Even as the demand for drug treatment slots continues to grow, an increasing number of people who enter drug treatment are being treated for marijuana as their primary drug of abuse, leading some observers to question whether scarce drug treatment resources are being wasted on people who don't need drug treatment. In its most recent set of drug treatment statistics released last week, the 2007 Treatment Episode Data Sets (TEDS), the federal Substance Abuse and Mental Health Services Administration (SAMHSA) reported that some 288,000 people underwent treatment for marijuana that year, or 15.8% of all drug treatment episodes.
marijuana -- sometimes but not usually a reason for treatment
The number is actually down slightly from its 2005 peak of 301,000 people in treatment for marijuana, but in line with trends for the past decade. Since 1997, the number of people getting treatment for marijuana each year has increased by roughly 50%, or about 100,000 people.
Former drug czar John Walters was fond of using the increase in the number of people being treated for marijuana to argue that it showed the increasing seriousness of marijuana use as a drug problem, but a closer look at the SAMHSA paints a different picture.
Of the people getting treatment for marijuana in 2007, 37.7% had not even smoked in the past month, raising questions about whether they even met the standard (but still arguable) definitions of marijuana abuse or dependence. When you add in the number who had smoked 1-3 times in the past month, the number rose to 53%. Other data set numbers raise similar questions. Only 14.8% of people in treatment for marijuana were self-referrals, as opposed to 56.9% getting treatment because they were ordered to by a court and another 28% in treatment because of referrals from family, schools, employers, or substance treatment or medical providers.
By way of contrast, the self-referral percentages for other drugs are much higher. Among alcohol users in treatment, 29% were self-referrals, for heroin, 58%; cocaine, 36%. Only methamphetamine users had a similar self-referral rate, with 20%.
People in treatment for marijuana are also younger than people in treatment for other drugs. For marijuana, 40% were under 19 at the time of admission, compared to 9% for stimulants, 11% for alcohol, 5% for opiates, and 3% for cocaine. A whopping 75% of people in treatment for marijuana were under age 30, compared to no more than 40% for any other of the major drugs.
The American Psychological Association's Diagnostic and Statistical Manual (DSM-IV) defines substance abuse as "a maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one or more of the following occurring within a twelve-month period:
(1) Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g. repeated absences or poor work performance related to substance use, substance related absences, suspension, or expulsions from school; neglect of children or household).
(2) Recurrent substance use in situations in which it is physically hazardous (e.g. driving an automobile or operating a machine when impaired by substance use).
(3) Recurrent substance related legal problems (e.g. arrest for substance related disorderly conduct).
(4) Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by effects of substance (e.g. arguments with spouse about consequences of intoxication, physical fights).
While it would appear questionable that all those people being treated for marijuana fit those criteria, a SAMHSA researcher said this is indeed the case. Deborah Trunzo, DASIS team leader for SAMHSA's Office of Applied Statistics, said that DSM diagnosis is not reported by all states, but in those states that did report: "Almost three quarters of marijuana admissions for whom DSM diagnosis was reported in 2007 had a DSM diagnosis of marijuana abuse or dependence. The remaining quarter had a DSM diagnosis of abuse or dependence on another substance or a psychiatric disorder. The data from 2006 were similar."
The no use in the past month figures for marijuana are not that shocking either, said Dr. Peter Delaney, Assistant Surgeon General and director of the Office of Applied Studies at SAMHSA. "You may have noticed that 29% of all admissions report no use of their primary substance in the 30 days prior to admission ranging from a low of 16% for heroin to a high of 50% for hallucinogens," Delaney pointed out. "There are a number of explanations for this including individuals coming into treatment may have been on a wait list and may not be currently using their primary drug of choice while preparing to enter treatment -- individuals enter treatment from the jail, other treatment settings, or are referred from court even though they have been abstinent for some time."
There are other explanations, too, Delaney said. "Some people may not be using marijuana presently but report it as the 'favorite' drug, others who are referred for marijuana problems may actually be reporting that alcohol is the problem but the referral trumps the report and finally, as one of the state representatives noted when asked about this phenomenon, many individuals entering treatment do not tell the truth about their use, and providers often see increases in reporting of use at discharge because treatment works."
Not surprisingly, drug reformers, academics and treatment professionals had significantly different takes on the SAMSHA marijuana treatment numbers and what they mean.
"There really is marijuana dependence, and there is an effective treatment for it, but, as the SAMSHA data reveal, it has little to do with what's going on in treatment programs around the US," said Dr. Mitch Earleywine, associate professor of psychology at the State University of New York -- Albany and author of "Understanding Marijuana: A New Look at the Scientific Evidence."
The problem is with the way marijuana fits into the hallmark symptoms of dependence, which are tolerance and withdrawal, Earleywine said. "It is hard to document marijuana tolerance, but the Marinol (THC) studies show tolerance so everyone assumes there must be marijuana tolerance. Also, novice users are less good at knowing how much of a hit they can hold, so experienced users often look more sensitive to marijuana because they're really just more efficient about how they smoke," he said.
Marijuana withdrawal is so subtle it took 2,000 years to document, Earleywine added. "The symptoms are irritability, moodiness, disturbed sleep, craving for marijuana, and -- get this -- loss of appetite," he noted. "When withdrawal occurs, it appears to dissipate within about three weeks, at most." For Earleywine, marijuana withdrawal is about as serious as withdrawal from caffeine.
"The SAMSHA data's suggestion that folks in treatment haven't used marijuana in a month makes it pretty clear that they aren't really dependent at the time of treatment," Earleywine said. "That fact doesn't mean they couldn't benefit from some therapy, but it confirms that an inpatient stay is ridiculous. And yes, someone addicted to crack or meth is missing the chance if some marijuana user is in the program instead."
Noting that only about 15% of people in treatment for marijuana sought treatment themselves and more than half are there because of the courts, Earleywine suggested that most of the rest don't need to be there, either. "Usually, those remainder folks are in there because some family member found a joint and demanded treatment. As you can imagine, clinical work with these guys can be a complete waste of time."
He cited a case in point. "I remember one case that involved a woman in her early twenties in a wheelchair who lived with her parents," he related. "Her folks found her stash and sent her to a ritzy place filled with Betty Ford types. The poor woman had no negative consequences at all. The first week she kept stating this fact but it was interpreted as 'denial,' so she had to spend the next two weeks pretending she really had a problem so the staff would tell her parents that she was making progress."
Earleywine was similarly critical of the DSM-IV criteria for dependency that included repeated legal problems related to smoking pot. "Obviously, these are a confounding of drug laws and enforcement practices. If abuse statistics rise, it can have little to do with the drug or the rates of misuse and everything to do with how much the cops feel like busting people."
"These figures show that there are an awful lot of people in treatment for supposed marijuana abuse or dependency who, by everything we can glean from the numbers, don't look very much like addicts," said Bruce Mirken, communications director for the Marijuana Policy Project. "They are disproportionately employed compared to people in treatment for other drugs, especially when you consider how young the population in treatment for marijuana is. Their lives have not been rendered unlivable by a drug problem, but because of an arrest, they are given a choice between treatment and jail when they actually need neither," he said.
"What is really striking is the extraordinarily high percentage of people referred by the criminal justice system versus the amazingly low percentage of self-referrals. These are not people who walked into the clinic saying 'I need help,'" Mirken said.
"These are people being coerced into treatment mandated by the courts," said Paul Armentano, Deputy Director for the National Organization for the Reform of Marijuana Laws (NORML). "Nationally, more than half have been referred to treatment by the criminal justice system. These are people who have been arrested, they're likely not regular users, they quit using while going through the court system, but are mandated to take treatment to avoid going to jail. You don't see this pattern when it comes to other drugs, where people are much more likely to seek treatment themselves."
"These figures reflect the obsessions and myopia of the Bush administration," said Ethan Nadelmann, executive director of the Drug Policy Alliance. "Part of it reflects the ideology of abstinence -- that once you're in the system you have to stay clean. But it means that people who are recreational marijuana users are unnecessarily put into treatment, wasting their time, money, and energy, and wasting valuable treatment resources. Most people understand that marijuana treatment programs are mostly silly, but everyone has to participate in the charade because possession or use of marijuana remains a criminal offense."
Patricia Greer, president of the executive committee of the Association for Addiction Professionals, was reluctant to downplay marijuana abuse or dependency, but did hint that perhaps some people in treatment did not need to be there. "If you are a chronic user, you could probably use treatment," she said, "but if you're a recreational user just smoking on the weekend, why not treat it like a DWI with a little counseling?" she suggested.
Greer was also hesitant to differentiate between problems with different drugs. "Empirically, they may look different, but in terms of psychological dependence, they are very much alike," she said. "The question is whether your life is unmanageable, are you experiencing employment, school, or relationship consequences. If so, you have a problem. Marijuana may not look that serious, but if it's serious to the people around you, then, yes, it's serious."
There is a small percentage of the marijuana using population who can fairly be identified as dependent, said Armentano. "The Institute of Medicine study said that among those who smoked marijuana, about 9% may exhibit some symptoms of dependency at some point in their lives. Other reviews have placed that number much lower," he noted. "Still, there are a small number who probably are, and those are the people who are voluntarily checking themselves in for treatment."
But there is dependency and then there is dependency, Armentano argued. "People become dependent on all sorts of things, but it's important to delineate marijuana from many other substances when we're talking about physical dependence," he argued. "If alcohol addicts try to quit cold turkey, they can die from withdrawal, and alcohol is not alone in that. But if we're talking about marijuana, we're not talking about serious withdrawal symptoms; we're talking about a little irritability and maybe a couple of nights of trouble falling asleep."
"The majority of our people are being treated for alcohol dependence," said Christine Jones, clinical supervisor for the Pennington County City/County Alcohol and Drug Program in Rapid City, South Dakota. "People with chronic alcoholism remain our biggest problem. For a few years, we had an awful lot of meth, but now it's OxyContin and prescription opiate abuse."
When asked specifically about marijuana, Jones said it is common as a secondary drug of abuse, but her facility was mainly treating alcoholism and meth and opiate dependence. "We have a few who are primary marijuana abusers, but the numbers are way higher for alcohol," she said. "Most of our clients are court ordered."
That led Jones to ask whether the treatment community was doing its job properly. "The question is how well does the substance abuse field do at gate-keeping so that it is addressing clinical needs rather than judicial concerns," said Jones. She said that treatment providers should be assessing clients through procedures such as the American Society for Addiction Medicine's patient placement criteria, which uses a six-dimensional matrix to assess treatment needs. "It is the responsibility of the drug and alcohol field to ensure that the level of treatment they are obtaining is appropriate for what their needs are," she said.
"If you have a marijuana smoker, and he is using occasionally and holding a job and maintaining his responsibilities, it's a misuse of money to send him to a treatment center," said Jones. "Use isn't an automatic indicator that someone needs treatment, but if someone is having repeated problems with marijuana and lots of other problems in his life, you might want to take a look at how the problems and the marijuana use are related," she said.
But drug reformers remained unconvinced, and had suggestions for what to do. "We need to change our marijuana laws," said Mirken. "There is probably a small percentage of people who have a genuine problem with marijuana, and treatment should be available for them, but not coerced treatment for marijuana possession, which is leading to a completely dysfunctional situation. In most states, there are waiting lists for treatment slots. You have to ask how many treatment slots are being occupied by court-ordered marijuana treatment when there are folks with serious problems with cocaine and heroin sitting on waiting lists and not getting help. If that's the case, it's an outrage."
"The single most important thing we can do is make treatment available for people who want it before they get arrested," said Nadelmann. "To the extent that people are being diverted to treatment in the criminal justice system, we have to insist on the primacy of treatment principles over criminal justice principles. When the criminal justice system is involved in drug treatment, that means coerced abstinence, and that's a fundamental problem. Abstinence may work for some people, but it is a mistake to apply that to entire populations of people with drug issues caught up in the criminal justice system," he said.
"There's a superb treatment for marijuana dependence developed by Roger Roffman at the University of Washington and his colleagues," said Earleywine. "It consists of about 12 sessions of outpatient meetings that focus on identifying why you want to quit, what situations usually lead to use, how to change your thoughts about use, how to prevent relapse, how to handle various life stressors, and great ways to plan alternative fun activities. Extremely few programs around the country use this approach. Most of the drug treatment centers around the country have inpatient stays and 12-step meetings with the occasional watered-down group version of some of the topics from the established treatment."
"It's absurd to mandate people attend treatment who don't need it, it's a waste of taxpayer and private dollars," said Armentano. "There are hundreds of thousands of people seeking treatment for real drug problems who can't get it because treatment slots are limited. To think that we are sending hundreds of thousands of marijuana users to treatment who don't need it at a time when treatment resources are so limited is just ridiculous. This is a policy that is purposefully endangering the health of those who most desire or need drug treatment."