I have long supported making marijuana available for medical purposes, but I will admit that it was a kind of abstract or theoretical support. As an addiction psychologist and psychotherapist, I engaged with marijuana in a very different way. For most of my patients, cannabis use was a historical experience, one rooted in the high school or college years. For others, it was a secondary substance that only occasionally entered our work, typically in a fairly non-problematic way. For a third group, however, marijuana was of central importance—usually playing the role of an anxiolytic or anxiety-reducing medication. These patients were very dedicated to its use and very frightened by the thought of having to live without it, despite the decline in productivity and the diminishing of life engagement that it was causing in their lives.
For the past nine years I have been treating a woman whom I will call Frida. Frida is an extremely artistic, profoundly empathic and intellectually gifted woman whose life has been crippled not only by a decades-long struggle with arthritis, back pain, and knee and foot injuries, but also by depression and the aftermath of a complex and at times emotionally traumatizing childhood. She also wrestles with profound grief over not having been able to develop her gifts and so often being forced to sit on the sidelines.
Despite extensive searches for answers in the worlds of both mainstream and alternative medicine, Frida has seen her physical condition continue to decline, and she has gone through several rounds of deep suffering in which her level of pain was almost intolerable. A grimly ironic complication is that she cannot tolerate prescription opioid medications, which greatly disturb her stomach after just a few days of use. In light of this, medical marijuana (recently authorized but still not available in New York state) might offer hope for relief.
What are its properties?
Over the past several months, a number of professionals have expressed their fears about marijuana policy, including medical marijuana, in the pages of Addiction Professional. At heart, these individuals appear to believe that marijuana is a dangerous drug. I think, however, that this is not a correct or useful way to categorize marijuana. Marijuana is not a dangerous drug—it is a complex drug.
Drawing on both scientific research and anecdotal reports, one can discern roughly 10 attributes of the plant. For example, marijuana can:
Trigger psychotic experiences in vulnerable youth;
Be addictive for roughly one-tenth of those who try it;
Cause anxiety and panic attacks in both new and experienced users;
Sap ambition and desire, and contribute to Amotivational Syndrome;
Bring great joy and pleasure, lead to increases in creativity, and enhance the quality of the user’s life;
Relieve deep anguish, pain, and suffering in body and mind in ways that sometimes cannot be equaled by prescription medications;
Serve as a substitute medication for prescription opiate and other addictions;
Prevent blindness related to eye disease;
Possibly help in the treatment of cancer and some nervous system diseases; and
Facilitate meaningful spiritual experiences.
In short, I do not believe that we have ever encountered a drug or medicine with such a vast array of risks and benefits.
The movement toward medical marijuana legalization seems to be growing daily, so I believe it is likely that marijuana and a wide array of cannabinoid-based treatments will be available in the future. Given that, is there a role for addiction professionals in this new cannabinoid-centered treatment landscape? And if so, what might it be?
In both my addiction psychotherapy work and my general psychotherapy practice, there are two central and overlapping goals or outcomes that I keep in mind. The first is to work with patients to increase their internal experience of freedom. As many know, the word “addiction” is related to an ancient term referring to a kind of slavery. That is why addiction treatment is liberation work. Addicted people have limited choices. For them, the use of drugs is too often a dominant thought, a recurring theme in their conversations, and a primary motivator of their actions. Successful treatment frees people from the tyranny of addiction, facilitating greater internal freedom and the capacity to be more self-determining.
My second goal is to promote and facilitate the development of personal complexity. Problematic and addictive substance use damages identities, and impels people toward a state of ontological or existential simplicity—a state in which getting, using and recovering from drug use becomes the central life activity. As our patients heal and recover, they begin to expand their repertoire and interact with a wider range of social groups. With greater intent and focus, they begin to do such things as parent children, play softball, develop careers, organize family events, volunteer at needle exchanges, connect to spiritual or religious institutions, fall in love, pursue mastery of an art form, and care for animals. In fact, one good way to assess the progress of patients involves tracking the range of topics they speak about and the number of non-using settings in which they participate.
Chronic pain and medical illnesses can have a similar effect on the life structure and psyche of patients. They too decrease the possibilities for the individual—both internally and socially. This means that medical marijuana will be a healing and therapeutic agent to the degree that it increases internal freedom and promotes personal complexity.
Conversing with patients
Based both on our knowledge of addiction and mental illness and a willingness to immerse ourselves in an understanding of the extraordinary benefits that cannabinoids offer, I can foresee the usefulness of creating models of “medical marijuana coaching.” Building on the concept of the Ideal Use Plan of Andrew Tatarsky, PhD, a “Wise Use” paradigm could be developed to address such complexities as clarifying therapeutic goals; understanding the benefits and interactions between THC and cannabidiol (CBD); balancing the pros and cons of different methods of use; and creating clinical strategies around the parameters of frequency, duration, strain and dose.
Most importantly, the model would involve working collaboratively with patients to make sure that their freedom and complexity are increasing and that they are neither losing control of their use nor developing adverse mental health consequences.
This means that we might want to speak to patients in the following way: “I know that you are suffering and in pain. There are anecdotal and research reports that support the idea that marijuana and its derivatives might be helpful for people who are wrestling with the issues that you are facing. I am guardedly optimistic that cannabis can improve the quality of your life and, possibly, help heal some of your illnesses. However, there are dangers here and there is much that we do not know. If you are interested, I would like to begin this journey with you so that we can maximize the benefits, minimize the risks, and achieve the best possible outcomes. It is, of course, your decision as to how you would like to proceed.”
I suspect that some who are reading this might ask, “How can you recommend the use of marijuana without a firm body of research to support your claims?” My answer is twofold. First, there already is a somewhat extensive body of research that concerns both basic properties and the effects of cannabinoid-based medications. Second, there is the tragedy perpetuated by the National Institute on Drug Abuse (NIDA). I have great admiration for NIDA and I believe it has made unparalleled contributions to the development of effective, humanistic and science-based treatments for addictive disorders. NIDA, however, has not only refused to engage in serious research on the medically beneficial properties of marijuana, but it also has actively and purposefully discouraged and obstructed research into the use of cannabinoids. It has done this despite enormous social need, thousands of anecdotal reports, and an ongoing stream of compelling scientific papers supporting the efficacy of cannabis as a medicine for many chronic illnesses—often from research centers outside the United States.
Elie Wiesel said, “Ethics is the awareness of someone else’s pain.” Chronic pain is the number one medical problem in America. At present, we also have thousands of veterans who are living with devastating psychological and physical wounds, and we are entering an era in which more people likely will be living with chronic illness. The national experiment in using prescription opioid medication for treating pain and suffering has brought both relief and a new addiction epidemic. It is now time to turn to medical marijuana—with both caution and hope—as a possible answer.
The more we learn about marijuana, CBD and THC, the more impressive this plant appears. It is not a panacea and it definitely has dangers. Nonetheless, I believe that addiction professionals should be leading a “Wise Use” movement. We should be working with those who live in anguish so that they may reap the benefits and mitigate the dangers.
As healers, we live and act within the dynamic of two polarities. We must be humble because there is much that we do not know. But we also must be courageous or our patients will not get better or thrive. The game is afoot—it is time to begin.
Scott Kellogg, PhD, is President-Elect of the Division on Addictions of the New York State Psychological Association, and is a Certified Schema Therapist and a Gestalt Chairwork Practitioner in private practice in New York City. For more information, click here. Andrew Tatarsky, PhD, founder and director of The Center for Optimal Living in New York City and developer of the Integrative Harm Reduction Psychotherapy model, contributed to this article. The author also would like to thank Julie Netherland, PhD, of the Drug Policy Alliance for sharing her thoughts on an earlier version of the article.