Commentary on Spradlin et al.: Is marijuana use common in OCD?

Abstract

Spradlin, Mauzay, and Cuttler (2017) report some of the most compelling data to date regarding the relationship between obsessive compulsive symptoms and cannabis misuse. Beyond establishing an association between these constructs, they validated a model which suggests that individuals with significant obsessive compulsive symptoms may use cannabis to cope with their distress, compounding overall misuse. Within the strengths of the study, there are two points upon which we wish to comment. First, Spradlin et al. (2017) fairly characterize their sample as an undergraduate cohort who endorsed significant cannabis use. It is unclear to what extent these findings may translate to clinical samples of individuals with obsessive compulsive symptoms. Clinically, we have seen very significant marijuana use among those reaching out for intensive treatment, which typically represents a more severe patient cohort relative to those managed in standard outpatient care. For instance, of 174 adults completing an intake interview inquiring about intensive OCD treatment over the past 6 months, 51 endorsed current or past cannabis use. This may suggest, similar to Spradlin et al. (2017) that a significant percentage of individuals with OCD may attempt to cope with obsessional distress through cannabis use. Interestingly, although there has been a relative proliferation of intensive OCD programs in the past decade, very few accept patients with significant co-occurring substance use. Given the relative frequency with which this is occurring, it poses a significant challenge for this complex patient cohort to access evidence based intervention. That is, if a person with significant OCD is using cannabis to maladaptively cope with obsessional distress, they would not be able to access appropriate care for both OCD and substance misuse, which would likely perpetuate the cycle of illness. With this in mind, we highlight the need for OCD specific dual diagnosis programming at intensive and residential levels of care. Second, Spradlin et al. (2017) note that using cannabis as a method of coping may function as a temporary solution that does not address maintaining factors in OCD. This point is a critical one. The cognitive-behavioral model of OCD (and any anxiety disorder for that matter) indicates that an obsessional trigger evokes distress which motivates compulsions and/or avoidance behaviors which negatively reinforces future symptom engagement (Abramowitz, 2006). Exposure to the potential of the feared outcome occurring teaches the affected person that the feared outcome does not take place, s/he can tolerate associated distress, and/or they can cope with the situation when it does not go ideally. Cannabis use, therefore, does not allow the patient to effectively and in an unaltered state successfully confront OCD triggers. In the absence of such corrective learning, both obsessive compulsive and cannabis use symptoms are likely to persist and exacerbate over time. Given evidence of cannabis as a gateway drug (Secades-Villa, Garcia-Rodríguez, Jin, Wang, & Blanco, 2015) together with the debilitating nature of OCD (Markarian et al., 2010), this combination has significant potential for resulting in sustained and escalating severity. In sum, Spradlin et al. (2017) represents an extremely important report drawing attention to a likely increasing phenomenon in light of growing access to medical marijuana. The psychiatric community at this time is ill equipped to treat OCD co-occurring with significant cannabis use (or any significant substance use for that matter). Therefore, further study and development of dual diagnosis interventions at varying intensities of care is warranted.