Episode 86

So far we don’t have a determination about what is “normal” marijuana use.  We have very little direction on marijuana use at all. Even medical marijuana doesn’t have a dosing or recommended amount. It doesn’t have anything saying don’t use more than this in a 24 hour period. Just here’s your weed. So what would “normal” use look like? What would normal recreational use be? What would normal/average medical use look like? Eventually I think we will have this information, but for now we only have opinions. My opinion is based on my own history with the drug, information based on years of working with people who use marijuana and the science of what happens when a person uses marijuana. 


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 86.  Last week, we started talking about marijuana and we addressed a number of things and today we’re just continuing that conversation. I’ve seen lots of questions online in groups and people who’ve reached out to me with specific questions. So I’m going to be answering more of those in today’s podcast.

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.  

So how did we get here? Marijuana becoming illegal was a hundred percent about race. There were certainly people who thought marijuana was dangerous because they saw people acting differently and were nervous and there wasn’t a lot known. We have evidence from people in the Nixon administration that the anti-marijuana rhetoric was deliberately placed on the African-American community. This is similar to opium being placed on the Asian community in the early 1900s. The administration at the time associated it with a specific group of people and villainized them, and the drug. 

Where we are now was that medical marijuana became that way as a loophole. Not because the medical community wanted it to be that way. It was a way to get marijuana, to be legal and circumvent the federal law. What it turned out to be was really different from what we normally do for medical stuff. In Minnesota, medical marijuana is legal. You can get a medical marijuana card for pretty much any reason if you have a doctor that’s willing to prescribe it. There are certainly things that marijuana has been helpful for specifically nausea, appetite, relief from pain for cancer patients and people who have wasting disease related to HIV and aids.

I don’t know that many people have a problem with people who have progressive potentially fatal illnesses smoking weed. I recall working with a client years ago who had a particularly aggressive disorder that created basically benign, but multiple painful tumors all over the body. We were helping her get sober from her pill addiction, and she was addicted to pain pills for a clear reason.  When the staff and I would discuss this case, I really didn’t have a problem with the fact that she was smoking marijuana because the kind of pain she was under marijuana was helping it a little bit.

Not nearly as well as an opiate, but opiates have way more kinds of risks and actually increased pain over time.  That’s a different podcast. So she was smoking marijuana and it just wasn’t something that I thought we should get really upset about. What we did do was talk about harm reduction. We talked about times of day, she had a child, she was raising and so we had to make sure that she was not smoking a ton while she was interacting with her kid, and I think we helped her get it to an okay level. 

The thing about medical uses of marijuana is it doesn’t need to be smoked. It can be in a liquid form where you just take it. There’s a medication called Marinol that is basically the liquid form  of marijuana. Not what we’re talking about with THC oil, that’s different because that’s been concentrated, but Marinol is an approved medication but that’s not what people who are using marijuana are asking for. They want to be able to smoke whenever and wherever. 

Current standards for medical marijuana have no dosing instructions from the doctor. There’s no amount or prescribed amount that they should take. It is simply a card that allows you to buy marijuana, use it and possess it legally. Imagine if it was the same way with say benzodiazepines. Let’s say you got a card saying that you could have access to Xanax, Klonopin Ativan for medical reasons. And you could take as much as you want. It sounds ridiculous, but it’s essentially the same thing. 

Now, of course, those substances aren’t the same; they don’t have the same risks, but if we’re talking about a mood altering substance being used for a medical reason, why is there no oversight?  No checking in about how it’s working, whether it’s working. It is simply a “here’s my card. Now I can smoke weed” sorta situation.   

I’m betting there are doctors in the United States who have different standards about it. In general, what I’ve seen over my career since medical marijuana became legal in many places is that there isn’t much oversight at all. When someone tells me that they have a medical marijuana card in my brain, all it tells me is I can smoke weed without legal issues. 

So I want to talk about what medical marijuana would look like. If we applied a medical lens to the use of marijuana, it would look really different than what it looks like. Now. It would be a medication that was dispensed by a pharmacy or whomever that has been regulated is free of contaminants and in a dosage form that would be helpful and formulated in a way that will be released in the most effective way possible.

That could be liquid. That could be in a pill form. However the body would be able to receive it and have it get to the CB-1 receptors in the endocannabinoid system more quickly. That’s how it would look. The medications that we use for any number of medical issues are because they’re more likely to assist with these symptoms and there’s research and they’re formulated really carefully and they’re regulated.

So let’s pretend it’s not even a prescription, but it’s something that people can use like Omeprazole, which is used for dealing with acid reflux and ulcers and can be found over the counter that has a dosing schedule.

The same thing goes for marijuana. The level of marijuana that we’re talking about to help with symptoms is low and it’s not going to make them high. There’s a researcher named Dr. Shields. She is the Chief Scientific Officer at a company called Real Isolates LLC. They work on natural products as therapeutic options for patients with chronic disorders, including research on cannabis smoke extracts.

Here’s part of what she says. “It’s not substance use. It’s a dose schedule. Many pharmaceuticals use the same technique to maintain. What’s called a quote “steady state” or a constant level in the. However, if you need cannabis to function, then you need to know that using too much will cause a different imbalance with different problems. To avoid this you should aim to use the smallest dose possible that still gives you symptom relief. This is called the minimum therapeutic dose and it’s the safest level for chronic patients”. She goes on to say, “I think it’s totally okay to use more whenever you need to, but tracking your usage is important. 

She suggests using a journal. “Staying close to my therapeutic minimum allows me to never take tolerance breaks because I never developed much of a tolerance. Plus having a little constant tolerance is associated with reduced PTSD symptoms for me. So I’m definitely more hashtag #stable with cannabis on a strict daily dosing schedule”. 

So at first glance, when you look at Real Isolates, it’s going to look totally pro marijuana. If you look at the science about it, that’s not what it’s saying. It’s acknowledging that THC works on the cannabinoid system in our bodies and can impact our CB one and CB two receptors, which is important when we’re talking about symptom relief.

She’s talking about having a dose, a concentrated form and keeping track of it. She’s not talking about using weed to get high. I think that’s troubling because when we talk about. Legalizing and use for medical marijuana. It is a very different discussion than what we’re having when we’re talking about actual medical use of THC and what they’re recommending. It feels like a medical thing. And the loophole at used turned into where it’s awesome for medical stuff, and everybody should use it, etcetera. At least that’s the vibe I get. 

When we break it down, the medical community that is open to using THC, they’re doing it from a scientific perspective, which does not include buying an eighth off the street and smoking daily. That’s not at all what’s happening here. 

So filtering out all of this noise can be really hard. There’s so much stuff about marijuana all over and some of it’s total bullshit and some of it’s alarmist and some of it is comically ridiculous and finding the truth about it is difficult. That’s part of why I wanted to talk about it because it’s one of those things that when it comes up, it’s just hard to know what to say.

My opinion is that nobody needs 99% THC oil to treat symptoms. That’s like lighting a cigarette with a blowtorch. You can do it. It might work, but it’s got collateral damage. For people who want to use THC in some form to treat symptoms we have some research on certain things, but not so much for the mental health issues that we would be working on.

So let’s talk about what would be “normal” marijuana use. What’s interesting is we don’t have that statement yet from the CDC and the NIH, like we talked about with alcohol. We don’t know how much is normal if the THC levels at 15% or what’s normal if the THC levels at 99%,

I think they can quantify that just like they do with alcohol. They use the alcohol content to determine how much of something is a shot or a drink. So I think they can figure that out. 

For me, typically people aren’t smoking marijuana to get no impact. Typically they want to feel some kind of high or a buzz or something. It’s not because they like the taste, because it’s different. They might like the smell because some people do, but it’s not the same. 

If we assume that their goal is to get high and to experience that, not like blown out of their mind, but like high. I would say once a week, maybe twice a week would be not as concerning, but if they’re getting checked out more than that every week, I think that’s not normal. I think that’s a step up from there. 

So let’s just relate it to alcohol. If someone’s getting buzzed once a week. I don’t know that that’s a problem twice a week. It’s kind of on the edge, but I think it’s probably okay and depending on how it impacts their responsibilities, jobs, kids, family, whatever. But if someone’s getting buzzed three nights a week, to me, that feels like we’re a step up. And so I’m going to use that bar for marijuana to. Just assuming that the person’s getting baseline high. Not totally stoned and unable to function just high so that they feel giddy or light or they’re having fun or whatever.

So for me, that’s what I consider normal in a world where marijuana is legal. They have to decide how much marijuana will get them to that level. If they’re waking up and they’re still high to me, that’s a lot. If they are smoking to the point that they can’t speak, that’s a lot. If they’re smoking to the point that they feel giggly and it’s fun to watch some dumb movie that makes them laugh like crazy, or they’re able to just enjoy music when they’re high, whatever. I don’t think there’s any shame that’s needed. I think there is a way to use marijuana recreationally.

When you’re evaluating someone’s substance use, we want to know how often and how much.  When it comes to substances, how much is important, we also want to know how it affects them though. So if somebody is drinking 12 beers while watching a game and they’re still able to function, that tells us a lot about their tolerance because 12 beers and I’d be on mass.

If someone’s smoking marijuana and after a few hours are still able to go to sleep normally wake up, feeling good. Like they got rest.  I don’t know that that’s an issue. What I want to do here is give you some guidelines on what to ask and what you’re looking for. 

If you agree with my assertion about what is normal marijuana use, and somebody has used it above that, what you’re looking for is, is that a problem? Are there consequences? Maybe there isn’t a problem yet. Maybe there never will be. And perhaps because tolerance is a thing and also progression of use, it may become a problem. And so we keep an eye on it, just like anything else that people do. 

One of the problems with using substances to manage symptoms is that it’s effective the same way cutting is effective. Cutting relieves pressure. It takes their mind off of the emotional issue because their physical body is sending them signals. Because it’s effective it can reinforce itself. The same way goes with substances. 

We want people to use adaptive coping skills to use when they’re alone or with people. We want people to be able to manage their symptoms and move through it so they can continue on with their day or activity or whatever they’re doing. 

So that brings us to talking about our clients. What do we do with people who are smoking marijuana. Especially those of you who are doing it in a state where it’s legal. That can feel really difficult because what do you say, do you put limits on it? Is it fine that they’re smoking all the time and showing up for therapy?

Well, if this is the first podcast of mine you’ve listened to, then maybe you haven’t heard my stance on this. And so I’ll repeat it here. I do not do therapy with people who are under the influence period. I wouldn’t do therapy with someone who is drunk and I’m not doing therapy with someone who’s high. I don’t care that it’s marijuana. It affects their cognition. It separates them from time and space and I need them emotionally present in order for us to do therapy. 

That said, I don’t require them to be totally free from substances. I just want them to not be high while we’re talking. So when I meet with someone, I talk with them about what therapy would look like. And what’s needed for therapy and I’m evaluating how much they’re using and when, and where they’re at with their substance use. If they don’t see it as a problem, it’s not on my agenda to make them see, it’s a problem because first of all, I don’t know if it’s a problem.

And secondly, we talk about what they’re coming to therapy for.  I do set my limits around what I will do and what I won’t do. There was a time when I was on a crisis call rotation. The agency I was with, we had a crisis line that we ran and all the clinical staff had a rotation. I distinctly remember one night, it was probably two in the morning and the crisis phone rang. I got up, went into another room and sat in a chair and ended up talking with a woman for an hour and a half. And she was clearly drunk. 

She called the next night and was drunk again with the same statements. And I was like, you know what, no. I asked her if she’d been drinking and she hung up. From that point forward, I was like, okay, we can’t have meaningful conversations about skills and goals while someone is intoxicated. When someone called and they would be drunk. What I was looking for was getting them to a safe spot with someone who can keep an eye on them and giving them a number to call in the morning to be able to follow up. I’m not working on deep work when someone’s under the influence.

It’s kind of the same way when someone’s smoking weed. Yeah they’re more functional certainly than someone who’s drunk, but there is distance. And so what I do is I ask them not to smoke within four hours of coming to see me because that’s about how long it is until they’re not actively high in my opinion. There’s no science behind that it’s just an estimate. And what I have found is that it’s generally. 

I had this conversation the other day with a client that I hadn’t seen in awhile, and this person was actively using a number of things. And I knew they were actively smoking marijuana even while at work. This person had come back to me wanting to talk about trauma, specifically EMDR. So we talked about the substance use and it turns out using marijuana for the most part and alcohol had been using other substances, but not right now.  I felt better about that, so we talked about what it would take for us to move forward. 

I’m not requiring sobriety to do EMDR. I’m requiring that this person is in control enough to be able to prioritize therapy, which means not smoking within four hours of coming to see me showing up and being able to be focused and be able to practice some things during the week.

I also will additionally ask them sometimes not to smoke for a couple hours after we’re done.  Part of that is just working on a slight increase in distress tolerance and what I’m doing by setting these limits is I’m low key. Letting them know that marijuana impacts the therapy process and that I’m not accepting them being high as their natural, permanent state. I’m not casting judgment on it, not giving him shit about it, not asking him to stop. I’m simply setting boundaries around our work.

When someone’s in therapy and they smoke marijuana, I am asking them to try other skills before they smoke marijuana. If they’re feeling really stressed out and normally they would turn to smoke, I’m asking them to hold off and to try some things.  The reason I do that is trying to help people see a life where they don’t have to rely on substances to function. 

A lot of the people who smoke marijuana are not addicted in a way that’s going to be difficult for them. Lots of people smoke recreationally too. And I accept that I have no issue there.  Just like any other habit, I want to find out what purpose their marijuana has in their life. What is behind their use? What started it? What increased it? And what is it like now. 

Using it once a day and only at night to go to sleep is very different from getting up and smoking a bowl and then at lunch, and then after work, etcetera, it’s extremely different. It’s still not ideal to use marijuana to sleep because of the sleep cycles and not getting enough repairative sleep, et cetera, et cetera.  In terms of how it normally is with depressants, we want people to be able to sleep unaided as sleep specialists will tell you. 

That  sleep medications or other sleep aids are meant to be used temporarily.  Part of the reason is that they lose efficacy over time, and they want people to be able to return to quote “normal sleep” onset and duration. 

Marijuana use in your clients will impact therapy and therapy progress. It just will. It will, in my opinion, make it slower and keep them from being able to process at the level that is most effective.

Think of marijuana like looking through a barrier. It’s clear ish, but kind of foggy a little bit and depending on how high they are, of course it could be way foggier. But it’s still a barrier and it separates them from themselves and from us. Sometimes people need that for a while because being without it feels raw and the world feels scary and that’s okay.

I have no need to push people faster than their body wants them to go. I am a firm believer that we respect the traumatized parts of them and the fear they have. Oftentimes when I’m in the prep for EMDR, people are worried that they’re not going to be ready. And what I tell them is, look, we’re not going to start processing until you tell me okay, I’m ready. 

It doesn’t mean they’re ready to jump into the deep end, but they’re ready to stick a toe in, to walk in up to their knees maybe. I’m going to walk side by side with them. I’m going to challenge the substance use because what a pain in the ass, it’s so much nicer to not have to deal with it. And if they’re not at the place where they recognize it as a pain in the ass, that’s all right. I’m just setting limits around therapy. 

If you take away the pressure to get someone sober, it’s way more helpful for you to be able to do the job they’re asking you to do. There will come a moment where you might not be able to do further work unless the substance use is addressed. When you get to that point, you can talk about it. I am all about using immediacy with clients. 

I want to have a real and genuine and authentic relationship with them where they know that I am a hundred percent on their side. That I will be honest with them. If I think they’re doing something that is harming them and that if they continue to do it, like I’m not going to give him shit about it. And when they come to me later and tell me that I was right about something, I would never, ever even think of the,” I told you so”, because it doesn’t occur to me. I don’t necessarily want to be right about something they’re doing, being harmful. And sometimes outside people are able to see things more clearly.

That’s why people come to us, right? We’re a mirror. We help them see things that they can’t see on their own. There is no need for an adversarial relationship about marijuana. I also don’t believe you should ignore it. You wouldn’t ignore other things that impact people’s mood, just because it’s legal in your state doesn’t make it not impact them. 

I don’t ignore medical things just because I’m not a doctor. I explore them. And then I refer them to their physician. I talk about thyroid often. I’ll talk about vitamin D levels. I’ll talk about other things that affect mood. I love to work with the medical community to make sure that we’re looking at a more holistic view of somebody’s life, not in this sort of segmented way that we are now.

So I would encourage you not to ignore it. Decide what you want to say, what your own boundaries are going to be, and start out that way. I’ve done a couple episodes talking about the reasons why we should talk about substance use, how to start talking about it, what questions to ask and all of that is designed to help you think about it and find a way that feels right for you and authentically you and we’ll give you the clinical information that you need.

A side note, if you were working with someone who is not able to stay sober for four hours beforehand, I would ask them what they are able to do and that we’ll work up to that point. I imagine that would be somebody with some pretty significant PTSD or panic disorder and letting them know that that’s where we’d like to get to, because we can’t do much more than supportive psychotherapy if they’re actively high, when they show up. No judgment. Just adjusting expectations. 

I know that addressing substance use can feel really weird when you haven’t had a lot of training. It doesn’t have to be that way. It will feel a little weird at first, but along the way, the more you talk about it, the better it will be and  the more you will feel like it’s natural for you to talk about it and for your clients that it’s natural for you to bring it up.

My encouragement is always going to be along the lines of just jumping in and starting to ask questions. Just like when we started therapy, just like when we learn a new modality, it feels a little weird and like we’re stumbling over words here and there and it gets easier. I remember starting EMDR and feeling like, am I fucking this up? Am I doing this wrong? The practice with other colleagues was super helpful to help me feel like, okay, I’m just going to keep doing it and keep practicing and I will get better at this. 

Now I don’t have those feelings about EMDR. I love it. It’s a great modality and I’ve seen it do amazing things for people. In the beginning. It was very clunky. Substance use is like that. You will get used to asking about it, even if in the beginning it feels kind of clunky. If you have questions about it or things that pop up, I encourage you to reach out. I am always happy to consult and talk about things or answer questions because I am passionate about this.

I really, really believe that we are uniquely positioned to be asking people about their substance use. We have way more time than any other kind of provider they would normally ask such a question 

Next week, we’re going to be hearing a recovery story and I’m excited to bring it to you. 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.

This podcast is designed to provide accurate and authoritative information in regards to the subject matter covered. It is given with the understanding that neither the host, the publisher or the guests are rendering legal, clinical or any other professional information.

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