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Brief Counseling for Marijuana Dependence: A Manual for Treating Adults
- By SAM HSA
- Published 03/10/2009
- Addiction Research
- Unrated
SAM HSA
The Substance Abuse and Mental Health Services Administration (SAMHSA) is concerned with facilitating recovery for people with or at risk for mental or substance use disorders.
http://www.samhsa.gov/
The Center for Substance Abuse Treatment (CSAT), part of the Substance Abuse and Mental Health Services Administration, funded three clinical sites and a Coordinating Center (CC) to design and implement the Marijuana Treatment Project (MTP) in the late 1990s.
A major focus of CSAT is rigorous testing of approaches to treat marijuana dependence in both adults and adolescents. MTP studied the efficacy of treatments for adults who are dependent on marijuana.
At the time of funding, MTP was one of the largest Knowledge Development and Applications initiatives funded by CSAT. Another was the Cannabis Youth Treatment (CYT) Study, which resulted in the CYT Series, a five-volume resource that provides unique perspectives on treating adolescents for marijuana use (Godley et al. 2001; Hamilton et al. 2001; Liddle 2002; Sampl and Kadden 2001; Webb et al. 2002).
This manual for Brief Marijuana Dependence Counseling (BMDC) is based on the research protocol used by counselors in MTP. The manual provides guidelines for counselors, social workers, and psychologists in both public and private settings who treat adults dependent on marijuana.
The 10 weekly one-on-one sessions in the BMDC manual offer examples of how a counselor can help a client understand certain topics, keep his or her determination to change, learn new skills, and access needed community supports (exhibit I-1).
Stephens and colleagues (2002) describe the MTP rationale, design, and participant characteristics. Findings from MTP are presented in supplemental reading B of section VII.
Me? Hooked on Pot?
Many individuals for whom this intervention was designed often have difficulty accepting that they are dependent on marijuana. The topic is controversial, even for those who walk through a counselor’s door to talk about their marijuana use.
People who become clients in BMDC may have
• Put off actions and decisions to the point of being a burden on family and friends
• Given up personal aspirations
• Had nagging health concerns, such as worries about lung damage
• Made excuses for unfinished tasks or broken promises
• Experienced disapproval from family and friends
• Been involved in the criminal justice system
Case Examples
Doug -- A Caucasian father of two teenagers, Doug was in his early 40s when his wife forced him to talk to a counselor about marijuana.
He was not happy to be in the counselor’s office. “What’s the big deal?” he asked. “It’s just pot.”
Doug’s wife had given him an ultimatum: either he quit getting high or she would move out.
She delivered this ultimatum when their 15-year-old son was suspended from school for smoking marijuana.
When they were younger, Doug and his wife smoked pot together. As their children grew older, however, his wife gave it up.
For a long time, she tolerated Doug’s continued use, with their agreeing that he’d be discreet. Both felt that the children should not know about his using.
Doug tried to be careful, but a few times his son had walked in on him using marijuana. “Why can’t you settle for my promising to try harder to hide it from the kids?” he argued. “It’s not as if it’s really a problem. After all, our family benefits from my income.”
Given what he said in the first several minutes he spent with the counselor, he saw the real issue as his wife’s refusal to be reasonable. But Doug also mentioned that he wondered, “What will people think if word gets out that I smoke marijuana?”
Shirley -- Shirley struggled with thoughts about marijuana and its effects. An African-American mother of three girls, Shirley was troubled by what she perceived as a conflict between her personal and professional lives.
Getting high helped her relax and sleep. Shirley had first smoked pot with a favorite uncle, and other members of her close-knit family had experienced getting high. No one was critical of her smoking.
However, Shirley wanted to be an elementary school teacher. While student teaching, she was struck by the incongruity of having chosen a profession that called for being a good role model for children yet regularly getting stoned.
She had thought a lot about quitting. When she tried to stop, she felt agitated and had difficulty sleeping. Shirley worried that she might not succeed in changing. She started seeing a counselor to sort out her confusion.
Like Doug, Shirley was grappling with a complicated issue. Doug and Shirley perceived aspects of their marijuana experiences as positive, yet they were troubled by possible consequences.
Miguel -- A 36-year-old married Hispanic man, Miguel has known for years that getting high is no longer a casual part of his life. When he tried to stop, he got angry at the slightest provocation, could not relax, and inevitably returned quickly to frequent use.
Not too long ago, Miguel made an appointment at a drug treatment agency but never showed up. The agency employee who answered the phone asked him, “Is marijuana the only drug you use?” He thinks that he needs help but doubts that anyone would understand how he feels.
He does not want to be treated like an addict.
Brief Marijuana Dependence Counseling
These three examples illustrate several important questions commonly asked by people about their marijuana use:
• Is it possible to be dependent on marijuana?
• Do I want to stop using because of what I’ve experienced?
• Can I succeed in stopping, given the challenges I’ve faced in the past?
The counseling approach presented in this manual addresses these issues among others. It comprises three key intervention components: motivational enhancement, cognitive behavioral skills training, and case management.
Each session presents examples of how a counselor might introduce certain topics, facilitate the client’s resolution to stop using marijuana, provide skills training, and help the client access needed community supports.
Background Before 1994, no published, controlled trials of treatment for marijuana use disorders existed, which is surprising because marijuana long has been the most frequently used illicit substance in the United States.
Interest in treatment for people who use marijuana may have been lacking because of myths that extensive marijuana use did not lead to dependence and that no adverse consequences were associated with misuse (Roffman et al. 1988; Stephens and Roffman 1993).
The relatively mild withdrawal symptoms associated with marijuana use may have led to a belief that dependence was unlikely and that people who needed treatment abused other substances and their marijuana use was a secondary concern (e.g., Rainone et al. 1987).
Similarly, most early reviews found few serious negative consequences associated with marijuana use (e.g., Hollister 1986; Wert and Raulin 1986a, 1986b).
However, recent research shows that a significant number of adults are dependent on marijuana and experience negative consequences secondary to their use of marijuana.
Current Findings About Marijuana Use
Marijuana is the most commonly used illicit substance in the United States (Clark et al. 2002; Substance Abuse and Mental Health Services Administration 2003). According to the 2003 National Survey on Drug Use and Health, 14.6 million people ages 12 and older had smoked marijuana in the preceding month (Substance Abuse and Mental Health Services Administration 2004).
It is estimated that approximately 4.3 million people used marijuana at levels consistent with abuse or dependence in the past year. Given that it is an illicit substance, any use of marijuana carries with it some significant risks.
However, this document focuses on people who use marijuana heavily or are dependent on it. This treatment manual is directed primarily at these persons but may be useful for other persons with substance abuse or substance use disorders.
Studies have demonstrated that tolerance and withdrawal develop with daily use of large doses of marijuana or THC (Haney et al. 1999a; Jones and Benowitz 1976; Kouri and Pope 2000).
About 15 percent of people who acknowledge moderate-to-heavy use reported a withdrawal syndrome with symptoms of nervousness, sleep disturbance, and appetite change (Wiesbeck et al. 1996).
Many adults who are marijuana dependent report affective (i.e., mood) symptoms and craving during periods of abstinence when they present for treatment (Budney et al. 1999).
The contribution of physical dependence to chronic marijuana use is not yet clear, but the existence of a dependence syndrome is fairly certain.
An Epidemiological Catchment Area study conducted in Baltimore found that 6 percent of people who used marijuana met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (American Psychiatric Association 1994), criteria for dependence and 7 percent met DSM-IV criteria for substance abuse (Rosenberg and Anthony 2001).
Coffey and colleagues (2002) found that persons who use marijuana more than once a week are at significant risk for dependence. In the 1990s, the number of people who sought treatment for marijuana dependence more than doubled (Budney et al. 2001).
Therefore, a large group of adults who smoke marijuana is dependent and may need and benefit from treatment. Surveys of people using marijuana who are not in treatment consistently show that a majority report impairment of memory, concentration, motivation, self-esteem, interpersonal relationships, health, employment, or finances related to their heavy marijuana use (Haas and Hendin 1987; Rainone et al. 1987; Roffman and Barnhart 1987; Solowij 1998).
Similar marijuana-related consequences are seen among those seeking treatment for their marijuana use (Budney et al. 1998; Stephens et al. 1994b, 2000). People using marijuana who participated in previous treatment studies averaged more than 10 years of near-daily use and more than six serious attempts to quit (Stephens et al. 1994b, 2000).
These individuals had persisted in their use despite multiple forms of impairment (i.e., social, psychological, physical), and most perceived themselves as unable to stop. During the past decade evidence has emerged that a variety of problems are associated with chronic marijuana use.
Although the severity of these problems appears to be less than that of problems caused by other drugs and alcohol, the large number of people using who may have these problems raises the possibility of a significant public health problem.
Like those who use other mood-altering substances, many individuals who use marijuana chronically perceive the problems to be severe enough to warrant treatment. The results of earlier studies on treatments for marijuana problems indicated that some adults who used marijuana responded well to several types of interventions, such as cognitive behavioral, motivational enhancement, and voucher-based treatments (Budney et al. 2000; Stephens et al. 1994b, 2000).
Relapse rates following treatment were similar to those for other drugs of abuse and, as found with other types of substance abuse treatment, improvements in drug use were accompanied by other positive gains, including improvements in dependence symptoms, problems related to marijuana use, and anxiety symptoms.
However, the generalizability of the treatment findings appeared to be limited by the predominantly white, male, and socioeconomically stable (i.e., educated and employed) characteristics of the samples. Therefore, the results of these studies may be limited to this fairly homogeneous group of people who are marijuana users.
A major focus of CSAT is rigorous testing of approaches to treat marijuana dependence in both adults and adolescents. MTP studied the efficacy of treatments for adults who are dependent on marijuana.
At the time of funding, MTP was one of the largest Knowledge Development and Applications initiatives funded by CSAT. Another was the Cannabis Youth Treatment (CYT) Study, which resulted in the CYT Series, a five-volume resource that provides unique perspectives on treating adolescents for marijuana use (Godley et al. 2001; Hamilton et al. 2001; Liddle 2002; Sampl and Kadden 2001; Webb et al. 2002).
This manual for Brief Marijuana Dependence Counseling (BMDC) is based on the research protocol used by counselors in MTP. The manual provides guidelines for counselors, social workers, and psychologists in both public and private settings who treat adults dependent on marijuana.
The 10 weekly one-on-one sessions in the BMDC manual offer examples of how a counselor can help a client understand certain topics, keep his or her determination to change, learn new skills, and access needed community supports (exhibit I-1).
Stephens and colleagues (2002) describe the MTP rationale, design, and participant characteristics. Findings from MTP are presented in supplemental reading B of section VII.
Me? Hooked on Pot?
Many individuals for whom this intervention was designed often have difficulty accepting that they are dependent on marijuana. The topic is controversial, even for those who walk through a counselor’s door to talk about their marijuana use.
People who become clients in BMDC may have
• Put off actions and decisions to the point of being a burden on family and friends
• Given up personal aspirations
• Had nagging health concerns, such as worries about lung damage
• Made excuses for unfinished tasks or broken promises
• Experienced disapproval from family and friends
• Been involved in the criminal justice system
Case Examples
Doug -- A Caucasian father of two teenagers, Doug was in his early 40s when his wife forced him to talk to a counselor about marijuana.
He was not happy to be in the counselor’s office. “What’s the big deal?” he asked. “It’s just pot.”
Doug’s wife had given him an ultimatum: either he quit getting high or she would move out. She delivered this ultimatum when their 15-year-old son was suspended from school for smoking marijuana.
When they were younger, Doug and his wife smoked pot together. As their children grew older, however, his wife gave it up.
For a long time, she tolerated Doug’s continued use, with their agreeing that he’d be discreet. Both felt that the children should not know about his using.
Doug tried to be careful, but a few times his son had walked in on him using marijuana. “Why can’t you settle for my promising to try harder to hide it from the kids?” he argued. “It’s not as if it’s really a problem. After all, our family benefits from my income.”
Given what he said in the first several minutes he spent with the counselor, he saw the real issue as his wife’s refusal to be reasonable. But Doug also mentioned that he wondered, “What will people think if word gets out that I smoke marijuana?”
Shirley -- Shirley struggled with thoughts about marijuana and its effects. An African-American mother of three girls, Shirley was troubled by what she perceived as a conflict between her personal and professional lives.
Getting high helped her relax and sleep. Shirley had first smoked pot with a favorite uncle, and other members of her close-knit family had experienced getting high. No one was critical of her smoking.
However, Shirley wanted to be an elementary school teacher. While student teaching, she was struck by the incongruity of having chosen a profession that called for being a good role model for children yet regularly getting stoned.
She had thought a lot about quitting. When she tried to stop, she felt agitated and had difficulty sleeping. Shirley worried that she might not succeed in changing. She started seeing a counselor to sort out her confusion.
Like Doug, Shirley was grappling with a complicated issue. Doug and Shirley perceived aspects of their marijuana experiences as positive, yet they were troubled by possible consequences.
Miguel -- A 36-year-old married Hispanic man, Miguel has known for years that getting high is no longer a casual part of his life. When he tried to stop, he got angry at the slightest provocation, could not relax, and inevitably returned quickly to frequent use.
Not too long ago, Miguel made an appointment at a drug treatment agency but never showed up. The agency employee who answered the phone asked him, “Is marijuana the only drug you use?” He thinks that he needs help but doubts that anyone would understand how he feels.
He does not want to be treated like an addict.
Brief Marijuana Dependence Counseling
These three examples illustrate several important questions commonly asked by people about their marijuana use:
• Is it possible to be dependent on marijuana?
• Do I want to stop using because of what I’ve experienced?
• Can I succeed in stopping, given the challenges I’ve faced in the past?
The counseling approach presented in this manual addresses these issues among others. It comprises three key intervention components: motivational enhancement, cognitive behavioral skills training, and case management.
Each session presents examples of how a counselor might introduce certain topics, facilitate the client’s resolution to stop using marijuana, provide skills training, and help the client access needed community supports.
Background Before 1994, no published, controlled trials of treatment for marijuana use disorders existed, which is surprising because marijuana long has been the most frequently used illicit substance in the United States.
Interest in treatment for people who use marijuana may have been lacking because of myths that extensive marijuana use did not lead to dependence and that no adverse consequences were associated with misuse (Roffman et al. 1988; Stephens and Roffman 1993).
The relatively mild withdrawal symptoms associated with marijuana use may have led to a belief that dependence was unlikely and that people who needed treatment abused other substances and their marijuana use was a secondary concern (e.g., Rainone et al. 1987).
Similarly, most early reviews found few serious negative consequences associated with marijuana use (e.g., Hollister 1986; Wert and Raulin 1986a, 1986b).
However, recent research shows that a significant number of adults are dependent on marijuana and experience negative consequences secondary to their use of marijuana.
Current Findings About Marijuana Use
Marijuana is the most commonly used illicit substance in the United States (Clark et al. 2002; Substance Abuse and Mental Health Services Administration 2003). According to the 2003 National Survey on Drug Use and Health, 14.6 million people ages 12 and older had smoked marijuana in the preceding month (Substance Abuse and Mental Health Services Administration 2004).
It is estimated that approximately 4.3 million people used marijuana at levels consistent with abuse or dependence in the past year. Given that it is an illicit substance, any use of marijuana carries with it some significant risks.
However, this document focuses on people who use marijuana heavily or are dependent on it. This treatment manual is directed primarily at these persons but may be useful for other persons with substance abuse or substance use disorders.
Studies have demonstrated that tolerance and withdrawal develop with daily use of large doses of marijuana or THC (Haney et al. 1999a; Jones and Benowitz 1976; Kouri and Pope 2000).
About 15 percent of people who acknowledge moderate-to-heavy use reported a withdrawal syndrome with symptoms of nervousness, sleep disturbance, and appetite change (Wiesbeck et al. 1996).
Many adults who are marijuana dependent report affective (i.e., mood) symptoms and craving during periods of abstinence when they present for treatment (Budney et al. 1999).
The contribution of physical dependence to chronic marijuana use is not yet clear, but the existence of a dependence syndrome is fairly certain.
An Epidemiological Catchment Area study conducted in Baltimore found that 6 percent of people who used marijuana met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (American Psychiatric Association 1994), criteria for dependence and 7 percent met DSM-IV criteria for substance abuse (Rosenberg and Anthony 2001).
Coffey and colleagues (2002) found that persons who use marijuana more than once a week are at significant risk for dependence. In the 1990s, the number of people who sought treatment for marijuana dependence more than doubled (Budney et al. 2001).
Therefore, a large group of adults who smoke marijuana is dependent and may need and benefit from treatment. Surveys of people using marijuana who are not in treatment consistently show that a majority report impairment of memory, concentration, motivation, self-esteem, interpersonal relationships, health, employment, or finances related to their heavy marijuana use (Haas and Hendin 1987; Rainone et al. 1987; Roffman and Barnhart 1987; Solowij 1998).
Similar marijuana-related consequences are seen among those seeking treatment for their marijuana use (Budney et al. 1998; Stephens et al. 1994b, 2000). People using marijuana who participated in previous treatment studies averaged more than 10 years of near-daily use and more than six serious attempts to quit (Stephens et al. 1994b, 2000).
These individuals had persisted in their use despite multiple forms of impairment (i.e., social, psychological, physical), and most perceived themselves as unable to stop. During the past decade evidence has emerged that a variety of problems are associated with chronic marijuana use.
Although the severity of these problems appears to be less than that of problems caused by other drugs and alcohol, the large number of people using who may have these problems raises the possibility of a significant public health problem.
Like those who use other mood-altering substances, many individuals who use marijuana chronically perceive the problems to be severe enough to warrant treatment. The results of earlier studies on treatments for marijuana problems indicated that some adults who used marijuana responded well to several types of interventions, such as cognitive behavioral, motivational enhancement, and voucher-based treatments (Budney et al. 2000; Stephens et al. 1994b, 2000).
Relapse rates following treatment were similar to those for other drugs of abuse and, as found with other types of substance abuse treatment, improvements in drug use were accompanied by other positive gains, including improvements in dependence symptoms, problems related to marijuana use, and anxiety symptoms.
However, the generalizability of the treatment findings appeared to be limited by the predominantly white, male, and socioeconomically stable (i.e., educated and employed) characteristics of the samples. Therefore, the results of these studies may be limited to this fairly homogeneous group of people who are marijuana users.
