“Ken”was a daily marijuana user with a turbulent family background and a history of alcohol and drug use. He had almost given up alcohol and other drugs, but had failed repeatedly at quitting marijuana in spite of his wife’s unhappiness and his inability to produce sperm. During a relapse-prevention program, “Ken” symbolically pitched his marijuana bong into the trash can and successfully abstained throughout the 12-month follow-up period. He felt good about his accomplishment, his relationships improved, and he was confident about being able to maintain abstinence.
“Ken” was part of a Virginia Tech psychology professor’s research that has spanned a number of years and has overturned some common misconceptions about the nature of marijuana use and the methods of treating those dependent on marijuana.
The research suggests, for example, that psychological addiction is as difficult to break or more difficult to break than a physiological addiction, according to Robert Stephens, professor of psychology. The researchers, including Roger A. Roffman of the University of Washington, also learned that brief treatment programs – as short as two sessions – achieved as high a success rate as did longer programs. They learned, too, that any professional intervention results in more improvement than no intervention at all.
Before the late 1980s, there was essentially no research on treating adults dependent on marijuana. It was assumed that they did not want or need treatment and, if they did want to stop, they could do it themselves. “In spite of the fact of marijuana use being illegal, people have thought of marijuana as a relatively benign drug that doesn’t cause problems,” Stephens says. Also, marijuana does not appear to produce the physiological changes associated with tolerance and withdrawal that are thought to be the cause of addiction to other drugs. For those reasons, securing funding for research was difficult.
Although no studies have yet linked marijuana to lung cancer, there is evidence that marijuana causes structural and functional changes in the lungs similar to those caused by smoking cigarettes, Stephens says. Marijuana has more tars than cigarettes, and, even though marijuana abusers do not smoke a pack of marijuana cigarettes a day, they tend to inhale more deeply and hold the smoke in longer. Thus, there is reason to be concerned about the long-term effects on the lungs, Stephens says.
Users commonly report experiencing problems with attention, concentration, and short-term memory while smoking. Also, as the “Ken” story points out, some studies, though inconsistent, have shown that marijuana use can lower the sperm count temporarily. Recent studies have also indicated that marijuana smoking by pregnant women may decrease the oxygen supply to the infants, as cigarette smoking does.
In the mid-1980s, Roffman publicized a telephone number for people to call if they wanted to stop using marijuana. The phone calls demonstrated that a large group of people who were almost daily smokers of marijuana were interested in treatment.
Stephens and Roffman were on the faculty at the University of Washington when they received a grant from the National Institute of Drug Abuse to study the effectiveness of treatments. They advertised for adults who wanted to stop using marijuana and screened out those who had alcohol or other drug abuse or dependency.
In 1987 in Seattle, they put 212 subjects into two different programs. In both treatment programs, groups of 10 to 12 people met with two therapists for 10 sessions over three months.
The first group participated in relapse-prevention therapy to help them identify situations that lead to use of the drug – being around other users, being depressed or stressed, or being bored – and then helped them develop plans, skills, and coping strategies to use in those situations. The methods were mostly the same as those used in treating other drug abuse – relaxation exercises, imaging, role playing, and enlisting the support of others. The researchers thought this intervention would be more useful to the participants.
The second group participated in the type of treatment more readily available at the time – a discussion/support group with therapists present. Participants talked about their problem and what they wanted to do about it, but were given no help identifying weak spots and no skills or strategies for coping.
After treatment, the participants were assessed for marijuana use and were monitored for a year. The results were unexpected.
“The two treatment programs did equally well,” Stephens says. As many as 70 percent stopped using marijuana in both programs. A year later, only about 25 percent were still abstinent. However, on average, the entire group had reduced use by nearly half.
“The results are encouraging if you look at all the people who stopped, or discouraging if you consider how many went back to using,” Stephens says.
The results were similar to those of programs for alcohol, cigarette, heroin, or cocaine treatments. “That led us to believe that the problem with drug dependency is not physiological dependency,” Stephens says. People abusing drugs that cause severe physiological dependence, such as heroin or alcohol, can be helped through the physical withdrawal with little discomfort.
“It’s the psychological functions that the drug serves and the reliance on drugs to get so many needs met – escape, dealing with bad moods, having fun, relieving boredom – that are difficult to break,” Stephens says. “No wonder a drug is so hard to give up, because it’s difficult to find anything else that fills all those roles.”
Psychological addiction is as difficult to break or more difficult to break than a physiological addicition.
In 1989, Stephens received a grant for two related additional studies. He moved to Virginia Tech, but continued to oversee the research being done in Seattle under Roffman's direction.
First they followed up with participants from the first study after two and one-half years. “Roughly one-half of the people who were doing well a year after treatment had returned to problem levels of use,” Stephens says. “But, to compensate, one-third of the people who were doing poorly after treatment were now doing well.”
Stephens and his group then did another treatment study. They put 291 people who wanted to quit into one of three groups to learn the effectiveness of different types of treatment. “The participants in the first study may have done well because they were motivated and it didn’t matter what we did with them,” Stephens says. The second study would find out.
One group’s conditions were similar to those of the previous relapse- prevention treatment program in which they identified high-risk situations and learned coping skills. The program included 14 sessions over four months. One added option was that they could involve a significant other in the treatment program for four additional group meetings designed to help the couple work together.
The second group’s members were seen individually for only two Individualized Assessment and Intervention (IAI) sessions one month apart. Participants were given feedback based on an earlier assessment that summarized the problems they were having, the amount of use, and the times they could not resist using marijuana. Then a technique called motivational interviewing was used to help them develop motivation to want to stop by looking at the ways marijuana was affecting their lives. They were given instructions about how to change and ways to cope with difficult situations, and were allowed to bring a significant other to the second session.
The third study group was given no treatment for four months to see if motivation alone, without any treatment, would get results.
At the end of four months, the three groups were compared. “Both the four-month relapse-prevention and IAI produced greater rates of abstinence and reduction than the delayed treatment,” Stephens says. About 45 percent of the participants were abstinent, compared with 17 percent of the group receiving no treatment. (That group subsequently received treatment.)
“Some treatment of either kind worked better than no treatment, but four months of treatment did not do any better than the two-session motivational intervention,” Stephens says. A year later, the two groups fared about the same as the original study group.
“The treatments,” Stephens says, “seem to work by helping users resolve their ambivalence about quitting and identifying ways or means of kicking the habit. Even then, there’s a large group not improving significantly.” The studies did show that those who curtailed or stopped use did not replace marijuana with other drugs or alcohol, Stephens says. They also showed that people wanted to stop using basically for intrinsic factors: they felt bad that they lacked control over their use of marijuana (they had withdrawal symptoms when they tried to stop); they felt they procrastinated when using; they lacked self confidence; they suffered memory loss; they were afraid they would suffer a serious illness.
To a much lesser extent, they wanted to stop using because their families were nagging them, they were having financial difficulty, the use impaired their work or school performance, or, very seldom, they were having legal problems.
Stephens is now involved with a multi-site treatment study. Funded by the Substance Abuse and Mental Health Services Administration’s Center for Substance Abuse Treatment, the study will be conducted with 150 subjects in each of three locations: Seattle, Miami, and the University of Connecticut. “We hope for a more diverse socio- economic and racial group,” Stephens says. “It’s possible that they will need more treatment to find strategies for coping. Maybe the short-term therapy works only for people who already have sufficient resources available.”
Stephens also is seeking funding to study whether the treatments work with individuals who are more ambivalent about changing their marijuana use. “We believe there are a lot of adults who are nearly daily marijuana smokers who won’t come forward because they don’t see a huge problem in their life, but are concerned that they are using every day,” Stephens says.
“We don’t want to bombard them with longer, unnecessary treatment,” Stephens says. “We hope to look at reaching more marijuana users with shorter treatments instead of longer programs.”