You can't send my ass to rehab for just WEED! Part 2—Marijuana withdrawal is real

Lawrenz was in his 30s, on parole after serving a sentence for “criminal sale of a controlled substance”—legalese for dealing drugs or “hustling.” That's how most of my clients referred to the activity that landed them in prison, an experience they gave evocative names like “up top” and “in the mountains.” Lawrenz was a gregarious, handsome, cheerful person who appeared eager to resume part-time custody of his two young daughters and seek legitimate employment.

And yet his THC levels did not decrease.

THC stands for “tetrahydrocannabinol,” the component of marijuana responsible for its trippy effects: dilation of time, decreased motivation, goofy cheerfulness, and paranoia. Toxicology assays measure the amount of THC in a person's system. Since marijuana is stored in the body's fat cells, it takes a long time to clear. Whereas alcohol is gone between 12-24 hours after ingestion, and cocaine and heroin take roughly 3 days, marijuana can last up to 30 days. (We had one particularly rotund client who continued testing positive for about 55 days.)

But not at the same concentration. The more time that passes without use, the less marijuana is expelled. We're able to monitor this by measuring the concentration of marijuana in a urine sample. We don't expect a person to go from 500 to 0 overnight, but gradually, each week should show a lower amount.

That wasn't the case with Lawrenz. He talked an excellent game in our first few sessions, expressing a commitment to sobriety and responsible parenting. I encouraged and praised him—and kept testing him. After a few weeks of declining THC levels, I noticed a sharp uptick.

“Oh yeah,” Lawrenz said breezily. “My cousins were visiting from back home, and they were passing around some blunts. Without even thinking I took a few pulls before I pulled myself up short and said, 'Lawrenz, you crazy? You on parole!'”

“Where's back home?” I asked, wondering if it was a Caribbean nation where everyone had marijuana for breakfast.

“South Carolina,” he said. “My cousins and me, we been smoking weed together most of our lives. Since we was kids. It's a habit, but it's a habit I am going to break.”

I validated his intentions. “I really think you are,” I said. “I know how important spending time with your daughters is to you, and I know their mother won't let you around them if you smoke up first.”

“That woman has a nose like a bloodhound,” Lawrenz remarked dryly.

Still, somehow his THC levels remained fluctuating but high. He would almost zero out only to increase slightly or dramatically the next week. I listened to his excuses and discussed him during case conference meetings. When the time came to make a report to his parole officer, I had to be honest.

P.O. Macgruder called me shortly after I sent him the report by fax. “Is Lawrenz shitting me?” he asked.

“Kind of,” I said. “I do believe he's looking for work, and I believe he's spending time with his children, but there's no denying that he's still smoking, off and on.”

“What kind of treatment are you giving him that he keeps on getting HIGH?” grumbled Macgruder. He was actually one of the more patient and sensitive parole officers I came into contact with, but his patience was running out.

“We've increased his treatment here,” I said. “He's going to group five days a week, which is more than almost anyone else.” Lawrenz loved group therapy, and not just to hear the sound of his own voice. He enjoyed listening to the other clients discuss their struggles and tried hard to encourage them to persist, despite their unsympathetic employers, impatient wives or girlfriends.

“He does have a number of absences, though,” I mentioned. Lately, Lawrenz had taken to “forgetting” some his appointments with me, and some of his groups. Absentmindedness is another symptom of marijuana abuse.

“So what's next?” asked Macgruder. “Violate him?” That would mean Lawrenz would spend a few days or weeks on Rikers Island. If he accrued enough parole violations, he'd go back upstate.

“The next step could be a higher level of care,” I said. “A 28-day rehab.”

“Will rehab take him just for smoking weed?” he asked, incredulous.

“They will if I tell them you said he has to go,” I said. I'd recently learned the power of invoking a parole officer when arguing with Medicaid managed care plans. “Her parole officer wants her in this program,” I had insisted on behalf of another client, and by golly they paid for her to attend this program.

“Let me make some calls,” I said. “I'll see who has a bed for him, and then I'll call him and make the arrangements for him to be picked up.”

“Can it happen tomorrow?” asked Macgruder.

“I will try my hardest,” I said, and called Lawrenz. I would have had to call him anyway, since he'd missed his individual session with me earlier that day.

"You can't send my ass to rehab for just weed!" he said.

"It's that or a parole violation," I said. "Rehab is better than jail, isn't it? There are some really nice programs you can go to. One's in the Hamptons; I think they do yoga on the beach. And there's in the Catskills that offers equine therapy."

"Playing with horses can help get you straight?" he asked skepticallly.

"That might be more for trauma patients," I acknowledged. "But it's an amazing program. Let me call around and see who has a bed."

The nicer private rehabs, located on bucolic upstate farmland or near the beach, were all full, and Lawrenz's P.O. wasn't willing to wait. But a state-run addiction treatment center in Brooklyn had an opening. Initially disappointed that he wouldn't be enjoying walks on the beach or interacting with horses, Lawrenz packed a bag and spent about 22 days in treatment. (Insurance rarely covers a full 28 days anymore.)

He came back quieter, a tad humbler, and full of praise for the program. “I started going to Marijuana Anonymous meetings in the community,” he said. “We went every day. Now I have a home group and a sponsor.”

“You wouldn't have gotten that in the Hamptons,” I joked. “What else did you do?”

“Well, the first week I lost about seven pounds,” he said.

“I'm going to rehab,” I announced. “What happened?”

“I had a lot of nausea and... digestive discomfort,” he said delicately. "Felt like my stomach was in knots all the time."

“Makes sense,” I said. “It's the opposite of the munchies.” Marijuana is famously used to help cancer patients undergoing chemotherapy cope with nausea. Without marijuana in his system, Lawrenz experienced a rebound effect.

When a person is addicted to a powerful substance like marijuana, the body responds to each use with a strong counter-reaction in an attempt to maintain homeostasis—the body's metabolic balance. Stopping use abruptly can thus trigger strong symptoms that are the opposite of the substance's effect, because the body is still trying to counter the effects of the withdrawn substance. (That's why it's called "withdrawal.")

For example, a person addicted to opiates like heroin who goes into withdrawal will be agitated, anxious, and angry—the opposite of a blissful high. Since heroin is a muscle relaxant, which often causes constipation, heroin withdrawal can also include severe diarrhea.

(I can attest to this symptom. Although I've never taken heroin, I was prescribed Percocet, an opiate painkiller, for knee problems. I took it once or twice a day for weeks, whenever the pain was very bad. One day, the pain remained minimal and I didn't take anything. That night, I was up almost every hour on the hour, dashing to the commode to expel what seemed like gallons of water. I was extremely nauseated as well, although nothing exited that end. At about 3 a.m., I blearily realized I was probably experiencing a bit of the withdrawal that my clients in the methadone program had endured. Increased clinical knowledge is always a good thing, although it was a rather thin silver lining in this case.)

Lawrenz experienced nausea because his digestive system was accustomed to a certain level of marijuana and operated in opposition to that level—even after he stopped smoking and his levels decreased. Withdrawal is part of detox, the process a user undergoes when clearing their system of a substance. Detox is almost always highly unpleasant; in the case of alcohol and benzodiazepine withdrawal, it can even be fatal. Opiate withdrawal, interestingly, is excruciatingly uncomfortable—I can assure you of this—but not fatal, as long as precautions are taken against dehydration. Neither is marijuana withdrawal; in fact, many people don't believe it exists, since it's not as dramatic as opiate or alcohol withdrawal. Lawrenz would be happy to assure the skeptics that you can indeed suffer a marijuana hangover.

“I was really cranky too, that first week,” he continued. “I realized that there have been so many times in my life when I wanted to smoke but couldn't, either because I didn't have any money or I was with my kids, and I got really snappish with them. Irritable."

"You were in withdrawal," I said.

"Yeah. I didn't think of it in those terms, but I was," said Lawrenz. "That first week was tough. I was restless and anxious, climbing the walls. If I'd been on the outside I know I would have given in and smoked up. But I didn't have a choice in there, so I had to tough it out.”

“How did you cope?” I asked.

“They had some old boxing equipment in the exercise room,” he said. “I worked out with the heavy bag and I jumped rope. My MA sponsor belongs to a really cheap gym, and he can help me get a membership. I'm going to keep at it. I used to box for fun with my cousins. One of my uncles used to box and he taught us.”

“Exercise is a great way to deal with anxiety and irritability,” I said. “And you've lined up some good social support. I'm kinda glad I couldn't send you to the Catskills rehab with the horse farm.”

“Or rehab on the beach in the Hamptons,” said Lawrenz.

Both the Catskills and Hamptons rehabs are excellent programs, but it was the somewhat cramped, no-frills facility in the heart of Brooklyn that enabled Lawrenz to focus on the changes he needed to make, including joining a 12-step program where he could attend as many groups as he needed for support and encouragement.