An Issue of Substance
Recreational marijuana is now sold legally in Massachusetts. What does that mean for Austen Riggs?
Massachusetts voted to legalize medical marijuana in 2012 and approved the sale of cannabis for recreational use in 2016. This has led to the recent opening of the state’s first dispensaries—one of them less than 10 miles from Stockbridge and at least two others in Berkshire County with still more planned. Given that half of the patients who come to Riggs for treatment have a diagnosed substance use disorder, the relatively easy access to legal cannabis could add to the challenges they face.
After the recreational use law passed in 2016, the Substance Use Services committee convened a patient and staff group to consider how to address the issue, and after months of meetings they broadened the discussion to the larger community. “And it ends up that we think about legal marijuana pretty much the way we think about legal alcohol,” Clinical Social Worker Daltrey Turner, LICSW, explains; marijuana, much like alcohol, is an unprescribed substance that can affect thinking and potentially interfere with the effectiveness of treatment.
It is important to note that Riggs maintains a substance-free campus and patients are asked to sustain a period of abstinence before coming to Riggs and undergo a substance use assessment upon admission. If someone’s primary diagnosis is a substance use disorder they are most often referred elsewhere, says Elizabeth Weinberg, MD, coordinator of Substance Use Services. For those who are appropriate for Riggs, substance use issues are complicated. “Often people come here in trouble that they haven’t fully identified,” Weinberg explains, “and a lot of what we find is that there is an addictive process—a multi-layered complex relationship with a substance—which is in the context of more complicated difficulties that span substance and non-substance issues.”
So, it’s not as simple as looking at substance use as a symptom or substance abuse as a disease. “Every time someone comes here, we have to try to have an open mind,” says Substance Use Counselor Susan Quinn, LMHC, LADC. “I think the problem for us is that we’ve been taught in many cases an addiction disease model. We can’t do that here; we have to look every time at the larger context.”
In other words, says Turner, “We don’t have a demarcation line around substance use because we are thinking about it dynamically: What purpose is it serving them? What’s the way in which they are using it? What are their risk factors as far as propensity for deep depression and suicide and psychosis?”
Weinberg notes that “Cannabis seems to increase the risk of onset of psychosis and increases the vulnerability of people who are already psychotic or having psychotic symptoms. So,” she continues, “it’s concerning that people who are quite young—in the age range where they would be vulnerable to a first psychotic break—are the most likely to be interested in using legal marijuana.”
Research on cannabis is in its infancy, but Substance Use Counselor Bruce Bradley Gilbert, MA, LMHC, points to the work being done by Staci Gruber, PhD, director of the recently launched Marijuana Investigations for Neuroscientific Discovery (MIND) at McLean Hospital/Harvard Medical School. She has observed distinct differences in the psychological effects of marijuana’s components—the psychoactive compound THC (tetrahydrocannabinol) and the non-intoxicating CBD (cannabidiol). Says Bradley-Gilbert, “The psychological effects of THC are increased anxiety, paranoia, hallucinations potentially, whereas CBD may act as an anxiolytic and even have antipsychotic effects.” And while CBD alone may have promising therapeutic applications, he and his colleagues are cautious about its therapeutic implications until more is learned. It is also important to note that cannabis is still classified by federal law as a highly controlled substance, which means research using cannabis is scant; this makes it difficult to draw conclusions about the possible roles of THC and CBD.
Of course, the two components can’t be separated out for those who eat or smoke cannabis. If the new availability means some patients may use marijuana off campus, the approach is similar to that with potential alcohol use—“an individualized conversation with the particular patient and their treaters,” says Turner, adding that “there are some people for whom we can imagine them using something moderately, in a boundaried and minimal way, that doesn’t feel as problematic; and there are people who might not have a substance use disorder who we would still recommend against their using alcohol or marijuana.”
The conversation and the research are ongoing. With much yet to learn, Quinn is comfortable responding to patients who might say “Well, it’s legal; why not?”
“What I say is: We don’t have enough research yet.” That, she adds, is a matter of “institutional responsibility.”