What Is Cannabis Use Disorder? with Jared Harp, DO

Podcast Transcript

John Horton:

Hello, and welcome to another Health Essentials Podcast. I'm John Horton, your host.

By many accounts, marijuana use for adults appears to be reaching historic highs, no pun intended. Not surprisingly, this trend has also led to an uptick in folks dealing with cannabis use disorder, or CUD. It's estimated that about 1 in 17 people have shown signs of this mental health condition within the past year. Today, we're going to take a closer look at CUD with the help of addiction psychiatrist Jared Harp. He's among the many experts at Cleveland Clinic who pop into our weekly podcast to guide us toward healthier living. So with that, let's explore why cannabis use disorder is a growing concern and, more importantly, how it can be addressed.

Welcome to the podcast, Dr. Harp. We are happy to get some time with you today.

Dr. Jared Harp:

Thanks so much, John. I'm really happy to be here and talk about this important topic.

John Horton:

Well, it is an important topic. And I know by every metric I could find, there's just no question that cannabis use disorder is becoming more of an issue in our society. What's driving this surge in problematic marijuana use?

Dr. Jared Harp:

Yeah, you couldn't be more right, John. It's something that we're seeing certainly. And like most things in life, it's multi-factorial.

John Horton:

Yeah.

Dr. Jared Harp:

It's really been a perfect storm of increased access, increased potency of some of the products, commercialization of the products and, really, a general sense of normalization of use and a decreased perception of risk.

John Horton:

Well, it does always seems like there is never just one reason, and I think we're going to get into all those things you just talked about a little bit more as we move on.

But just in talking about cannabis use disorder, where's the line for defining whether somebody has this disorder or whether they're just using marijuana in, I guess, a responsible way as a wellness approach or just a chill pastime?

Dr. Jared Harp:

Yeah. So the line often comes when you start to appreciate that there's a loss of control of your use, that there's consequences of your use, and that despite all of those things, you can't stop. That's often where the line starts.

John Horton:

I don't have familiarity with that. I know I enjoy a beer, as people who listen to this podcast will know because it comes up enough. But I know we all know with that, you have one, maybe it's not an issue. But it's when you start … you're having a six-pack a night, you run into a problem. Is that kind of the same thing that you see with cannabis? Is it just how much you're taking in, how often you're hitting those tokes?

Dr. Jared Harp:

Well, I think there can be a component of that. When you look at someone who's having a struggle with substance use in general, be it alcohol, be it cannabis, it's often not as much related to necessarily why they're using it or even how much at times; it's really about how much are they able to control, how much they're having and the relationship that they have with the product.

So while it's true that many people do, say, have a beer every day, or many people do smoke marijuana every day, that doesn't necessarily mean that there's a use disorder or a problematic use of those products. It does increase your risk, I would say. Certainly, if you're using more often or using higher amounts, you're more at risk of having problematic use, but that's not really the core of the addiction.

John Horton:

It sounds like it's whether you feel like you need it to get through the day and function.

Dr. Jared Harp:

I think that's true. In a lot of ways, it breaks down into what's commonly referred to in addiction as “The Four Cs.” We've touched on them a little bit.

Cravings is one of them, which is what you're describing to some extent there. A desire or urge to use.

Compulsive use, where you're using even when you don't necessarily want to.

A loss of Control, where you're using way more or for longer time periods than you intended to.

And then, Continued use despite consequences.

I think those are really the components that we're looking for when we're saying is this an addiction, or is this just somebody who is using something regularly?

John Horton:

Now, when you start getting to that point, when you're hitting some of those Four Cs that you just laid out, what are some of the signs, then, that follow, that you see in your everyday life that show that this is becoming problematic?

Dr. Jared Harp:

Yeah, absolutely. A lot of times, it looks like, for marijuana, say, you go to the dispensary and you buy a product and you say, "This is going to last me a week." And then, it's gone in two days, and you're back at the dispensary. It's, "Hey, I got a big job coming up. I can't wait to start, this is the perfect job. I've been looking forward to this job, this is exactly what I want. I know they're a no-drug tolerance policy workplace, I know they're going to do a urine drug screening when I start, but I am really having trouble abstaining from use before I have to-"

John Horton:

…you can't walk away from it for even a little bit.

Dr. Jared Harp:

…exactly. And those are all just signs that you have goals in your life and that you're working toward, and marijuana, or other substances for that matter, are interfering in that and really taking control and hijacking your life in a way that you don't want.

John Horton:

Yeah. It seems like it becomes the top priority for you above just everything else.

Dr. Jared Harp:

That's the truth of it. As you develop more of a problem with any substance, your life becomes very substance-specific. Cannabis seems to be the center of your universe. Whereas before, it could have been a variety of things, a number of things. That's never a good place to be. It's not where people want to be.

John Horton:

No, no.

Now, how do you see this manifest in other ways? I'd imagine you see physical effects, your mental well-being, social relationships. Are these all things that will start showing signs of strain if you start developing cannabis use disorder?

Dr. Jared Harp:

Yes, they certainly will. You'll notice some of the behavioral changes, like we were just talking about with the loss of control and things along that line. But there are physical consequences as well. The ones that people most generally notice are a little bit of a brain fog or mental fogginess, maybe some impairment to their concentration. And, therefore, memory as well, because when you can't concentrate and focus on things, you're not really encoding memories very well.

John Horton:

That makes sense, yeah.

Dr. Jared Harp:

Yeah. And paradoxically, sometimes worsened anxiety, worsened sleep, which are things that people often use marijuana for. With long-term heavy use, those things can worsen, especially when you're not using the product anymore.

John Horton:

Yeah, that's kind of ironic. You're doing it to try to relax, to get to bed, and then, yet, somehow, it's going to affect your sleep, and then it just seems like it turns into a vicious cycle.

Dr. Jared Harp:

That's one of the cruelties of addiction in general, is that many times, people are using substances for a variety of reasons. Sometimes, it is truly just because they enjoy the substance, that is true. That's a subset of people. But many times, it's to treat a very specific thing, whether it's pain, insomnia, anxiety. And oftentimes, substances do work in the short term, but long term, it just makes them worse. You become more reliant on the substance and, exactly as you said, it's a vicious cycle.

John Horton:

Yeah. And when you start trying to use that substance, like you said, to fill a hole that you feel like is in your life, it sounds like that's that slippery slope you get on where you start getting toward that addiction or that use disorder.

Dr. Jared Harp:

Exactly. And that's the signs that make you raise your eyebrow that maybe this is something that needs further exploration and ideally, some help.

John Horton:

With relationships and everything, do you see people actually just start cutting people out and start almost closing doors on their friends and family, and things like that?

Dr. Jared Harp:

Yeah. It's kind of like we had talked about earlier, your world can get really, really small when you're suffering with an addiction, and cannabis is no exception to that. It may start with maybe a family member has a child, a young child, and they don't want you smoking around them. So you're like, "OK, I can't smoke there, maybe I won't go there."

John Horton:

Yeah.

Dr. Jared Harp:

Then, all of a sudden, that whole component of your family is starting to drift away. And friends, social situations. It can go from there.

John Horton:

Yeah. How quickly do you see these sorts of things happen? Is this over a long term that we're talking about, or can it just happen like that?

Dr. Jared Harp:

I think for some substances, it can happen very quickly. For cannabis, it seems to be more of a longer term. And that's one of the things that can be kind of insidious and subtle about it and can lead to people not realizing how problematic their addiction is potentially. Because it is so slow happening, one thing happens, several months later, another thing happens, and before you know it, you end up in a spot that you hardly recognize, but you don't even know how you got there, and it was just one little step at a time.

John Horton:

It sounds like that classic, that example everyone uses with the boiling water and the frog, where it keeps getting a little worse, a little worse, a little worse, and you just don't realize it, I guess, in real-time as it's taking place.

Dr. Jared Harp:

It's a perfect analogy. It really is the truth of it. With some substances of abuse, there can be some very obvious and hard and heavy consequences that are so obvious and very hard to ignore. Sometimes, cannabis use can be a little bit more subtle in its challenges.

John Horton:

Where does synthetic cannabis fit into the picture? I know sometimes, it's marketed as a safe alternative to marijuana. I'm guessing that might be a little marketing magic going on there.

Dr. Jared Harp:

I think you're onto something. I wish it was a safer alternative. Unfortunately, it's quite the opposite really. These are not very well-regulated products. These are products that, although they interact in similar receptor systems of the body as cannabis, they do so in unpredictable and sometimes quite potent ways, and there can be some very dangerous adverse consequences from their use.

John Horton:

Do you ever see people thinking that if they just switch over to the synthetic version, that somehow, it's going to be better, and they just are drawn that way?

Dr. Jared Harp:

Yeah, I have seen that. I think that, more often, I see that people switch to other cannabis products, thinking that they're going to be safer. Maybe they switched to vaping, vaping products for THC delivery instead of smoking the leaf product. Or maybe they switched to edible products. There's so many different products available, which is one of the things we touched on in the beginning of the conversation. That there's a high commercialization and a lot of marketing of different products that are quite appealing that can make this more of a challenge for people. But sometimes, people switch to those other forms with the thought that they could be safer.

John Horton:

Yeah, that's a really interesting point because I think everyone thinks just cannabis use, you're just thinking smoking and that's it. But it does sound like you can really veer off into all these other areas with, like you said, the edibles and the vaping, and all that. And I think it all contributes to that same addiction, that use disorder that we're talking about that puts you into that bad spot.

Dr. Jared Harp:

100%. Although it is true that there might be some of those products that are slightly safer. I think in general, when you're not using a combustible version of a product, you're exposing your lungs to a little bit less harmful damage that could be collateral damage from use. But you're still engaging the same addictive pathways in your brain. You're still engaging the same systems that can lead to problems.

John Horton:

Yeah, you're using it to fill that same hole. Whatever it is that you're trying to fill, somehow, marijuana, the cannabis, is what you're using to fill that gap.

Dr. Jared Harp:

Indeed. Yeah, I think that's exactly right.

John Horton:

So if you've fallen under the cannabis spell one way or the other, what kind of treatment approaches are available to address the addiction?

Dr. Jared Harp:

Yeah. I think that's one of the nice bright spots and the good news in the conversation is that-

John Horton:

…we like good news.

Dr. Jared Harp:

…there are treatment options available. They're effective, people get better. To me, the conversation always starts with partnering with the patient and talking about what is it that you're getting from the marijuana use. What are you looking to solve with the marijuana use? You've referenced several times in the conversation what kind of hole are we trying to fill with the marijuana use. Once you can identify that, then you can look at alternative approaches to try to solve some of those things, be it anxiety, insomnia, any number of things, and that's often where it starts.

John Horton:

I get the sense, too, with marijuana, there's a definite chemical reaction that's happening in your body. So if you're going to get off of it, is this the sort of thing where you go through withdrawal symptoms and things like that?

Dr. Jared Harp:

You can, you can certainly. And I think that's really one of the myths and underappreciated facts of cannabis use. When you're using regularly, when you're using heavily, you can absolutely experience withdrawal symptoms. And often, it's the same things that you were trying to treat with it. It's worsened anxiety, worsened sleep, irritability, restlessness, changes to your appetite, maybe decreased appetite, and some of those things can be really characteristic.

John Horton:

So what's the process, then, if somebody is going to go in and seek treatment? Obviously, it sounds like there's a two-pronged thing. One, it's getting off of cannabis first, and drying out is a phrase that comes to mind. That doesn't seem like it fits for cannabis. It's more of an alcohol term, but just to get the point across. And then, it seems like on the other hand, it's also a figuring out why you had to crutch on it and then addressing that.

Dr. Jared Harp:

Exactly. I think it's exploring your relationship with marijuana, first of all. Exploring what it's doing for you, what it's not doing for you. And then, beginning to develop alternative strategies to manage those things. Whether it's through cognitive behavioral therapy, which is a therapeutic technique that can help with developing coping strategies and coping skills. Whether it's utilizing techniques we use here called “motivational interviewing,” to increase engagement in treatment and help with abstinence. There's a lot of different approaches that are going to be used to help people to address that underlying challenge that they were experiencing. Medications could even be a component of that, too, certainly.

John Horton:

Yeah. And once you have this and you find out, you reached a point where you have this use disorder, is that something where it's … you always need to be cognizant of it? This isn't something where you can go back and just, "Well, I'm going to have one this week," is it? You pretty much have to walk away from it and leave it alone?

Dr. Jared Harp:

Yeah, that's a challenge, and that's an individualized question I think. Like with many things, there's a spectrum of severity of your challenges with cannabis, or really, any other substance. Some people who maybe have more of a milder struggle with cannabis use, they might be able to, at some point in the future, with some treatment and other strategies, return to controlled moderate use. That's possible. People who do have, on the more severe end of that spectrum, who have really experienced a lot of loss of control, have had a lot of consequences, those times, it becomes a little bit more challenging to approach that because there can be a high risk of falling back into those same patterns that led to the problems to begin with.

John Horton:

Yeah. It sounds like so much of it goes with why you're using it in the first place, and that may be some of how, then, things go moving ahead.

Dr. Jared Harp:

Yeah, exactly. It's all about an evaluation of your relationship with the substance, what it's giving you and then trying to find alternative ways to solve those problems and healthier ways to manage those struggles that you're having.

John Horton:

Do you sometimes find that there's a stigma with cannabis use disorder that sometimes prevents people from coming in and getting the help that they need?

Dr. Jared Harp:

Certainly. In marijuana and cannabis, it's a little bit paradoxical in this way. It's two-pronged. In one side of things, there certainly is a stigma regarding the label of having a use disorder, having an addiction and that is certainly a challenge, no doubt.

John Horton:

Yeah.

Dr. Jared Harp:

I think we all understand and appreciate that that can be stigmatizing, and although the stigma is going away, it's still very much present.

But on the other hand, because marijuana use is becoming very normalized, it's becoming widely legalized for recreational use, there's a growing feeling that marijuana can be harmless. Sometimes, these patients will feel as though, "It's just weed."

John Horton:

Yeah.

Dr. Jared Harp:

How could it possibly be a problem? It's this dual-edged issue where sometimes it's a minimization or an unappreciation of the dangers of the use, and also, there's still the existing stigma that could prevent people from coming for treatment.

John Horton:

Yeah. I feel like we're still, even as a society, struggling with how we view marijuana use. The reality is it was illegal for so long and I think it becoming allowed, it's a slow process for people to be open and accept that this is now part of life sometimes.

Dr. Jared Harp:

You're exactly right. All of us are working to change our perceptions, we all have so many things that ingrained through years of messaging, be it from the DARE folks, for those who are old enough to remember, or some of the-

John Horton:

…I do remember that.

Dr. Jared Harp:

…"This is your brain on drugs," scrambled egg advertisements. There's a lot of things that are built into us that we're all working to develop more nuanced appreciations of. You're right that the perception is changing. I think to some extent, our perception of the risk of marijuana has shifted maybe a little bit too much in the other direction. It was, "It's all bad, it's all bad, it's going to ruin your life." And now, "It's only helpful, it can't hurt you." And I feel like we'll find ourselves more toward the middle of that as time goes on. But I feel like we're a little bit too far on the pendulum right now.

John Horton:

If somebody thinks that they may have an issue with cannabis use and they're struggling with it and they feel like it's starting to take over, what's the first step they should take?

Dr. Jared Harp:

Yeah. If you're starting to feel as though, that you're having some struggles with cannabis use, really go through those Four C evaluations. Really take a close look at how it's affecting, if there's consequences in your life, to relationships, to work or other things. Really assess your control over it. If you're using as you intended or have things escalated in a way that you never wanted them to. Really go through those things that we talked about. And if you notice that maybe a couple of those things, or even just one of those things, is problematic, then there's help available.

John Horton:

And let's go over those Four Cs again.

Dr. Jared Harp:

Yeah.

John Horton:

I know you just said Consequences, Control.

Dr. Jared Harp:

And then Cravings.

John Horton:

Cravings.

Dr. Jared Harp:

And Compulsive use.

John Horton:

OK.

Dr. Jared Harp:

Yeah. So compulsive use would be, just, use … you're continuing to use it even when you don't even feel like you want it or need it.

John Horton:

So if you're checking those boxes, you should probably check in with somebody and talk about why you need it so much and what you can do about it.

Dr. Jared Harp:

I think that's well put.

John Horton:

Well, Dr. Harp, we've covered a lot of ground here. I guess before we let you go, if you were going to have somebody walk away from this discussion with one thing, what do you want to make sure that it is?

Dr. Jared Harp:

So it would just be that cannabis use is common, it's becoming more common by the year, but that doesn't mean it's harmless. And if you're someone who is using cannabis and using it with some regularity and you start to notice some of those things that we've talked about, to where maybe it's not going the way that you had hoped it would, seek evaluation, seek help. There's help out there. Help works. People get better. And there's a lot of options to help you along the way.

John Horton:

Hopefully, people take that advice and reach out if they have those issues. So thank you very much for coming in today. I think this was an immensely helpful conversation that can really have a huge impact on people who may feel like they've reached that point where they need a little help.

Dr. Jared Harp:

Thanks so much for having me. I really appreciate it.

John Horton:

Cannabis use disorder can negatively affect your mental and physical health, while also undermining your ability to function in the world around you. If marijuana has turned your life upside down, reach out for help. Treatment is available. It's just a matter of asking for it.

If you liked what you heard today, please hit the subscribe button and leave a comment to share your thoughts. Until next time, be well.

Speaker 3:

Thank you for listening to Health Essentials, brought to you by Cleveland Clinic and Cleveland Clinic Children's. To make sure you never miss an episode, subscribe wherever you get your podcasts or visit clevelandclinic.org/hepodcast. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.