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We Talked to a Doctor Who Treats ‘Cannabis Use Disorder’

You apparently can have too much of a good thing. Photo via Flickr user Katheirne Hitt

This post originally appeared on VICE Canada.

With the exception of a few sober stints, Jeffrey has been waking and baking every day for the last six years.

The 24-year-old script supervisor, who grew up in a small town outside of Seattle, told VICE he started smoking weed when he was 18, introduced to it by a friend at a campfire.

Within six months, he said he was going through a couple grams a day.

“For me it felt like about as classical of an addiction as you could get. It really kind of changed and took over everything. Every morning I woke up and it was the first thing you thought about.”

Marijuana is the most popular “illicit” drug in the world. With legalization set to take place in Canada next year, Dr. Jonathan Bertram, an addictions physician at Toronto’s Centre for Addiction and Mental Health, told VICE the “law of averages” means more and more people are likely to run into it at some point in their lives. Advocates point out that it is far less harmful than legal substances like tobacco and alcohol. But, according to Bertram, that doesn’t mean it’s immune to being abused.

While the idea of being addicted to marijuana is highly contentious—many people believe it’s impossible—doctors actually have a term for weed dependency: cannabis use disorder. The diagnosis itself is only three years old—it was first referenced in the 2013 version of the Diagnostic and Statistical Manual of Mental Disorders. The US-based National Institute on Drug Abuse says 9 percent of marijuana users will abuse it.

According to Bertram, many of his patients say they started using cannabis either for recreational reasons or because it helped them with a physical condition—like insomnia—but that over time the benefit they received from cannabis began to diminish and in some cases the habit started having a negative impact on their lives.

“Their use ends up dominating a big part of their lifestyle and their day. Because of their use they can’t carry out things they normally would,” he said, including attending school, work, and completing homework or tasks. Teenagers are more susceptible to developing a problem.

“They have a lot of trouble keeping up with their relationships except for the ones that revolve around cannabis use.”

Related: Watch VICE’s documentary ‘Canada’s War on Weed’

Jeffrey said his chronic use led him to feel more depressed and emotional.

“I was just much more self critical. I had all these feelings of insecurity and they were very much heightened.”

He also said he stayed indoors alone more, stopped hanging out with friends who didn’t also smoke, and stopped caring about his diet or his interest as a musician. Three years ago, he posted a thread on Reddit titled “How heavy-marijuana smoking ruined my life,” where he described “scouring the disgusting carpet for weed crumbs, sneaking nugglets from my friends when they weren’t looking, lying to my parents about needing more money, and having panic-attacks when I couldn’t find weed.”

Bertram told VICE he sees patients who use weed to ease their anxiety; it works at first, but eventually, as they build up a tolerance and consume more and more to achieve the same effect, some experience “rebound anxiety” where their symptoms actually worsen due to the marijuana. While it’s rarer, he said people also have physical withdrawal symptoms stemming from marijuana dependence, including breaking into sweats and vomiting.

The primary treatment, he said, is cognitive behavior therapy—a form of psychotherapy that helps people develop specific techniques to deal with their everyday thoughts and problems. A secondary option is a drug called nabilone, which mimics the therapeutic effects of the cannabidiol (cbd) in cannabis but not the psychoactive one.

But Bertram said there’s far less evidence of the effectiveness of such treatments than there is for treatment for addictions to other substances, i.e. methadone for opioid addiction.

When Jeffrey felt his weed addiction was out of control, he reached out to his family for help. He said his parents took turns living with him for a couple weeks at a time.

“I would get anxiety, but I’m with my mom so I couldn’t smoke. So I had to just deal with that and talk through it.”

He went cold turkey for a month and a half. But, more than three years later, he said he’s still blazing every day.

“(Before) it was a lot more ‘I need to normalize my emotions, I need to mask this pain.’ Now I do it much more like ‘Hey, let’s throw on a trippy movie.’ I’m kinda more just having fun with it.”

Bertram said it is possible to treat people with cannabis use disorder by having them smoke up more moderately—but only if their reasoning, impulsivity, and ability to manage emotions haven’t been impacted by using the drug.

Overall, he said he sees far fewer patients with cannabis use disorder than those dealing with other addictions, like alcohol and opioids. But he said more research on cannabis dependency is needed.

“It definitely has to be studied more because people are using it and people have all kinds of different opinions on it,” he said.

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The National Institute on Drug Abuse says 9 percent of marijuana users will abuse it.

Supportive social networking on Reddit for individuals with a desire to quit cannabis use

Shaina J. Sowles

a Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA.

Melissa J. Krauss

a Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA.

Lewam Gebremedhn

a Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA.

Patricia A. Cavazos-Rehg

a Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA.

Abstract

Background:

Online communities can provide social support to those in need and can foster personal empowerment for individuals experiencing distress. This study examines the content of a Reddit community dedicated to the support of people trying to quit using cannabis, in order to develop an understanding of the type of social networking occurring on this subreddit (e.g. community).

Methods:

A total of 100 Reddit posts and their replies (i.e. comments) were collected from the subreddit on June 12, 2015. Posts were qualitatively coded for expression of DSM-5 symptoms of cannabis use disorder (CUD) as well as other prominently featured themes. Comments on posts where individuals were seeking support/advice were also coded.

Results:

91 people posted the 100 Reddit posts, and of those 35 (38%) people described enough symptoms to be classified as mild disorder severity, 15 (16%) moderate and 11 (12%) severe, as outlined in the diagnostic criteria for CUD. Over half of posts (n=51) were seeking advice and/or support from members of the community. There were 174 comments made by 108 unique people on the advice/support seeking posts. Most were supportive/encouraging in nature (140, 80%) and gave advice to the post author (126, 72%).

Conclusions:

This exploratory research highlights the potential of online communities as tools for individuals coping with addiction recovery, and future research should investigate if involvement in such communities would be a beneficial supplement to more traditional recovery practices.

INTRODUCTION

Reddit is a popular content-sharing social networking site (www.reddit.com/about/) with roughly 7% of U.S. adults using this platform. 1 Reddit has over 200 million unique visitors every month with around four million users logging in every day, 2,3 and the user base consists largely of young (18–29; 58%) males (69%). 1 Reddit is organized into many different subreddits (i.e. communities) where people can post and comment on others’ content.

In a recent commentary, Reddit was praised for multiple subreddits that “help people get sober and stay sober”. 4 Accordingly, in this study we examine one large subreddit (nearly 25,000 subscribers) that exists as a space for discussions surrounding cannabis cessation and sobriety from other like-minded individuals. In order to respect the anonymity of the group members, throughout this report the community will be referred to as QuitCannabis.

Online communities can provide social support and can foster personal empowerment for individuals experiencing distress. 5,6 Such mechanisms are important for helping individuals avoid and cope with relapse-inducing situations as indicated by the Relapse Prevention Model (RPM). 7 In this study, we examined the content of QuitCannabis posts to develop an understanding of the type of social networking occurring on this subreddit. Specifically, we looked for the mention of symptoms of cannabis use disorder (CUD) as outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to identify the CUD symptoms expressed by individuals using this subreddit for its intended reason, “to help people stop smoking [cannabis]”. In keeping with the RPM, we investigated if the responses (i.e. comments) to posts provide specific strategies for coping with the possibility of relaspe. 7 In doing this, we aim to inform the potential value of using online support groups, like QuitCannabis, to support the CUD recovery process.

METHODS

This study was granted a non-human subjects determination by the University’s Human Research Protection Office. All Reddit posts in this study are publicly available. However, given the ethical concerns of social media research, 8 no usernames of the post authors are reported. Similar precautions have been observed in other social media studies. 9–11 Data collection

Reddit organizes user-generated content (i.e. posts) using various filter tabs. Posts appearing under the “hot” tab are determined by an algorithm that considers the time the entry was posted as well as the number of up and down votes the post receives. 12 This tab captures posts that are rapidly gaining popularity (i.e. recent and more upvotes) on the site. Depending on the user’s settings, the first page in a subreddit can display up to 100 posts. Therefore, we collected the first 100 “hot” posts and all accompanying comments from QuitCannabis on June 12, 2015 using NCapture, an online extension of NVivo 10 qualitative analytic software. NCapture takes a screenshot of web-based content and generates a PDF for coding in NVivo. The post author’s username, number of post comments, and comment author usernames were recorded

Theme development

Reddit Posts.

Two research team members examined half of the 100 post sample to inductively develop codes based on reoccurring themes within the data. Recurring themes of interest and/or fitting with the RPM are described below. Individuals tended to self-report symptoms consistent with CUD. The DSM-5 criteria for CUD are: 1) consuming cannabis in large amounts; 2) persistent desire or unsuccessful attempts to cut down/control use; 3) spends lots of time trying to obtain or use cannabis; 4) experiencing cravings or strong desire to use; 5) trouble fulfilling major obligations (work, school, home); 6) use causes/makes worse social or interpersonal problems; 7) gives up or reduces important activities; 8) uses in situations that are physically hazardous; 9) has a physical and/or psychological problem from cannabis use; 10) increased tolerance; 11) experiencing symptoms of withdrawal. 13

All 100 posts were coded for the expression of these symptoms. For each unique post author (91 Reddit users posted the 100 posts), the DSM-5 criteria were tabulated based on their posts and each user was assigned a DSM-5 disorder severity level of mild (2–3 criteria), moderate (4–5 criteria) or severe (>6 criteria). 13 Most posts did not specify how long they had been experiencing a symptom; therefore some CUD symptomology language was altered in the codebook to remove the “time” criteria.

We coded when QuitCannabis was mentioned as a good/motivating/encouraging resource or when considered a useful relapse prevention tool. Environmental/social barriers to quitting were coded, which the RPM signifies as high-risk situations for relapse. Posts that discussed tactics for quitting, including cognitive reframing to deal with triggers and changes to lifestyle (i.e. exercise more, meditate) were coded, which are consistent with the RPM’s framework to prevent relapse. 7 . Additionally, we coded when individuals sought advice/support on QuitCannabis, experienced/looked forward to positive results from quitting, and/or mentioned using cannabis to self-medicate from a physical or psychological problem. Multiple themes could appear in a single post.

Clinical characteristics were also recorded including duration of sobriety from cannabis, duration of use, frequency of use, and age of first use.

Post comments.

The number of comments was recorded for each post at the time of data collection. In posts where individuals were seeking advice and/or support, the comments replying directly to the original post were also coded to ascertain the nature of the responses. From the comments, we captured the comment author’s username (i.e. commenter) and any indication if/how long the commenter was sober from cannabis use. The sentiment of the post was identified as being supportive/encouraging/positive, negative, or neutral/unable to discern. Separately, it was recorded if the commenter provided advice to the post author. Types of advice were coded based on intervention strategies outlined in the RPM: 1) Cognitive reframing procedures (i.e. advice that recommended alternate cognitions for mentally processing/coping with recovery process) and/or 2) Lifestyle intervention strategies (i.e. advice that recommended engaging in a specific activity as a coping mechanism). It was also noted if the advice was given in response to coping with a high-risk situation, 7 and if there was a specific suggestion to counseling or a 12 step program. Comments that gave advice that could be detrimental to maintaining sobriety were also coded.

Coding

Posts.

Each of the 100 posts was coded by three team members. Posts were divided into five sets of 20. Each set was first coded separately by each of the three coders, and then discrepancies were discussed until a consensus was reached. Discussing discrepancies within the group allowed coders an opportunity to reflect on how their own personal impressions of the data impacted their code selection. The agreed upon codes then reflect a more objective interpretation of the material. 14 These agreed upon codes were then entered into NVivo for tabulation of themes.

Comments.

Responses/comments to posts where individuals were seeking advice and/or support were classified by two members of the research team for presence of the themes outlined above. Comments were first coded separately by each coder and any discrepancies were addressed before coming to a final agreement.

Statistical analysis.

The indicators of CUD and advice giving were compared by cannabis use status (used within the past 30 days versus did not use within the past 30 days) of the post author or commenter using Pearson chi-square tests or Fisher’s exact tests as appropriate. SAS version 9.4 for Windows (SAS Institute, Inc., Cary, NC) was used for these analyses.

RESULTS

Characteristics of the Reddit posters in QuitCannabis

The 100 posts were posted by 91 unique usernames (i.e. post authors), with a median number of four comments per post (range 0–33). Post authors commonly mentioned duration of sobriety (51/91, 56%). The majority (36/51, 71%) indicated being sober for less than one month, and of those, most were sober for less than one week (29/36, 81%). Only six people had been sober for over one year (6/51, 12%).

Of those that mentioned duration of use (38/91, 42%), 39% specified using between 1–5 years (15/38), and 29% between 6–10 years (11/38). Eight posts expressed cannabis use for longer than 10 years (21%), and four for less than one year (11%). Only 17 posts revealed age of cannabis initiation (M=16 years, SD=2.5 years).

DSM-5 cannabis use disorder criteria

Of the 91 unique post authors, 35 (38%) people described enough symptoms to be classified as mild disorder severity, 15 (16%) moderate and 11 (12%) severe, as outlined in the diagnostic criteria for CUD. 13 The remaining 30 (33%) people expressed less than two symptoms, and therefore were not classified into a severity category. It is possible that these individuals could meet the criteria for CUD, however because they did not express those symptoms in the post, their CUD status remains unknown. A greater proportion of post authors who were current users (i.e. sober less than 30 days) displayed enough symptoms to reach at least mild CUD (28/37, 76%) than non-users (6/17, 35%) (χ 2 df=1=8.1, p=0.004).

Of the DSM-5 criteria mentioned, having a physical and/or psychological problem from cannabis use was expressed most often (42/91 people, 46%), followed by expressions of persistent desires or unsuccessful attempts to cut down/control cannabis use (40/91 people, 44%). Other common symptoms described included withdrawal symptoms (33/91 people, 36%), cravings (29/91 people, 32%), cannabis consumed in large amounts (24/91 people, 26%), social or interpersonal problems caused or worsened by cannabis use (21/91 people, 23%), giving up or reducing social/occupational/recreational activities (18/91 people, 20%), and spending lots of time trying to get or use cannabis (18/91 people, 20%) ( Table 1 ).

Table 1.

Frequently observed DSM-5 cannabis use disorder criteria among QuitCannabis post authors (N = 91)

DSM-5 diagnostic criteria # of posts Examples
Physical and/or psychological problem from cannabis use 42 • I feel that I’ve not only lost a lot of who I was, but that I’ve also lost control of my own mind.
• I feel as though my sleep quality has been very poor because of smoking. I feel exhausted all the time.
• After smoking I experienced psychosis, depression, anxiety, I just felt like shit. I was slurring my words, talking too fast, saying weird things, it just wasnt fun.
Persistent desire or unsuccessful attempts to cut down/control use 40 • I’ve relapsed recently, probably 3 days ago. I was trying to ween myself off of my antidepressants and it was proving difficult. So naturally I smoked, because it’s not like I know how to do anything else.
• I’m here because I am addicted. I need help. I’ve tried quitting on my own and I can’t do it.
Withdrawal symptoms 33 • If I don’t smoke I am very irritable, my head aches, I cannot sleep, and I cannot eat.
• When I don’t smoke for a few hours, I feel my temper start to rise and I get a tension headache and chest tightness and get angry at stupid things.
Cravings or strong desire to use 29 • It seems like I am constantly thinking about getting high, and this day has dragggggged on for what seems like forever.
• It is now 9am and i’m struggling to not just text my dealer and go get high in the sun.
Consuming cannabis in large amounts 24 • I used to smoke pot all [day] everyday, my life sort of revolved around it. I would wake up and go smoke and go home to sleep, then repeat.
• I was 16 years old and I was smoking once a day. Then twice. Then four times. I would never come down. I was always happy.
Cannabis use causes/makes worse social or interpersonal problems 21 • My girlfriend will break up with me and she is the only thing I really care about. I’m fucking terrified.
• i’ve stolen, lied, and swore my allegiance to this plant.
Gives up or reduces important social, occupational or recreational activities 18 • Marijuana makes me complacent with just sitting and doing nothing. Sitting and being lonely. Sitting and avoiding my hobbies. Sitting and watching TV.
• Weed made me more reclusive and over time it’s replaced huge portions of my life – mainly my social life and all interests and activities I used to enjoy.
Spending lots of time trying to get or use cannabis 18 • stoned was the only way i knew how to navigate the world.
• all I remember doing this past year has been chasing a high anywhere and everywhere I could.

Other less frequently observed DSM-5 categories include not fulfilling major obligations (11/91 people, 12%), using cannabis in physically hazardous situations (3/91 people, 3%), and tolerance issues (2/91 people, 2%).

Other Popular Themes

Of the 100 posts, over half (n=51) were seeking advice and/or support from members of the QuitCannabis community. The post author mentioned experiencing/looking forward to positive results from quitting in 43 posts. QuitCannabis was mentioned as a good resource or the author was supporting/motivating others in 42 posts. Other common themes included mentioning environmental or social barriers that facilitate use (37/100 posts, 37%), discussing tactics for quitting cannabis (34/100 posts, 34%), and using cannabis to self-medicate from physical or psychological problems (20/100 posts, 20%) ( Table 2 ).

Table 2.

Additional themes observed in QuitCannabis posts (N = 100)

Theme # of posts Examples
User is seeking advice and/or support from the QuitCannabis community 51 • What should I expect in withdrawals these next few days?
• I’m just hoping someone can reassure me that things aren’t to bad and they do get better?
• Is there any things I can do to make the transition of smoking often to never a little easier?
User is experiencing/looking forward to positive results from quitting 43 • I’m cautiously optimistic and pretty happy…The mental haze has begun to dissolve
• I’ve been spending a lot more time with friends and doing hobbies I enjoy. Without pot, I have so much more free time.
• I’m an entirely different person now. I have the concentration to do everything and my lack [of] memory is no longer freaking me out.
QuitCannabis is a good resource; author is supporting/motivating others 42 • If you’re reading this and having a tough time too, know that you’re not alone. Call me corny, but posting on here is something that is helping me to reach my ‘checkpoints,’
• Thanks to everyone here, you’ve been my sole source of support, and I can’t imagine doing it without this group. Keep up the good work and fighting the good fight.
Environmental or social barriers that facilitate use 37 • My mum and her friend who lives with us smoke, all of my friends smoke. and they don’t think cannabis can be addictive.
• …if not for rap music I might never have gotten into this stuff in the first place.
• I’m quitting, but my girlfriend who I live with isn’t, how can I avoid relapse at this time?
Tactics for quitting cannabis 34 • My best friend dropped by and I gave him all my smoking stuff (grinder, papers etc).
• My goal is to quit cold turkey… I plan on replacing smoking with fitness.
• I know this isn’t going to be easy, as I’ve already made steps in the right direction by signing myself up for addictions counseling.
Uses cannabis to self-medicate a physical or psychological problem 20 • I’ve used cannabis for the past months or so to help with some depression and anxiety I’ve also been dealing with lately.
• I have stomach problems and I used Marijuana to help cope with it, it just made me feel so much better.

Comments on advice/support seeking posts

A more in depth analysis was conducted on the 51 posts where the user was seeking advice or support. There were 177 comments directly replying to these 51 posts. Three comments were authored by the same person who wrote the original post and were removed from further analysis, leaving 174 comments made by 108 unique people. Half of these individuals did not disclose their length of sobriety from cannabis within the comments (54/108, 50%), however 31% (n=34/108) indicated they had been sober for less than 30 days (i.e. current users) and only 13% (n=14/108) had been sober for more than 30 days (i.e. non-users). Six people mentioned they were in recovery (i.e. a successful quitter, no longer uses cannabis), but did not mention a specific time frame.

The overwhelming majority of the 174 comments were supportive/encouraging in nature (140, 80%). There was only one negative comment, and the remaining were neutral or sentiment could not be discerned (33/174, 19%). Roughly 72% (n=126) of comments gave advice to the post author. Of those, 42% (n=53/126) suggested some form of lifestyle intervention, 17% (n=21/126) presented a strategy for cognitive reframing, and 20% (n=25/126) suggested both a lifestyle intervention and a strategy for cognitive reframing (see Figure 1 for examples). Advice on how to cope with a high-risk situation was observed in 24 (19%) comments, and 9% (n=11/126) specifically suggested counseling or a 12 step program. The advice presented in the remaining comments was not specific enough to be classified. Advice that could be potentially damaging or threaten an individual’s recovery was only observed in 3 (2%) comments. Further comparisons revealed that among commenters, a greater proportion of those who were non-users provided advice (19/20, 95%) compared to those who were current users (23/34, 68%) (Fisher’s exact test p=0.022).

QuitCannabis advice-seeking posts with accompanying comments demonstrating types of advice provided

DISCUSSION

We found that the QuitCannabis subreddit is an accessible online platform for users seeking support and encouragement from other like-minded individuals. Most responses to posts in QuitCannabis were supportive and provided advice. The individuals on QuitCannabis who provided details on their length of sobriety were often in the early stages of quitting (i.e. sober less than 30 days), which contrasts with some in-person support groups like Alcoholics Anonymous where a successful non-user/quitter (i.e. sponsor) provides support and guidance to a recent quitter. There could be a cause for concern if the interactions on this site were not supportive or were providing coping strategies that could be detrimental to a successful recovery. However in our analysis of the advice provided on QuitCannabis, only three of the 126 comments provided concerning advice (i.e. “give [the cannabis pipe] to a stoner friend who will give it back no big deal if you want it again”), while the remaining comments were sound advice on how to mentally and physically cope with the struggles associated with quitting cannabis use. The lack of advice referring QuitCannabis users to seek out treatment is noteworthy, but not surprising when considering that cannabis users often quit without treatment and tend to express that treatment is not necessary to quit. 15,16 Considering individuals early in the recovery process are particularly vulnerable to relapse, 17 QuitCannabis appears to offer individuals quitting cannabis use with a space for self-expression, social support, anonymity, and can foster a sense of community, 18–20 which are important factors to potentially decreasing relapse risk. 21 Our findings also highlighted QuitCannabis users’ perceived environmental/social barriers to quitting. As these barriers potentially signal high-risk situations for relapse, 7 clinicians in training could use QuitCannabis as a tool for better understanding barriers to quitting and/or could allow practitioners to keep up with the contemporary issues related to cannabis (for example: latest jargon utilized by their clients).

Our study has limitations in that we only examined the content of 100 QuitCannabis posts appearing under the Reddit “hot” tab. As with all social networking sites, Reddit is a constantly evolving platform, and so the posts under this tab may vary from day to day. Collecting more posts from all tabs over multiple days may have provided a more holistic snapshot of the posts within this subreddit, and this larger sample size could have impacted our results. Additionally, severity estimates of CUD should be viewed as only suggestive, as the Reddit posts may have omitted one or more symptom criteria and we also have no way of identifying the individuals posting on this subreddit.

Despite popular opinion that cannabis is not addictive, 22,23 QuitCannabis demonstrates the self-reported struggles associated with quitting cannabis use. This exploratory research highlights the potential of online communities such as QuitCannabis as tools for individuals coping with addiction and choosing recovery, and future research should investigate if involvement in such communities would be a beneficial supplement to more traditional recovery practices.

ACKNOWLEDGEMENTS

The authors would like to acknowledge Washington University School of Medicine research assistant, Nina Kaiser for her assistance coding the Reddit posts.

This publication was supported by the Washington University in St. Louis Young Scientist Program, the Washington University Institute of Clinical and Translational Sciences grant UL1 TR000448 from the National Center for Advancing Translational Sciences (NCATS) of the National Institutes of Health (NIH), as well as the National Institutes of Health [grant numbers R01DA032843 (PCR), R01DA039455 (PCR)]. None of the funding sources had any role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication.

Footnotes

The authors declare that they have no conflicts of interest.

Ms. Sowles led the acquisition of the data, analyses, interpretation of results and manuscript writing. Ms. Krauss contributed to interpretation of results and critical revisions to the manuscript. Ms. Gebremedhn participated in the acquisition of the data, coding of Reddit posts and drafting the manuscript. Dr. Cavazos-Rehg provided mentoring on all aspects of the project, including the study design, acquisition of the data, analyses, interpretation of results, and revisions to the manuscript.

Supportive social networking on Reddit for individuals with a desire to quit cannabis use Shaina J. Sowles a Department of Psychiatry, Washington University School of Medicine, St. Louis,