Address client myths about marijuana: professionals can counteract mixed messages in society that impede healing.

Despite slight decreases in use in recent years, marijuana remains the most commonly used illicit drug in our country. More than 1.2 million Americans ages 12 and over participated in substance use treatment for marijuana in 2006, making it the second most prevalent substance of concern behind alcohol. The percentage of Americans seeking treatment for marijuana use more than doubled from 1993-2005. (1), (2)

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Clients in treatment for alcohol and marijuana use are somewhat more prone to denial, justification and rationalization than clients in treatment for "harder" drugs such as cocaine, heroin and meth-amphetamine. I suspect this is the case because many people have smoked marijuana without experiencing significant consequences, because many of marijuana effects develop gradually and are therefore difficult to recognize, and because societal attitudes about marijuana are ambivalent.

Some clients adhere to beliefs about marijuana use that make it more difficult for them to recognize the harmful impact of use on their lives. Here I will explore four "marijuana myths" I have encountered in my practice, and I'll offer strategies for generating critical thinking about these myths.

Myth # 1: Marijuana is all-natural. Therefore, it is safe and healthy to smoke it. (Variations: "God put it on this earth for a reason." "It grows in nature, so it's fine.")

Today's marijuana is not the same substance as the plant that grew indigenously in nature. The main psychoactive ingredient in marijuana is delta-9-tetrahydro-cannabinol (THC). The average THC content in seized street marijuana more than doubled in 14 years, increasing from under 4% in 1983 to 9.6% in 2007. (3) This increase is attributed to decades of crossbreeding and cultivation techniques used by people intending to synthesize a more potent substance.

The belief that marijuana is healthy because it grows in nature presupposes two ideas:

* If something grows in nature, then it must be healthy. Using this logic, one could argue that rubbing poison ivy on one's skin or eating poisonous mushrooms is healthy. In truth, some things in nature are healthy for consumption while others are not.

* Plants that grow in nature were intended to be smoked by humans. If marijuana exists for some cosmic purpose, that doesn't necessarily mean it was intended to be smoked. Perhaps human beings weren't designed to smoke anything, since inhalation of smoke is a tissue irritant that is initially rejected by the body. Tobacco, opium and coca all occur in nature, but I have encountered few marijuana users who believe that smoking those substances is healthy Historically, marijuana has been used for other purposes (e.g. rope, clothing, mats, fishnets and oils).

Myth #2: Marijuana is harmless. (Variations: "No one dies from it." "It never hurt anyone.")

There is an element of truth in this belief given the lack of strong evidence that marijuana use causes fatal overdose. However, overdose is just one way in which substance use can be fatal. In the 2002 Drug Abuse Warning Network (DAWN) report, marijuana was the only substance involved in 2 overdoses, 35 deaths by suicide, 53 accidental deaths and 69 other drug-related deaths. A national estimate of deaths associated with marijuana only is 581, but that figure might be low as some metropolitan areas do not include marijuana in toxicology tests and others do not report any toxicology results. This number also excludes any deaths in which any substance besides marijuana was also detected. (4)

Recent advances in technology have allowed scientists to unlock some of the mysteries of the brain. THC molecules bind to receptor sites in areas of the brain responsible for the regulation of the functions found to be adversely affected by marijuana use, giving us an explanation for how marijuana does what it does.

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For example, marijuana use can cause significant impairment when a person drives a vehicle or operates machinery, which undoubtedly poses a risk for accidents, legal problems and fatality. (5) Chronic use has been linked to cancers, respiratory ailments and immune system malfunction. (6), (7), (8), (9) Marijuana causes sleep stage irregularities, affecting memory, immunologic functioning and subjective well-being. (10) Marijuana-related memory impairment can have vocational and educational implications. (11) Chronic use has been linked to reproductive impairment. (12) Clients with Axis I conditions (e.g., ADHD, bipolar disorder, psychotic disorders) are prone to self-medicating with marijuana, but use can exacerbate their symptoms. (13), (14)

Some clients used marijuana extensively during the pivotal developmental stage of adolescence. They self-medicated with marijuana when they experienced aversive emotional states, whereas their non-using peers were developing healthier coping strategies. Impaired emotional regulation and amotivational syndrome are often the results. Having trained their minds to depend on a foreign substance to achieve homeostasis, these individuals are left with few coping tools after they abstain. I have worked with clients who considered prison, unemployment and even death as viable alternatives to life without marijuana. Knowing the potential negative consequences of marijuana use might help clients make more informed decisions about use, abstinence and recovery.

Myth #3: Most people smoke marijuana. (Variations: "Everyone does it." "You can't tell me you haven't.")

Slightly greater than half of young Americans have tried marijuana at least once. Findings from the 2007 Monitoring the Future survey suggest that 42% of all 12th -graders have used marijuana at least once, 32% have used in the last year, and 19% have used within the last month. (15) Findings from 2006 suggested that 57% of Americans ages 19 to 30 had tried the substance at least once in their lives, 26.5% had used in the last year, and 14.9% within the last month. (16) However, most Americans do not continue to use the substance or use it regularly, as is the case with the typical client in treatment. If it were true that most Americans used regularly, that would not prove that marijuana use was harmless for all people. Nonetheless, clients who present with cannabis-related disorders might be prone to rationalizing their use based on a belief that "everyone is doing it," whereas knowing that abstinence is not atypical might be encouraging.

I am reminded of an effective yet admittedly deceitful intervention I implemented in a residential therapeutic community for young men on probation. I shared a statistic that fewer than one in four high school seniors have smoked marijuana in the last 30 days. The group room erupted with disbelief. I asked the clients what percentage they thought was accurate, recorded their responses, and calculated an average of 35%. A few weeks later, I told the clients that a new study had come out estimating that 35% of all high school seniors smoked marijuana in the last 30 days. Again, the clients disagreed and offered their own estimates, with their responses this time averaging at about 45%. A few weeks later, I told them that a new study estimated that 45% of all high school seniors smoked marijuana in the last 30 days. Again, they disagreed, offering estimates averaging closer to 50%.

I explained to them that every time I gave them a new number, it was one they had previously generated. I gently pointed out their tendency to outbid their own predictions and asked them if they could think of an explanation. One client said, "The more we believe that others are using, the better we feel about our own use."

Myth #4: Marijuana makes you creative. (Variations: "It expands your awareness." "It opens you up to new possibilities")

Personally, I think marijuana could enhance creativity for some people, especially given its enhancement of the senses and subjective nature of the concept of creativity. Thus far, I haven't found any research to substantiate my opinion. When defined as divergent thinking, creativity is not enhanced by occasional use of marijuana and is diminished with regular use.(17) In a series of experiments in the 1960s and '70s, participants evaluated their works as more creative when they were high than when they were abstinent, suggesting that people think themselves to be more creative only when experiencing euphoria.(18) Clients who value their creative works could be encouraged by the fact that many successful artists are abstinent or in recovery, fueling confidence that one can be creative simply by using one's natural abilities.

Clinical application

Marijuana myths can be explored and challenged in several ways. Psychoeducational materials such as books, pamphlets and DVDs are helpful, especially if clients are asked to facilitate a "teach-back" to other clients. For clients who enjoy or are skilled at reading, I promote bibliotherapy. However, many clients prefer more visual forms of media. I recently started playing segments from the first episode of the VH1 series "Celebrity Rehab With Dr. Drew", which can be viewed for free at www.vhl.com/video/play.jhtml?id=15786l4&vid=201065. The brief segment on actress Jamiee Foxworth illustrates cannabis dependence.

I advise against directly confronting marijuana myths too quickly in the early phases of treatment. Challenging misconceptions will be most effective after a strong therapeutic alliance has been fostered. I suggest that readers explore the techniques and approaches incorporated into motivational enhancement therapy.

Once rapport is well-established, a counselor can introduce more challenging information with less risk of raising a client's defenses. In one exercise, I present a marijuana myth and ask the client to imagine that she is an attorney whose paycheck depends on proving to a jury that the myth is true beyond a shadow of doubt. Once we've explored the case for the myth, I ask the client to switch sides and cast doubt on the myth. This can be a particularly interesting exercise in a group environment.

Since many clients are rigid thinkers ("This is all just propaganda"), I implement strategies that promote cognitive plasticity, training clients to use critical thinking skills and develop flexibility in their thought. Many of the methods I use prime the pump for critical thinking without directly countering myths.

I use inventories that put clients in touch with their values, some of which seem to contradict their substance use (e.g., health). Morbid as it sounds, I ask clients to draw a picture of a tombstone, put their name on it, and write what they want the world to remember them by. Epitaphs can creatively tap into value systems. Clients create lists of long- and short-term goals and explore how marijuana use has affected or could affect goal attainment. With clients who are parents, we role play what they would do if they found out their children were smoking pot. They typically express disapproval of their children's use, opening the door for exploration of double standards. I also might ask the parent how she might respond if her child justified marijuana use by stating a myth.

I ask clients to draw boxes with four labels: 1) pros of smoking; 2) cons of smoking; 3) pros of not smoking; and 4) cons of not smoking. Typically, clients end up with more content in boxes 2 and 3 than in boxes 1 and 4, providing a visual illustration of the benefits and drawbacks of use. This balanced approach gives clients who are considering abstinence the opportunity to anticipate and grieve losses, reducing distress when they initiate abstinence. We then explore healthier alternatives to attaining benefits.

Therapeutic relationship

I believe that the most important factor in confronting myths is the therapeutic alliance. When counselors are perceived as empathetic, compassionate and non-judgmental, denial is diffused enough so that the seeds of change can be planted. If your client is becoming defensive, I recommend shifting gears to content that promotes rapport. You can always return to the more direct substance-related content once the therapeutic alliance has been strengthened.

Above all else, I would caution counselors ro examine themselves. We are not solely responsible for moving clients through the stages of change to an enlightened road of recovery. We are supportive and empathetic helpers. If I make a diligent effort to help clients think about their use, I am already succeeding.

References

(1.) Budney AJ, Roffman R, Stephens RS, et al. Marijuana dependence and its treatment. Addiction Sci Clin Prac 2007 December;4.

(2.) Substance Abuse and Mental Health Services Administration. Results From the 2006 National Survey on Drug Use and Health: National Findings. Retrieved Sept. 5, 2008 from www.drugabusestatistics.samhsa.gov/NSDUH/2k6NSDUH/2k6results.cfm#7.2.

(3.) Office of National Drug Control Policy. New report finds highest-ever levels of THC in U.S. marijuana. June 12, 2008. Retrieved Sept. 5, 2008 from www.whitehousedrugpolicy.gov/news/press08/06l208.html.

(4.) Center for Effective Drug Abuse Research & Statistics. Marijuana-Only Drug Abuse Deaths, 2002. Retrieved Sept. 15, 2008 from www.drugwatch.org/CEDARS/MarDcaths2002e.pdf

(5.) Ashton CH. Pharmacology and effects of cannabis: a brief review. Br J Psychiatry 2001;178:101-6.

(6.) Aldington S, Williams M, Nowitz M, et al. Effects of cannabis on pulmonary structure, function, and symptoms. Thorax 2007;62:1058-63.

(7.) Medscape Medical News. Marijuana ingredient promotes tumor growth, impairs antitumor defenses. June 22, 2000. Retrieved Sept. 29, 2008 from www.medscape.com/viewartcle/411952.

(8.) Tashkin DP, Baldwin GC, Sarafian T, et al. Respiratory and immunologic consequences of marijuana smoking. J Clin Pharmacol 2002;42:71S-81S.

(9.) Hashibe M, Tashkin DP, Morgenstern H, et al. Epidemiologic review of marijuana use and cancer risk. Alcohol 2005;35:265-75.

(10.) Norton AL. A hidden effect of marijuana use. Addiction Professional 2008 Jul-Aug;6:37-9.

(11.) Ilan AB, Smith ME, Gevins A. Effects of marijuana on neurophysiological signals of working and episodic memory. Psychopharmacol 2004:176:214-22.

(12.) Nahas GG, Frick HC, Lattimer JK, et al. Pharmacokinetics of THC in brain and testis, male gametotoxicity and premature apoptosis of spermatozoa. Hum Psychopharmacol 2002; 17:103-13.

(13.) El-Mallakh RS, Brown C. The effect of extreme marijuana use on the long-term course of bipolar I illness: a single case study. J Psychoactive Drugs 2007 June;39:201-2.

(14.) Thirthallie J, Benegal V. Psychosis among substance abusers. Current Opinions Psychiatry 2006;19:239-45.

(15.) Johnston LD, O'Malley PM, Bachman JG, et al. Monitoring the Future: National Survey Results on Drug Use, 1975-2007 (Vol. 1). Bethesda, Md.: National Institute on Drug Abuse; 2008.

(16.) Johnston LD, O'Malley PM, Bachman JG, et al. Monitoring the Future: National Survey Results on Drug Use, 1975-2006 (Vol. 2). Bethesda, Md.: National Institute on Drug Abuse; 2007.

(17.) Bourassa M. Vaugeois P. Effects of marijuana use on divergent thinking. Creativity Res J 2001; 13:41 1-6.

(18.) Farthing GW. The Psychology of Consciousness. Englewood Cliffs, N.J.: Prentice Hall; 1992.

More Online

For Aaron Norton's perspectives on marijuana's effects on sleep patterns, visit www.addictionpro.com/norton0708.

BY AARON NORTON, MA, CRC, CAP

Aaron Norton, MA, CRC, CAP, is a Registered Mental Health Counselor Intern at Integrity Counseling, a private practice in Largo, Florida (www.integritycounseling.net). His e-mail address is [e-mail].