In a single state, let’s say California, you can walk into a dispensary and buy weed legally while down the block your neighbor is still in prison for a weed possession charge from a decade ago. Weed, like most topics we talk about on this show, is complicated. One caller wants to know if something can even be addictive if there is no physical withdrawal, while another wants to know how to set boundaries for her daughters who are smoking weed daily and don’t think it’s an issue. In this episode, Nzinga uses weed to break down what she means when she says addiction is continued behavior despite negative consequences.
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[00:28] Dr. Nzinga Harrison: Hello and thank you for listening to In Recovery, I am Dr. Nzinga Harrison, your host. I’m a psychiatrist, physician, addiction expert, mom, wife, chief medical officer and co-founder of Eleanor Health. And this is a question and answer show about all things addiction, not just drugs, but sex, exercise, all sorts of things that you wouldn’t necessarily think about. That said, this week we’re going to talk about weed.
[00:59] Claire Jones: So, OK, in preparing for this episode, I went down a deep, deep hole of the history of weed in the United States. And I think it’s important that we bring up a couple of things because weed has been wrongly associated with BIPOC.
[01:19] Dr. Nzinga Harrison: Well, OK, since you just asked that question, Claire, what pray tell do you mean by BIPOC?
[01:25] Claire Jones: I mean black, indigenous and people of color.
[01:34] Dr. Nzinga Harrison: Yes. Basically black and brown people.
[01:39] Claire Jones: OK, so weed in BIPOC communities is often tied to crime and violence and was highly criminalized which then put a disproportionate amount of black and brown people in jail. And so it’s like racism almost creates these different versions of weed. Like there’s this weed that causes crime. There’s a weed that I grew up around in Colorado that was super, super chill, bro. Let’s go hit the slopes. There’s the weed that I was also taught is a gateway drug. And then there’s the weed that’s helpful for pain, that’s also now being legalized in a lot of states. And all of this is not true, so what are your thoughts on this Nzinga?
[02:16] Dr. Nzinga Harrison: Yeah, so it’s actually not just marijuana that has racist history in this country. So racism and drug use have always been inextricably linked. And so when you look at this, you said like there’s the weed that’s associated with violence. There is no marijuana strain that is literally associated with violence and going out and committing crimes and robbing people. This is all the same drug. And I’ll say — let me get on a little bit of a soapbox, Claire. And this movement for medical marijuana, which is an important movement, and this movement for CBD, but also this movement towards high-end — we don’t want to call it marijuana. It’s cannabis. That, my friends, is rooted in racism because it’s the same thing. So people who are really into cannabis will know the name Henry Anslinger. Henry Anslinger is the one that started using the word “marijuana” super racist-ly. And so people will say, oh, the origin of the word marijuana is racist. And it’s like, no, no. The origin of the word marijuana is from Mexico. Anslinger started using the word marijuana to make people afraid of foreigners and Mexicans that are using it and criminalizing it. So he used it in a racist way. Actually saying we’re not going to use the word marijuana because we have to separate medical cannabis from marijuana, it’s actually the other side of the same coin. Because the idea is like, no, we have this high-end walk into a beautiful dispensary where you pay, you know, premium prices for the experience. That’s not the same as those people who are buying marijuana on the street.
[04:22] Dr. Nzinga Harrison: There is no them and there is no us. It is thus. So marijuana from the street, cannabis from the dispensary. That’s the same drug. Crack cocaine. Powder cocaine. That’s the same drug. Heroin. Pain pills. In your body, those are tapping the same receptors. Beer, liquor. That’s the same drug. And so we draw all of these like, oh, no, I drink wine. I don’t drink hard liquor. You can have an addiction to wine because that’s alcohol. I don’t smoke crack. I do lines. That’s the same drug. Thus.
[05:29] Claire Jones: OK, so let’s start with our first question, which is from a social work student who works at a domestic violence shelter.
[05:39] Caller: I’ve seen a lot of addiction firsthand. But that to me has been, I guess, easy to understand because it’s been those drugs where there’s a big consequence if you stop utilizing them. So I’ve seen heroin withdrawals and stuff like that.
[05:59] Claire Jones: OK. So she gets it when it comes to addictions that are more commonly known. But where she is confused is with her brother, who she says is using marijuana as a band-aid for trauma.
[06:08] Caller: That is something that is hard to understand, I think, because there is no negative consequence to him stopping using that substance. I guess, other than like some of those feelings from childhood coming up and him having to deal with that.
[06:27] Claire Jones: OK. So I think what her main question is, is like I understand that weed can be addictive by the way that we have defined addiction on this show. Just like anything can be addictive. But what is the psychology behind something that isn’t physiologically addictive in the same way that substances like heroin or opioids may be? And how does withdrawal even, like, fit into the definition of addiction?
[06:50] Dr. Nzinga Harrison: Ooh, OK. So the first answer to your question is that marijuana is physically addicting. It is physiologically addictive and psychologically addictive. And so I want you to think about it like this: our bodies are always operating in medicine in what we call homeostasis. And so it’s like this narrow range that your body is operating in and your body is constantly adapting itself. It’s adapting its receptors. It’s adapting its chemicals. It’s adapting its electrical signals to be in response to the environment, whatever is going on around you. And so even — I think I may have told this story before, but like, even if you get up every morning at 8 a.m. and you immediately eat breakfast, then after you do that for several days in a row, your body sets up an equilibrium so that it literally starts preparing you at 7:30, 7:45. It’s going to make your stomach churn. It’s gonna get your enzymes pumped up. So then when you wake up at eight o’clock, you have all of those signals that I’m hungry, it’s time to eat, because that’s the homeostasis we’ve set up to this pattern that has been in our life. The exact same thing is true for any substance that you’re putting in your body. So although marijuana is not as addictive — and the way I’m defining that is if I took 100 people with the exact same genetic risk for addiction — because, you know, everybody’s genetic risk differs based on your DNA. But if I took 100 people with the exact same genetic risk for addiction and regularly gave them marijuana, every single one of them, all 100, would develop physiologic dependence to the marijuana. If I gave it to them in the same amount at the same time each day, because their body is going to adapt to that as being part of what I can expect, a small percentage of those will go on to develop marijuana or cannabis addiction. If I take the same 100 people and do the exact same experiment with alcohol, same thing, 100 percent of their bodies are going to become physiologically dependent on the alcohol, because your body is setting up a homeostasis in expectation of that dose of alcohol every day. A larger percent of those will get addicted to alcohol than to marijuana because alcohol is more addictive. If I did the same experiment with pain pills, more might get addicted to pain pills. The same experiment with cigarettes, which is one of the most addictive. So every substance has a physiological physical addiction risk, including cannabis.
[09:46] Claire Jones: So what if we took that 100 people and we got them on the course of waking up at 8:00 and eating breakfast, and then they don’t one day and they will feel that withdrawal. They will be starving. So would eating breakfast at eight technically be something that is physiologically addictive?
[10:11] Dr. Nzinga Harrison: Not addictive, because remember I said all of those people will have a physical dependence, but remember, the definition of addiction is continued use despite negative consequences. And so you will wake up that first day you don’t eat, so you cold turkey from food and you’re going to be starving. But the next day, if you don’t eat two days in a row, you will be a little less hungry. And the third day, you’ll be even less hungry because your body is re-calibrating to the new situation. So it’s the same thing if you smoke every day. That first day you don’t smoke, your cravings are going to be off the charts. Your appetite is going to be off the chart. Your irritability is going to be off the chart. Your anxiety is going to be higher. And when I say off the chart, I just mean increased, because different people will have different levels of withdrawal. But that’s the typical withdrawal syndrome because your body’s recalibrating from that physical dependance.
[11:11] Claire Jones: So it’s not the physical dependence that necessarily — that’s like not really the determining factor here with different addictions. What you said earlier about the fact that more people in that group are going to become addicted to alcohol than they will the number of people that will become addicted to marijuana, that seems like the distinction. Why is alcohol more addictive?
[11:32] Dr. Nzinga Harrison: That is the distinction. There are a lot of things that determine how addictive a substance is. And so part of it is how much dopamine signal it can generate. So the bigger dopamine signal it can generate, the more addictive it’s going to be, the faster it can bring on intoxication, the more addictive it’s going to be. The faster it comes off, the more severe the withdrawal syndrome, the more addictive that’s going to be because withdrawal drives craving, which drives use. If you smoke cannabis, you have so many blood vessels in your lungs that you get that to your brain so fast, you get high quickly. That is more addictive than if you eat it and your liver clears out 45 percent and then it has to go all through your whole blood system to get to your brain. And by the time the high comes on, it’s like 45 minutes later and gradual. That is less addictive. So there are a lot of different things that go into how addictive a substance is. Think of it the same way a person takes an asthma inhaler, steroid inhaler every single day. Once you start taking that asthma inhaler every single day, you will become physiologically, physically dependent on that asthma inhaler. And the first day you forget to take it, after several days, you will feel that in your lungs. You’re not addicted to your asthma inhaler. You’re not losing your job. You’re not having fights with your loved one. You’re not being hung over. You’re not having other negative physical consequences, other negative relationship consequences. So you’re not addicted to it, but you are physiologically dependent on it. But if you’re not having negative physical, psychological, relationship, life consequences, you are not addicted to it.
[17:36] Claire Jones: Our second question comes from Alex, who grew up in California.
[17:43] Caller: Hi, Nzinga. I grew up mostly in the Los Angeles area from about eight years old until my early thirties. Growing up in California, even before legalized medical and recreational marijuana, there was obviously a culture of marijuana use. You know, weed was just the thing that was around there. I grew up by the beach. And, you know, people used it. And there was this feeling that, you know, it was pretty harmless. It wasn’t a drug like an opioid where you could get hooked and have, you know, physical withdrawal symptoms. I use weed, but I feel like I have pretty good control over that use. I can stop and start when I feel like it. And, you know, I can definitely recognize the signs when it’s, you know, getting in the way of other things.
[18:37] Claire Jones: So in her specific case, for Alex herself, maybe not so addictive. But then when it comes to her family, it’s sort of a different story.
[18:45] Caller: My dad has a disability related to polio as a child. And so he has said that he uses marijuana for pain as well as using it as a creative stimulant because he’s a writer. However, I have seen situations where he has not had access to marijuana and the type of emotions that he has around that really to me seem like he is having withdrawals and doesn’t know how he will function without it.
[19:20] Claire Jones: OK, so then in this case, because it seems like her dad is either like in an increased amount of pain or his just his mood changes because he’s having those physical withdrawals does that mean that he is addicted?
[19:36] Dr. Nzinga Harrison: So if we’re going to go to the medical definition, remember, we don’t do anything that does not have positive effects for us. So even though the negative effects might be outweighing the positive effects, there are still positive effects there. If we try to move Alex into whether your father has an addiction to marijuana, cannabis, however you want to call it that, I would go to our DSM diagnostic criteria for cannabis use disorder. And we have 11 for substance use disorder. And so one is using the substance in a way that is dangerous to yourself. And so out in Colorado, we actually have a lot of people that are getting totally stoned and then going skiing. And that’s why when marijuana got legalized, we saw an increase in marijuana-related injuries in the emergency departments in Colorado. That’s hazardous use. If you’re having social or interpersonal problems related to use, that’s another criterion. If you’re not fulfilling your major role obligations. So if you’re like my dad couldn’t take care of us because he was smoking so much weed, he couldn’t even make it to my soccer game. That’s another diagnostic criteria. Withdrawal is one of our diagnostic criteria. Tolerance is another one, which is like having to use more and more and more and more and more. And so withdrawal alone does not mean you have a problem because we don’t make a diagnosis until you meet two criteria. But withdrawal definitely gets us closer to a diagnosis because it’s one of the criteria that makes sense.
[21:20] Claire Jones: That makes sense. Let me confirm, though, going back to 8:00 breakfast. So if I am one of those 100 people and that first say that I don’t eat breakfast at eight o’clock, I experience physical withdrawal. But if I meet another set of criteria, let’s say that this is listed in the DSM-5, then if I met another one of the criteria, then it would be something I am addicted to.
[21:54] Dr. Nzinga Harrison: That’s exactly right.
[21:57] Claire Jones: Well I guess really this is confirming what we have been saying for this whole show, which is like you can be addicted to literally anything.
[22:05] Dr. Nzinga Harrison: Yeah. Mild. Moderate. Severe. And so the problem is that again, this is back to them and us. We conjure up this image of what a person with addiction looks like. And that image that we’ve been trained into is severe rock-bottom image. And what we’re trying to do on this show is like, one, we don’t want to wait until you get to severe rock bottom. We want to catch it before it even gets to mild. Or I see one diagnostic criteria, dad, which is when you don’t smoke your marijuana, you are clearly in withdrawal. And we want to be able to make our interventions there before dad gets to four criteria and has a moderate substance use disorder before he gets to a criteria and has a severe cannabis use disorder. Let me touch on another part of Alex’s question. So her dad is a survivor of polio and he uses marijuana for pain as well as using it as a creative stimulant. All of these can be true. Dad can be using marijuana for pain. Dad can be using marijuana as a creative stimulant. Dad can also have a cannabis use disorder if he’s meeting diagnostic criteria. So remember going back to we don’t do things that don’t bring some kind of benefit. And so those benefits that marijuana or cannabis is bringing her dad will make it more difficult for him to see if he has a cannabis use disorder, but also there will have to be a way to get those benefits from something other than marijuana if he chooses to stop using.
[23:52] Claire Jones: Taking everything that you’ve established into consideration, what would you say to a parent like Wendy? She says that her two daughters are smoking a lot and she’s concerned because there’s a history of addiction in both her side of the family and her husband’s family. And their oldest son has been in recovery for 17 months. So let’s listen to her voicemail.
[24:15] Caller: Hi. I am a mother of four kids. And right now I have two, my two girls are teenagers. They’re 18 and 16. Both have been struggling. They smoke at this time mostly daily. And my rule at our home is that there should be no drugs in or around and nobody high in the home, which seems like a reasonable rule to me. They are not complying with that all the time. My consequences are recovery oriented. So the younger girl is in weekly counseling, the older one is doing BBT group twice a week. Yet it’s really hard as their mom to know that they go out every night and smoke weed. Despite Alanon and working all my programs, it makes it hard to feel peaceful when I feel like my kids are hurting. So I have tried to focus on connection with them and listening to them. They tell me that they’re doing it because it helps them. But I can see that it isn’t. Neither girl is thriving in school or relationships, and it’s hard to watch.
[25:42] Dr. Nzinga Harrison: Oh, yeah, Wendy, this is such a difficult situation to be in as a loved one, period, but as a parent especially. I think your approach sounds right. So I really love the recovery-oriented approach. You know, you took me to church when you say both of the girls are having weekly counseling because I’m always trying to get everybody in counseling and therapy. I love the BBT group twice a week. I think that’s amazing. The question I have here is root causes. So we know that your girls are genetically predisposed because of the addiction in your husband’s family. I wonder if there are not also other environmental, psychological, family dynamics, stressors that are contributing. Because when we see adolescents like this, what we know is that they’re struggling. They’re struggling emotionally. They’re struggling with relationships. They’re struggling some other kind of way. And this is the way that they are making it known that they’re struggling. And so I think you’re doing the right things, trying to get to the root cause in terms of setting good boundaries. I need you to do that. So, you know, on this show, we talk about enforcing boundaries compassionately. And so your boundaries have to be associated with negative consequences, because that’s the other thing — once negative consequences get sufficiently high, sometimes that can trigger a motivation for a change. And so if you say you can’t be in this house high, but there’s no consequence associated with that, they’re gonna be in your house high. If you can find a family therapist that you’re all in together, or even your individual therapist, to help you figure out what boundaries you can set and what consequences you can actually enforce, and start putting those in place. Then I think you may start to see some movement. The last thing I will say, because you have four kids, a lot of times siblings can touch siblings in a way that parents can’t touch siblings. Then if they could maybe open that conversation and you guys could be a unified front. That might help, too.
[27:56] Claire Jones: In a funny way, it kind of negates everything that we’ve just talked about. The point is, like it doesn’t really matter. What you said is it seems like your girls are suffering. And if that is something that you see, then that is what you treat. And the addiction, like you always say, is just part of the symptoms of it.
[32:25] So let’s talk about treatment. So, you know, whenever we talk about treatment, what I always say: biological, psychological, social, cultural, political. We already talked through political. Culturally, we see a culture change in this country happening from marijuana being completely and utterly criminalized. I’m talking about people serving life sentences for marijuana-related charges. All the way to the swing through medicinal marijuana, through CBD preparations, all the way over to the states now that have recreational marijuana approved. And so that kind of culture — it starts in a family of culture and a community all the way up to the state, all the way up to the country. And so you have to be aware what your cultural environment is and try to be helping folks operate within that. Going back to social. Social, what we’re talking about is stress. So you already know the higher your stress, the more you’re craving for marijuana is going to be. And so if a person is setting a goal to reduce cannabis use or to be completely absent from cannabis, then you have to be looking at the stressors and putting in interventions for that part of the formula, because that is going to drive the desire to smoke. That’s going to drive cravings. Backing up then, the psychological. When we look at the evidence-based interventions that we have for cannabis use disorder, there are three. One: cognitive behavioral therapy, CBT. So the basic premise of CBT — and CBT is the evidence-based intervention for literally, you know, almost everything that we have that goes along the emotional-thinking behavioral spectrum. And the reason is because it’s a specific type of psychotherapy that has this triangle. So think of the three points on the triangle as your thoughts, your emotions or your feelings, and your behaviors. And so what it says is going around that triangle, your thoughts affect the way you feel about things, affect what you do, affect what you think, affects how you feel. That triangle whips around in both directions. And so your brain will actually do that automatically with no input from you. The same is true for literally everything. And so for marijuana, you feel anxious. You think, I could smoke marijuana right now and that will make the anxiety feel better. And then you smoke. And so what cognitive behavioral therapy does is it helps you identify what are the thoughts and what are the emotions that are leading to that behavior and put intentionality in it so that you can make a different choice.
[35:09] Dr. Nzinga Harrison: The second is contingency management. This is basically the longer you don’t use, the more positive rewards I will give you. So, like, every day you don’t use, I’ll give you $5. And if you don’t use for a week, that goes up to $10 a day. So what you’re trying to do is build the motivation for that positive reward to reduce the motivation for using the substance. It actually has good data. The third is motivational enhancement therapy. And so this is basically used to move people through the stages of change. And this is a longer one that could be a whole episode. Motivational enhancement therapy actually helps people recognize the consequences of use and then goes through this whole system of interventions to try to develop the motivation to make the behavioral change and then put the supports in place to be able to maintain that change. Those are the psychological interventions. Did you know there are biological interventions, medications for cannabis use disorder? That’s why I did it backwards so that this could be my denouement. The drum roll says we actually don’t have any FDA approved medications, but we do have medications that the literature is showing us are probably beneficial for reducing cannabis use in people that have cannabis use disorder. The first one is called an N-acetylcysteine. It’s an antioxidant. We don’t know the mechanism of action. We don’t know why it reduces marijuana use. And so if you have cannabis use disorder and you’re trying to reduce your use and or you’re benchmarking to complete abstinence, when you see an addiction specialist you should ask about N-acetylcysteine. The second one is gabapentin. You may have heard of gabapentin, we use it for a lot. It’s a seizure medication and we use it in alcohol withdrawal. We use it for anxiety. We use it for nerve pain, for diabetes. I’m talking about gabapentin gets all kinds of jobs done.
[37:38] Dr. Nzinga Harrison: The last one, nabiximol. Now, nabiximols is not approved for use in the United States. Nabiximol is actually a whole-plant extract cannabis that has a one to one ratio of THC and cannabidiol. And so there will be some addictive risk because it’s THC and cannabidiol. And so you’ll have to evaluate that in terms of your strategy for reducing your marijuana use. This is what I would say when I have people that I’m taking care of who are smoking whole plant. So a harm reduction strategy is to go from smoking to edibles. The next harm reduction step down is from THC to CBD. And so nabiximol is a harm reduction step down from smoking because you’re not smoking. And it’s a harm reduction step down because it’s regulated and you know exactly what you’re getting. So you could think of nabiximol kind of like the Suboxone of cannabis use disorder. Here are my words of wisdom: I say this all the time, just because it’s natural and grows in nature does not mean it is without risks. So I don’t want you to be lulled into this idea that because marijuana is not as addictive as heroin or cocaine, or because cannabis, you don’t see the same level of negative consequences in as many people, that that level of negative consequences can exist because it can. And I have taken care of people who have had that level of consequences from cannabis use disorder. And keep an eye on yourself and keep an eye on your friends and keep an eye on the people you care about and be willing to speak up. That concludes our show for this week.
[40:05] Dr. Nzinga Harrison: In Recovery is a Lemonada Media original. The show is produced by Claire Jones and edited by Ivan Kuraev. Music is by Dan Molad. Jessica Cordova Kramer and Stephanie Wittels Wachs are our executive producers. Rate and review us and say nice things. And follow us @LemonadaMedia across all social platforms, or find me on Twitter @naharrisonmd. If you’ve learned from us, share the show with your others. Let’s help destigmatize addiction together.