Marijuana is now legal – for either medical or recreational use – in 31 states and strains are getting stronger and stronger.
Its legalization has been buoyed by ever-growing evidence that it does not have debilitating health consequences of other federally outlawed substances.
Yet the National Institutes of Health estimate that four million Americans are addicted to marijuana.
The drug is becoming easier to access and more potent in more places, increasing the risks of addiction, yet there are addiction treatment medications, such as we have for alcohol and opioids, for treating marijuana addiction.
Marijuana has a long-standing reputation as a ‘gateway drug’: an easy entrance into the world of illicit substances.
But concern over the next drug someone might pick up has also overshadowed research, warnings and public awareness of the risks of marijuana itself.
Marijuana is addictive.
Marijuana addiction and withdrawals are not life-threatening like opioid addiction – but dependence on the drug can still disrupt the lives of millions of hooked Americans
‘One way to look at marijuana is the way we look at something like alcoholic beverages,’ suggests Dr Edwin Salsitz, an addiction specialist at Mount Sinai Hospital in New York City.
‘Most people are social users and don’t run into any trouble wit hit, but about 20 million people in the US are alcohol-dependent or alcoholics.
‘But there are groups of people that do develop and addiction [to marijuana] in the same way they do to alcohol.’
Attempting to distinguish between those two categories – dependence and alcoholism (i.e. alcohol addiction) – complicates efforts to research both marijuana dependence and addiction.
The two categories of misuse have historically been separated based on whether someone is physically dependent or mentally addicted to a substance.
‘It’s hard to separate out what is physical versus psychological,’ says Dr Salsitz.
‘Marijuana does not fit in with other drugs in terms of addiction features. Some drugs, like alcohol, have a very clear withdrawal syndrome. Marijuana has one, it’s just not as severe, but it does create cravings.
‘Addiction only occurs when there’s harm from whatever you’re addicted to, and you know you just can’t stop.’
Scientists have a hard time agreeing on where the addiction threshold is for marijuana, but studies estimate that about four million Americans qualified as having a ‘marijuana use disorder’ in 2015, according to the National Institute on Drug Abuse (NIDA).
That group accounts for about nine percent of all marijuana-users. But addiction rates nearly double – rising to 17 percent – among people that started getting high in their teenage years.
These are the ones that Dr Salsitz sees and is the most concerned about at the Mount Sinai addiction clinic.
‘Marijuana has become one of the initial drugs that teens try along with alcohol and tobacco,’ he says.
In fact, there are now more teenagers that report smoking marijuana than there are admitting to smoking cigarettes.
Teenagers, particularly those who are unhappy with their circumstances, lives and the drudgery of school are picking up weed for a lower risk way to escape further, Dr Salsitz says.
‘There’s a whole debate going on now with medical use. States are legalizing it, making it appear that marijuana really carries no risks at all,’ he says.
‘Over the last 30 years, there has been an inverse relationship between how teens perceive risks or negative consequences of marijuana and how much they use. The higher the risk-perception of the drug, the lower the use.’
‘So now, there’s the sense that, “If it’s good for medical stuff, how bad can it be? It’s no big deal,”‘ especially among teenagers, Dr Salsitz says.
To be clear, more often than not, the answer is that it is not so bad. But, ‘like all other addictions, it’s a matter of degree: how much [is someone using], how often, and does it interfere with their life,’ he adds.
Dependence and addiction to marijuana develop much like they would to any other drug.
The brain’s reward center – which releases feel-good chemicals in response to stimuli and behaviors – has a set of cannabinoid receptors that get switched on when marijuana is present.
Pressing those cannabinoid buttons over and over by using marijuana chronically leads to the development of tolerance, meaning you need more marijuana to feel the same sensations as you did with your previous tokes.
This resets a person’s baseline so that eventually they need marijuana and its various cannabinoids just to feel normal, at which point they become dependent.
That stage may now come on more quickly, as marijuana strains are now power potent than ever before.
Dr Salsitz estimates that back in the 1960s and 1970s, the THC-potency (the psychoactive component of the drug) was only in the single digits.
Today, marijuana is commonly 15 or sometimes even 20 percent THC, meaning that the timelines from uptake to dependency and dependency to addiction are shorter.
Marijuana addiction, however, ‘doesn’t have the dramatic withdrawal syndrome – like alcohol or benzodiazepines or opioids. It’s more subtle, more psychological and it doesn’t kill anyone,’ explains Dr Salsitz.
But that in fact may increase the odds that anyone, but especially a teenager, gets addicted as well as underlie the difficulty in breaking that addiction.
‘I think that teens are not dumb, they know there is more of a risk to taking other drugs. But with marijuana, there still has never been a true overdose,’ says Dr Salsitz.
‘In general, when people stop using marijuana, a lot of the negative things that have occurred in their brains tend to gradually resolve.’
On the other hand, the fact that there are not such dire long-term consequences may be why there are no medications to treat marijuana addiction.
There are several therapies used to treat addiction and ease withdrawal symptoms from opioid, alcohol and tobacco addictions, each.
Currently, there are no such medications for treating marijuana addiction, though there are some studies of Marinol – a THC-based drug approved by the Food and Drug Administration to treat chemo-related nausea – for treating addiction.
Instead, addiction specialists like Dr Salsitz have to rely on ‘a whole basket of psychosocial treatments, like individual therapy, cognitive behavioral therapy and motivational interviewing,’ without the assistance of medication, to treat patients.
Down the line, he hopes that the US government will step in to regulate marijuana potency and issue more thorough advisories on consumption.
‘Marijuana is a drug, it’s a plant and can’t tell what exactly concentrations are of different cannabinoids in the plant. Like other drugs, in vulnerable populations, this can lead to substance use disorders, which can have very negative consequences for individuals,’ says Dr Salsitz.
‘We should be putting an age limit on use of marijuana like we have for alcohol. If it’s reasonable for alcohol, why shouldn’t it be reasonable for marijuana?’