Marijuana Issues and Therapy-A podcast for Therapists

Episode 85

Marijuana gets a lot of press coverage in the United States. The federal government still has it as an illegal substance, schedule 1 (which means it’s on par with heroin). States are starting to legalize recreational marijuana. Medical marijuana has been around for years in many states, but not all. Now that it is more mainstream and people are more open about their use, it’s coming up in therapy and in our online therapists support groups. I’ve seen all places on the spectrum represented in those groups. Lots of people wondering what they should do about weed? Today we’ll talk about some basic facts and discussion about people’s use to treat their mh symptoms. Next week, we’ll cover what is “normal” use of marijuana and what medical marijuana could look like.

Transcript

You’re listening to the All Things Substance podcast, the place for therapists to hear about substance use from a mental health perspective. I’m your host, Betsy Byler and I’m a licensed therapist, clinical supervisor, and a substance abuse counselor. It is my mission to help my fellow therapists gain the skills and competence needed to add substance use to their scope of practice. So join me each week as we talk about All Things Substance.

Welcome back to the All Things Substance podcast. This is episode 85. Alcohol and marijuana are the most common things that we hear about in outpatient therapy. They’re the substances most likely to be used by our clients or for our clients to have experience with. Last week. I answered some questions about alcohol and if you haven’t had a chance to check those out, head over to betsybyler.com/podcast, and it’s episode 84.

Since this is a two-part episode, we’ll be talking first about the current state of the debate and basic facts about marijuana. Secondly, we’ll be talking about what is normal if we were to define a normal marijuana use and what is medical. Because what we have right now for medical, isn’t set up like anything else that is called medical.

Marijuana is an interesting substance. It has a ton of controversy around it in the United States and mostly that’s about legalization. I did an entire episode about legalization earlier in the podcast and a couple of other episodes about marijuana, looking at facts and common claims, trying to put some light on marijuana and what’s actually accurate.

You can find those episodes at betsybyler.com/marijuana, and it’ll have all the episodes I’ve done regarding the cannabis plant. So I want to start with a little bit of discussion about marijuana in general and I want to be real clear about my own bias. Marijuana isn’t necessarily a gateway drug for everyone, but it was for me.

I fell in love with it when I first tried it as I was struggling as a teenager and found that marijuana was an answer. It quickly became something that I used every day, multiple times a day for several years. What happens with marijuana is that it stops working after a while. If you’re smoking three, four times a day, you’re not getting high anymore, you’re just smoking to feel normal.

Well, if you’re using marijuana in order to stop feeling things or keep memories at bay , it isn’t going to work for that anymore. Additionally, you’re not getting high and if that’s part of the thing that you need, or that you’re wanting, you have to use something else. It’s not marijuana’s fault that this happens. It’s just how biology and tolerance works.

I’ve also seen marijuana be the starting place for a lot of people who got very deep into their addiction and progressed to the point where they were using a bunch of other really dangerous things. It was an easier accessible thing that didn’t feel as dangerous. My opinion is that weed isn’t just no big deal. I don’t think it’s the worst thing on the planet and I also don’t think it’s neutral.

I think that probably the majority of people who have smoked marijuana in their lives have a non-addictive relationship with it. Most people are not smoking every day, all day, and might use it recreationally. What we’re talking about as therapists is not just recreational once in a while use.

Marijuana Issues-Two sides of the spectrum

So when we talked about alcohol last week, we talked about what’s normal drinking. So if there is such a thing as normal drinking than what’s normal marijuana use, and how does that differ from using marijuana for a medical reason?

Well, I don’t see a lot of people talking about what is normal marijuana use. What I see are two very distinct sides on this issue. The pro marijuana side, that is marijuana is great. It should be legal and then the extreme of everybody should smoke weed, it’s amazing and it will heal all sorts of things. Which just isn’t true. I cover this in the episode on common claims and talk about what medically has been proven through research.

The other side views marijuana as the gateway to a life of drug use and addiction. That side tends to vilify marijuana to talk about it being bad and evil and the cause of degradation of society practically. I was at a training a few years ago on prevention and the speaker I was listening to suggested that marijuana is as dangerous as alcohol. And I just had to pause the video I was watching for a minute because in no way, is that accurate.

Marijuana typically isn’t going to kill you. It’s possible because THC poisoning is a thing with the advent of the 90 to 99% THC content. It is entirely possible for someone to overdose on marijuana and it’s possible that there are complicating medical factors that are going to create issues. THC poisoning shows up in emergency rooms all over the country, and it looks like psychosis vomiting and nausea and it’s really, really unpleasant.

The chance of it killing someone is rare, certainly, but people have died from an overdose of over the counter medications and so to think that marijuana has never killed anybody, that’s also not statistically likely. So it can be really hard for everyone else in the middle to figure out what they think and to find a place that feels reasonable.

That’s what’s hard about marijuana I think. In the therapist groups I’m in, I see people talk about marijuana and we absolutely represent this spectrum with the majority of us being somewhere in the middle and feeling kind of unsure about what to say about it. Most of us don’t think that everybody should be smoking weed and most of us don’t think that weed is the worst thing on the planet. Some people are firmly in the legalization category and others aren’t sure what to say about it.

Marijuana Issues-Legalization

Of course, there are people who are very against legalization for various reasons. For myself, in terms of legalization, spoiler alert on that episode I am mostly for legalization. Legalization has very racist roots and I believe was focused on in order to give people something to rally against, I suppose, and the whole reefer madness bullshit that was happening as well. It was sort of a panic created around it and it was targeted at the African-American community. It wasn’t made illegal because it was dangerous. It was made illegal so that people felt safer and there was no money behind it in order to lobby to keep it legal. We don’t have evidence that it’s somehow linked to the degradation of our society.

Yet it remains a schedule, one substance along with things like heroin, which is ridiculous. The issue I have with legalization is that currently there’s no way to tell how high someone is in a given moment. We have breathalyzers in order to tell how drunk someone is, we can do a blood test to determine how much alcohol content there is.

The problem with marijuana is that it stays in your system for 30 or so days and so all it does is tell us how many nanograms of THC are in somebody’s system. And that’s unhelpful because that could be from weeks ago, not right now.

The majority of people I’ve worked with who smoke weed on a regular basis, believe that they’re better drivers or that it doesn’t affect them. That they’re actually better at life with marijuana. I can’t comment on whether or not they’re better at life. I can comment on the fact that marijuana is a depressant biologically and so it’s going to have an impact on their central nervous system. There isn’t any way around that.

Because of that, their reaction times are going to be slowed. It also has psychedelic properties depending on the strain. And that’s going to have some distortion in perception and separate them from time and space a bit. The idea that people who are smoking marijuana chronically are going to work, taking care of vulnerable people, driving, doing surgery, whatever the case may be, that makes me uncomfortable. I want to know how high a person is in a given moment. If we had that technology, I would be totally for legalization a hundred percent.

I don’t feel the need to vilify marijuana, even as a substance use counselor, even as a person in recovery, even as someone who spent years totally hooked on marijuana and unable to function without it. I have no need to vilify it. I just want to be able to think about public safety in terms of, I don’t want people driving around high. There are times when I was high and driving that I forgot I was driving. Like straight up, I completely forgot I was driving or that I was driving and things were distorted jumping around a little bit because marijuana is laced with a lot of stuff and you can’t tell.

Marijuana Issues-When it’s not just Marijuana

When I got arrested in high school for possession, with intent it’s because the person I was smoking with and I had bad reactions because the marijuana was laced with PCP or phencyclidine and we had no way of knowing that. I had smoked marijuana thousands of times. I’m sure by that point and was totally used to functioning being at school or work or whatever, completely high. The marijuana we got was from the same dealer. I thought it was from the same batch and. Usually when you’re buying the plants of marijuana, you’re not thinking about getting something laced with something you’re thinking about whether or not it’s going to be any good or not.

Currently, we have a large problem with marijuana getting laced with things. In my own area. And this is a county of 40,000 people. That’s it. We had a teenager overdose on fentanyl because the marijuana she had used had fentanyl in it. They didn’t know that and the only reason that that child is alive is because Narcan, which is the antidote to opiate overdose, was able to be administered. That’s in a place of 40,000 people.

The chances that the marijuana for those of you in the United States, having some kind of fentanyl in it, it’s happening around you. Fentanyl, which is the most concentrated form of an opiate that we have currently, is getting into all sorts of drugs. It has tainted the drug trade everywhere. People who smoke meth will use test strips to tell if there’s fentanyl in their meth. Because people who are using meth, were overdosing on fentanyl. People who smoke meth are not downer kind of folks. They use meth because it’s meth and fentanyl is a completely different drug.

Marijuana Issues-Problems with crossing state lines

There are a lot of problems with marijuana and that doesn’t mean that I’m going to support keeping it illegal. I think for the majority of the middle, what we don’t want is what tends to happen when certain states go and make it legal.

My therapy office is about three minutes from Minnesota, even though I’m in Wisconsin and about two or two and a half hours from Michigan in the UPP, the upper peninsula. Michigan has recreational marijuana legal. So there’s a dispensary in a place called Ironwood, Michigan.

Ironwood Michigan is a tiny spot and people don’t go there for pretty much any reason except to go through it, to get to somewhere else. But on a morning, there will be a hundred cars lined up to get into the dispensary to get marijuana. These are Wisconsin and Minnesota plates for the most part. And you can imagine how the people in Ironwood feel about that. Yeah. It’s bringing some money into their community, but it’s not going to be the amount that people have claimed will come to the community. Instead, you got random strangers chilling out in your small town, getting stoned.

We have the same problem when synthetic drugs were legal. They were illegal in Wisconsin, but legal in Minnesota. The local store that we had in Duluth, Minnesota called the Last Place on Earth, had a huge line down the block and around the corner every morning. All of the shop owners hated having that place there. Synthetic drugs to be fair are way more dangerous, deadly and totally out of hand. Well, eventually. Minnesota was able to get laws passed that made synthetics illegal and was able to shut that down.

So the question is where does that leave us? Our jobs as therapists are to help people identify problem areas in their lives and move to a place of more freedom and positive functioning so that they can enjoy things and not get bogged down by mental health symptoms. What does marijuana have to do with our job? In order to really talk about that we need to talk about just some facts about marijuana.

Marijuana Issues-It’s addictive

Marijuana is addictive. I have no idea why the myth started or persisted that it’s “psychologically addictive”, but not physically addictive. It doesn’t make any sense. Nicotine and caffeine are physically addictive. Because when you have a substance that your body gets used to there’s withdrawal syndromes. Marijuana absolutely has a withdrawal syndrome. It’s just not super intense.

So usually when someone is withdrawing from marijuana, they get irritated and have lower distress tolerance. Sometimes headaches, vivid dreams, and just general feelings of being on edge or restless. This usually lasts for a few days, maybe four or five, kind of like nicotine when someone’s quitting smoking. The harder part comes later when all of the habits of marijuana use are popping up and they’re not using anymore. They have triggers and times of day they would normally use. They have trouble sleeping because a lot of people use it at night before they go to bed.

It takes a little while for that stuff to resolve. It also takes a little while for the brain fog to clear. People who are smoking marijuana chronically often will tell you that there isn’t a brain fog. What I can tell you from my experience is that people who tell you that chronic marijuana use doesn’t give you some kind of brain fog that’s because they still smoke.

People who have quit smoking weed after smoking chronically absolutely will tell you that there’s a brain fog. I’m not saying it’s like being drunk, but it is there. After about a month or so you notice that it’s lifting. Sometimes it takes a little longer, depending on how long you’ve been smoking to feel better in terms of more clear and for the cravings to go away. But marijuana is addictive. Your body builds a tolerance and there is a withdrawal syndrome.

Marijuana Issues-it’s not regulated

In its street form, marijuana is not benign. There are a ton of different strains of marijuana. There is no way of telling what kind it is, even if it’s the plant. Right now, the majority of, teenagers and young adults that are using marijuana are using it in liquid form. And they’re using it in vapes or in dab pens, which has to do with THC in the form of wax that gets smoked. And there’s no way to tell what’s in there.

I’ve been thinking about why someone would lace marijuana with another drug. I’ve worked with a ton of people who were dealing drugs over the years. The majority of people that I’ve worked with were dealing drugs to support their habit. But I have met a few true drug dealers. Most of them aren’t really using substances as much and really don’t feel like what they’re doing is wrong at all.

What I’ve seen in people who are truly drug dealers, is that they’re actually pretty anti-social. There’s also a criminal element to it and the idea that it’s not their responsibility, what happens to people after they buy the drugs they’re selling that people have a choice.

So the people lacing marijuana with things are going to be, whoever is putting together the big product. Certainly a small-time dealer might do it. Why? Fentanyl’s cheap, but it does cost money, putting PCP in weed or acid or meth or whatever. Marijuana gets tainted with a lot of things and why? I’m not sure I have found a good answer.

Usually the answer is money. Why drugs get cut with fentanyl is that they can give more of a kick and they don’t have to spend as much money on the actual product. So for instance, someone buying heroin, it’s not straight up heroin. They can cut it with fentanyl, which is a powder that looks just like heroin. A little bit of fentanyl goes an incredibly long way.

Fentanyl is synthetically made and heroin comes from plants. It’s just not as plentiful so I can see money being a factor. But with marijuana, I just don’t get that. I feel like the attitude that I’ve seen from true drug dealers, not people supporting their habits, but business people. Is that there’s a little bit of control there. A little bit of, I want to fuck with people and I can, and this is a way to do it and isn’t that funny? I’ve seen that and , is always unsettling. But regardless of why it is happening.

When we talk about legalization and people on the very pro legalization side are like weeds fine. Let’s put it everywhere. I struggle with that. It could be that marijuana becomes regulated, but it hasn’t so far. No one is overseeing the products and testing the products that go through the dispensary. They have some regulation, but it’s not very much at all, depending on the state. And so it’s not making anything safer from having some kind of other substance in it.

So let’s take CBD for instance, CBD comes from the cannabis plant. It does not contain enough THC to get someone high. It comes from hemp for the most part anyway, and in order to be declared hemp, it has to have less than 3% THC by dry weight.

CBD products are everywhere. Yet the research tells us that the majority of the CBD products on the market are not what they say they’re. They contain any number of chemicals. Some don’t even have CBD in them at all when they’ve been tested. So the recommendation is to make sure that the CBD that people are using has been tested by a third party lab and usually there is a certificate.

And the company who produces CBD and has it verified will tell you because they want you to know. That’s the kind of CBD that people should be using, but it’s more expensive because they have to go through a lab and get the certificate.

Marijuana Issues-THC content is higher than ever

One of the other things I wanted to make sure I talked about that is just a basic fact, is that THC content is higher than it ever has been. THC is the psychoactive component in marijuana. THC is the thing that makes weed, weed and the lack of it makes CBD what it is. THC content in the mid nineties was around four to 10%. In the year 2000 we had THC content that is on average between five and 12%. In 2010. Now we’re up to the base amount being about 10% THC and by 2018, the average amount is 15 and a half percent. Since THC is the thing that gets you high that matters.

When you smoke marijuana chronically and by chronically again, I mean, On a daily basis, typically multiple times a day, but at least daily, you can tell the difference between different strains of marijuana. You can tell if it’s more potent, you can tell if that’s a kind that would be called creeper where you can’t tell how high it is, like it takes a little while that you fully kick in. And the problem with that is that you smoke to the point. You think you’re good and don’t add a decent high and don’t want to go higher and then all of a sudden it hits you like a truck. All of that has to do with THC content.

And so in the mid nineties, if we’re talking four to maybe 10% at really higher and read more expensive strains of marijuana to now we’re around 15 to 16% on average for someone who’s smoking the flowered plant that’s way higher. There were times when even someone like me who was smoking constantly would get something that was higher and it would knock me on my ass. Like so high, you can’t speak, kind of knocking you on your ass. So what people are smoking in terms of the flowered plant is high, but that’s not even the thing that is concerning to me.

It’s the THC oil. So if you want to know more about THC oil or dab wax, that’s going to be episode 20 and that’s going to tell you all about it. For here. I’ll tell you that wax is originally a liquid that comes out of burning the plant with some butane and solidifies into wax. The wax is then smoked and it has the highest THC content that you could get. That’s been around at least in my area for probably 10 years.

The THC oil now represents the majority of the people. I know that smoking marijuana is using oil. It doesn’t smell as bad, it is easier to conceal and it has a higher THC content and so you don’t need as much to get the same high.

So on the low end, THC oil is going to be at least 60% THC, but more likely than not it’s in the upper 90. So instead of 15 and a half percent on the plant, we’re talking about 90 to 99% THC. That is an incredible amount of THC. What happens here is that people who are smoking marijuana, they’re able to smoke way more because their tolerance is going up and up and up. That is also going to affect the level of impairment. It still is the same that when they get used to it, they feel like they can function just fine.

Marijuana Issues-It impacts therapy

This has implications for us. It does impact their cognition, whether they recognize it or not. It is not possible for them to be smoking marijuana and for it to not affect their central nervous system and their brain functioning. Marijuana crosses the blood-brain barrier. It works on the endocannabinoid system and that’s part of why it works so well, is that it’s similar to some of those same functions we have in our bodies. For therapy that matters.

Some of the issues for us, with people who are smoking marijuana chronically, is that they typically don’t have a very clear view of how it impacts them. If they’re smoking marijuana on a daily basis and they’ve been doing that for years, they don’t really know what it’s like to be without it. Once they get past the withdrawal phase.

Sometimes they might, sometimes people take what they call tolerance breaks, which is when they go without it for a couple of weeks to try to cut back on how much they have to smoke. That only lasts for a little while though, because tolerance doesn’t go down permanently and they’re going to be back up to their original amount within a month, most likely. But they don’t really know what the difference is. And so when you talk to them about it, they a lot of times will tell you there’s no issue that they feel better, that they feel calmer, that it helps their anxiety.

Even though there’s also other issues like a motivational syndrome where they don’t feel like doing anything. Or feeling more depressed or more down, or having a lot more trouble with thinking about existential crises. A lot of times not being able to look at the downside of continually needing a mood altering substance to function.

Marijuana Issues-Impact on Anxiety

I don’t believe that marijuana helps anxiety. I think that it might make you feel that way because it distracts you from it and because it’s a depressant will slow down the central nervous system and therefore brain function. But in terms of helping anxiety, that is not how I view that. I know what that feels like and I understand why people would say that. They smoke and then they don’t feel panicked. To me it isn’t the same thing, but to them, it is a relief from a symptom and that is very real.

I think sometimes what people expect is that we’re going to want them to function with the level of anxiety they have without marijuana and that they just have to deal with it. That is not what we want for them. I don’t think people should have to have anxiety that is incredibly high.

So the way I describe it to my clients is that if they were in a room like a square room with purple goo, I know that sounds silly, but I don’t want anyone to freak out about drowning when I use this example.

So pretending that the anxiety is the purple goo. If the anxiety is at ankle level, that’s super manageable. It impedes them a little bit, but they can move around and do things. If it’s at the knee level, a little harder, but again, doable. When we get to waist and to chest height and to neck height, that’s a lot of anxiety and I want them to understand why things are so hard for them.

I use it as a shorthand to try to help them, let me know where their anxiety is at. When somebody has anxiety that is at waist level and above unmedicated and using marijuana. I recognize that they’re going to need medication in order to bring that down.

For some people, marijuana does increase their anxiety, but the dissociative sort of psychedelic effect makes it less noticeable because it is distracting and you kinda zone out. And so for them better and the anxiety they feel off of it is unbearable because withdrawal makes that worse.

I believe that when someone is using a drug to manage their symptoms, it is a sign that they are not able to cope with the level of symptomatology they have. If they’re going to work on cutting back or stopping altogether, we need to be prepared to help them manage the symptom level they have.

Using marijuana and using an antidepressant, not super effective, but not deadly in the way that using alcohol on prescription medications can sometimes. So a lot of times I’ve had people go on their antidepressants and have them in their system for, I don’t know, four to six weeks. As long as they’re not having bad side effects, then they can start cutting back on marijuana. They’re going to still have withdrawal, but we’re looking at increasing distress tolerance and helping them decrease their dependence on marijuana.

Not because it’s evil and now because it’s going to kill them. But because being addicted to something is a pain in the ass. When you are addicted to something, whether it’s cigarettes or drugs or alcohol or whatever, you have to think about it all the time. When can I get something? Do I have enough? Where can I be? Am I going to smell like that? Are people going to notice, or my eyes bloodshot? It is stressful.

Those people who have gotten off of a substance once they get past the withdrawal phase and the cravings, then they’re like, yeah, it’s way less stressful. I don’t even have to think about it now. It is freeing to not need that substance in order to function instead. .

Next week, we’re going to continue our talk about marijuana. I hope you’ll join me for that podcast. I hope you’ll join me for that podcast. And until then, have a great week.

Thank you for listening to the All Things Substance podcast. For show notes, links and downloads, please visit betsybyler.com/podcast. If you loved what you heard today, it’d be great if you would share those with your therapist friends and colleagues. If there are topics that you think would be useful and you’d like to hear me cover them, please let me know. Just send a message to podcast@betsybyler.com. I’ll see you on next week’s podcast. And until then have a great week.

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