Research Paper
Is recovery from cannabis use problems different from alcohol and other drugs? Results from a national probability-based sample of the United States adult population

https://doi.org/10.1016/j.drugpo.2017.12.007Get rights and content

Abstract

Background

The policy landscape regarding the legal status of cannabis (CAN) in the US and globally is changing rapidly. Research on CAN has lagged behind in many areas, none more so than in understanding how individuals suffering from the broad range of cannabis-related problems resolve those problems, and how their characteristics and problem resolution pathways are similar to or different from alcohol [ALC] or other drugs [OTH]. Greater knowledge could inform national policy debates as well as the nature and scope of any additional needed services as CAN population exposure increases.

Method

National, probability-based, cross-sectional sample of the US non-institutionalized adult population was conducted July–August 2016. Sample consisted of those who responded “yes” to the screening question, “Did you used to have a problem with alcohol or drugs but no longer do?” (63.4% response rate from 39,809 screened adults). Final weighted sample (N = 2002) was mostly male (60.0% [1.53%]), aged 25–49 (45.2% [1.63%]), non-Hispanic White (61.4% [1.64%]), employed (47.7% [1.61%]). Analyses compared CAN to ALC and OTH on demographic, clinical, treatment and recovery support services utilization, and quality of life (QOL) indices.

Results

9.1% of the US adult population reported resolving a significant substance problem, and of these, 10.97% were CAN. Compared to ALC (M = 49.79) or OTH (M = 43.80), CAN were significantly younger (M = 39.41, p < 0.01), had the earliest onset of regular use (CAN M = 16.89, ALC M = 19.02, OTH M = 23.29, p < 0.01), and resolved their problem significantly earlier (CAN M = 28.87, ALC M = 37.86, OTH M = 33.06, p < 0.01). Compared to both ALC and OTH, CAN were significantly less likely to report use of inpatient treatment and used substantially less outpatient treatment, overall (p < 0.01), although CAN resolving problems more recently were more likely to have used outpatient treatment (p < 0.01). Lifetime attendance at mutual-help meetings (e.g., AA) was similar, but CAN (M = 1.67) had substantially lower recent attendance compared to ALC (M = 7.70) and OTH (M = 7.65). QOL indices were similar across groups.

Conclusion

Approximately 2.4 million Americans have resolved a significant cannabis problem. Compared to ALC and OTH, the pattern of findings for CAN suggest similarities but also some notable differences in characteristics and problem resolution pathways particularly regarding earlier problem offset and less use of formal and informal services. Within a shifting policy landscape, research is needed to understand how increases in population exposure and potency may affect the nature and magnitude of differences observed in this preliminary study.

Introduction

The recent changes in the policy landscape regarding cannabis in the US and other countries (Ammerman, Ryan, & Adelman, 2015; Bestrashniy and Winters, 2015, Budney and Borodovsky, 2017) introduces new challenges for public health, health care policy, and international drug treaties and conventions. Beginning in the 1970s in the US, the declaration of the war on drugs by the Nixon administration established a broad and largely punitive rhetoric condemning all forms of psychoactive drug use (other than alcohol and nicotine which were already legally available and commercialized). This categorical policy view pertaining to illicit psychoactive substances lasted many decades until special interest groups and public health and criminal justice reform advocates began to suggest that not all illicit psychoactive substances carry the same risk (Weiss, Howlett, & Baler, 2017).

This has been particularly true in the case of cannabis (marijuana). While cannabis use still causes life-impacting problems in 6 million US adults, corresponding with 30% of those who use it (Hasin et al., 2015, Hasin et al., 2016), research has shown its clinical, public health, and public safety profiles are more benign compared to other drugs including alcohol (Lachenmeier & Rehm, 2015; Nutt, King, Saulsbury, & Blakemore, 2007). Together these trends have led to a re-examination of the long-standing uniform prohibition policy pertaining to all psychoactive drugs. Specifically, more nuanced discussions have considered the depth and range of associated health and safety harms resulting from differing policy positions ranging from prohibition to the decriminalization, legalization, and commercialization of different psychoactive substances. This new openness and debate has ultimately promoted policies and legislation relating to decriminalization and medicalization of cannabis use in most states, and legalization for purely recreational use in an increasing number of states (Carliner, Brown, Sarvet, & Hasin, 2017). Interest in the potential therapeutic properties of cannabis in treating pain has heightened also in the midst of the current US opioid overdose crisis. Emerging research, for example, has observed that states with medical cannabis laws have lower levels of opioid overdose deaths (Bachhuber et al, 2014), that appears to imply a causal connection between greater cannabis use and less opioid use. More recent prospective epidemiological data, however, suggest cannabis use leads to increases, and not decreases, in opioid use (Olfson, Wall, Liu, & Blanco, 2017).

Compared to other drugs, such as alcohol or opioids, much less is known about the clinical and public health consequences of cannabis at population levels. Also, while it is known that about 3 in 10 individuals who are using cannabis in the past year also meet criteria for a cannabis use disorder (e.g., continuing to use despite physical and psychological consequences, impaired control over use, tolerance, withdrawal; Hasin et al., 2015), very little is known regarding whether, and how, people who suffer from these disorders or the broader array of cannabis-related problems, resolve those problems. Also generally not known is whether such problem resolution prevalence and processes are similar to or different from those involved in resolving problems related to other substances.

When considering substance-related harms and problem resolution, it is necessary to go beyond purely clinical diagnostic groups (e.g., cannabis use disorder) to examining the broader array of affected individuals because many people who misuse substances actually do not meet diagnostic criteria for an alcohol or other drug (AOD) disorder but can still suffer from significant problems and contribute substantially to the economic and public health burden of disease. For example, more than 66 million Americans report hazardous/harmful alcohol consumption (i.e., consuming 5+ standard drinks within two hours; Surgeon General’s Report, 2016) at least once during the past month, increasing risk of accidents, social problems, violence, and alcohol-poisonings. While only a minority of these individuals meet diagnostic threshold for alcohol use disorder, harmful consumption accounts for three-quarters of the yearly economic burden attributable to alcohol (Centers for Disease Control and Prevention [CDC], 2015). Also, in 2015, almost 13 million individuals reported past year misuse of a pain reliever—increasing risk for a variety of consequences including overdose—but only 2.9 million met diagnostic criteria for a prescription medication disorder from the perspective of the diagnostic and statistical manual of mental disorders, 5th edition (DSM-5; Surgeon General’s Report, 2016). Given the public health and safety burden conferred by this broad population of individuals engaging in various degrees of problem use, understanding more about them and how they resolve such problems is important, regardless of whether or not they meet criteria for an AOD disorder, per se. Furthermore, shifts in national emphasis in public health and health care policy in recent decades emphasize the need to examine an array of substance-related impairment from individuals’ own perspective. There has been a push, for example, to move from “provider-centered” to “patient-centered” care, and more recently to the more holistic, “person-centered” care (National Academies of Sciences, Engineering, and Medicine, 2017). This shift has been particularly true in addiction and mental health, as these problems are typified by heterogeneous and dynamic phenotypic expression that can be resolved through a variety of different bio-psycho-social therapeutic inputs (Papadimitriou, 2017). For the broad array of self-defined alcohol and other drug (AOD) problems, these salutary inputs have been shown to come successfully from the individual sufferers themselves (i.e., unassisted or “natural recovery”) as well as from more formal treatment (i.e., “assisted recovery”), including medications Very little is known, however, about the characteristics of this large heterogeneous population of individuals with self-identified AOD problems (i.e., beyond a clinical diagnosis derived from epidemiological studies that use structured diagnostic interviews), and even less is known about how these individuals resolve and overcome this broad array of AOD problems.

With the likely expansion of cannabis legalization across states, subsequent increased population exposure to cannabis, and related increases in the public health burden attributable to cannabis problems (Cerda, Wall, Keyes, Galea, & Hasin, 2012; Hasin et al., 2015), policy makers will need data on how individuals suffering from a broad array of cannabis-related problems resolve those problems, so that they can make evidence-based decisions when levying cannabis taxes and fiscal appropriation for treatment and other recovery support services. It is conceivable, for example, that because cannabis use does not produce life-threatening withdrawal syndromes (Budney & Hughes, 2006), or is unlikely to produce dramatic behavioral impairments with intoxication that can often result in accidents (Andreuccetti et al., 2017), rates of formal medical detoxification and addiction treatment services utilization among primary cannabis users may be lower compared to individuals with other commonly used primary substances, such as alcohol, opioids, and stimulants. A further area of interest is how individuals who have suffered from problems associated with different drug classes (e.g., cannabis, alcohol, other drugs) function after they have resolved their specific drug-related problems. For example, it is conceivable that substances that may not alter and impact individual users’ lives so dramatically, such as cannabis, may be associated with less psychological distress, and greater quality of life and happiness once the substance-related problems have abated.

To this end, using a national probability based population sample of the non-institutionalized US population, this study: 1. Provides valid estimates of the proportion of US adults who identify as having successfully resolved a significant cannabis problem; 2. Describes and contrasts the demographic, clinical, and treatment and other recovery support service use histories of those resolving a primary cannabis use problem, with those resolving a primary alcohol or other drug use problem; and, 3. Compares those resolving a primary cannabis use problem with those resolving a primary alcohol or other drug use problem on indices of psychological distress, quality of life, happiness, self-esteem, and recovery capital.

Section snippets

Sample and procedure

The National Recovery Survey (NRS; Kelly, Bergman, Hoeppner, Vilsaint, & White, 2017) target population was the US noninstitutionalized civilian population 18 years or older that had resolved an AOD problem, indicated by affirmative response to the screener question: “Did you used to have a problem with drugs or alcohol, but no longer do?”. Data were collected by the survey company GfK, using its “KnowledgePanel” probability sampling. (GfK, 2013). The KnowledgePanel uses address-based sampling

Prevalence of cannabis problem resolution in the US population

A weighted prevalence of 9.1% of the sample responded yes, to the question of whether they “once had a problem with drugs or alcohol but no longer do”; of these we report that 10.97% of these had resolved a cannabis problem (i.e., were in the CAN group), which translates into 2.4 million American adults. Approximately one-half (51.2%) and one-quarter (25.3%) of eligible respondents reported an alcohol (i.e., ALC group) or other drug problem (i.e., OTH group), respectively. Approximately 12% of

Discussion

Using a national probability-based sample of the US non-institutionalized adult population, findings from the current study suggest that of all Americans who report resolving a significant AOD problem (22.35 million), 10.97% report resolving a cannabis problem. Furthermore, compared to both ALC or OTH individuals, CAN individuals, overall, are younger, and also younger when they began regular, weekly, use of their primary substance and when they resolved their drug problem. They also were more

Conclusions

With legal, social, and political changes in the drug policy landscape regarding cannabis use, preliminary information on how individuals resolve a broad array of cannabis problems can inform the national debate and also the potential future need for different types of services that may be required to address problems secondary to increased access and exposure in the general population. This study is the first nationally representative investigation on cannabis problem resolution suggesting

Funding

This study was funded by the Recovery Research Institute at the Massachusetts General Hospital, Boston, MA. MCG is supported by the National Institute on Drug Abuse (T32DA007292).

Conflict of interest

None.

References (52)

  • A.J. Budney et al.

    The potential impact of cannabis legalization on the development of cannabis use disorders

    Preventive Medicine

    (2017)
  • A.J. Budney et al.

    The cannabis withdrawal syndrome

    Current Opinion in Psychiatry

    (2006)
  • CDC National Center for Health Statistics

    National Health and Nutrition Examination Survey: NHANES response rates and CPS totals

    (2013)
  • H. Carliner et al.

    Cannabis use, attitudes, and legal status in the U.S.: A review

    Preventive Medicine

    (2017)
  • Center for Behavioral Health Statistics and Quality

    2015 national survey on drug use and health (NSDUH): Methodological summary and definitions

    (2016)
  • Centers for Disease Control (CDC) et al.

    Excessive alcohol use: At a glance 2016

    (2015)
  • A. Cservenka et al.

    The burden of binge and heavy drinking on the brain: Effects on adolescent and young adult neural structure and function

    Frontiers in Psychology

    (2017)
  • N.S. da Rocha et al.

    The EUROHIS-QOL 8-item index: Comparative psychometric properties to its parent WHOQOL-BREF

    Value in Health

    (2012)
  • M. Dennis et al.

    Global appraisal of individual needs (GAIN): administration guide for the GAIN and related measures

    (2002)
  • GfK

    KnowledgePanel design summary

    (2013)
  • B.F. Grant et al.

    Epidemiology of DSM-5 alcohol use disorder: Results from the national epidemiologic survey on alcohol and related conditions III

    JAMA Psychiatry

    (2015)
  • T. Groshkova et al.

    The Assessment of Recovery Capital: Properties and psychometrics of a measure of addiction recovery strengths

    Drug and Alcohol Review

    (2012)
  • S.A. Gruber et al.

    Marijuana on the mind? The impact of marijuana on cognition, brain structure, and brain function, and related public policy implications

    Policy Insights from the Behavioral and Brain Sciences

    (2017)
  • D.S. Hasin et al.

    Prevalence of marijuana use disorders in the United States between 2001 and 2002 and 2012–2013

    JAMA Psychiatry

    (2015)
  • D.S. Hasin et al.

    Prevalence and correlates of DSM-5 cannabis use disorder, 2012–2013: Findings from the national epidemiologic survey on alcohol and related conditions-III

    American Journal of Psychiatry

    (2016)
  • Cited by (10)

    • Systematic review of untreated remission from alcohol problems: Estimation lies in the eye of the beholder

      2019, Journal of Substance Abuse Treatment
      Citation Excerpt :

      Of the 27 studies, 24 (89%) were conducted in North America, and almost half (n = 12) were longitudinal. In terms of sampling, most studies (n = 20, 74%) used convenience sampling, with one study using probability-based sampling (Kelly, Greene, & Bergman, 2018), and other studies using population-based representative data from the US (Dawson, 1996; Dawson et al., 2005; Dawson, Grant, Stinson, & Chou, 2006), Canada (Sobell et al., 1996), Germany (Bischof, Rumpf, Meyer, Hapke, & John, 2005), and Netherlands (Tuithof, ten Have, van den Brink, Vollebergh, & de Graaf, 2016). This review identified 124 estimates of untreated remission from alcohol problems, which were taken from the 27 studies.

    • Smoking cessation in the context of recovery from drug and alcohol problems: Prevalence, predictors, and cohort effects in a national U.S. sample

      2019, Drug and Alcohol Dependence
      Citation Excerpt :

      Greater knowledge would improve understanding of dynamic changes in the natural history of smoking cessation in this vulnerable population and inform the nature and timing of smoking intervention efforts and policy initiatives. To this end, using a nationally representative sample of US adults who have successfully resolved a significant AOD problem (Kelly et al., 2017, 2018a, 2018b), this study: 1. estimates the prevalence of never, former, and current smoking, and if quit, when specifically in relation to their AOD problem resolution, smoking cessation occurred; 2.

    • Expanding the reach of alcohol and other drug services: Prevalence and correlates of US adult engagement with online technology to address substance problems

      2018, Addictive Behaviors
      Citation Excerpt :

      These data would inform both the baseline reach of ROOT - absent major policies to aid dissemination - and a scientific agenda for future research in the area. This current study leveraged a geo-demographically representative sample of US adults who resolved a substance use problem (from the National Recovery Study, or NRS; Kelly, Bergman, Hoeppner, Vilsaint, & White, 2017; Kelly, Greene, & Bergman, 2017; Kelly, Greene, & Bergman, 2018) to conduct the first nationwide investigation of ROOT. This analysis of ROOT in the NRS had the following specific aims:

    View all citing articles on Scopus
    View full text