More and more clients are flooding our facilities with regular marijuana use, demanding that secondary diagnosis of substance use/abuse/dependence, along with that lovely 30xMJ coding for our DMH Dual Diagnosis requirements. Once mentioned, eyes roll, heavy sighs fill the air, judgment clouds the room, and the client is cast in the same group as meth-heads and heroin addicts when their use is revealed in supervision. An admission of bong possession automatically elicits referrals to substance abuse programs, unsolicited psychoeducation, and numerous nagging sessions about how the client needs to stop smoking out. In essence, we waste a lot of resources on drug treatment and drug discussions on clients who don't want it and may not need it. Though they smoke are we genuinely and accurately assessing the impact marijuana has on their disorder and whether it contributes to a functional impairment? And in the long run, the constant chiding can damage the therapeutic relationship when the client gets tired of you acting like their mothers.
Let me note now that I have never smoked/ingested marijuana in my life, and I don't plan to, but I appreciate a good glass of wine/beer and the occasional bit of liquor. This is hardly a concern for my doctor, and no one in my life circle has approached me out of fears for my well-being because I enjoy a drink once in awhile after a hard week at work. Like alcohol, many individuals smoke marijuana socially, to relax, to have fun, to unwind after a tough day without any presenting functional impairment. But for some reason, they get twice the judgment. Ironically, they may suffer half the consequences. Naysayers for marijuana screech about the effects on the lungs, the heart, the brain, but the effects of alcohol on the liver and brain and carries with it a significantly higher risk of death. Marijuana does not have definitive research on the long term health effects, but it has been shown that marijuana does not impact lungs the same way that cigarettes does, and there is virtually no risk of overdose. And beyond the scope of recreational purposes, medical marijuana has been soothing the ill for years.
Much research has been done on the effects of THC on various physical ailments, such as reactions to chemotherapy, glaucoma, pain management, Multiple Sclerosis, and seizures, just to name a few. Unfortunately research into the effects of marijuana on mental illnesses is much more limited, likely in part because there are still so many stigmas they're fighting (organizations like NAMI continue to battle marijuana use, citing increased symptomology, the inevitable opening of the drug gateway, and criminal behaviors). Because of this limited research, many articles and agencies discuss the known side effects of marijuana on emotionally healthy individuals while disregarding the effects of marijuana on the mentally ill and the possibility that it may reduce symptoms of significant emotional disorders.
How many times have we heard about our clients' marijuana use as self-medication? "It helps me sleep," "it calms me down when I'm anxious or stressed," "the voices aren't as loud after I smoke." Many mental health professionals have balked at this because of the research they know about the bud. I vividly remember my client telling her psychiatrist the weed helped reduce her voices and calmed her manic episodes, and he vehemently spat back "No, it doesn't! It does not help you!" as if he had recently taken up residence in her chaotic mind and could dictate to her her own feelings. Here's what these doctors actually know: it has been shown over time that mentally healthy people can, at times, suffer from reactions to marijuana which increase anxiety and paranoia. Mentally healthy people may experience hallucinations and delusions when under the influence. Mentally healthy people may show signs of depression when high. All of which is true. But another fact is certain strains of marijuana are depressants (not 'boo-hoo I'm sad' depressants, but 'chemicals that slow the cognitive processes of the brain' depressants). Depressants can be used to calm the sympathetic nervous system, slow the synaptic firings of the axons, reduce the heart rate, and relax tension in the body (all physiological symptoms of anxiety and mania). One small study at Harvard found that marijuana calmed the brains of bipolar individuals considerably. Adversely, there are strains of marijuana that are stimulants, which activate the brain, increase energy, alertness, and motivation, which could in turn assist with symptoms of depression and ADHD. And considering that we give kids with ADHD amphetamines like it's candy, would it hurt to invest in researching a less harmful and more natural drug?
The reality is there are still side effects to marijuana, and while the research is lagging, some studies have definitely found a link to cognitive difficulties in children and young teens who smoke, mainly because their brains are still developing (these effects were not found in young adults who began smoking after the age of 18). But the harsh truth is also what was briefly alluded to before, that our prescription medications are just as if not more dangerous. The synthetic chemicals we pump into each pressure molded tablet have several concerning side effects that can impact our children for years to come (ask the young males who developed breasts after taking Risperdol). With many popular drugs, we still do not know what long term effects will impact a young child's brain and many of these medications were developed for young adults and older adults before they were haphazardly doled out to our youth. So if we're going to scream about dangerous drugs, let's talk about your medicine cabinet. That is, if your rebellious teenager hasn't sold everything in them to the junkies on the street yet.
But if we let our kids have marijuana, can't that lead to other more intense and dangerous drugs? Here's the thing about the gateway myth: if the drugs are being used recreationally, clients have no greater risk of graduating to crack or heroin than you have of becoming an alcoholic because you had a glass of wine watching Game of Thrones last Sunday. The ironic thing is the risk becomes greater when individuals abuse marijuana as a form of a coping skill or self-medication, to numb themselves. So why the hell am I advocating for marijuana in mental illness, you ask? Because prescribed and controlled, it is no longer self-medicating; you are under the care of a physician, which is no more dangerous than taking Zoloft or Adderall as prescribed. And if you teach your clients appropriate coping skills in addition to their new medication and assist them in processing their illness, as we do with therapy and psychotropic treatments, the illness should gradually become manageable as it would any other way. Thus, eliminating the need to bury or numb the suffocating emotions and devastating poisonous thoughts.
So with all this talk of Mary Jane tolerance, what is our role as a mental health provider when our client says they smoke weed? Well, the first step would be to determine if the weed is impacting their mental stability or contributing to their diagnosis (this is hard to do because again, there's no research on it). More importantly, assess for functional impairment, much like you would when you're determining if the client is a social drinker or an alcoholic. If they smoke weed on the weekends but their grades are good or they're going to work on time every day, I'd say the weed's not a big issue at the moment. If they are flunking school because they'd rather stay home and hot box the day away or if they smoke then go drag racing, it's time to grab the drug brochures and write down that 800 number.
In regards to medicinal use, aside from the abundance of studies we still need to wait on, it is crucial to acknowledge that while marijuana may someday be an alternative to prescriptions, many factors need to be considered and reviewed before the client could be advised to keep smoking. The doctor would have to take into consideration the client's diagnosis, mental health history, physical health, and family history. For example, if the client does not have schizophrenia, but there is a strong family history for it, you're not going to want to provide a drug that could trigger their first psychotic break. But with research comes information and precautions: knowing the right type of marijuana strain for which disorder, knowing what the recommended dosage should be, ensuring that the client is getting pure medicinal marijuana and nothing laced or synthetic that they may pick up on the streets, and providing education for safe use and risk reduction.
There are so many unanswered questions, but just because we are unsure of the unknown doesn't mean that we should demonize our clients for doing generally the same thing we do with our drinks, or that we should disregard the potential for a drug that is already helping many people with medical illnesses. As we know, science is a living breathing creature that is always growing and changing. Years ago they said marijuana caused cancer, now they not only use it in cancer treatment, but developing research is showing marijuana can kill certain types of cancer cells. So who knows what we will find in the future. For now, chill. Legalization is coming, and with it will require a whole new approach to drug assessment and treatment, and we should be ready.