ARC Journal of Volume 3, Issue 2, 2018, PP 5-12 www.arcjournals.org

The Effect of Marijuana on the Outcome of Maintenance Treatment (MMT)

Thersilla Oberbarnscheidt1, Norman S Miller2* 1Western Psychiatric Institute and Clinic, University of Pittsburgh, O’Hare Street, Pittsburgh, PA 15213, USA 2Clinical Professor of Psychiatry, Department of Psychiatry, Medical College of Georgia, Augusta University, Augusta, Georgia, Currently President of Health Advocates, PLLC, 2760 East Lansing Drive, Suite 3, East Lansing, MI 48823, USA

*Corresponding Author: Norman S Miller, Clinical Professor of Psychiatry, Department of Psychiatry, Medical College of Georgia, Augusta University, Augusta, Georgia, Currently President of Health Advocates, PLLC, 2760 East Lansing Drive, Suite 3, East Lansing, MI 48823, USA, E-mail: [email protected]

Abstract: addiction and opioid dependence is a constantly growing problem in the US and about 33 million opioid users globally are affected. The illicit use of prescription is a major factor for increased mortality and medical emergencies. The illicit use of opioids is associated with health problems, criminal actions, low socio-economic function and worst case, death. Methadone maintenance treatment is the most commonly researched treatment method for opioid use disorder. Methadone is a long-acting synthetic opioid that is used as harm reduction and prevent withdrawal symptoms, reduce cravings without induction of the euphoric effect that illicit opioids cause. About 245,000 people are enrolled in opioid treatment programs throughout the US. Poly substance use is very common among methadone maintenance patients and marijuana is the most frequently used drug. The percentage of patient’s using marijuana while enrolled in MMT reported as high as 50%. The interpretation and consequence of the positive THC in the drug screen is left to the treating physician. Due to the high rate of positive THC in urine drug screens in the methadone patient population the detected THC has in many cases/treatment-centers no consequences for the patient. Very limited treatment guidelines are available how to respond to the patient population using marijuana. This article is a systematic review utilizing databases PUBMED, MEDLINE, Psych INFO, EMBASE. This article is designed to develop treatment guidelines for positive THC findings in urine drug screens of patients enrolled in MMT Keywords: Alcohol consumption, gender difference, CVD mortality, Russia, 1956-2010. 1. INTRODUCTION the world's opioid supply and 99% of the world's supply. Retail sales that Opioid use disorder, defined by the DSM V use opioid medications, including methadone, criteria, has been an increasing problem over the , -based , last three decades. hydrocodone, , meperidine, and The constitutes only 4.6% of the , have increased from a total of 50.7 world population; however, it consumes 80% of million grams in 1997 to 126.5 mg in 2007 (1).

Figure1. Primary non- /synthetics admission rates, by State (per 100,000 population aged 12 and over)

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This is an overall increase of 149% with In the US the number of opioid users has tripled increases ranging from 222% for morphine, since the 1990s and affects current about 33 280% for hydrocodone, 319% for million users globally. Particularly the illicit hydromorphone, 525% for fentanyl-based, and use of prescription opioid medications becoming 866% for hydrocodone to 1,029% for more frequent compared to other opioids for methadone. New surveys of opioid medications example heroin leading to increasing numbers and mortality show a steadily rising rate of of emergency room visits and higher death rates unintentional deaths due to prescription and (3, 4). therapeutic use of opioid medications (2).

Figure2. Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over) 2. OPIOID ADDICTION/OPIOID USE DISORDER Chart1. DMV Criteria for Opioid Use Disorder (4) The core essential features of addictive behavior A problematic pattern of opioid use leading to due to drugs is involuntary and reflects a loss of clinically significant impairment or distress, as control over opioid use: manifested by at least two of the following, occurring within a 12-month period: 1. Taking the opioid in larger amounts and for longer than intended 2. Wanting to cut down or quit but not being able to do it 3. Spending a lot of time obtaining the opioid 4. Craving or a strong desire to use opioids 5. Repeatedly unable to carry out major obligations at work, school, or home due to opioid use 6. Continued use despite persistent or recurring social or interpersonal problems caused or made worse by opioid use 7. Stopping or reducing important social, occupational, or recreational activities due to opioid use 8. Recurrent use of opioids in physically hazardous situations 9. Consistent use of opioids despite acknowledgment of persistent or recurrent physical or psychological difficulties from using opioids 10. Tolerance as defined by either a need for markedly increased amounts to achieve intoxication or desired effect or markedly diminished effect with continued use of the same amount. (Does not apply for diminished effect when used appropriately under medical supervision) 11. Withdrawal manifesting as either characteristic syndrome or the substance is used to avoid withdrawal. 3. METHADONE MAINTENANCE TREATMENT Studies have shown a significant decrease in (MMT) criminal activity as well as reducing mortality rates among patients with opioid use disorder (6, The treatment of opioid use disorder is the most 7). researched therapy form for maintenance management in persons suffering opioid The treatment with methadone is a federally addiction (4, 5). Methadone is as a long-acting regulated process that requires a slow and synthetic opioid is most widely researched careful titration of the medication to avoid the pharmacological treatment for maintenance risk of overdose. The phases in order to reach therapy for opioid addiction and dependence. maintenance phase include initiation, induction Methadone does not induce the euphoric feeling and stabilization. In the early course of that illicit opioids cause but is used to reduce treatment, the patient is especially vulnerable to cravings and withdrawal symptoms (6, 7). illicit drug use due to the gradual process to

ARC Journal of Addiction Page | 6 The Effect of Marijuana on the Outcome of Methadone Maintenance Treatment (MMT) establish the therapeutic blocking dose of their risk for Marijuana users for other illicit opioid receptors (8). The gradual introduction to substance use disorders as well as alcohol use methadone treatment takes several weeks and disorder (17, 18, 19) requires patience which is not easy to An increasing number of states are currently in understand from the perspective of an addict. the process of legalizing the use of marijuana “The Here-and-Now-Thinking” will get and making the drug even easier available and addressed in counseling sessions and new goals more socially acceptable (20). Marijuana is and approaches will be illustrated and taught classified by Drug Enforcement Agency (DEA) (9). in the US as a Schedule I drug which, like Importantly, behavioral changes and heroin, contains substances with a high potential identification of triggers are addressed during for abuse, with no current accepted medical use the therapy session: People, Situations and and a lack of accepted safety for medical use Places. Therapy sessions are an important factor (21).Marijuana induces the release of in the success for the MMT (10). Therapy and endorphins in the brain from the nucleus counseling is an important factor in the success accumbens and the orbito-frontal cortex, which of MMT. Polysubstance use is addressed and produce the feeling of pleasure and reward. strategies to have shown to decrease illicit drug Endorphins are hormones that are naturally use in MMT patients are take-home doses, dose produced in the brain that have an opioid- like changes, time of dosing as well as rewards in effect. In addition, Marijuana acts as a form of money, goods and services (11). dopamine agonist in the brain, stimulating reinforcement regions in the meso-telencephalic Although MMT is overall and efficacious dopamine system. (22, 23). Research with treatment for reducing illicit opioid use, it has marijuana due to its federal regulation is very high drop-out rates and often times is turning limited. Studies mostly focus on the interaction out to be in a longer time frame than initially of cannabinoids with opiates in terms of intended, the relapse rates and mortality rates signaling and eventual synergistic effects. after 1 month 1 year and 5 years are much more successful than the abstinence-based treatment The use of marijuana causes higher drop-out (10,12,13). One very important factor for the rates in school and lower academic performance success for MMTis the identification of causes and causes overall decreased life satisfaction for relapses or factors that predict relapses. which might be a “trigger” for consecutive drug Lapses are crucial to study because they offer an use. As with published reports on social security disability associated with prescription opioid opportunity to intervene early in the relapse medications, it is likely that marijuana use leads process (14, 15).Some opponents of the MMT to high rates of disability that is caused by the criticize such programs because MMT patients marijuana (24, 25, 26). As with opioid addiction take an opioid medication to “substitute” for and induced disability, disability due to their major drug of abuse. They may be less marijuana renders the user unable to perform likely than patient’s in abstinence-oriented social, occupational, and avoid legal treatment to hold rigorous abstinence goals, and consequences at government expense. abstinence goals might be less predictive of Prescribed opioid use in relation to disability, abstinence while addicts deciding to enroll in which has been more extensively studied, can abstinence-based programs might present more serve as a comparison to marijuana addiction “determined” to stop using (16). affecting disability claims. In a study of disabled 4. POLY SUBSTANCE USE AMONG MMT Medicare beneficiaries under age 65 years, there PATIENTS was a significant overall rise in prescription opioid consumption. This increase was not Poly substance use is fairly common among driven by overall use in more people using MMT patients (3, 4, 17). Marijuana is seen as opioids but rather the proportion of those using the most frequently used “gateway drug” that opioids chronically and addictively, at least 6 introduces the users to the use of illicit and on average 13 prescriptions per year. The substances. This is also mostly due to the authors state that the effectiveness of such a perception that marijuana is seen as “natural” or sustained and high dose is supported by scant “harmless”. Cannabis use disorder is a classified evidence in this study (24). DSM V diagnosis as well (5). About one in ten persons is to be estimated to become dependent Specifically, for marijuana and disability, a upon cannabis. Studies have shown an increased study looked at the level of drug abuse among

ARC Journal of Addiction Page | 7 The Effect of Marijuana on the Outcome of Methadone Maintenance Treatment (MMT) individuals enrolled in the Supplemental accidents (30-33). Security Income and Social Security Disability 2. Mental Health: Marijuana use causes programs. Among these individuals, 23% had a earlier onsets of Bipolar disorder in lifetime dependency on marijuana, consistent predisposed persons. It also can cause manic with the various populations of federal aid episodes in already existing bipolar recipients. This finding illustrates that almost disorder. In addition, marijuana causes one quarter of individuals receiving federal aid psychotic symptoms and paranoia that can were using marijuana regularly. This percentage be severe and lead to hospitalizations. will undeniably increase as the marijuana is Marijuana use also increases anxiety and more easily accessible through legal means as depression (34, 35, 36). with opioids and marijuana addiction will lead to disability (24).The study also illustrated that 3. Cardiovascular system: The effects of the individuals that had the most difficulty Marijuana on the cardio-vascular system obtaining work were the group with the most range from tachycardia and increased psychiatrically impairments. Marijuana use cardiac labor to ischemia in organs due to increases psychiatric symptoms and is higher levels of carboxyhemoglobulin (37, associated with psychiatric disorders at 38). alarmingly high rates. Therefore, marijuana use 4. COPD: Marijuana causes similar to and addiction lead to increased unemployment nicotine symptoms of COPD and users and disability rates resulting in extremely high wheeze and frequently cough (34, 37). costs not only to the individual but also to the public. As in the case of prescribed use, 5. Immune system: Marijuana use suppresses marijuana is not a permanent and medically the immune system in the user which causes necessary disability under Social Security especially in HIV patients a higher risk and Disability and/or other forms of disability. rate of opportunistic infections (37, 38). Marijuana associated disability is reversible and 6. Reproductive System: THC suppresses the improves or resolves with cessation of adrenal cortical hormones prolactin, thyroid marijuana use (24-29). hormones and growth hormones (34, 38). 5. RISKS OF MARIJUANA USE 7. Cancer: Increased risk and incidence of Marijuana is derived from the plant cannabis certain cancers: Gliomas, prostate and sativa and most commonly smoked in its natural cervical cancers (37, 38). form. Other possible routes are eatables, oils and 8. Pregnancy: THC alters the neurological lotions or even suppositories (30,31). Marijuana development in the embryo in utero. consists of more than 421 components and 60 Marijuana is getting transferred through the pharmacologically active cannabinoids. The two breast milk (36, 38). best-described cannabinoids are THC and (CBD). Most of the other In addition, Marijuana causes dependence, compounds are not yet understood and their tolerance and addiction. Tolerance to cannabis mental and physical effect are unknown occurs in relation to mood, psychomotor (32).Marijuana has a high addiction potential, performance, sleep, arterial pressure, body impairing the user’s judgment and leading to temperature and antiemetic properties (25, hazardous situations when used despite the 38).The attempt to discontinue its use causes withdrawal symptoms consisting of: anxiety, negative consequences in user’s personal life, depression, decreased appetite, headaches, occupation and lastly health (30,31). Marijuana insomnia, irritability, muscle tension, nausea, is known to cause severe toxic effects on the nightmares and unpleasant vivid dreams (28,38). user including physical as well as psychological Marijuana has a long half –life and, due to its effects: lipophilic quality, persists in the body for a long 1. Cognition: Marijuana causes an impairment time following its last exposure and makes its in cognition and judgement. A study with effects dangerous to predict in terms of its airline pilots showed that even if their toxicity. This pharmacological quality judgement was subjectively not impaired, differentiates marijuana from other drugs for they showed impairment in cognitive tests. example opioids and alcohol, which are cleared The reduced cognitive function might also out of the user’s system in a shorter, specific be the causing factor for increased criminal time window and do not accumulate and have activity and higher rate of motor vehicle more predictable effects (38, 39). ARC Journal of Addiction Page | 8 The Effect of Marijuana on the Outcome of Methadone Maintenance Treatment (MMT)

Marijuana acts as a dopamine agonist in the with their treatment goals. The group tested 300 brain, stimulating reinforcement regions in the patients per urine drug screen from two different meso- telencephalic dopamine (DA) system (34, clinics but in their analysis had difficulties 38, 39). Further, marijuana is not FDA approved distinguishing from other co-occurring and classified as s Schedule I medication with substance use (42). Weiss et al showed no no proven medical benefit (40). adverse outcome in a group of adolescents with cannabis use while in Opioid maintenance 6. EFFECTS OF MARIJUANA METHADONE treatment. The study included 152 patients 15- MAINTENANCE TREATMENT 21 years who were followed for 12 weeks. The The rate of patient’s using Marijuana while patients enrolled in this study were mild users enrolled in MMT is on average as high as 50% and used cannabis only 3 days per month (52, but reported to range from 40-95%. The high 53). percentage of patients using marijuana as a co- Budney et al did not show a difference in occurring substance is a big challenge for the treatment outcomes for MMT patients either in treating physician in MMT programs (41, 42). his study that had 107 patients enrolled. 60% of There is no clear clinical guideline for the his patients were using marijuana upon intake interpretation and consequences of the positive and 94% of those continued to use while THC finding in the routine UDS obtained in enrolled in MMT. The group did notice a higher MMT programs. The current opioid dependence incidence of marijuana users in MMT to not be treatment philosophies in the U.S. range from married, have higher financial difficulties and be mandated drug-free policy, meaning the patient must commit to abstinence to all substances to more frequently involved in drug dealing or remain in treatment to maintenance-only engaging in sharing of needles (46). approach where methadone treatment is Wassermanet al discovered that marijuana use provided and all other substance use is tolerated. caused a significant increase in subsequent heroin use. The group followed 74 patients who Since marijuana is legal in certain States in the had stopped using heroin within the last 3 weeks U.S. and patients in MMT are able to obtain a and analyzed particular factors for relapse. The “Medical Marijuana Card” physicians are more group found a significant correlation between frequently accepting the positive THC without positive THC finding in urine drug screen and any negative consequences for the patient in called cannabinoid-positive urine as a robust terms of the patient’s progress in the treatment predictor of resumption of heroin use (14). program. Positive THC with legal marijuana Several studies did not notice any difference on status is seen equal to a written prescription the outcome in opioid agonist therapy medication by the physician. Studies on the depending on the use marijuana. (54,55). Few association of marijuana use and MMT studies (42,43) found that patients using outcomes have shown conflicting results, but the cannabis used less opioids while using majority of studies have shown adverse marijuana and marijuana is even called outcomes. Also, there appears to be a difference successful substitute for heroin. of the effect of cannabis depending on the stages of agonist therapy. The initiation phase is the There have several studies showing a negative most vulnerable phase and shows the most outcome on socio-economic functioning such as negative impact on the outcome (43,44). marriages or employment (56). Epstein and Preston showed in their study that cannabis use However, cannabinoids are known to impact increased the outcomes for jail time and family opioid signaling in the brain when administered conflict (45). An additional study by Newville et concurrently (43-49). The maintenance phase is al tested for an interaction of substance use on on the other hand less vulnerable and patients HAART adherence among MMT patients. They are more stable and progressed in therapy and showed an association between the non- behavioral changes. Poly substance use has been adherence to HIV medication adherence with associated with poorer treatment outcome for the use of cannabis while in opioid agonist patients in MMT compared to patients that only therapy (18). Another study done by Calsynin use opiates. This has been confirmed in studies 1998 looked at the change of MMT outcome back from 1970, 1971 (5, 50, 51, 52). and marijuana use after making a policy change Early reports from 1989 by DuPont and Saylor in the methadone clinic. 120 patients were already raised the concern that Cannabis use in enrolled with the status of dosing on site twice Methadone-maintained patients can interfere per week and positive

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THC in urine drug screens. The new policy take-home status and proper psycho-education required the patients to stop using marijuana in would be beneficial to the patient about the order to maintain their dosing status. Mean toxic effects of marijuana and the negative length of time in treatment was 105 months. The outcome on MMT. outcome was that 50% of the patients remained The list of the toxic effects of marijuana is long their dosing status of twice a week on site and negative drug screens. Those patients who lost and involves most organ systems and does affect their status suggested minimal negative impact cognition negatively as well as the judgment. from the policy change and mostly lost their Patients with impaired judgment are more likely status due to the use of other illicit substances. to use, which decreases the barrier to use heroin The patients reported productivity in the or other opioids in addition to the methadone counseling sessions guided towards desire to which is negative for the outcome of the quit since policy change. Criticism to this study maintenance treatment and also increases the are the small patient number and the selection of risk of overdose or death. Current studies are higher functioning patients (41). difficult to interpret since most have a high rate of cross- and small study populations 7. DISCUSSION with only a short follow up period. Also, there Methadone maintenance programs have been are significant differences noticeable in the shown to be a successful way to help patients comparison of most marijuana versus control with opioid use disorder. The overall the success populations mostly pointing to a lower socio- of MMT depends on elimination of the use of economic status to start with and a larger the drug of choice but also on the co-occurring amount of risk factors and psychosocial substance use. Evidence indicates that treatment instabilities. The use of marijuana has also retention is a major factor in success for the shown to further progress the decline in treatment. So, the focus in treatment should be psychosocial functioning. The loss of support on eliminating high risk behavior and co- from family through divorce or jail time in the occurring substance use, including the use of course are the named risks in the available marijuana. There are no clear defined guidelines studies, certainly not supportive of gaining or available for the physician in methadone clinics remaining in sobriety. how to address and respond to positive THC findings. The current literature shows In addition, there has been shown an association inconsistent data but overall the risks of between poorer treatment follow-up with HIV marijuana outweighs its benefit. medications and therefore negative consequences on that condition. Increasing Marijuana remains a Schedule I federally health problems also have a negative impact on controlled substance but the ongoing the outcome of MMT. The development of legalization in many states bears an increasing clinical guidelines for the physician to address risk for availability for the user. It also increases the licit as well as illicit use of marijuana in the difficulty how to justify the negative impact methadone maintenance programs are needed to of marijuana with legal status and on the other improve treatment outcomes for their patients. hand associate the illicit use with negative REFERENCES consequences in treatment phase or take-out. Can marijuana be justified as a medication in [1] Fischer B, Kreates A, Buehringer G, Reimer J, MMT without any negative consequences? How Rehm J. Non-medical use of prescription does the legally consumed marijuana affect the opioids and prescription opioid-related patient’s brain differently than the illicit one? To harms:why so markedly higher in North America compared to rest of the world? address these concerns will remain up to the Addiction 2013 (109) 177-81. treating physician but the clinic should have [2] Eriksen J, Sjogren P, Bruera E, Ekholm O, consistencies in policy of these positive THC Rasmussen NK. Critical issues on opioids in and THCRx findings. “Medical Marijuana” is chronic non-cancer pain: an epidemiological not prescribed by a physician and not filled in a study. Pain. 2006 (125)172-179. pharmacy. In addition, the actual content of the [3] United Nations Office on Drugs and Crime. marijuana and percentage of THC varies with World Drug Report. 2016 each sample. Users utilize the marijuana at their [4] Degenhardt L, Hall W. Extend of illicit drug own discretion without any guidance from a use and dependence, and their contribution to physician or medical follow-up. Patients need to the global burden of disease. Lancet 2012, be aware of the consequences regarding their (3:379):55-70. ARC Journal of Addiction Page | 10 The Effect of Marijuana on the Outcome of Methadone Maintenance Treatment (MMT)

[5] DSM V, Diagnostic Manual [19] Best D, Gossop M, Greenwood J, Marsden J, [6] Mattick RP, Breen C, Kimber J, Davoli M. Lehmann P, Strang J. Cannabis use in relation Methadone maintenance therapy versus no to illicit drug use and health problems among opioid replacement therapy for opioid opiate misusers in treatment. Drug Alcohol dependence. Cochrane Database Syst. Rev. Rev. 1999;18:31–8. 2009; CD002209. [20] Head AC, Use of cannabis for medicinal [7] Martínez-Luna NG et al, Harm purposes. Council on science and public health reduction program use, psychopathology and report, (2015). 3: 28. medical severity in patients with methadone [21] Huestis MA, Human cannabinoid maintenance treatment, Adicciones. 2018 Jan pharmacokinetics. ChemBiodivers. 2017. (4) 15;0(0):897 1770-1804. [8] Kelly SM, Grady KEO, Mitchell SG, Brown [22] GrotenhermenF, The toxicology of cannabis BS, Schwarz RP. Predictors of methadone and cannabis prohibition. ChemBiodivers2007 treatment retention froma multi-site study: a (4): 1744-1769. survival analysis. Drug Alcohol Depend. 2012; [23] Iverson L (1992) Cannabis and the brain. Brain 117:170-5. 125: 1252-1270. [9] Roberts JR. Methadone maintenance. The [24] Swartz A, Lurigio A, Goldstein P (2000) basics. Emerg Med News 2009: 260:9-11. Severe mental illness and substance use [10] White WL, Campbell MD, Spencer RD, disorders among former supplemental security Hoffman HA, Crissman B, DuPont RL. income beneficiaries for drug addiction and Patterns of abstinence or continued drug use alcoholism. Arch Gen Psychiatry 57: 701-707. among methadone maintenance patients and [25] Sharma P, Murphy P, Bharath MMS, their relation to treatment retention. J Chemistry, Metabolism, and Toxicology of Psychoactive Drugs. 2014; 46:114-22. Cannabis: Clinical Implications. Iranian J [11] Preston et al, Methadone Dose Increase and Psychiatry 2012 7(4): 149-156 Abstinence Reinforcement for Treatment of [26] Moore THM, Zammit S, Lingford-Hughes A, Continued Heroin Use during Methadone Barnes TRE, Jones PB, Burke M, et al. Maintenance, Arch Gen Psychiatry. 2000; Cannabis use and risk of psychotic or affective 57(4):395-404. mental health outcomes: a systematic [12] Bailey GL, Herman DS., Stein MD, review. Lancet. 2007; 370:319–28. Perceivedrelapserisk and desire for Medication [27] Degenhardt L, Hall W, Lynskey M. Exploring assisted treatment among persons seeking in the association between cannabis use and patient opioated etoxification. J depression. Addiction. 2003; 98:1493–504. SubstAbuseTreat. 2013;45(3):302-305. [28] Volkow ND, Baler RD, Compton WM, Weiss [13] Rosenthal RN. Medications for addiction SRB. Adverse health effects of marijuana treatment (MAT). Am J Drug Alcohol use. N Engl J Med. 2014; 370:2219–27. Abuse.2018; 44(2):273-74. [29] Wittchen H-U, Fröhlich C, Behrendt S, Günther [14] Wasserman DA, Weinstein MG, Havassy BE, A, Rehm J, Zimmermann P, et al. Cannabis use Hall SM. Factors associated with lapses to and cannabis use disorders and their heroin use during methadone maintenance. J relationship to mental disorders: a 10-year Drug Alcohol Depend. 1998; 52:183–92. prospective-longitudinal community study in adolescents. Drug Alcohol Depend. 2007; [15] Cotton BP, Bryson WC, Bruce ML. Methadone 88(Suppl 1):S60–70. Maintenance Treatment for older adults: Cost and logistical consideration. Psychiatr Serv. [30] Grotenhermen F, Chemestry and Biodiversity 2018 Mar 1; 69(3):338-340. (4/2007), 1744-1769, The Toxicology of cannabis and cannabis prohibition. [16] Chou R, Korthuis PT, Weimer M, et al. Medication-Assisted Treatment Models of Care [31] Harma P, Murthy P, Bharath MMS, Chemistry, for Opioid Use Disorder in Primary Care Metabolism, and Toxicology of Cannabis: Settings Chou R, Agency for Healthcare, Clinical Implicatons, Iranian J Psychiatry, Research and Quality (2016) Dec. 2012 (7:4):149-156. [17] Taylor OD. Poly substance use in methadone [32] Lamarine RJ, Marijuana: A modern medical maintenance therapy (MMT) patients. J. Hum. chimera, J Drug Education 2012 (42)1: 1-11. Behav. Soc. Environ. 2015; 25:1–8. [33] Crippa A, Waldo A, Martı R, Atakan Z, [18] Newville H, Berg KM, Gonzalez JS. The Mcguire P, Fusar-poli P. Cannabis and anxiety: interaction of active substance use, depression, a critical review of the evidence. Hum and antiretroviral adherence in methadone PsychopharmacolClin Exp. 2009; 24:515–23. maintenance. Int J Behav Med. 2015; 22:214– [34] Stein MD, Anderson BJ, Anthony JL. Social 22. phobia, alcohol, and marijuana use in a ARC Journal of Addiction Page | 11 The Effect of Marijuana on the Outcome of Methadone Maintenance Treatment (MMT)

methadone-maintained population. J Dual [46] Hill KP, Bennett HE, Griffin ML, Connery HS, Diagn. 2008; 4:75–86. Fitzmaurice GM, Subramaniam G, et al. [35] Fischer B, Rehm J, Hall W. Cannabis use in Association of cannabis use with opioid Canada: the need for a “Public Health” outcomes among opioid-dependent youth. Drug approach. Can J Public Heal. 2009; 100:101–4. Alcohol Depend Elsevier Ireland Ltd. 2013; 132:342–5. [36] Grover S, Basu D (2004) Cannabis and Psychopathology: Update [47] Simpson D. Treatment for drug abuse: follow- up outcomes and length of time spent. Arch [37] Grotenhermen F , Müller-Vahl K (2012) The Gen Psychiatry. 1981; 38:875–80. therapeutic potential of cannabis and cannabinoids. DtschArzteblInt 109: 495-501. [48] Ghitza UE, Epstein DH, Preston KL. Nonreporting of cannabis use: predictors and [38] Sharma P, Murthy P, Bharath MM (2012) relationship to treatment outcome in Chemistry, metabolism, and toxicology of methadone-maintained patients. Addict cannabis: Clinical implications. Iran J Behav. 2007; 32:938–949. Psychiatry 7: 149-156. [49] Ball JC, Ross A. the Effectiveness of [39] U.S. Department of Justice, Drug Enforcement Methadone Maintenance Treatment. Springer Administration, Diversion Control Division, NY. 1991: 1-30. Practisioners Manual, https://www. deadiversion.usdoj.gov/pubs/manuals/pract/ [50] Weis, et al, Effects of Cannabis on Methadone maintenance treatment, Jama,July 30, 1973, [40] Calsyn DA, Saxon AJ, An innovative approach Vol 225, No. 5, Pages 453-560. to reducing cannabis use in a subset of methadone maintenance clients, Journal of [51] Lee SC, Klein-Schwartz W, Doyon S, Welsh C. Drug and Alcohol Dependence 1999 (53): 167- Comparison of toxicity associated with 169. nonmedical use of benzodiazepines with or methadone. Drug Alcohol [41] DuPont, RL, Saylor KE. Marijuana and Depend. 2014 May 1; 138:118-23. benzodiazepine in patients receiving methadone treatment. J Am Med Assoc 1989 (261): 3409. [52] Bliem B et al, Creativity in cannabis-users and in drug addicts in maintenance treatment and in [42] Scavone JL, Van Bockstaele, Impact of rehabilitation. Neuropsychiatry 2013; 27(1):2- Cannabis use during stabilization on 10. Methadone maintenance treatment, Am J Addict. 2013; 22(4): 344-351. [53] Best D et al, Cannabis use in relation to illicit drug use and health problems among opiate [43] Kidorf M, Brooner RK, Treatment initiation misusers in treatment. Journal of Drug and strategies for syringe exchange referrals to Alcohol Rev. 1999:1831. methadone maintenance: A randomized clinical trial. Drug Alcohol Depend. 2018 Apr 16; [54] Saxon et al, An innovative approach to 187:343-350. reducing cannabis use in a subset of methadone maintenance clients, J Drug and [44] Epstein DH, Preston KL. Does cannabis use Alcohol Depend. 1999 Jan 7; 53(2):167-169. predict poor outcome for heroin-dependent patients on maintenance treatment? Past [55] Nierenberg TD et al, Cannabis versus other findings and more evidence against. Addiction. illicit drug use among methadone maintenance @003; 98:269-279. treatment. Psychol Addict Behav. 1996(10): 222-227. [45] Budney AJ, Bickel WK, Amass L. Marijuana use and treatment outcome among opioid- [56] Kandel, D. B., Marijuana users in young dependent patients. Addiction. 1998; 93:493– adulthood, Archives of General Psychiatry, 503. (1984) 41, 200-209.

Citation: Thersilla Oberbarnscheidt, Norman S Miller. The Effect of Marijuana on the Outcome of Methadone Maintenance Treatment (MMT). ARC Journal of Addiction.2018; 3(2):5-12. Copyright: © 2018 Authors. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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