June 1, 2018
Avoiding and overcoming addiction: The cautionary side of cannabis legalization
People around the world use cannabis for a wide range of reasons, including religious, cultural – and simply recreational. For thousands of years, cannabis has been a powerful weapon in the arsenal humans have developed for celebrating and for taking the edge off.
"We all need distractions and pleasures," says Dr. Chris Wilkes, a professor in the Cumming School of Medicine’s Department of Psychiatry and section chief for child and adolescent community and specialized services. "Whether we're tired, or upset, or celebrating something, most of us have used some kind of substance. Alternatively, we may engage in other activities such as eating food, shopping, exercise, sex, gambling, whatever. These are some of the common ways we cope with life’s stresses and have fun."
While turning to physical or material distractions to blow off steam is perfectly normal, some people's use eventually becomes problematic and drifts into the arena of addiction, or what's nowadays called "use disorder." Use disorder is defined as impairment of control over your use, meaning you regularly use more than you intend to, or more often than you intend to. This is the compulsive craving for an activity or substance, with continued use despite negative outcomes. In other words, you keep using even when you know it's causing problems in other areas of your life, like your relationships, your job or your health.
As Canada legalizes cannabis, Wilkes is concerned that people who are more likely to develop use disorders or experience negative medical consequences will have easier access to the drug, and don't fully understand its risks. "Because it's a natural product, people will think it's safe," he says. "They're often misinformed about the dangers for children, adolescents, pregnant women and people with mental illnesses."
Wilkes is also worried that there won't be enough medical and mental health support services available to people who develop problems with its use. "The available treatment resources, messaging and education haven't kept up with the intention of legalization," says the member of the Hotchkiss Brain Institute’s (HBI) Mathison Centre for Mental Health Research & Education. "Addictions are common, but we haven't actually put more money into treatment services."
Mental health and addiction
Wilkes, a clinician, treats at-risk children and youth who have been involved with Children's Services and have been referred to him through family courts. Many have mental health issues, and many are already using cannabis and other, more serious drugs such as opioids or crystal meth. According to Wilkes, people with pre-existing mental health conditions are more likely to experience adverse effects due to cannabis use, and more likely to develop use disorders.
"We know some people are more vulnerable," says Wilkes. "If you have a family history of mental illness, or come from a background of adverse childhood events, you've come through a period of toxic stress and you have a stressed brain. In mental health, the biggest trigger for people to use substances is because they're anxious or unhappy, or they're feeling depressed. And when people are suffering or in distress, they look for relief. If you take something that gives you a pleasant feeling, then you want to do that more often."
Wilkes says that once people are in that cycle of dependence, it can perpetuate itself. "What happens is you progress to what we call a salience disorder," he says. "You go looking for that, and your other rewards – being with people or doing other activities – become less relevant. That's the addiction pattern."
Another cause for concern is that because cannabis is often marketed as a safer, more natural alternative to pharmaceuticals, some people with mental illnesses will stop taking their prescription medication and use cannabis. "We see people who stop their antipsychotic medication and anti-depressants and use cannabis instead," says Wilkes. "They think it's a natural product, so it's good for them, and they end up in the hospital."
Number one addictive substance
While cannabis is generally thought to be less addictive and less harmful than other substances, it's still the number one illicit substance for which Canadians seek treatment, according to Dr. David Hodgins, PhD, a professor in UCalgary's Department of Psychology and a member of the HBI.
Hodgins says that while the percentage of cannabis users who develop problems is lower than with other illegal drugs, the sheer number of cannabis users means more people on the whole get into use disorders. "Most people who use cannabis don't get into difficulties with it," says Hodgins. "And the health consequences aren't as dramatic as with other illicit drugs, or even licit drugs like alcohol. But even though fewer people proportionally get into problems, the gross number is larger."
Because the health consequences of other drugs are more severe, Hodgins says cannabis use disorder doesn't get as much attention. But with legalization, Hodgins predicts an increase in use, which will lead to an increase in problem use. "More people are going to experience negative impacts," says Hodgins. "How we handle that is an important issue."
Steps to self-recovery
In addition to increasing funding and resources for people who seek treatment for cannabis use disorder, Hodgins says it's important to develop supports to help people overcome problem use on their own. Seeking treatment isn't feasible for everyone because of cost, practicality and stigma. But Hodgins' research into addiction recovery has shown that many people are able to overcome use disorders naturally, without treatment.
"There are multiple pathways to recovery," says Hodgins. "Treatment is an essential part of our care system, but we should also expand the system to promote self-recovery."
In order to help people recover from use disorders on their own, Hodgins' research also looks at common elements of addictions and common steps to recovery. "We're looking at commonalities between different addictions," says Hodgins. "Right now, substance addictions and behavioural addictions – things like gambling addiction, video game addiction, pornography addiction – all tend to be treated differently. But the underpinnings are similar. Our goal is to develop what we call a trans-diagnostic clinical approach that focuses on helping to improve the underlying factors."
Hodgins says people who manage to recover from use disorders on their own do so with methods similar to what people learn in treatment. "It's things like making a commitment to staying away from cues for using," he says. "Getting involved in other activities is another important strategy in recovery. Some people outside of treatment naturally figure out how to do that."
Learning how people who recover naturally do so is an important step in helping others do the same. "We're looking at how to promote that," says Hodgins. "We know some people don't want to go to treatment so can we provide them with web-based support or other supports? How can we move them in the right direction in a faster and more efficient way?"
Cannabis learning curve
While neither Hodgins nor Wilkes expect legalization to go perfectly smoothly, both also acknowledge that a harm-reduction approach is likely to be more successful than criminalization.
"We shouldn't have a repressive approach to the use of drugs," says Wilkes. "We need to be much more open, generally. But we need to regulate, and we need to inform, and we need to have supports and treatment services available."
Hodgins points to other substances and activities that were once illegal, specifically alcohol and gambling. "We've chosen to make alcohol and gambling available, and to encourage people to use them safely," he says. "On balance, we seem to be comfortable with that. I think we'll get to the same comfort level with cannabis. People are doing it anyway, so let's put some rules around it."
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ABOUT OUR EXPERTS
Dr. Chris Wilkes, MD, is a professor in the Cumming School of Medicine’s (CSM) Department of Psychiatry and section chief for child and adolescent community and specialized services. He is a member of CSM’s Mathison Centre for Mental Health Research & Education at the Hotchkiss Brain Institute.
Dr. David Hodgins, PhD, is a professor in UCalgary's Faculty of Arts. His research interests lie in the area of addictive behaviours, including alcohol and gambling addictions, and comorbid psychiatric disorders. Read more about David