The Challenge of Substance Use Treatment Centers in Addressing Cannabis Use in the Age of Cannabis Legalization

Background and Purpose: As cannabis legalization spreads across the United States, it is critical to examine its impact on substance use disorder (SUD) treatment organizations, and derive the normative structures that underlie attitudes among cannabis clients in SUD treatment. This analysis examines SUD treatment providers’ perspective on the challenges of treating cannabis users, and on clients’ cannabis use and attitudes toward the substance and treatment.

Methods: Data were collected using in-depth phone interviews from 128 clinical directors of SUD treatment centers throughout the United States to examine treatment delivery for clients who use cannabis. Interviews were coded by two independent coders and thematically analyzed through iterative rounds of coding that identified and characterized themes.

Results: The sample of treatment center clinical directors was predominantly female (61%), White (76% White; 11% Black/African American; 8% LatinX; 3% multiracial; 1% Alaska Native; 1% Pacific Islander). Clinical directors reported strong resistance among their centers’ clients to abstinence from cannabis during treatment, this being common among both clients with a primary cannabis SUD as well as those admitted with other primary SUDs (e.g., alcohol, heroin, prescription opioids, cocaine). While secondary cannabis users tended to accept the goal of abstinence for their primary SUD, many resisted the idea of abstinence from cannabis specifically. The main themes associated with client resistance were the: 1) minimization of the harmful effects of cannabis; 2) skepticism about the benefit of treatment and abstinence; 3) political or legal justification for continued use; and 4) medical justification for continued use, including the use of cannabis to treat other SUDs as well the use of cannabis to treat other physical and mental health issues. We found that treatment providers in states with recreational cannabis were more likely to report these four themes. Notably, this pattern of abstinence resistance did not typically include a parallel resistance to abstain from the use of alcohol.

Conclusions and Implications: SUD treatment typically expects abstinence from psychoactive substances during and after treatment. Resistance to abstinence from cannabis presents a challenge for treatment centers’ operational practices, especially those that expect complete abstinence from all substances, and may undermine treatment effects. This finding could have larger implications for the growing debate among those treating SUDs regarding the measurement of treatment outcomes. The legalization status of cannabis may have a potent effect on encouraging the anti-abstinence stance. The neutralized perceptions of the effects of cannabis may represent a combination of implications of safety associated with recreational legalization coupled with implications of the medical benefits of cannabis associated with medical legalization.