Dual Diagnosis: Open Access Open Access

Keywords

Marijuana addiction; Drug use; Substance abuse

Introduction

The proposed study will examine child welfare social worker’s perceptions of marijuana use as compared to the perceptions of opiate use among pregnant women. The proposed study will attempt to identify if there is a significant difference in social worker’s perceptions between these two groups of women and determine if a person’s life experiences or other demographic information might play a role in creating a perception. Once perception is determined, the researcher will analyse the data to conclude if it would be beneficial to advocate for increased availability of treatment options for marijuana addicted pregnant women.

Statement of the problem

According to both the American Society of Addiction Medicine (ASAM) and the Substance Abuse and Mental Health Services Administration (SAMHSA), use of marijuana and opiates are only increasing. Based on this it would seem to make sense if the general public’s perceptions of marijuana and opiate use were changing due to the increase in use and abuse of these drugs. When considering those who use these substances, a particular section of this population is in need of specific attention: pregnant women. This group of substance users are judged especially harshly by society due to a lack of education around why people use and abuse substances [1]. Another issue at hand is that both marijuana and opiates are legal and prescribed throughout the United States, but even so, somehow the thought of a pregnant woman using marijuana seems to be more forgiven than a pregnant woman who is using opiates [2]. In part due to this disparaging and overall disapproving view held by much of society, there are significantly less treatment options to address marijuana addiction. This research aims to link people’s perceptions to their behaviour, and also wants to assist in determining if there is a need to advocate for more treatment options when it comes to marijuana addiction [3].

Scope of the problem

As of 2015, over 2.5 million Americans had a substance use disorder related to opiates, and 4 million Americans were either dependent on or used marijuana [4]. These statistics are astounding, and this problem has an enduring effect on all parts of American society. The disease of substance abuse does not discriminate based on race, income level, or gender [5]. Furthermore, if the disease of substance abuse is not treated appropriately then the person with this illness will likely continue to have a negative impact on their own life as well as anyone else in their life, including their children.

Justification and purpose of the proposed study

The proposed research will be asking the following questions: Do even professional social workers have a harsher perception of pregnant women who use opiates as compared to pregnant women who use marijuana? If so, why, as both substances are legal and both can have detrimental effects on mother and child? Based on the research results, is there a need to expand treatment options for pregnant women who are using either marijuana or opiates? This study is important for many reasons. First among these is the fact that there is a gap in the research when it comes to looking at social worker’s perceptions of pregnant women who use marijuana and comparing them with those who use opiates. There is a need to study professional social worker’s perceptions of these groups of people through the Social Learning Theory lens in order to collect data and help determine the link between human perception and human behaviour, specifically related to the treatment referrals made by social workers. Using the data collected throughout this study, it might be possible to make a case for an increased need for treatment options to address marijuana addiction, as there are currently significantly fewer options to treat this as compared with opiates [6].

Review of Literature

This review of the literature was initiated by an advanced search through the following databases: ProQuest: Social Science Database and Health & Medicine Database, PsychINFO via EBSCOhost, and JSTOR, as well as other reputable web sources directly related to the topic of substance use. Textbooks were also utilized in order to obtain the most relevant information. The articles are predominately limited to the past 10 years, with a few exceptions for notable articles. Throughout the review of the literature the statistics regarding drug use in America turned out to be quite striking. According to the American Society of Addiction Medicine (ASAM) as of 2015, over 2.5 million Americans had a substance use disorder related to opiates [4]. Even more stunning, according to the Substance Abuse and Mental Health Administration (SAMHSA) as of 2015, 4 million Americans were either dependent on or used marijuana [7]. These statistics are staggering, and according to both ASAM and SAMHSA, use of marijuana and opiates are only increasing. With these statistics being what they are, it would make sense if the general public’s perception of marijuana and opiate use was changing due to the increase in popularity of these drugs. According to those who consume illicit drugs tend to have a more accepting perception of drug use in general [8]. However, a specific subset of the substance using population in the United States is pregnant women. This group of substance users endures a particularly complicated perception of their drug use from the general public due to carrying a child [2]. It would be interesting to discover if those who are marijuana users are afforded more leniency in the court of public opinion as compared to opiate users seeing as how both of these substances are legal in parts of the United States.

In this paper we will specifically explore social worker’s perceptions of marijuana use versus opiate use among pregnant women. This population is significant due to the fact that there appears to be a gap in the literature when it comes to comparing professional social worker’s perceptions of pregnant women’s use of marijuana to pregnant women’s use of opiates. To take this a step further, it is important to consider this topic in order to understand the need for increased education regarding substance abuse as a disease, not a choice, no matter the substance, and subsequently expand treatment options for pregnant women who are using one of these substances, if this is found to be necessary at the end of the study. This will be examined first by defining the topics and looking closely at the perceptions of marijuana use in the United States, followed by uncovering the perceptions of opiate use in the United States. Next the trends in the literature will be considered to include demographics as well as education or awareness. Finally, ending with understanding the importance of perception and human behaviour through the lens of the Social Learning Theory. Throughout the review of the literature, careful attention will be paid to studies that include pregnant women, as this is the target population for this particular analysis.

Definitions

Marijuana: Marijuana is a plant that has the chemical ingredient delta-9-tetrahydrocannabinol or THC for short. This chemical reacts with the human brain to create a mind-altering result when ingested in the body. Usually smoking the plant does this, but mixing it into foods and eating it can also accomplish the psychoactive effect [9]. Marijuana has been illegal in the United States since the early 1900s, but on January 1, 2014 the state of Colorado began allowing the sale of this drug for recreational use [10]. This change in the legal status of marijuana has raised many questions for professionals in a variety of fields from doctors to mental health professionals to law enforcement officers. It is also notable that the medical use of marijuana is legal in 23 states and Washington D.C., but not all 50 states.

In reviewing the literature further there are many who have serious concerns with marijuana use as it relates to a person’s physical health. Marijuana can be linked to such medical risks as cardiac, pulmonary, hepatic, and vascular disorders and an increased likelihood of infectious diseases and cancer [11]. Moreover, marijuana has been connected with serious mental health concerns such as psychosis and suicidal ideation; it has also been linked to depression and anxiety [9,10] additionally reports that the potential for abnormal fetal development is increased among pregnant women who use marijuana, as well as a newborn’s probability to have an unpleasant temperament upon birth. Specific to pregnant women, there have been studies that connect marijuana use during pregnancy to preterm labor, low birth weight, and stillbirths, all of which are serious medical concerns for both mother and child [12]. However, in being sure to remain objective, there are other studies still that have been reviewed that indicate no difference in birth outcomes of the newborn [13].

As it relates to formal treatment of cannabis use disorder, the literature is vague regarding what options are most common and most effective, but some that are mentioned are a harm reduction model of lessened use, regular psychotherapy to include Motivational Interviewing (MI) techniques, and medication management, if deemed appropriate. On the other hand, the literature is very specific as to how professionals who are working with pregnant substance using women should proceed in their care of the patient: supportively and nonjudgmentally in order to provide the most effective care [14]. It is important to point out that the literature is lacking in specific treatment modalities regarding marijuana use disorder. Perhaps this is so because of the pervasive perception in American society that marijuana is not a harmful drug when compared to other illicit substances available today.

Opiates: Opiates come in many forms; for clarity the CDC breaks down the drug class of opiates or opioids into four categories: natural opioid analgesics (or prescription opioids) that include morphine, codeine, oxycodone, hydrocodone, hydromorphone, and oxymorphone; methadone, a synthetic opioid; synthetic opioid analgesics other than methadone, including drugs such as fentanyl and tramadol; and heroin, an illicit opioid made from morphine [15]. However, no matter the category opioids fall into according to the CDC, they all have a similar effect when consumed. Throughout the literature it is clear that opioids are highly addictive due to the euphoric high they produce when taken. Opiates are typically prescribed to combat pain, and as expected, this drug has a remarkable effect on the nerves in the human body that lessens pain greatly [16]. Unfortunately, these drugs are frequently misused which too often leads to overdose. In fact, there are many articles in the literature at this time that discusses the “opioid epidemic” [17-19] as the occurrence of opioid-related overdoses has increased from roughly 19,000 in 2014 to 22,000 in 2015 [15]. Similarly, according to [20] doctors throughout America have continued to prescribe opiates in increased amounts, to the point that they are the most commonly prescribed medications in the country.

This increase in use of opioids undoubtedly encompasses pregnant women as well. To that end, each year there are many infants who are born addicted to opiates due to their mother’s use of legal or illegal versions of the drug. Moreover, between 2000-2009 the rate of children born with withdrawal symptoms from opiates tripled [20]. These withdrawal symptoms include but are not limited to tremors, irritability, seizures, tight muscle tone, and sleep problems [21].

Partially due to the current societal awareness of the negative effects of opiate use, there are many treatment options throughout the country for opioid use disorder. These treatment options include Substance Abuse Intensive Out Patient Therapy (SAIOP), residential treatment programs, Cognitive Behavioural Therapy (CBT), Dialectical Behavioural Therapy (DBT), and methadone maintenance, among others [6]. To be clear, when comparing treatment options the literature discusses regarding marijuana use disorder, there are significantly more evidencebased treatment options for opioid use disorder throughout the country.

Social learning theory: Cognitive behaviourist, or social learning theorist, Albert Bandura, first articulated the Social Learning Theory. Mr. Bandura endeavours to understand people through the belief that individuals are able to have a consequential impact on their environment. Meaning, the way that people process information provided to them determines how they react to any given situation [3]. This theory is particularly important to the topic of social worker’s perceptions of marijuana use versus opiate use among pregnant women because it is directly related to how people react to information provided to them, such as a pregnant woman using marijuana or opiates, and how they process this information and then form a perception based on their personal experiences. In fact, the Social Learning Theory helps to illustrate the fundamental relationship between perception and human behaviour, as these two things go hand in hand.

According to Bandura, the Social Learning Theory combines learning and cognitive processes to explain behaviour. In his most renowned experiment Bandura revealed the powerful influence of observational learning by exposing one group of children to a movie that incorporated children participating in violent behaviours, and another group of children exposed to a movie that was considered neutral. After having viewed the films both groups of children were taken to a playroom and were permitted to play freely. The outcome of this experiment was that the children who had observed the more violent movie employed more violent behaviour than the other children in the experiment [3]. The importance of a person’s perception when it comes to how it directly affects their behaviour is captured in this experiment, and is further explored throughout the literature, specifically as it relates to substance use [1,22-24].

Trends

Demographics: A review of the literature shows that using Social Learning Theory to explain people’s opinions and perceptions regarding drug use is common, as mentioned previously. According to the research, it appears that a person who has used some type of substance in the past tends to hold a more accepting view on substance use in general [8]. The literature also tells us that being male and younger has been associated with positive attitudes regarding marijuana use [25]. Furthermore, the research available shows that the media and government’s focus on fighting against or legalizing certain drugs has a direct effect on attitudes held toward marijuana and opiate use [1].

However, there is a gap in the research when it comes to comparing perceptions while taking into account the participant’s race, ethnicity, place of employment, and socioeconomic status. It would be interesting to discover if a person’s race, ethnicity, place of employment, or socioeconomic status plays a part in how they perceive a pregnant woman using marijuana as compared with the perception of a pregnant woman using opiates. The Social Learning Theory would tell us that depending on what experiences a person has had, these will help to determine how they perceive things, and based on this, it is likely that a person’s race, ethnicity, place of employment, and socioeconomic status would also contribute to the view developed regarding this topic [3]. The literature reviewed uses the Social Learning Theory as a theoretical framework for exploring substance use among teenagers mostly and largely fails to consider the societal perceptions of substance using pregnant women [1,8,26].

Education/Awareness: A common theme throughout the examination of the literature is that increased exposure to substance use is linked to a person’s perception being more tolerant of others using substances [1,23].

Education and awareness are crucial determining factors to how a person interprets the idea of a pregnant woman using marijuana, or a pregnant woman using opioids, and where either of these aforementioned behaviours lies on a continuum of concerning practices. Due to the consistent findings in the literature, special attention will be paid to the education level and awareness or exposure a person has had to substance use when conducting future research on this topic.

Perception

After a careful review, the conclusion was reached that the existent literature minimally addresses perceptions of drug use in general, and completely fails to examine the perception of marijuana use versus opiate use among pregnant women [1,8,26]. This is unfortunate as the notion of perception is significant, and is often linked to human behaviour. This study attempts to understand how people perceive pregnant women who use marijuana as compared to pregnant women who use opiates and to consider this topic in order to advocate on behalf of the need for increased education regarding substance abuse as a disease, and subsequently expand treatment options for pregnant women who are using one of these substances, if this is found to be necessary at the end of the study.

When reviewing the literature regarding marijuana use, the research indicates that it is likely that perceptions of pregnant women using marijuana will not be favourable, but they also will not be as condemning as the views regarding a pregnant woman using opiates [27]. This is based on the mixed findings throughout the research regarding the effects on the fetus of exposure to marijuana. There is a significant health risk associated with fetal exposure to marijuana [12]. Conversely, [13] conclude differently and determine that there are no statistically significant findings regarding harm or potential harm to a child exposed to marijuana in utero.

In regards to perceptions of pregnant women using opiates, the research is clear that this behaviour is seen as definitively detrimental to both the mother and child [18-20,28]. The only minor exception to this view is when it comes to physician prescribed methadone in order to assist the mother with a previously diagnosed addiction to a different form of opioids [20].

To this end, the cultural impacts of these perceptions are all but staring us right in the face: there are significantly more substance abuse treatment providers available to assist pregnant women with opioid use disorder than there are to assist women with cannabis use disorder [29]. This is important because even though not every researcher agrees, there is data available that clearly show possible negative bearings marijuana can have on an infant as well as a new mother [14]. The need for increased education regarding the possible implications of marijuana use while pregnant is clear.

Conclusion

The purpose of this review was to examine the literature currently available on the topic of perceptions of marijuana use versus opiate use among pregnant women. It is clear, based on the research reviewed, that marijuana and opioids both have legitimate medicinal uses. It is also true that both of these substances have their professional critics due to a number of adverse effects each of these substances boasts. As it relates to the perceptions social workers hold of marijuana use and opiate use among pregnant women, this is a place in the literature that needs to be further explored in order to most benefit pregnant substance-abusing women through increased education of society regarding substance use disorders and additional treatment modalities, if the findings deem this necessary. This subject should continue to be evaluated through the Social Learning Theory framework in order to best understand the interconnectedness of perception and human behaviour, and how these two things can come together to create greater societal change.

It is vital that social workers and other social service professionals do not allow their perceptions or personal biases cloud their judgment when providing treatment options to clients. Whether a client is pregnant and using marijuana or opiates, both substances can be very harmful to the unborn child. It is essential that social workers self-awareness when treating clients [30].

Social workers shall demonstrate an appreciation of their own cultural identities and those of others. Social workers must also be aware of their own privilege and power and must acknowledge the impact of this privilege and power in their work with and on behalf of clients. Social workers will also demonstrate cultural humility and sensitivity to the dynamics of power and privilege in all areas of social work.

It is essential that practitioners are aware of the private and power they have in their professional perceptions towards their clients. If practitioners are unaware of their power and attitudes, it can lead them to stereotype clients' as wells as their service referrals and treatment recommendations. The [30] stated: "Self-awareness and self-reflection also helps in understanding the process of cultural identity formation and helps guard against stereotyping." Social work and social service professionals must continue to use self-awareness and reflection to provide competent and professional practice. As opioid and cannabis misuse continues to be on the rise, it is vital that social work, social service, and human service professionals contribute more research on this subject matter.

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