You can't send my ass to rehab for just WEED! Part 3—I need it for my HEALTH

Marijuana is a potent plant. THC, the component that induces goofiness and the munchies (and sometimes paranoia), is only one of its more than 500 active compounds—many of which also have a distinct impact on people.

Isaac was a plump, blond Chassidic Jew in his early 20s, referred to our outpatient substance abuse program by his probation officer. He had been accused of molesting a teenager, which he vehemently denied; as a victim of childhood sexual abuse, he said, he would never inflict that kind of suffering on another. He lacked health insurance and hadn't seen a doctor in several months—dangerous for a diabetic.

Isaac's admission toxiology results were positive for marijuana, and during my first session with him, I asked why he smoked. It's important to understand a client's patterns of substance use so that you can address all the factors that maintain their use.

“I smoke to keep my blood sugar low,” he told me. “Just one joint a day. Not even a whole joint. I need to keep smoking until my Medicaid is active and I can see an endocrinologist.”

Skeptical at first, I did some research and found a strong association between marijuana use and lowered blood sugar. And his THC levels were relatively low—not declining, but steadily low. It was possible he was restricting his use to one joint a day or less.

Every week I checked in with him concerning his Medicaid status. Our biller also checked frequently—we couldn't collect any payment for our services until he was officially enrolled in a Medicaid, although we'd be able to back-bill once his coverage was activated. Because he'd been arrested and spent some time in jail until pleading guilty and receiving probation, it took a while for his Medicaid to be reactivated.

Once it was, I began strongly encouraging Isaac to find an endocrinologist. For some reason he couldn't return to the one he'd been seeing before his arrest—that could have been due to his insular community, in which anyone's business was everyone's business, and everyone knew why he'd been arrested and what for.

When he finally made an appointment with another endocrinologist, he had to wait several more weeks. He could have gone to the emergency room if his blood sugar spiked, but not if his condition wasn't emergent. All the while I kept monitoring his THC levels, which didn't rise but also didn't fall.

I asked Isaac to bring me a note from his endocrinologist after every appointment, which he dutifully did. He was put on several medications, including insulin. Yet his THC levels did not decrease.

“I need to wait a little longer,” he said when I confronted him with the evidence of his continued use. “It takes at least two months for the medications to build to a stable level in my system.”

I'm not an endocrinologist. And I was juggling the needs of the other clients on my caseload. And Isaac's endocrinologist wasn't very good at returning phone calls. But after two more months, I reviewed Isaac's levels, and they had not declined.

In the age of micromanaged care, treatment needs to look like it's having an effect. A person who's in a non-intensive outpatient program who hasn't stopped using needs to be bumped up to a higher level of care. We increased Isaac's schedule so that he attended groups every day of the week as well as an individual session. But his THC levels did not decrease.

When we think of addiction, we might think of someone swilling bottles of alcohol, snorting piles of cocaine, or shooting heroin into every vein in their body. (Heroin addicts are better than phlebotomists at finding veins.) But sometimes an addiction can level off—for a while. Isaac wasn't smoking huge quantities of THC; his levels were never very high. But they also didn't zero out. I guess you could call him a functional marijuana addict.

The problem with “functional” addiction is that it doesn't last. Sooner or later, an addict will lose control over limited use, and it will increase. And keep increasing until the person quits or dies. I wasn't sure how much marijuana use it would take to kill a person—it's not as lethal as cocaine, heroin, or alcohol—but I knew that any amount of marijuana use was fatal to Isaac's probation; this was years before it was legalized.

Since we couldn't offer Isaac a higher level of care at our program, I suggested that he go to rehab. He and his family were extremely reluctant.

“They won't understand me because I'm Chassidic,” Joseph said.

“I can make sure you get strictly kosher meals, and they understand about the Sabbath,” I argued. “This is New York City, not Iowa. You are not the first Orthodox Jew to go to rehab in these parts. And you need to get out of your environment to develop new skills that will help you stop using.”

“I won't be able to go to synagogue,” he said. “I go every day.”

I didn't want to be insensitive to his sincere religious beliefs, but I also had to be frank: “Missing a month of synagogue is better than jail,” I said, “which is where you will go back if your probation officer violates you. He's tired of waiting for you to test negative.”

Although Isaac was mandated to treatment by probation, we couldn't force him to go to rehab, and I guess I wasn't a good enough counselor to convince him. Thirty days after he stopped coming to the program and responding to calls. I notified his probation officer that Isaac was discharged for noncompliance.

I don't know what happened to him. That's the downside of working as a therapist in public agencies. Your clients are only yours for a set period of time. You develop a close emotional bond with (at least some of) them, and then they're gone. Hopefully because they completed the program successfully and they're on their way to productive independent life.

Others stop coming to treatment and disappear. Depending on why they were in treatment—whether it was their decision or whether they were mandated—you may or may not hear what becomes of them.

Randall was one such. He'd been forced to stop taking his medication for bipolar disorder while in prison upstate; for reasons I can't fathom, that was a requirement for release. By the time he landed in our program, referred by his parole officer, he was coping with his symptoms by smoking marijuana.

As usual after incarceration, it took weeks before his Medicaid was reactivated. During that time I tried to help him cope with his symptoms, especially anxiety. We discussed which medications had worked best for him in the past, so that he could tell his new psychiatrist. We processed some of his traumatic prison experiences.

Finally Randall's Medicaid recertification was approved, and we made an appointment for him to see a psychiatrist. He brought in the prescriptions he'd filled. And I waited to see his THC levels start declining.

They didn't. Every week, Randall had another excuse for why he had to keep smoking marijuana. The meds weren't working. He needed a dose adjustment. His living situation, with his mother and younger siblings, was stressful. (I suspected the younger siblings were also smoking marijuana, which couldn't have made abstinence any easier.) And week after week, his THC levels decreased and increased, dipped and resurged, never zeroing out.

Because of the rebound effect, while marijuana initially might make people feel relaxed and easy, its aftereffects can include increased anxiety. I tried to explain this to Randall, but, increasingly irritable, he refused to see the connection.

Every month I had to prepare a report for Randall's parole officer. It included his attendance and toxicology results. I tried to provide context for the bare facts; consideration for Randall's mental illness, the stress he was facing. But eventually I had to consider that Randall wasn't using marijuana to manage his bipolar symptoms. He was using because he couldn't stop.

I suggested rehab, but Randall declined: “I don't want to be locked up again.” I tried to convince him that rehab was a much less restrictive and punitive environment than prison. “And the food's much better too,” I said, lamely trying for a joke.

Randall wasn't convinced. He started missing appointments at our program. After two weeks of no attendance, I called him and pleaded for him to consider rehab.

“You don't understand!” Randall insisted. “You don't understand!” Nothing I said could coax him back. After another week of absences, I called his parole officer.

“Randall's in the wind,” he said—another strangely poetic term used to describe a harsh reality. On the run from parole, Randall wouldn't be able to use his Medicaid, see a psychiatrist or fill prescriptions. I don't know what happened to him.

I've tried to dispel some myths about marijuana. It can be physically harmful, sometimes greatly so. It can have curative powers, because it's a potent plant. It's definitely addictive, and its withdrawal symptoms can be both physical and emotional.

Marijuana users like to argue that it's less harmful than legal substances like alcohol and tobacco. That might be true, but that doesn't mean it's harmless—or not addictive. I've seen people with decades of heroin or crack use decide to stop using and succeed. But Randall and Isaac couldn't stop smoking marijuana. I guess they weren't ready to stop.