975 through 1978 the perceptions of harm from marijuana decreased among high school students. During the late 1970s and throughout the 1980s the perception of harm increased as the use of marijuana dramatically decreased. However, in the early 1990s perceived risk again began to drop, again followed by an increase in use. 3 These national data show that attitudes about marijuana precede changes in its use. The increase in positive attitudes toward marijuana use that resumed in the 1990s could be due to a number of events. 3 A decrease in media coverage of the harmful effects of the drug, a decrease in anti-drug advertisements, and a decrease in funding for drug abuse prevention programs in schools, all occurred during this period. At the same time, popular music groups began to highlight positive aspects of marijuana in their music. Additionally, it is possible that parents who came of age in the 1960s during the earlier surge of marijuana use might not have known how to tell their children to avoid drugs. New educational initiatives and decreases in media glorification of drug use could trigger a trend toward an increase in the appreciation of the risks of marijuana. People who hold positive attitudes toward drug use also might misperceive the prevalence of drug use among their friends. For example, college students who use marijuana believe that marijuana use on their campus is higher than is actually reported. 53 Thus, although peers are significant predictors of marijuana use, use of the drug also can change a person s perceptions about peer group use. Attitudes toward marijuana use influence initiation to the drug, but do not explain the development of addiction. Addiction could be more strongly related to a person s motives for using the drug. People who do not use the drug and who hold negative attitudes toward marijuana also expect that its use will result in negative consequences. Alternatively, people who use marijuana less important to these patients. One of their treatment goals will be to find other more appropriate ways to enjoy themselves besides using marijuana. Figure 11. Motives for marijuana use Expand Awareness Conformity Enjoyment & High Be Sociable Cope with Negative Mood Average Score 1 Psychiatric Vulnerability As discussed earlier in the Psychiatric Consequences section, we have seen that marijuana can trigger a psychiatric disorder in people predisposed to it. Psychiatric disorders also appear to increase the risk of marijuana use. Psychological predictors of marijuana use include poor control of emotions, depression, anxiety, poor coping skills, low self-concept, deviance, rebelliousness, and an inability to be empathetic with others. 46 Psychiatric conditions, such as depression, posttraumatic stress disorder, and conduct and antisocial personality disorders have been found to precede and predict future marijuana use. High rates of psychiatric problems have been found among people who are addicted to cannabis. Approximately 90% of this population has experienced a psychiatric illness during their lifetime. 57 Rates of psychiatric illness also are high for patients admitted to Caron who have used marijuana in the month prior to treatment. 18 As shown in Figure 12, over 15% of these patients report they were treated at least one time in an inpatient psychiatric hospital, and over 12% receive a pension for a psychiatric disability. More than 23% of these patients have experienced suicidal thoughts in their lifetime, and over 10% have tried to commit suicide. In addition, over 62% of the patients are prescribed a psychiatric medication, and more than 73% have experienced serious depression or anxiety Inpatient Psychiatric Treatment Psychiatric Pension Lifetime Suicidal Thoughts Lifetime Suicidal Attempt Clinicians have long been aware of a link between marijuana use and mood disorders such as depression and bipolar disorder. However, we have been uncertain whether the mood disorder preceded or was the result of chronic marijuana use. Recent long-term research has found that a depressed mood often precedes initiation to marijuana, indicating that depression is a risk factor for marijuana use. 9 People who are victims of violence, such as physical or sexual assault, or who have witnessed violence toward others are at an increased risk of developing posttraumatic stress disorder (PTSD), a psychiatric condition related to the experience of traumatic events. PTSD has been found to increase the risk of marijuana use. 58 Sensation seeking is a type of behavior in which people are drawn to novel, often risky and dangerous, experiences. Sensation seeking is a trait embedded in our biological makeup, and high-sensation seekers have brain differences that can reduce normal levels of stimulation. People with high sensation seeking needs appear to receive stimulation directly from drugs like marijuana, and also receive stimulation from being part of an illicit drug culture. 59 Sensation seeking behaviors among young adolescents have been found to predict increases in marijuana use. 60 Sensation seeking often is related to deviant and illegal activities. The psychological condition for this type of behavior is known as a conduct disorder or antisocial personality disorder. Children and adolescents are the main populations diagnosed with conduct disorder, and young adults are the population most often diagnosed with antisocial personality disorder. It is widely recognized that adolescents who engage in problem behaviors, such as delinquency, gang membership, aggression, and early sexual activity, are also likely to use marijuana. Although antisocial behavior can follow initiation to drug use, antisocial behaviors also have been shown to precede and predict later marijuana use. For example, one study found that antisocial behaviors displayed by 9- and 10-year-old children were the best predictor of marijuana and alcohol use in adolescence Percent of patients 14 15

9 Treatment and Recovery It takes more than willpower to recover from an addiction. Recovery requires a high level of motivation and the development of a new set of skills to avoid and abstain from drugs. Often people must make significant changes in their lifestyles to maintain their recovery. Treatment programs offer clinical expertise and experience to facilitate recovery. Recently, innovative treatment strategies for adolescents and adults have been tested in academic and community treatment settings. Many of these evidence-based treatment approaches have been incorporated into residential and outpatient treatment programs, such as Caron Treatment Centers. Overall, evaluations of treatment programs and strategies find that treatment works! People with serious addictions to drugs, such as marijuana, generally benefit from treatment in a number of areas of functioning, including the main problem of addiction. Seeking Treatment The 1990s saw a dramatic rise in the use of marijuana and initiation beginning at young ages. Currently, marijuana is the primary substance of abuse for 47% of adolescents admitted to publicly funded addiction treatment programs, 62 and the generation of new marijuana users could increase future demands for adult addiction treatment. If current rates of marijuana initiation continue, it has been estimated that the need for treatment will increase by 57% by People tend to enter addiction treatment because they, or people close to them, recognize negative consequences of their drug use and are unable to abstain from using drugs or alcohol on their own. The severity of cannabis addiction is not necessarily a predictor of seeking treatment. Adults who are addicted to cannabis and who have been treated previously, or who are alcoholic and depressed, are likely to seek professional help regardless of the severity. 64 How parents and the child perceive cannabis addiction predicts adolescent engagement in treatment. Parents who have positive expectations for their child, or who are aware of their child s deviant behaviors, are likely to seek treatment. It also found that these adolescents reported high levels of family conflict. 65 Adult and adolescent treatment programs should address the skills and lifestyle changes necessary to attain and maintain abstinence, and should address psychiatric, relationship, legal, and medical problems, when necessary. However, adolescents and adults differ in their treatment needs. Adolescents tend to be less motivated than adults to want treatment and tend to drop out of treatment prematurely if it is not designed to meet their needs. Thus, adolescent treatment programs should have age-specific strategies to motivate young patients. These programs also need to address academic-related problems and peer groups, because both of these factors predict continued use of the drug and relapse for adolescents. In addition, adolescents are not free to change their living arrangements, but often are embedded in dysfunctional family systems. Therefore, a major component of adolescent treatment is a focus on the family unit, with goals of increasing positive and effective family management and decreasing conflict and poor communication. Adult treatment programs, on the other hand, can focus more on employment skills and adult relationships. A number of treatment strategies for cannabis addiction have been rigorously tested in clinical trials. A clinical trial compares one or more treatments against each other. Generally, patients who volunteer to take part in a clinical trial are randomly assigned to a treatment group in order to minimize differences between the groups. Treatments that tend to produce good outcomes, such as lowering posttreatment use of marijuana and raising psychosocial functioning, are called evidence-based treatments because they have at least one study attesting to their efficacy. Since there are no pharmacological treatment interventions for marijuana that are supported by clinical trials, the available evidence-based treatments use psychological and behavioral methods. In addition, these treatments have been specifically designed either for adult or adolescent populations. Evidence-Based Treatment for Adolescents As mentioned earlier, adolescents often have low motivation for recovery. Motivational enhancement therapy (MET) is designed to increase motivation. Therapists who use MET are trained in empathic listening and accurate reflection of their patients. Instead of confrontation, MET s goal is to make the patient feel understood. MET therapists are not passive. They actively reflect on discrepancies between the patient s goals and behaviors in order to motivate the patient to take responsibility for change. MET was developed for use with adults, 66 and was adapted for use with adolescents in the Cannabis Youth Treatment Study. 67, 68 The study was designed to look at five different treatment interventions and develop evidence-based manuals that could serve as models for the treatment field for adolescents. Another treatment that was combined with MET in the Cannabis Youth Treatment Study is cognitive behavioral therapy (CBT). CBT was developed in the 1970s as a psychotherapeutic approach that promotes effective ways of thinking and behaving. It was adapted for use in the adult treatment of addictions, 69 and was recently adapted and studied as part of the Cannabis Youth Treatment Study. CBT helps patients to identify dysfunctional ways of thinking and to replace those thought patterns with more productive cognitions. CBT also emphasizes skill development as patients learn effective strategies to avoid drug-use situations and to refuse drugs. Therapists teach these skills in individual or group sessions through the use of brief lectures, role-playing, homework, and other exercises. Because adolescents are embedded in their families, treating the entire family instead of concentrating be solely or mainly on the adolescent can be valuable and useful. The Family Support Network (FSN) was developed specifically for the Cannabis Youth Treatment Study. It is designed to enhance family communication, improve parental behavioral management skills, and increase family commitment to the recovery process. In addition to separate treatment (such as CBT or MET) for the adolescent, parents receive educational sessions that focus on adolescent development, drug use, and family management. Parents also receive home visits for the purpose of individualizing and practicing their skills. Group educational sessions also foster the development of support networks for parents. Another family-based approach that has been studied in the Cannabis Youth Treatment Study is multidimensional family therapy (MDFT). 68 MDFT was developed specifically for the treatment of adolescents with substance-use disorders. Treatment focuses on the adolescent, the parents, family communication patterns, and community system involvements such as juvenile justice or school systems. Treatment focuses on the establishment of a therapeutic alliance with all members of the family and community systems, assessment of family functioning, and therapeutic activities to promote positive changes in individual, family and social systems and how they have influenced the adolescent. MDFT combines individual sessions with the adolescent or parents with family sessions. Acknowledgements and rewards are useful motivations for people, and especially adolescents, to change their behavior. In the adolescent community reinforcement approach (ACRA), therapists help adolescents connect to positive social and recreational activities, and teach skills to refuse drugs. Parents are included in the treatment process. ACRA was used as an outpatient treatment as part of the Cannabis Youth Treatment Study. 68 A similar, but more intensive outpatient aftercare program known as Assertive Continuing Care was developed for youth following discharge from inpatient or residential treatment. 70 This treatment approach combines ACRA with case management to assure the adolescents receive necessary community services. It is very similar to Caron s successful Recovery Care Management aftercare program. Evidence-Based Treatment for Adults A number of treatments have been developed and tested for adult cannabis addiction. Cognitive behavioral, motivational enhancement, support groups, and reward-based treatments have demonstrated success in reducing marijuana use. A combination of treatments appears to be more helpful than any single treatment type. For example, a clinical trial found that motivational enhancement therapy (MET) combined with cognitive behavioral therapy (CBT) and case management produce better results than a brief motivational enhancement approach. 71 Reward-based treatments often involve the use of vouchers as rewards for the achievement of a treatment goal such as attending sessions or abstaining from drug use. Vouchers usually have a monetary value and can be redeemed for goods or services selected by the participant such as entertainment admissions, recreational equipment, or educational or vocational classes. Adding abstinence-based vouchers to other behavioral treatment for cannabis addiction has been shown to improve marijuana abstinence rates compared to providing behavioral treatment alone. 72 Brief marijuana dependence counseling (BMDC) was designed to address the multiple addiction, psychological, and social needs of adults who are addicted to cannabis. 73 BMDC combines interventions to increase motivation, and case management to increase the patient s ability to receive necessary treatment for non-substance-related problems, and cognitive behavioral skills to abstain from marijuana. Unlike other research-based treatments that require rigid adherence to a specific protocol, BMDC is designed to be flexible and to meet the individual needs of different patients. Treatment Works! Scientific and clinical evidence strongly indicate that treatment works for a majority of people with cannabis use disorders. A large evaluation of over 1000 adolescents who received either residential, outpatient or short-term inpatient treatment found that less than half of the youngsters reported marijuana use in the year following treatment. 74 This study, known as the Drug Abuse Treatment Outcomes Study for Adolescents (DATOS- A), also found sharp decreases in heavy drinking, use of other illegal drugs, and delinquent behavior. Adolescents who received treatment also reported better school performance and psychological adjustment following treatment. The results of this study are especially impressive given the adolescents had multiple and severe psychological and social problems and were not an easy group of youngsters to treat. Similarly, a review of the literature on the treatment of cannabis addiction found that adults generally improve with treatment. 75 Longer-term treatment and treatment that individualizes a variety of therapeutic approaches to meet the needs of specific patients appears to be more beneficial than short-term treatments or rigid single-approach interventions. DATOS-A found that adolescents who stayed in treatment longer were more likely to maintain the positive benefits of treatment one year later, regardless of the severity of their addiction and other psychosocial problems. 74 Benefits of treatment may appear during the course of a treatment episode. Motivation, craving, and psychological functioning are important predictors of successful addiction treatment. Patients who abuse or who are addicted to cannabis were assessed for their levels of motivation, 76 cravings for 16 17

10 18 marijuana, 17 and depressive symptoms 77 at admission and prior to discharge from Caron. As shown in Figures 13, 14, and 15, we found significant positive changes in these areas during the course of treatment. Figure 13 shows that patients generally acknowledged low recognition that they have a serious problem with marijuana upon admission to a Caron residential treatment program. By the time they are ready to be discharged, their awareness that harm will continue if they do not change their behavior has significantly increased. Likewise, upon admission, patients generally report a moderate willingness to take the changes necessary to stop their marijuana use. However, by discharge they generally report they have begun to take steps to change their behavior and they have experienced some success. Figure 13. Motivational change in treatment Average Score Admission Discharge As shown in Figure 14, patients admitted to Caron for cannabis disorders generally have moderate levels of cravings. Generally, marijuana-related cravings significantly decrease during the course of treatment. Psychiatric functioning also improves during the course of treatment. As shown in Figure 15, patients generally enter treatment at Caron with moderate levels of depressive symptoms. By discharge, however, their symptoms usually are within the normal range. Figure 14. Craving change in treatment Admission Discharge Recognition Taking Steps Average Score Figure 15. Depression change in treatment Admission Discharge Average Score Popular culture has long considered marijuana to be a benign recreational drug. However, this report shows the negative impact that marijuana use can have on people s lives. It may cause severe physical and cognitive damage and may trigger psychiatric illness in vulnerable populations. Chronic and high use may lead to cannabis addiction. Cannabis abuse and addiction are related to a decreased ability to function in a number of areas. People who abuse cannabis generally abuse other substances, like underage alcohol and nicotine use. They may be introduced to part of a drug abuse subculture that promotes other deviant behaviors, like delinquency, crime and use of other illicit drugs. Treatment provides hope for this population. The past decade has witnessed advancements in treatment approaches. Two major studies of treatments designed specifically for cannabis addiction, the adult Marijuana Treatment Project 71 and the adolescent Cannabis Youth Treatment Study, 68 have demonstrated the effectiveness of treatment. Similar to the successful treatment of other addictions, treatment for cannabis addiction needs to be individualized to the specific needs of each patient. Motivation should be addressed when patients are not interested in change. Skill development should be tailored to patients strengths and circumstances. Family involvement and family education may enhance the treatment of adolescents and adults who are embedded in family relationships. Attention also must be paid to the medical, psychological and social needs of this population. Longer treatments also appear to be more effective than very brief approaches. And, perhaps most importantly, patients should not be forgotten when they are discharged from a treatment program. Aftercare that continues to monitor and engage the patient in recovery-oriented activities facilitates change from addiction to recovery Marijuana Dependence and Treatment at Caron David Rotenberg, MA, MBA, CAC Diplomate Executive Director, Caron Adolescent Services Caron Treatment Centers D Despite the fact that oxycontin, methamphetamine and a variety of prescription drugs seem to garner the bulk of the media s, and the chemical dependency treatment field s attention lately, marijuana remains the drug of choice for adolescents and young adults in America. At Caron, our clinical team has embraced the fact that not only does marijuana remain popular, but it is also viewed in an ever-more-benign fashion by our patients. Furthermore, marijuana is not only perceived as a soft drug by our patients, but also, perhaps for the first time, by the parents of our young patients, as well. It took my motivation. It made me fall from an A student to a C student. I quit all of my sports teams. I stopped playing music and doing art. I became very distant from my parents and the rest of my family. I changed my friends. I stopped paying close attention to my personal hygiene. Does this series of statements describe an alcoholic or heroin addict? Hardly. This series of quotes describes the impact of chronic marijuana usage on our patient population. Despite the devastating truth inherent in these quotes, our patients continue to distance marijuana from other hard drugs. In many cases, however, the only difference between the use of hard drugs and marijuana is physical withdrawal symptoms. Nevertheless, marijuana users protect their drug, their perception of its benign impact on their lives, and their ongoing right to use it, as enthusiastically as a crack addict or heroin addict chase their next fix. Our clinical staff at Caron understands the cultural viewpoint of America s youth, and its embrace of marijuana, not as a gateway drug, but as a rite of passage and as an accepted part of young peoples behavioral repertoire. We understand the skewed logic that applies when patients with chemical dependency differentiate themselves and their drug of choice from the norm. We understand that the chemically dependent population, and particularly the younger portion of this population, will consistently seek gray areas and loopholes to maintain chemical usage and related abhorrent behavior. We assist patients in identifying marijuana as a harmful drug that leads to dependency not as a safe alternative to the other chemicals that are more readily viewed as harmful and addictive. By employing an integrated treatment approach that is steeped in 12-Step tradition and philosophy, Caron encourages productive changes via insight, behavioral transition, spiritual growth, and family involvement in treatment, as well as throughout the recovery process. We do so in a nurturing way that parallels the tranquil theme of our geography, allowing the marijuana addict to achieve and maintain a level of harmony that so often seems linked to the rationale for the drug s use in the first place. 19

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Tims, Charles Webb, Yifrah Kaminer, Thomas E. Babor, M.C. Roebuck, Mark D. Godley, Nancy Hamilton, Howard A. Liddle, and Christy K. Scott The cannabis youth treatment (CYT) experiment: Rationale, study design and analysis plans. Addiction 97 (Suppl. 1): Diamond, Guy S., Susan H. Godley, Howard A. Liddle, Susan Sampl, Charles Webb, Frank M. Tims, and Robert Meyers Five outpatient treatment models for adolescent marijuana use: A description of the cannabis youth treatment interventions. Addiction 97 (Suppl. 1): Marlatt, G. Alan, and Judith R. Gordon, eds Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors. New York: Guilford Press. 70. Godley, Mark D., Susan H. Godley, Michael L. Dennis, Rodney Funk, and Lora L. Passetti Preliminary outcomes from assertive continuing care experiment for adolescents discharged from residential treatment. Journal of Substance Abuse Treatment 23: Marijuana Treatment Project Research Group Brief treatments for cannabis dependence: Findings from a randomized multisite trial. Journal of Consulting and Clinical Psychology 72 (3): Budney, Alan J., Stephen T. Higgins, Krestin J. Radonovich, and Pamela L. Novy Adding voucherbased incentives to coping skills and motivational enhancement improves outcomes during treatment for marijuana dependence. Journal of Consulting and Clinical Psychology 2000 (68): Steinberg, Karen L., Roger A. Roffman, Kathleen M. Carroll, Elise Kabela, Ronald Kadden, Michael Miller, David Duresky, and Marijuana Treatment Project Research Group Tailoring cannabis dependence treatment for a diverse population. Addiction 97 (Suppl. 1): Hser, Yih-Ing, Christine E. Grella, Robert L. Hubbard, Shih-Chao Hsieh, Bennett W. Fletcher, Barry S. Brown, and M. Douglas Anglin An evaluation of drug treatments for adolescents in 4 U.S. Cities. Archives of General Psychiatry 58: McRae, Aimee L., Alan J. Budney, and Kathleen T. Brady Treatment of marijuana dependence: A review of the literature. Journal of Substance Abuse Treatment 24: Miller, William R., and J. Scott Tonigan Assessing drinkers motivation for change: The stages of change readiness and treatment eagerness scale (SOCRATES). Psychology of Addictive Behaviors 10: Beck, Aaron T., and Robert A. Steer Beck Depression Inventory. San Antonio: Harcourt, Brace, Jovanovich. 52. Kandel, Denise B., and Mark Davies Progression to regular marijuana involvement: Phenomenology and risk factors for near-daily use. In Vulnerability to Drug Abuse, edited by Meyer D. Glantz and Roy W. Pickens. Washington, D.C.: American Psychological Assn. 53. Page, Randy M., and Andria Scanlan Perceptions of the prevalence of marijuana use among college students: A comparison between current users and nonusers. Journal of Child & Adolescent Substance Abuse 9 (2): Linkovich-Kyle, Tiffany L., and Michael E. Dunn Consumption-related differences in the organization and activation of marijuana expectancies in memory. Experimental and Clinical Psychopharmacology 9 (3): Chabrol, Henri, Eve Massot, and Etienne Mullet Factor structure of cannabis related beliefs in adolescents. Addictive Behaviors 29: Substance Abuse and Mental Heath Services Administration, Office of Applied Studies Youth marijuana admissions by race and ethnicity. The DASIS Report. Rockville, MD: SAMHSA. 63. Gfroerer, Joseph C., and Joan F. Epstien Marijuana initiates and their impact on future drug abuse treatment need. Drug and Alcohol Dependence 54: Agosti, Vito, and Frances R. Levin Predictors of treatment contact among individuals with cannabis dependence. American Journal of Drug and Alcohol Abuse 30 (1): Dakoe, Gayle A., Manuel Tejeda, and Howard A. Liddle Predictors of engagement in adolescent drug abuse treatment. Journal of the American Academy of Child and Adolescent Psychiatry 40 (3):

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