What Cannabis Legalization Means for the Treatment of Cannabis Use Disorder

Background and Purpose: It is important to examine the impact of cannabis legalization on substance use disorder (SUD) treatment to understand the evolution of attitudes and motivations among patients seeking cannabis-related treatment over time. This analysis identified common themes within cannabis use disorder (CUD) patients’ motivations for use and challenges in treatment.

Methods: Data were collected using in-depth phone interviews from 406 clinical directors of SUD treatment centers throughout the United States to examine how legalization impacts treatment. Respondents were asked a series of open-ended questions regarding attitudes surrounding legalization and unique challenges to treating cannabis patients. Interviews were coded by three independent coders and thematically analyzed through iterative rounds of coding that identified and characterized themes.

Results: More males (68%) than female patients (32%) were admitted with a primary marijuana diagnosis, and there was a growing population of older cannabis patients self-medicating for pain relief. Compared to the average of a treatment center’s total caseload, patients with a primary cannabis diagnosis were less likely to be White (mean 58% of total caseload; 47% of primary cannabis caseload) and more likely to be Black or African American (mean 21% of total caseload; 32% of primary cannabis). There were several justifications specified for the use of cannabis, which we coded into themes including: 1) medicinal use, 2) political rationale, 3) social normalization of use, 4) the belief that cannabis has a lower risk than other commonly used drugs. Respondents reported that patients’ justifications for cannabis use provided challenges to treatment, with many programs reporting a reluctant shift from treating cannabis through abstinence to a harm-reduction model. Another theme that emerged was the challenge of addressing the shifting landscape of cannabis legalization. Respondents reported that patients struggled with misinformation regarding legal access to cannabis, and were often unsure of the cannabis policies in their area. Respondents identified patients’ higher-potency THC, increasingly ingested through vaporizers or dab cartridges as an increasing concern. They also reported an increase in psychiatric complications in the form of cannabis-induced psychosis. In terms of treatment, respondents identified the importance of patients unlearning preconceived notions about cannabis. Despite these challenges, only 12% of respondents indicated having a specific detox strategy for cannabis and just 10% indicated offering cannabis-specific treatment.

Conclusions and Implications: Through this analysis, we gained insight into the population of primary CUD patients. Peoples’ motivations about their right to use cannabis strongly influence their susceptibility to treatment. Both positive and negative rhetoric surrounding cannabis use and CUD treatment may be misleading for patients when initially understanding the risk that cannabis might pose to their well-being. In the case of polysubstance users, cannabis, while addressed, is infrequently prioritized in treatment or detox. Maintaining motivation in treatment and newly adopted methods of harm-reduction are challenges to treatment of CUD. Moreover, treatment centers must evaluate their principles of harm reduction and how these principles are communicated and enforced for patients using cannabis as substitution for another substance, as well as those who attempt to use cannabis at a reduced rate.