2017: Where We are Today
In the U.S., we are seeing a paramount shift in attitudes and policy on The Big M: Marijuana. As of today, we have 28 states that have legalized medical marijuana, 16 states that have legalized CBD oils (that are known to treat certain seizure disorders), and there are 8 states that have legalized the recreational use of marijuana for adults. Although marijuana has long been a threat to the dogmatic ideology of addiction recovery, the legalization of the drug is making many treatment professionals uneasy in navigating this uncharted territory of government sanctioned marijuana use. In this article, I will discuss how I view the changes in marijuana policy and how this impacts the field of addiction treatment.
My Experience with Recovery and Marijuana
When I was 24, I entered a residential treatment facility for the first time. At the time I used alcohol, marijuana, and opiates on a daily basis and also had a past history of daily cocaine use. Upon entering treatment I had basically no knowledge of the disease concept, 12-Step work, or addiction treatment in general. All that I knew was that my relationship with alcohol and opiates was making my life miserable.
After being sick in bed for a few days, I became clearheaded enough to start to comprehend what I was hearing in treatment. Once detoxed, I immediately realized that the treatment center not only expected me to quit alcohol and opiates, but also expected me to stop using marijuana. This was a complete shock to me.
I had never even considered that to be “clean” required me to quit smoking pot.
Once I realized this, I went from being hopeful about my recovery to being completely unsure about my ability to remain abstinent and my future as a person in recovery. It wasn’t that I was unwilling to consider my marijuana use as harmful, but this new obstacle destroyed the future that I had imagined.
Medical or Recreational?: Needs VS. Wants
Many treatment providers hold unjustified fears about the legal use of marijuana. To address these, I’d like to share a few benefits that I foresee in legalization of marijuana as a recreational drug. In fact, I can see how certain policy and perspective can directly support abstinence based treatment.
It’s a common addiction treatment exercise to have clients reflect on the differences between needs and wants. The hope of the curriculum is that substance users will see that there is a difference between needing something, and wanting something. Once the difference is established, then hopefully, the substance user acknowledges the fact that drug use is a “want” not a “need.” Now that drug use is separated from being a need, the substance user can see that they have the ability to choose their relationship with drugs in the same way that they could change any unnecessary relationship.
As a substance treatment counselor myself, I know that trying to convince a person who uses medical marijuana to stop using cannabis is near impossible. This is because, in the client’s eyes, marijuana is not a drug; it is their medicine. When a drug is prescribed as a medicine it becomes a “need.” Medical marijuana users don’t “want” the use marijuana; they “need” to use marijuana. Telling a client to give up medical marijuana is telling them that we know more about medicine than their doctor (assuming you are not a doctor).
Living in the San Francisco Bay Area, I see that the prescribing process of marijuana is anything but medical. I have taken clients to medical marijuana doctors; a medical diagnosis is the last thing that is required to get a card. Of course, there are countless people who have legitimate medical reasons to use marijuana, but I would assume that there are just as many people who get prescriptions for no medical reason.
The benefit of legalizing marijuana for recreational use, from an abstinence treatment perspective, is that it creates more users who “want” marijuana, and less people who “need” it. Those individuals who were getting medical marijuana under a false diagnosis no longer need to go to a doctor; they can now just buy it legally. Now, when these users come into treatment, if they are honest with themselves, they will have to admit that they use marijuana, not because they need it, but because they are choosing to get high. I see this making a big difference in motivating clients to conform to abstinence based treatment and also avoids the unethical practice of telling clients to stop taking medication that was prescribed by a doctor.
Legal Sanctions Create Unmanageability
The First Step in 12-Step programs is that, “We are powerless over our addiction––that our lives have become unmanageable.” It is the second part of the step that most concerns us in the treatment field because it explains why the individual is seeking treatment. People come into treatment because some part of their life has become dysfunctional – a state which is independent of their amount of use or the level of physical and mental dependence. If a person is physically dependent on a drug and they are still able to manage their life to their standards, they will never seek treatment. Therefore, for those people seeking treatment, addiction has more to do with the drug’s effect on their social life than their physical one.
Of the criteria used in the diagnosis of Cannabis Use Disorder, 4 have to do solely with social function**. Here are the social criteria for cannabis substance use disorder.
- A great deal of time is spent in activities necessary to obtain cannabis, use cannabis, or recover from its effects
- Recurrent cannabis use resulting in a failure to fulfill major role obligations at work, school, or home
- Continued cannabis use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of drug use.
- Important social, occupational, or recreational activities are given up or reduced because of cannabis use.
** DSM IV listed reoccurring legal problems as a result of use but it was removed in the newest addition.
Overall, there are eleven total symptoms used to diagnose Cannabis Use Disorder; including the four social symptoms listed above. Social criteria alone make up over 1/3rd of the total diagnostic criteria. To be diagnosed with a severe disorder, a person must have at least six of the eleven criteria. Two criteria must be met for a mild diagnosis and four criteria for a moderate disorder. A person who meets all of, and only, the four social criteria would be diagnosed with a moderate substance use disorder without having any physical dependence or health issues.
Because marijuana is an illegal substance, cannabis users are at greater risk of suffering dysfunction in their lives due to the risk of the criminal justice system intervening in their life. Having a drug arrest immediately creates unmanageability in the substance user’s life, regardless of their level of addiction. These legal sanctions dictate how a person is able to navigate their social environment, not because of the drug use itself, because of the drug’s legal status in the community.
This last election we voters in California have completely legalized marijuana. This new law has, literally overnight, cured people of the diagnosable disease of addiction based on the four social criteria in the DSM by removing social obstacles that have obstructed people from controlling their own lives. Substance use disorder, in the social sense, changes across time due to the fluctuation of laws which completely negates the fact that addiction is a personal relationship between the drug and the individual.
Court Ordered Treatment May Not Best Target True Addicts
In California, clients who are in treatment solely for marijuana use makes up between 15-20% of all substance use treatment clients. These numbers appear to be dropping in correlation to the decreasing marijuana penalties in our country as a whole.
I wonder: How many of these marijuana users are in treatment only because the illegality of cannabis has made their lives unmanageable?
Undoubtedly, many of these treatment clients were having difficulty with their cannabis use, not because they are addicted but because of legal complications beyond their control. Since it is the legality of the drug that funnels individuals into treatment, through increased dysfunction due to legal consequences, treatment is not acting as a health care institution but rather an extension of the criminal justice system.
In my time working as a substance use counselor, I have seen clients who are in treatment only because they have violated their probation or parole due to violations of drug testing. These individuals may, or may not, have a problem with drugs but if they were using a legal drug such as alcohol, they would not have wound up in treatment. Again, in these cases, the treatment referrals have less to do with treating addiction, and instead act as a punishment for not following an arbitrary law that has been socially constructed.
As we begin to legalize marijuana, we will be opening up space for individuals who actually have drug addiction. It allows counselors to do their job without being manipulated by political and judiciary institutions. When clients are able to make their own decision about the role drugs play in the functioning of their lives, it benefits everyone.
Cannabis Laws Do Not Equally Affect All People
Drug use is, and always has been, a civil rights issue. It has been shown in countless research that people of color are arrested of marijuana offenses at much higher rates than whites, although whites use cannabis at equal rates to other racial groups. If cannabis laws affected all people equally, across racial and socioeconomic lines, we would be having a different conversation. In fact, it is a strong argument that the only reason that marijuana legalization has ever even been considered is because so many white people use pot. It was only when enough white people suffered the collateral damage of the war on pot that decriminalization was considered.
Because more people of color suffer more unmanageability from pot use they are more likely to have a more severe diagnosis of Cannabis Use Disorder. We as clinicians cannot sit back and allow a socially racist construction to interfere with the ostensibly unbiased work of clinically diagnosing individuals with medical disorders.
This is unacceptable and unethical.
By ignoring the racial implications in diagnosing individuals, when using social diagnostic criteria, we are directly implicit in perpetuating racism. This should make us angry, when we realize that we have unwittingly become active participants in a system of oppression.
Shouldn’t We Consider “Treatment” On a Client’s Terms?
In my opinion, the greatest failing of the disease model has been its ignorance that Substance Use Disorder operates on a continuum of severity. It is a myth that all addiction is the same and therefore requires the same treatment of abstinence. The disease model only caters to the most severely afflicted polysubstance user.
Arguably, there are many people who have such a chaotic relationship with substances that they can never safely use any substance for the rest of their lives. These are the people who benefit from the disease ideology, but what about people who fall lower on the spectrum of substance use? There are few treatment options for people who wish to change their relationship with substances on their own terms.
We do not know how many people there are who fall on the lower side of the continuum because these people avoid seeking the type of treatment that will tell them they have a chronic progressive disease. This lack of sympathetic treatment providers discourages individuals from seeking treatment at all. This is the great irony of disease treatment: that it is making the silent majority of users more isolated and mentally unstable.
This is why I see harm reduction as the only ethical practice of substance use treatment. Often thought of as radical, harm reduction allows clients to decide for themselves how they want to change their relationship with substances. We can still work with clients on treatment goals independent of their drug use. This includes giving a client the benefit of the doubt when they believe they can continue to smoke marijuana while changing their relationship with other substances. This allows the clinician to be a true agent of change, instead of policing individual’s behavior.
My Story, Continued
After spending 30 days in that residential treatment center, I had become convinced that I had the disease of addiction; that I could never use any substance without disaster (excluding nicotine and caffeine, of course.) After a short relapse on all my original substances, I joined a 12-Step fellowship and followed strict adherence to the disease concept of abstinence as the only way to live a successful recovery. I became fully involved in spreading the ideology of the disease of addiction. When I sponsored people who thought they could still use marijuana I stubbornly dictated to them that they are not “clean” or in “recovery” if they continued to use cannabis, even for medical reasons.
It should be obvious by this point that I have changed my view on what it means to be in recovery, although I have continued to remain abstinent of all substances for almost 10 years and continue my membership in a 12-Step fellowship.
For me, it is a personal decision to abstain from marijuana. I don’t abstain because it’s against 12-Step rules, or it might lead me back to harder drugs, or that it would reset my clean date. I don’t use marijuana simply because I choose not to and I believe that I can manage my life better without using cannabis. It is my choice and I allow others to make their own choice on whether or not they want to continue a relationship with marijuana––or any other drug for that matter.
We, as clinicians, need to follow our own advice when we tell our clients not to fear change. As a society our laws and perceptions are changing, and we risk becoming obsolete if we don’t change along with new ideas.
I realize that most of us don’t work in environments where we have the ability to change rapidly. Change is hard and slow; the disease model is so deeply entrenched into our work, and our world, that there will be major resistance to moving towards a harm reduction model. It is worth fighting for.
I, for one, am tired of policing people’s bodies and behavior. To be able to give clients the ability to decide their own behaviors is both liberating and ethical.
To this end, I maintain that legalizing marijuana is a step in the right direction for a healthy and equitable society.