Legal Marijuana? Anticipating the Issues
As recently as April 2012, President Obama referred to the legalization of drugs, indicating that he "doesn’t mind a debate" on the subject. While the debate regarding legalization has been raging for years, the issues the availability of legal marijuana raises for treatment providers are rarely addressed. The debate often focuses on other legal or moral aspects of marijuana use or purchase, and only in some cases touches on health or mental care needs that should be anticipated if marijuana could be purchased legally.
At present, most marijuana users who enter substance abuse treatment do so via the criminal justice system. Marijuana use or possession violates the drug free zone laws or ordinances set up around most American high schools. Many school districts maintain a "zero tolerance" policy, meaning that extenuating circumstances such as first offenses or small quantities are handled by law enforcement or referrals to treatment centers, rather than warnings or school level interventions.
This means that most commonly, the marijuana user who ends up seeking treatment is a young high school aged student dealing with normal adolescent developmental issues as well as any substance abuse concerns. If legalized, it is likely that high schools would continue to disallow the smoking of marijuana on school grounds, but the consequence for doing so would in all likelihood be neither legal nor treatment-oriented (not unlike current tobacco smoking rules and consequences).
So how would marijuana smokers wind up in treatment? Who would end up seeking help for marijuana abuse or dependence? Most likely, adults who attempt to stop smoking marijuana for health, economic, or personal reasons and discover that they cannot. People who continue to use marijuana after a teenage experimentation phase frequently continue to use for decades before "burning out" and wanting to quit. Middle-aged people, in their late forties or so, often reach this point.
The role of the treatment professional is to "start where the client is at," to walk a mile in their shoes, so to speak. After using marijuana regularly for several decades, withdrawal symptoms such as insomnia, irritability, and that vague malaise of "just not feeling right unless I smoke" can make going "cold turkey" anywhere from uncomfortable and difficult to nearly impossible. And for some people the discomfort can continue for months due to the incredibly slow rate at which the brain recovers. What will such a client be facing in terms of developmental and bio-psycho-social needs and issues?
For one thing, resistance to psychotropic medication may be a hurdle that treatment providers could face. Commonly marijuana smokers feel that they are not "taking a drug," and that the substance they are using to manage their moods is "natural." If depression, loss of appetite, and insomnia accompany quitting, then medications may be an important part of treatment, even as a short term aide. However, this might be a tough sell, at least for some marijuana users.
Also consider that for the client’s entire adult life, he or she has been seeing the world through a marijuana-affected lens. Marijuana heightens perceptions (e.g. colors seem brighter or more vivid, jokes seem funnier, etc), and now, at age forty-five and struggling to be drug-free, the world may seem a little drab or dull. While not necessarily high all the time (although many long-term marijuana users do adopt a "wake and bake" lifestyle, moving through the day getting high whenever possible), many life experiences such as marriage and the starting of a family have occurred while the client was at least partially under the influence. As a client works to live life without that high, many feelings may come up and need to be worked through – everything from guilt at not being fully present, to boredom or loss/grief at missing the experience of being high.
In addition, forty-five year olds start to experience age-related aches and pains. The physical body just doesn’t feel the same as it did when you were twenty. Having had your physical sensations affected by marijuana for several decades, it can be somewhat of a rude awakening to have that particular fog lift. Aches, twinges, and annoying physical discomforts are more easily tolerated or ignored when under the influence.
Treatment Goals: Abstinence or Harm Reduction?
Given how difficult or uncomfortable your client may be, his or her motivation to quit may wane. If marijuana is legal, then only personal reasons (as opposed to legal pressure) can provide motivation. How can you, as the treatment professional, bolster that motivation, or help a client choose a harm reduction path of lesser resistance?
Using a bio-psycho-social model, look at reasons for quitting from all angles: physical health, mental health, and social relationships. Help your client predict where he or she will be in another five or ten years. Explore the prognosis for each potential pathway: looking at impacts on physical and mental health and important relationships. Sometimes a harm reduction tack is the best to take, exploring reducing either frequency or quantity of use, or both. Sometimes helping your client strengthen their resolve to be completely abstinent is the right way to go. Helping them to make this decision for themselves and then stick with it may be the most helpful intervention of all.