April 20th, 2016
Nina still gets nostalgic from the smell of pot. It’s been nearly four years since she decided to quit. “I was a very hyper person, so I used cannabis to calm myself down, especially before sleep and when I was anxious,” she says. “Toward the end of university and once I started working in Manhattan, it was something I was more dependent on to function.”
The idea of “marijuana addiction” is likely to draw scoffs, like we’re dusting off old DARE propaganda. But like any substance or activity that’s enjoyable, pot use can become problematic for some people.
Addiction is a relationship between a person and a substance or activity; addictiveness is not a simple matter of a drug “hijacking the brain.” In fact, with all potentially addictive experiences, only a minority of those who try them get hooked—and people can even become addicted to apparently “nonaddictive” things, like carrots. Addiction depends on learning, context and psychology, not just neurotransmitters.
When Nina started her job at an upscale design firm, her once relaxing habit started to make her life more stressful. “I began smoking before work in the morning, and became increasingly paranoid that someone would smell it on me once I got there, but I couldn’t not smoke before work. I would carry it with me to work and sneak out for a break to smoke. I felt as though I couldn’t get through the day without smoking something,” she says. Nina, who was the firm’s director of marketing—a big position for someone so young—started showing up to work late and shutting herself in her office.
“I became antisocial, stopped going out for lunch with colleagues in order to sneak away and smoke alone, and sometimes stopped home during work errands to smoke more.”
She tried to quit, but couldn’t. Her boyfriend broke up with her. “He couldn’t imagine me not smoking for nine months in order to have a child with him, if we were ever to get married (it was a serious prospect at that time), and I was crushed,” says Nina. “I realized I had a problem, and checked myself into outpatient rehab.” She had suffered depression long before smoking marijuana, and flirted with other substances (cocaine, Adderall, Xanax, and MDMA), but she found marijuana was the hardest to kick. “The other ones just felt like phases, where cannabis felt like a lifestyle. And at a certain point, it became a resin-infused, dirty, lazy, unproductive, paranoid, depressive lifestyle that I couldn’t live with anymore,” says Nina.
Marijuana is commonly thought to be non-addictive, and for most people that’s true; about nine percent of those who use it, however, might become addicted at some point in their lives. So weed can become a problem. But what’s the solution?
Is Marijuana a Problem for You?
The New York City subway system currently features ads asking riders if marijuana is a problem for them, over a picture of some scattered plant matter that’s supposed to be weed. I was curious what the Columbia Medical School study entails. How do the scientists define marijuana addiction and what is the “cure” they are testing?
The series of studies at Columbia, funded by the National Institute on Drug Abuse, look at a course of treatment with medication in combination with different behavioral approaches. The current trials use Quetiapine, an FDA-approved medication for bipolar disorder and schizophrenia.
The symptoms of marijuana withdrawal include anxiety, insomnia, and trouble eating, while Quetiapine causes sedation, appetite stimulation, and anxiety-relief, says psychiatry professor Dr. John Mariani, who is conducting the study.
Each double-blind study lasts 12 weeks and enrolls five to ten self-selecting participants, mostly men, ages 18 through 65, who meet the threshold requirement of using marijuana at on average five days a week over the past 28 days. Many participants have successful careers, but feel as if marijuana is holding them back, says Mariani. Subjects participate in weekly drug counseling with a psychiatrist and are encouraged to set goals to either reduce consumption or achieve abstinence.
With no history of violence or overdose, problematic marijuana use is less severe than other substance use problems, says Mariani. “The consequences are more on what doesn’t happen. Cannabis has anti-anxiety, sedating effects. Anxiety helps us get to do things. Cannabis makes us less motivated to respond to things.” Study subjects often report symptoms of not getting anything done, not moving forward in their careers, or not being as present in their relationships.
Moreover, there is a caveat to the notion that marijuana use disorder has no physical effects on the body. “When someone uses [marijuana] regularly, it alters the regulation of the endocannabinoid system,” says Mariani. “[Dependent users] make fewer of their own [endogenous] cannabinoids. If someone stops smoking or using cannabis, there is a withdrawal state because of the relative dysregulation of the endocannabinoid system. That’s a physical change.”
Another trial at Columbia starting soon will measure how long a subject can remain abstinent from marijuana without other using medications before relapsing. Other trials have looked at the use of other medication combinations to treat addiction, such Dronabinol (a synthetic cannabinoid, also known by the brand name Marinol, which treats nausea and appetite loss) and Lofexidine (an anti-hypertensive, often used to treat opioid withdrawal). This combination, however, was found to be ineffective. “If we give them a drug that acts similar to marijuana will they smoke less? That’s the most effective strategy for other substance abuse problems,” says Mariani. “The most efficacious anti-addiction medicine acts the same way as the drug that’s being used, but that didn’t work for marijuana.” Another study will look at users with ADHD and treat them with a stimulant to evaluate any potential changes in their pot use.
But is taking pills to treat a drug problem the best approach? In fact, according to the National Institute on Drug Abuse, no medications have yet to be approved for treating marijuana use disorder. Often, approaches include Motivational Enhancement and Cognitive Behavioral Therapy.
“The behavioral component involves helping the person develop some strategies, things they can do as alternatives to marijuana use, and identifying types of situation in which they’re most likely to be at risk of using marijuana,” says Dr. Suzette Glasner, who teaches psychiatry and behavioral sciences at UCLA. “It takes some time and insight into your patterns to understand what kinds of situations might be what’s called ‘triggering’ for you.” That could include listening to certain types of music, going to concerts, or spending time with certain friends. If a patient experiences a craving, behavioral strategies, such as exercise, meditation, or any number of action-oriented responses are found to be useful, says Glasner.
Motivational Enhancement strategies help patients establish and sustain the motivation to change their marijuana use if the desire to do so. “The intention to change drug use has its most powerful effects when it comes from within the person,” says Glasner. “The goal of motivational therapies is to help marijuana users take a look at their own experience using marijuana, the consequences of using, the concerns they have about what will happen if they continue to use in the same way as they use currently, and how it might conflict with important goals or relationships—and then help mobilize the person’s own internal desire to change, rather than being prescriptive.”
For some people, marijuana use disorders can be addressed with significant lifestyle changes, as well. “However for others, the cannabis use may be a way of dealing with insomnia, intense anxiety, depression, and other ailments,” says Ingmar Gorman, doctoral student at the New School for Social Research and a clinical psychology extern at the Center for Optimal Living, which specializes in integrative harm reduction psychotherapy. “A lifestyle change might not be sufficient. Reducing cannabis use for these people can lead to an intensification of other symptoms. In such cases the support of a mental health professional who works with the person in a non-stigmatizing way is essential. This may include the use of medications and psychotherapy that reduce the symptoms that are contributing to the cannabis use.”
Problematic marijuana use often occurs in conjunction with psychiatric disorders, particularly depression and schizophrenia, according to a genome-wide association study under the direction of Dr. Joel Gelernter, professor of psychiatry, genetics, and neuroscience at Yale. “Cannabis dependence is genetically complex. Risk is influenced by a lot of genes of small effect,” he says. “Cannabis dependence shares a genetic risk with depression and individual risk genes with schizophrenia.”
The rate of marijuana use disorders are higher in populations of those who suffer depression and schizophrenia, he adds. So often the question comes down to whether marijuana increases the risk of diagnoses for these disorders, or whether they increase the risk of using marijuana in a disordered way (“presumably because it makes you feel better in some way”), Gelernter explains. “But our article supports something else entirely. Our article supports common genetic etiology.”
Correlation does not equal causation: Rather, Gelernter says that the same basket of risk genes that make it more likely for someone to develop problematic marijuana use also make it more likely to have depression or schizophrenia. “It’s not that one causes the other, but that they’re caused by the same thing.”
Of course, other factors, including environment and personality, contribute to addiction, as well, Gelernter adds. “People who are more into sensation seeking and open to experiences, as opposed to people who are more neurotic, are more likely to use substances,” he says. “But the specific substance is more dependent on the environment, what’s available.” No one factor, be it genetic or environmental, is fully responsible for addiction. “You can’t trace [marijuana use disorder] back to a single risk allele,” he says. “With all the political pressures to make it more available, to legalize, I think it’s important to understand the biology of susceptibility.”
It’s important to note that those who treat marijuana addiction or suffer from it are not diametrically opposed to the medical and legal weed movement. “I think there are people who have negative thoughts about MA [Marijuana Anonymous], who will say, ‘come on pot’s harmless, pot should be legalized,'” says Alan, a member of MA. “We don’t have an opinion about those things, it’s not about that. It’s certainly not an anti-marijuana organization. We were all potheads, most of us big smokers, and a lot of us are immersed in pot culture.”
Alan joined MA 18 years ago, within a year of quitting marijuana at the age of 43. MA’s community and the 12 steps, particularly Step 1 (“We admitted we were powerless over marijuana, that our lives had become unmanageable”), appealed to him.
“I smoked for many years [since age 14] without feeling that I was addicted, and then it just go to a point where it was something that I needed,” he says. “I realized that marijuana wasn’t the problem for me, marijuana was the solution. And unfortunately, at a certain point, it stopped working and the side effects and problems that came along with it became greater and greater. Even though it made sense logically to cut down and stop, that wasn’t something I could do.”
Alan, who established his own law firm in Los Angeles years before quitting marijuana, suffered various traumas, broke his leg, walked into an armed robbery, experienced relationship issues, and so had many reasons to smoke, “to escape and avoid.” Eventually, pot interfered with his ability to lead a productive life. “I essentially crashed. I ended up not being able to work, losing my house, losing my car, crashing on some guy’s sofa, thinking no, it’s okay, I can still get high, what the heck. That was the process going down and it was suggested to me at some point that I check out this place which turned out to be a rehab.” From there, he got involved with MA, and eventually re-established his law practice. “I got to my first MA meeting and went wow, these are my people. Here are other potheads and they’re just not smoking. I got to the point of coming to believe there’s another solution. The new solution is turning to something outside myself [Step 2].”
Alan had also unwittingly been self-medicating his ADHD, with which he was diagnosed in his early 40s. “I actually had a doctor say, ‘yea, it’s fine you should probably continue to smoke pot to help deal with anxiety,'” says Alan. “For me, the combination did not work well. When I first got sober, I was also given some prescription sleeping aid.” Now he now only uses ADHD medication as prescribed.
Those like Nina and Alan have gotten to the point where they can be around marijuana and not feel compelled to use it. Allen still hangs out with friends who smoke, and Nina still goes to festivals and hangs out with her family when they smoke. “I learned how to say no,” says Nina.
“I believe that every person is different, and the same way some people are more susceptible to alcoholism or game addiction, others are more susceptible to cannabis dependency.”
Nina’s current partner’s mother, who suffers from multiple sclerosis, uses marijuana medicinally, and her cousin works in a legal dispensary in Colorado. She recognizes the medical benefits of pot, and would even consider it in the future. “I fully support the existence and the legalization of cannabis. I recently spoke to [my cousin] about how many of his customers are sick and actually need cannabis to help with pain. I imagine that if I am ever in pain one day (and have the time or need to stay in bed) I would much prefer to use cannabis than any other painkiller or opiate on the market,” says Nina. “However, for now, I can’t imagine living a productive, happy life, if cannabis existed as a dominant or even a dormant factor in my world. I just can’t have it around me on a daily basis.”
Madison Margolin is a freelance journalist writing about drug policy. You can follow her on Twitter: @MargolinMadison.