Treating Addictions [Guest Post]

The ABCs of rehab.

[Journalists like me tend to get immersed in the scientific and medical aspects of addiction. Not a bad thing, to be sure—but sometimes a simpler rendition puts a finer point on the matter. Today’s guest post was contributed by Susan White, who writes on the topic of Becoming a Radiologist.  She welcomes your comments at her email id: susan.white33@gmail.com.]

It’s very easy to find fault and assign blame when you’ve never been in the other person’s shoes; how often have we found ourselves judging people for their bad habits? Why can’t he stop that obnoxious habit? Oh, she’s not strong at all, she cannot stop drinking! I would never sink to the drug-induced state he is in, not even if the worst things were to happen to me – it’s easy to say all these things because we don’t know what an addiction feels like and how hard it is for people to quit. They’re just like you and me; they don’t like the way they are, but their substance abuse controls their bodies, minds and everything they do or say.

To understand an addiction, you need to understand that the body goes through changes, both physiological and psychological. If the addiction is to alcohol, drugs or any other chemical substance, the high euphoric feeling is what makes you go back again and again. But as time goes by, the high decreases and you begin to take in more of the abusive substance in your quest for that initial euphoria. It’s a vicious cycle that feeds itself, and if you stop, you feel withdrawal symptoms because your body is so used to its daily or even hourly fix.

It takes a supreme effort to admit that you have a problem and seek help. Rehab centers work because they make the addict quit cold turkey; they are cloistered and controlled environments where addicts have no access to the abusive substance. The sudden withdrawal causes abnormal reactions in your body, and you’re treated with medicines that help soothe your frayed nerves. When the initial craving subsides, you’re put in therapy and other forms of rehabilitation. Your diet is regulated, and your body slowly starts to recover and rejuvenate. 

The hardest part of rehab however comes when you step out of the cocoon of the de-addiction center and enter the real world. You have to face the demon that had its tentacles around you and fight it down, and for some people, this is where they suffer a relapse. Once they are surrounded by temptation, they succumb and are soon back to their decadent and sorry state. Others however, are made of sterner stuff. They know that they cannot afford to lose control again and they are disciplined enough to say no when they come face to face with temptation.

Addiction, be it to a substance, person or thing, is not something to be taken lightly. Unless admitted to and treated at the earliest, it could end up having serious physical and mental consequences. 

Graphics Credit: http://www.nida.nih.gov/

Gambling Through the Ages

A brief history of playing cards.

In a recent email exchange with NIDA director Nora Volkow, I asked about gambling as a clinical addiction. “It is almost by necessity that we’ll find significant overlaps in the circuits that mediate various forms of compulsive behaviors,” she responded. “We have yet to work out the details and the all important differences, but it stands to reason that there will be many manifestations of what we can call diseases of addiction.”

This got me thinking about the history of addictive drugs, which I researched for my book, The Chemical Carousel.  The litany features long and ultimately unsuccessful histories of campaigns against heroin, against tobacco, against alcohol.

But does fairness demand that we add gambling to the historical list, given the suspicion with which playing cards have been held throughout the ages?

The origin of playing cards is suitable murky, but  they are generally thought to have been invented in China or India in the 10th Century AD, and subsequently refined and redesigned in the Muslim world. By the 1300s, hand-painted playing cards had made it to Europe, mostly affordable only by the nobility. When the advent of woodblock printing brought playing cards to the masses, gambling with cards took on an altogether different reputation. Gambling with cards was banned in Florence, Italy in 1376, followed by Lille, France, then Valencia, Spain, and Ulm, Germany.

The bans proliferated in the 15th Century: In 1404, a bishop in France had to crack down on card gambling among the priesthood. In 1423, St. Bernard of Sienna railed against paying cards so successfully, according to The Standard Hoyle,  that “cards, dice and games of hazard” were gathered up by the townspeople and committed to the bonfire. In 1476, King Ferdinand and Queen Isabella banned gambling with playing cards. None of these prohibitions were even remotely successful, and by the 1600’s the standard “French pack” of 52 cards and four colored suits emerged. They have been the standard in the world’s casinos ever since.

By the 17th Century, card playing was well established in America, despite attempts by the Pilgrims to prevent it. And ministers quickly found that the Indians were deep into dozens of gambling games of their own. Little known fact: The American Stamp Act of 1765,  the very act that got the early patriots so riled up, included taxes on newspapers, legal documents—and playing cards.

Extreme Christmas Lights Syndrome

An addiction to bright lights in the dark.

In 2004, psychologist John M. Grohol wrote a satirical piece for The Psych Central Report. I ran this last year, and it seems appropriate to excerpt it again:

"It is an age-old question that has haunted people since the first string of lights was strung in the 20th century," Grohol wrote. "Why do some people seem to go a little crazy with the amount of lights and displays they put on their homes and lawns? What makes some people think that this is a good idea? This growing phenomenon has turned into a full-blown behavioral addiction for some."

Indeed it has; one with its very own WebRing. It’s the time of year when afflicted people manifest CLA—Christmas Lights Addiction.

"It is an extreme behavior of an otherwise normal expression of a celebration of the holidays,” Grohol continues. “If you're one of these folks who can't live without their million-light holiday display, seek help. Imagine how much better your gift to the world would be if you donated your electricity costs to a local charity or homeless shelter.

"Leave the holiday lighting spectaculars to Radio City Music Hall or professional displays found in most communities done in formal gardens or the like. Let's try and get back to celebrating Christmas in a way that honors the heart of the tradition without turning it into some sort of glitzy and tacky sideshow of lighting horror.

Merry Christmas, Happy Chanukah, and Happy New Years to you All!"

Photo Credit: http://www.collthings.co.uk

Q & A with Nora Volkow

NIDA director discusses cannabis, addiction vaccines, and gambling.

Recently, Addiction Inbox was offered the opportunity to submit questions to Nora Volkow, the director of the National Institute on Drug Abuse (NIDA). Dr. Volkow was kind enough to provide detailed answers by email. In her responses, she reveals a broad clinical understanding of addiction, and speculates on what this brain disorder might mean for “other diseases of addiction” like gambling.

Q: Clinical studies, like those by Barbara Mason at Scripps Institute, have documented a marijuana withdrawal syndrome among a minority of users. Are we prepared to say that marijuana is addictive? Why didn't we identify this syndrome years ago?

Nora Volkow: Absolutely, there is no doubt that some users can become addicted to marijuana. In fact, well over half of the close to 7 million Americans classified with dependence or abuse of an illicit drug are dependent on or abuse marijuana. It is important to clarify that while withdrawal is one of the criteria used to diagnose an addiction (which also includes compulsive use in spite of known adverse consequences), it is possible for an individual to suffer withdrawal symptoms without he or she being addicted to an abused substance.

Now, to answer your specific question, the reason for the relatively late realization that people who abuse marijuana can develop a cannabis withdrawal syndrome (CWS) if they try to quit is probably the result of at least two factors. First is the fact (which you hint at already) that a clinically relevant cannabis withdrawal syndrome may only be expected in a subgroup of cannabis-dependent patients. This may be partially explained by marijuana’s uptake into and slow release from fat cells, which can occur over days or weeks after last use. Thus, cessation of marijuana use may not be so abrupt, and could thereby diminish signs of withdrawal. The second factor relates to the small to negligible associations between recalled and prospectively assessed withdrawal symptoms, which may have precluded many previous, recall-based studies from detecting or properly characterizing CWS. It is also worth pointing out that other addictions (e.g., cocaine) were also not initially thought of as capable of triggering withdrawal symptoms.”

Q: Are there any anti-craving medications you are particularly excited about at this time?

Volkow: In the context of nicotine addiction, we have a host of nicotine replacement options as well as 2 medications that work through different mechanisms—all of which reduce craving and the risk of relapse during a cessation attempt, particularly when combined with some form of behavioral therapy. However, sustained abstinence from nicotine has been difficult to achieve, even with the current therapeutics that are available. So, at this point, I am very excited about a novel approach to the treatment of addiction—an approach that relies on vaccine development. Currently there are anti-nicotine vaccines in clinical testing, which are designed to capture the nicotine molecules while still in the bloodstream, thus blocking their entry in to the brain and inhibiting their behavioral effects. And while these vaccines were not intended specifically to reduce cravings, they appear to be effective in helping subjects who develop a high antibody response sustain abstinence over long periods of time. Even those people with a less robust antibody response to the vaccine, decreased their tobacco use. So this approach appears very promising.

Similarly, in the context of opiate addiction, we are very excited about the cumulative positive results of the clinical experience so far with buprenorphine, a long-acting partial agonist that acts on the same receptors as heroin and morphine, relieving drug cravings without producing the same intense "high" or dangerous side effects.

Q: You have suggested in the past that certain forms of overeating are addictions. There is good evidence for this. What about non-substance addictions, like gambling?

Volkow: The brain is composed of a finite number of circuits, for, for example, rewarding desirable experiences, remembering and learning about salient features and stimuli in the environment, developing emotional connections to other members of the social group, becoming aware of changes in interoceptive (internal) physiological states, etc. These and a few others are the circuits that the “world” acts upon. So it is almost by necessity that we’ll find significant overlaps in the circuits that mediate various forms of compulsive behaviors. We have yet to work out the details and the all important differences, but it stands to reason that there will be many manifestations of what we can call diseases of addiction. Thus, addiction to sex, gambling, alcohol, illicit drugs, shopping, video games, etc. all result from some degree of dysfunction in the ability of the brain to properly process what is salient, accurately predict and value reward, and inhibit emotional reactivity or deleterious behavior.

As we learn more about the significant overlaps at the genetic, neural, circuit, and systems levels we may be able to reap the benefits from complementary research into these various chemical and behavioral addictions.

Photo Credit: http://www.thechallenge.org

Addicted to Bad Reporting

How should we cover drug dependence?

Journalists usually learn it early: Drug stories are crime stories. Articles about alcoholism and assorted “hard” drug addictions are typically sourced by law enforcement, and the frequently lurid results tend to dump recreational, illegal, and prescription drugs into the same stew.

This is a particular problem for patients on opioid substitution therapy, who take maintenance drugs such as methadone and buprenorphine (Suboxone). Both drugs are the subject of black markets the size of which is difficult to pin down, but the vast majority of users take the drugs under medical supervision in government-supervised health and social programs.

According to the World Health Organization (WHO), it is in everybody’s interest to get this straight. The U.N. agency reports that every dollar spent on drug treatment results in a savings of $7 in health and social costs. Treatment of opioid addiction with methadone or buprenorphine is now possible in 63 countries. “Substitution maintenance therapy is one of the most effective treatment options for opioid dependence,” says WHO. Such therapies reduce “heroin use, associated deaths, HIV risk behaviors and criminal activity.”

Nonetheless, the tendency among news writers to use phrases like “fake heroin,” “drug-using criminals,” and “giving drugs to drug users” led the International Harm Reduction Association (IHRA), with sponsorship from Schering-Plough, makers of the addiction treatment drug Suboxone, to suggest media reporting guidelines in a white paper issued earlier this year. In “Addicted to News: A Guide to Responsible Reporting on Opioid Dependence and its Treatment,” the authors reviewed 53 English-language articles about substitution therapy and discovered a continuing trend toward “sensationalist ‘tabloid’ stories’” leading to a “backlash against people with the condition, or an increase or exacerbation of the problem if it is glorified or publicized by a celebrity.”

Specifically, the IHRA identifies the following problems:

--Exaggerated terminology (“magic bullet,” “junkies,” “pharmaceutical narcotics”).

--Depiction of patients as criminals rather than people with a serious condition often requiring medical treatment.

--Undue emphasis on criminal activity related to substitution therapies.

--Assumption that the treatment has failed unless the patient is drug free.

--Portrayal of medical anti-craving drugs as indistinguishable from recreational drugs.

So what can a serious journalist do about it? IHRA is glad to provide some suggestions:

DO:

--Ask yourself, “what if this was me or someone close to me?’

--Use factual and correct terminology.

--Include balanced, up-to-date local statistics on treatment programs.

DON’T:

--Depend entirely on law enforcement as story sources.

--Use exaggerated or derogatory descriptions of patients in treatment.

--Try to localize a national or international story without close attention to its relevance to the local community.

--Allow celebrity news to warp the reporting of treatments available for this serious condition.

As the IHRA tirelessly points out, when patients are effectively treated, everybody benefits.

Graphics Credit: http://asp.cumc.columbia.edu

Drugs and Prison

The American Disgrace.

For years, drug policy discussions have foundered on a fundamental dilemma: If illegal and addictive drugs are freely available in the nation’s prison system—and there is no one who says otherwise—then how can we as a society expect to control the consumption of drugs outside the prison walls? Moreover, should people be jailed at all for simple possession?

In 1982, President Ronald Reagan inaugurated the “war on drugs." From 1980 to 1997, writes Glenn C. Loury in his book Race, Incarceration, and American Values, the number of people in prison for drug offenses increased more than 1,000 %. Only one out of five drug convictions involved any sort of distribution beyond simple possession, says Loury, although there is often dispute about these numbers and how they are derived.

In “Can Our Shameful Prisons Be Reformed?” which appeared in the November 19 issue of the New York Review of Books, David Cole argues that African-Americans “have borne the brunt of this war.” While white drug offenders in prison increased by more than 100 % from 1985 to 1991, the prison population of black drug offenders soared by 465 %. Citing figures from The Sentencing Project, Cole asks whether we are willing to accept “a system in which one out of every three black males born today can expect to spend time in jail during his life?”

America’s prison disgrace is everyone’s problem, however. Cole informs us that a new prison is opened in the U.S. every week, and that imprisoning someone costs $20,000 a year and up. We spend $7 billion on jails in 1980. Today, writes Cole, the figure is $60 billion.

Where are we going wrong? The answer is straightforward, and unavoidable: The War on Drugs. According to FBI crime statistics cited by Cole, the U.S. last year arrested 1.7 million people for drug crimes. “Since 1989, more people have been incarcerated for drug offenses than for all violent crimes combined,” writes Cole. “Yet much like Prohibition, the war on drugs has not ended or even significantly diminished drug use.” In addition, “about half of property crime, robberies, and burglaries are attributable to the inflated cost of drugs caused by criminalizing them.”

At the heart of the problem lies a long-standing dilemma. The American prison system does next to nothing for drug addicts, except assure them of a steady supply. The justice system does not systematically help drug addicts avoid prison, or reintegrate them into society when they get out. And, since a high number of chronic drug abusers also suffer from other mental disorders, the lack of consistent, well-funded, effective programs for ex-offenders virtually guarantees a revolving-door cycle of repeated incarcerations. For those drug felons who are not themselves addicts, and who are in prison due to simple possession charges, a program of mass parole would ease prison crowding significantly. There is really no reason why many of the prisoners in this class should have been locked up at all, but for draconian legislation passed in the heat of passion—like New York’s Rockefeller laws--about one drug “epidemic” or another.

In addition to converting the swords of the drug war into the ploughshares of job programs, education, and housing assistance, we need to recognize and act upon the obvious fact that young people who are in school are far less likely to end up in prison. Schools are a far more cost-effective solution than prisons. In addition, a RAND Corporation study cited by Cole concluded that treatment is "fifteen times more effective at reducing drug-related crime than incarceration."

In the end, the need for action is undeniable. As Cole writes, “The very fact that the US record is so much worse than that of the rest of the world should tell us that we are doing something wrong.”

Graphics Credit: http://correctionsproject.com

Marijuana Withdrawal: A Survey of Symptoms (Part 2)

By Dirk Hanson

[Originally published in The Praeger International Collection on Addictions. Ed. by Angela Browne-Miller. Westport, Connecticut: Praeger, 2009. Vol. 2 Ch. 7 pp.111-124.]


Results

All of the following comments can be found at the Addiction Inbox post on Marijuana Withdrawal. The unnumbered messages on the Web site are dated, and appear in chronological order.

Cave. (2008, February 8):

“Well I just stopped smoking pot after 4 years of everyday use, 5 days ago. I am feeling the withdrawal symptoms ridiculously hard. No appetite, slight nausea, extreme insomnia.”

Anonymous. (2008, February 26):

“My boyfriend (of 6 years) has been a smoker for approximately 16 years. He has tried to give up a few times seriously before but has never quite gotten there yet. His behavior is almost unbearable when he does. It really takes a toll on our relationship. I never realized that it could be so bad and that his actions are so exaggerated by withdrawal.”

Anonymous. (2008, February 26):

“I’m a 30-year-old man and have been a heavy cannabis user (3 to 4 joints per day, every day) since I was 19. . . . I’ve been through intense anxiety, depression, restlessness, lack of appetite. I can’t sleep for more than a few hours at a time and when I do, I sweat buckets. I have a terrible appetite, I’m cold all the time, like I can’t regulate my temperature.”

Anonymous. (2008, February 27):

“I thought I was going crazy because all other sites told me that there were no withdrawal symptoms from pot, I can’t think or eat and when I do finally get something down my gullet I get the runs straight after. . . . I feel like I have been hit by a truck and it has only been a week since I gave up.”

Anonymous. (2008, March 1):

“I am 31 and a heavy smoker of 10 years. . . . What is really troubling me, however, is the excessive dreaming. . . . The dreams are vivid and strong, enough to wake me up sometimes.”

Anonymous. (2008, March 3):

“This idea of ‘intense dreaming’ is very real and for the first 5 or 6 days after quitting I experienced life-like dreams/nightmares (99% nightmares), which would wake me from my sleep. . . . This idea of breaking out in cold sweat is also very real and quite scary when [it] occurs as [it] got me worried there was something else wrong with me.”

Scott. (2008, March 3):

“I was blown away when I saw ‘excessive sweating’ as I have been experiencing that for a few days. . . . If I could cut back drastically, that would be the ideal situation. But I know from experience that I can’t just smoke pot ‘a little bit.’ If I’m going to reduce, it’s going to have to be all the way to zero.”

Anonymous. (2008, March 7):

“I’m on day seven of abstinence and boy, do I feel lousy. Night sweats, anxiety, extreme insomnia, and loads of irritability/anger problems. . . . It’s a bit like when you have a bad flu. You plain feel rotten. Anything stress-related is magnified ten-fold.”

Bob. (2008, March 7):

“I’m 38 years old and have been using weed now daily for almost 21 years. . . . I’ve been ‘clean’ now for 4 days and so far it has obviously been difficult, but already I’m showing signs of improvement, the first two days I had no sleep at all. . . . My withdrawal symptoms: Loss of appetite, sweating, irritability, sudden crying fits.”

Anonymous. (2008, March 8):

“I am a 25-year-old female and I have been smoking pot since I was 13. I have NEVER stopped even a day that I can remember. Not unless I couldn’t get it. I have recently started to realize that it is a drug addiction. I was always on the ‘it’s not addictive’ side. I get very anxious if I think I’m not going to have any. . . . It is out of my control I think, and now I’m starting to not feel high. I REALLY wanna stop, but am so scared of the symptoms. I think I need help.”

Anonymous. (2008, March 18):

“Having read all of these comments and questions I no longer feel so abnormal. I have been experiencing most of these symptoms including vivid dreaming. . . . I have been a smoker since I was 15, every day smoking about 2–3 joints.”

Anonymous. (2008, March 24):

“I am a 25-year-old female. I started smoking at 18. . . . I quit a few weeks ago. . . . I can’t focus on anything. I can’t make myself do anything. . . . I snap at everyone, including my boyfriend who has been complaining about my excessive sweating. I didn’t even think of the sweating as a symptom until I read the other posts here.”

Anonymous. (2008, April 2):

“I just wanted to say I’m glad I found this site because as many people have noted the common wisdom is that there are few, if any, symptoms of withdrawal. . . . I’ve noticed the irritability and mood swings, which I expected, but didn’t make the connection between the vivid and frequent dreams and waking at night until I read all the other comments.”

Anonymous. (2008, April 8):

“I finally feel sane again after reading these postings. I am a 48-year-old male who has been smoking weed since 1975. Anywhere from 2–6 joints per day of good quality pot for the last four years. Decided to quit about a week ago and my life has been a living hell since. . . . Haven’t eaten a full meal in a week, very tired and depressed, stomach in knots.”

Anonymous. (2008, April 25):

“I quit weed 46 days ago. . . . pretty similar symptoms as everyone else and the most severe anxiety and depression I have ever known. . . . I can’t concentrate or focus, I can’t seem to forget about what has happened even though I want to, it feels as though my brain keeps reminding me about the ‘situation’ or some general anxious or negative thought just pops into my consciousness . . . like it’s never going to end, like my thoughts are caught in a vicious circle.”

Richard. (2008, May 3):

“It’s not suicidal ideation but it’s the feeling that life will just never ‘be right’. . . . when you suffer from symptoms that you’ve been told don’t exist, you are left looking for the wrong cause. So, if you’re told that marijuana withdrawal does not increase anxiety, anger, or ‘hopelessness,’ you want to look for a cause of those things. . . . I went through withdrawal periods where I was inappropriately angry at the wrong thing, thinking that specific PEOPLE were upsetting me when they were not.”

Discussion

The U.S. government’s essentially unchanged opposition to marijuana research has meant that, until quite recently, precious few dollars were available for research. This official recalcitrance is one of the reasons for the belated recognition and characterization of marijuana’s distinct withdrawal syndrome. According to research undertaken as part of the Collaborative Study of the Genetics of Alcoholism, 16 percent of people with a lifetime history of regular marijuana use reported a history of cannabis withdrawal symptoms (Schuckit et al., 1999, p.41). In earlier research, Mason discovered that those seeking treatment for cannabis addiction tended to cluster in two age groups—college age and mid-50s (Somers, 2008).

Budney et al. (2004, p. 1973) write:

Regarding cross-study reliability, the most consistently reported symptoms are anxiety, decreased appetite/weight loss, irritability, restlessness, sleep problems, and strange dreams. These symptoms were associated with abstinence in at least 70% of the studies in which they were measured. Other clinically important symptoms such as anger/aggression, physical discomfort (usually stomach related), depressed mood, increased craving for marijuana, and increased sweating and shakiness occurred less consistently.

Today, scientists have a much better picture of the tasks performed by anandamide, the body’s own form of THC. Among the endogenous tasks performed by anandamide are pain control, memory blocking, appetite enhancement, the suckling reflex, lowering of blood pressure during shock, and the regulation of certain immune responses. This knowledge helps shed light on the wide range of THC withdrawal symptoms, particularly anxiety, chills, sweats, flu-like physical symptoms, and decreased appetite.

Furthermore, we can look to indications for which marijuana is already being prescribed—anxiety relief, appetite enhancement (compounds similar to anandamide have been discovered in dark chocolate), suppression of nausea, relief from the symptoms of glaucoma, and amelioration of certain kinds of pain—for more insight into the common hallmarks of cannabis withdrawal.

What treatment measures can help ameliorate marijuana withdrawal and craving in heavy users who wish to quit? The immediate threat to any decision in favor of abstinence is what might fairly be called the “hair of the dog” effect. Note the findings of a 2004 paper in Neuropsychopharmacology: “Oral THC administered during marijuana abstinence decreased ratings of ‘anxious,’ ‘miserable,’ ‘trouble sleeping,’ ‘chills,’ and marijuana craving, and reversed large decreases in food intake as compared to placebo, while producing no intoxication” (Haney et al., p. 158).

Moreover, “Overall withdrawal severity associated with cannabis alone and tobacco alone was of a similar magnitude. . . . cannabis withdrawal is clinically important and warrants detailed description in the DSM–V and ICD–11” (Vandrey, Budney, Hughes, & Liguori, 2008, p. 48). It is possible that many more people are trying—and failing—to quit marijuana than researchers have previously suspected. Daily use of marijuana may be driven in part by the desire to avoid or eliminate abstinence symptoms (Haney, Ward, Comer, Foltin, & Fischman, 1999, p. 395).

To date, there is no effective anticraving medication approved for use against marijuana withdrawal syndrome. More than a decade ago, Ingrid Wickelgren wrote in Science: “For instance, chemicals that block the effects of CRF or even relaxation exercises might ameliorate the miserable moods experienced by people in THC withdrawal. In addition, opiate antagonists like naloxone may, by dampening dopamine release, block the reinforcing properties of marijuana in people” (1997, p. 1967). Since stimulation of THC receptors has homologous effects on the endogenous opioid system, various investigators have speculated that naltrexone, the drug used as an adjunct of heroin withdrawal therapy, may find use against symptoms of marijuana withdrawal in people prone to marijuana dependence (Tanda et al., 1997, p. 2049). Further research is needed on the reciprocal relationship between THC and opioid receptor systems.

Serzone (nefazodone), an antidepressant, has been used to decrease some symptoms of marijuana withdrawal in human subjects who regularly smoked six joints per day (Haney et al., 2003, p. 157). Anxiety and muscular discomfort were reduced, but Serzone had no effect on other symptoms, such as irritability and sleep problems.

Preliminary studies have found that lithium, used to treat bipolar disorder, curbed marijuana withdrawal symptoms in an animal study (Cui, Gu, Hannesson, Yu, & Zhang, 2001, p. 9867). Another drug for mania and epilepsy—Depakote—did not aid significantly in marijuana withdrawal (Haney et al., 2004, p.158).

Since difficulty sleeping is one common symptom of withdrawal, common prescription medications might be indicated for short-term use in the case of severe marijuana withdrawal. Some researchers have reported that even brief interventions, in the form of support group sessions, can be useful for dependent pot smokers (Copeland, Swift, & Rees, 2001, p. 45).

It is also plausible to suggest that the use of marijuana by abstinent substance abusers may heighten the risk of relapse. In a study of 250 patients at a psychiatric/substance abuse hospital in New York, “Postdischarge cannabis use substantially and significantly increased the hazard of first use of any substance and strongly reduced the likelihood of stable remission from use of any substance” (Aharonovich et al., 2005, p. 1507). However, the researchers found that cannabis posed a greater risk to cocaine and alcohol abusers. For heroin, “cannabis use after inpatient treatment did not significantly affect remission and relapse.”

It is surprising to note the relative paucity of previous clinical data the researchers had to work with in the case of alcohol and marijuana. “The gap in the literature concerning the relationship of cannabis use to the outcome of alcohol dependence was surprising,” according to Aharonovich and colleagues. “We were unable to find a single study that examined the effects of cannabis use on post-treatment outcome for alcohol dependence, despite the fact that the majority of patients now in treatment for alcoholism dependence also abuse other drugs. Clearly additional studies of this issue are warranted” (2005, p. 1512).

Addiction researcher Barbara Mason of the Scripps Research Institute of La Jolla, California, is overseeing a four-year study of the neurobiology of marijuana dependence under a grant from NIDA. The comprehensive project will involve both animal and human research, and will make use of state-of-the-art functional brain imaging. The federal grant will also be used as seed money for the new Translational Center on the Clinical Neurobiology of Cannabis Addiction at the Scripps Institute (“Scripps Given,” 2008).

Above all, it is time to move beyond the common mistake of assuming that if marijuana causes withdrawal in some people, then it must cause withdrawal in everybody. And if it doesn’t, it cannot be very addictive. This thinking has been overtaken by the growing understanding that a minority of people suffer a chemical propensity for marijuana addiction that puts them at high risk, compared to casual, recreational drug users. The fact that most people do not become addicted to pot and do not suffer from withdrawal is no more revealing than the fact that a majority of drinkers do not become alcoholics.

The idea of marijuana addiction and withdrawal remains controversial in both private and professional circles. For an unlucky few, a well-identified set of symptoms characterizes abstinence from heavy, daily use of pot. In this, marijuana addiction and withdrawal does not differ greatly from alcoholism—the vast majority of recreational users and drinkers will never experience it.

For those that do, however, the withdrawal symptoms of marijuana abstinence can severely impact their quality of life.

Note: Sources and references can be found at the end of Part 1 below.