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INFLUENCE OF DISPOSITIONAL MINDFULNESS AND SPIRITUALITY ON READINESS TO CHANGE CANNABIS USE

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CHAPTER ONE

Introduction

It is estimated that between 155 and 250 million people or 3.5% to 5.7% of the world’s population aged 15-64 have used drugs at least once in the last 12 months (United Nations On Drugs and Crime, 2010). Out of this number, it is estimated that approximately one in six problem drug users accesses treatment each year (United Nations on Drugs and Crime, 2014). However, there are large regional disparities, with approximately 1 in 18 problem drug users receiving treatment in Africa (primarily for cannabis use), compared with one in five problem drug users receiving treatment in Western and Central Europe, one in four in Oceania, and one in three in North America., (United Nations on Drugs and Crime, 2014). There is an increasing trend in psychoactive substance use and abuse in many African countries (Adelekan, Ndom, Makanjuola, Parakoyi, Osagbemi, Fagbemi, & Pute 2000; Reddy, Resnicow, Omardien, & Kambaram, 2007). In Nigeria, for example, where substance abuse was uncommon many decades ago, there is today ample visual evidence of drug use on the roadsides and motor parks of most urban centers where young adults could be seen using marijuana (Rasheed & Ismaila, 2010). Industrialization, urbanization and increased exposure to western life style have been noted to contribute to the increasing trend of substances use in Nigeria with alcohol and cigarette acting as gateway drugs to the use of other substance like cocaine, heroine, amphetamine, inhalants and hallucinogens (Abiodun, Adelekan, Ogunremi, Oni, & Obayan, 1994A).

According to World health organization, (1986) a drug is any substance that, when absorbed into the body of a living organism alters bodily functions. It is also regarded as a chemical you take that effects the way the body works. Furthermore, a drug is a substance that has a physiological effect when ingested or otherwise introduced into the body, example of these drugs includes, cocaine, heroin, amphetamine, alcohol and marijuana. For most of European and Asian countries, opiates continue to be the main drug of abuse and account for 62% of all treatment demands. In South America, drug related treatment continue to be mainly linked to the use of cocaine (59% of all treatment demand).

However in Africa, the bulk of all treatment demand is linked to cannabis 64% (WHO, 2004). Cannabis, commonly known as marijuana and by numerous other names, is a preparation of the Cannabis plant intended for use as a psychoactive drug and as medicine (Harcout, 2007). Pharmacologically, the principal psychoactive constituent of cannabis is tetrahydrocannabinol; it is one of 483 known compounds in the plant (Russo, 2013). Including at least 84 other cannabinoids, such as cannabidiol, cannabinol, tetrahydrocannabivarin, (El-Alfy, Ivey, Robinson, Ahmed, Radwan, Slade, Khan, ElSohly, & Rossb, 2010; Fusar-Poli, Crippa, Bhattacharyya, Borgwardt, Allen, Martin-Santos, Seal, Surguladze, O’Carrol, Atakan, Zuardi, & McGuire, 2009), and cannabigerol. According to UNODC (2009), “the amount of THC present in a cannabis sample is generally used as a measure of cannabis potency.” The three main forms of cannabis products are the flower, resin (hashish), and oil (hash oil). The UNODC states that cannabis often contains 5% THC content, resin “can contain up to 20% THC content”, and that “Cannabis oil may contain more than 60% THC content.

Cannabis is consumed in many different ways (Golub, 2012). Smoking, which typically involves inhaling vaporized cannabinoids (“smoke”) from small pipes, bongs (portable versions of hookahs with water chamber), paper-wrapped joints or tobacco-leaf-wrapped blunts, roach clips, and other items (Tasman,  Kay, Lieberman, First & Maj, 2011).

Vaporizer, which heats any form of cannabis to 165–190 °C (329–374 °F) (Rosenthal, 2002), causing the active ingredients to evaporate into a vapor without burning the plant material (the boiling point of THC is 157 °C (315 °F) at 760 mmHg pressure).

Cannabis tea, which contains relatively small concentrations of THC because THC an oil (lipophilic) and is only slightly water-soluble (with a solubility of 2.8 mg per liter). Cannabis tea is made by first adding a saturated fat to hot water (e.g. cream or any milk except skim) with a small amount of cannabis (Gieringer & Rosenthal, 2008).

Edibles: Where cannabis is added as an ingredient to one of a variety of foods. Marijuana vending machines for selling or dispensing cannabis are in use in the United States and are planned to be used in Canada (Blackwell & Tom, 2013).

Cannabis has psychoactive and physiological effects when consumed (Onaivi, Sugiura, & Marzo, 2005).  The immediate desired effects from consuming cannabis include relaxation and mild euphoria (the “high” or “stoned” feeling), while some immediate undesired side-effects include a decrease in short-term memory, dry mouth, impaired motor skills and reddening of the eyes, feeling of paranoia or anxiety (Hall & Pacula, 2003). Aside from a subjective change in perception and mood, the most common short-term physical and neurological effects include increased heart rate, increased appetite and consumption of food, lowered blood pressure, impairment of short-term and working memory (Mathre, 1997; Riedel & Davies, 2005),   impaired psychomotor co-ordination and concentration.

Modern uses of cannabis are as a recreational or medicinal drug, and as part of religious or spiritual rites. The earliest recorded uses date from the 3rd millennium BC (Booth, 2003). Since the early 20th century cannabis has been subject to legal restrictions with the possession, use, and sale of cannabis preparations containing psychoactive cannabinoids currently illegal in most countries of the world. The United Nations deems it the most-used illicit drug in the world, (United Nations on Drugs and Crime, 2010). In 2004, the United Nations estimated that global consumption of cannabis indicated that approximately 4% of the adult world population (162 million people) used cannabis annually, and that approximately 0.6% (22.5 million) of people used cannabis daily, (United Nations Office on Drugs and Crime 2006).

The medicinal value of cannabis is disputed. The American Society of Addiction Medicine dismisses the concept of medical cannabis because of concerns about its potential for dependence and adverse health effects. The United State Food and Drug Administration (FDA) states that the herb cannabis is associated with numerous harmful health effects, and that significant aspects such as content, production, and supply are unregulated. The FDA approves of the prescription of two products (not for smoking) that have pure THC in a small controlled dose as the active substance, (Scholastic, 2012).

Substance use became a public health issue in Nigeria in the 1960s with the discovery of cannabis farms in the country, arrests of Nigerian cannabis traffickers abroad, and reports of psychological disorders suspected to be associated with cannabis use (Obot, 2003). By the 1980s, the abuse of cocaine and heroin was added to the public health burden. Soldiers and sailors returning from Second World War introduced cannabis into Nigeria. The later introduction of cocaine and heroin into Nigeria was attributed to Nigerian Naval Officers in training in India who was involved with trafficking activities in the early 1980s (Obot, 2003). The most abused illicit drug in Nigeria is Indian hemp (marijuana, cannabis sativa, ganja, bush, igbo, we-we, gbanaa, hashish etc.), mainly in its herbal form. This is due to the fact that cannabis is home grown and relatively cheap. The price of one unit of cannabis is often about the same as that of a bottle of beer (UNODC, 2013). At 14.3%, the country has the highest one-year prevalence rate of cannabis use in Africa (UNODC, 2011; Onifade, Somoye, Ogunwale, Akinhanmi, & Adamson, 2013). The average globally assessed prevalence rate of cannabis use is 3% (UNODC, 2013).

The burden of use and effects of marijuana and other psychoactive substances on the youths is assuming a dangerous dimension (Eneh, 2004; Pela, 1989; Stanley, & Salines, 1991). In a study by Eneh and colleagues among secondary schools students in Rivers State, Nigeria, the prevalence rate of cannabis use was found to be 26%. While a study among secondary school pupils and high school pupils in Zambia and Santiago Chile found a prevalence rate of 10% and 7.3% respectively (Haworth1982; Florenzo, Mantelli, Madrid, Martini, & Salazar, 1982).

In a similar study carried out in Ilorin (Abiodun,  Adelekan,  Ogunremi,  Oni,  & Obagan 1994B) the psychological correlates associated with cannabis smoking were male sex, self-rated poor academic performance and self-reported poor mental health. Another study in Ilorin, Nigeria (Abiodun, et al, 1994) it was found that current use of cigarettes and cannabis occurred significantly more in the male population. No significant sex differences were noted for other drugs (salicylates, analgesics antibiotics and stimulants) surveyed. In South Africa, a study of illicit drug use among high school adolescents (Madu & Matla, 2003) found that drug use, cigarette smoking and alcohol consumption are associated more with males than with females and most of the respondents do so when they are bored, tired or stressed up or at parties.

In a neurological study by Albert, Bhattacharyya,Yucel, Poli, Crippa, Nogue, Torrens, Pujol, Farre and Santors, (2013) comparing different structural and functional imaging studies showed morphological brain alterations in long-term cannabis users which were found to possibly correlate to cannabis exposure. In another study by Santors, Fagundo, Crippa, Atakan, Bhattacharyya and Allen, (2010) found resting blood flow to be lower globally and in prefrontal areas of the brain in cannabis users, when compared to non-users. It was also shown that giving THC or cannabis correlated with increased blood flow in these areas, and facilitated activation of the anterior cingulate cortex and frontal cortex when participants were presented with assignments demanding use of cognitive capacity. Both reviews noted that some of the studies that they examined had methodological limitations, for example small sample sizes or not distinguishing adequately between cannabis and alcohol consumption.

Within the treatment field, there is growing recognition that individuals vary in their readiness-to-change (Carey, Purnine, Maisto, & Carey, 1999a). For example, (Prochaska, DiClemente, & Norcross, 1992) have provided a useful heuristic for understanding varying levels of motivation for change. Within their Transtheoretical Model, they posit five stages to represent the continuous and cyclic process by which people change addictive behaviors (precontemplation, contemplation, preparation, action and maintenance), and note that the vast majority of persons addicted to substances are not in the action stage (Prochaska & DiClemente, 1992). These stages will be discussed on a later part of this work. Even persons admitted to alcohol and drug treatment programs vary in their level of motivation for change (DiClemente & Hughes, 1990; Project MATCH Research Group, 1997).

Readiness-to-change may be considered a motivational state that is strongly influenced by cognitive, affective, environmental and interpersonal events (DiClemente, 1993). In addition, the notion of decisional balance (e.g., subjective pros and cons, or benefits and costs of a certain behavior) has been identified as a related construct that is a sensitive marker of movement through the early stages of change (Prochaska, Velicier, Rossi, Goldstein, Marcus, Rakowski, Fiore, Harlow, Redding, Rosenbloom, & Rossi, 1994). Self-report methods have often been used to measure readiness-to-change (Carey, et al., 1999a). A considerable literature has developed on the psychometrics of instruments purporting to assess readiness-to-change in substance abusing populations (Carey et al., 1999a). However, little evaluation of basic psychometric indices (e.g., reliability of measurement and construct validity) has been conducted with persons who have severe mental illness. In this special population of substance users, concerns have been raised regarding the degree to which diagnostic status, cognitive function or psychotic symptoms may influence the accuracy of a readiness-to-change assessment (Bellack & DiClemente, 1999). For example, deficits in self-awareness or abstract thinking seen in persons with schizophrenia may compromise their ability to self-report interest in and intentions to change. Also, the presence of negative symptoms (e.g., avolition, anergia and anhedonia) may interfere with the assessment of such motivational constructs as readiness-to-change. For these reasons, it is important to determine empirically whether readiness-to-change and/or decisional balance can be assessed reliably and validly in users who have not presented for treatment.

It is important to distinguish between “readiness-to-change” and “motivation-for-change”, readiness-to-change is the overarching construct. Motivation-for-change can be considered an internal cognitive/affective state, and can be considered necessary for behavior change (or maintenance of changes). Readiness-to-change, on the other hand, can be considered a broader construct, reflecting a number of factors that, combined, indicate the likelihood that someone will begin (or continue) to engage in behaviors associated with substance use reduction (e.g., including therapy, self-initiated quit attempts, or other behaviors in support of reduced use) (Carey, Purnine,  Maisto, Carey, & Barnes, 1999b). Readiness-to-change, therefore, includes motivation-for-change as well as other factors, including relevant behavioral skills and supporting external factors. In addition, resources and barriers may be presumed to affect motivation as well as action itself, through various paths. For example, a patient may be more likely to engage in change-related behaviors if he/she feels ready and willing to change, and if he/she has acquired the skills that make success more likely and if he/she anticipates receiving support and reinforcement from change efforts. A person with low motivation and few resources may first benefit from a motivational intervention, followed by skills training (Carroll, 1998). The present study seeks to examine the contribution of mindfulness and spirituality to readiness to change drug use among cannabis users.

Within the field of addictive behaviors, a growing number of studies have assessed efficacy of mindfulness-based interventions for problematic substance use (Chiesa & Serretti, 2013), and studies to date suggest several possible mechanisms. Neurobiological mechanisms in areas associated with craving, negative affect, and substance use relapse may be affected by mindfulness training (Witkiewitz, Lustyk, & Bowen, 2012), altering basic neurobiological processes related to reactive behaviors (Brewer, Elwafi, & Davis, 2012). Over 1000 articles and books became available on the topic over the past two decades. Mindfulness stems from Buddhist philosophy and meditation. It refers to a conscious and unbiased experience, with a focus on the temporary passing quality of thoughts, feelings, and life in general (Kabat-Zinn, 2003). Mindfulness meditation allows individuals to interpret bodily signals and the world around them without applying traditional value statements and feelings to them. Value statements can include self-talk such as “I’m pathetic for feeling guilty,” or “it’s shameful that I can’t stay focused on this meaningful conversation.” This type of inner commentary can be harmful because individuals are adding a layer of negativity to an already difficult situation. This negativity can result in feeling worse and less able to solve a problem, when perhaps one should not feel bad at all. By interpreting signals in their original form, an individual practicing mindfulness can evaluate events clearly without adding confusing and possibly inaccurate messages of emotional reactions or associations. This type of unpolluted experience can help individuals understand and respond to events clearly and honestly (Gunaratana, 2002).

For example, although an individual may see a nice car passing by and become overwhelmed by jealousy and begin to think negative thoughts about the driver, one employing mindfulness will observe the feeling of jealousy, label it as jealousy, and then allow the feeling to pass without dwelling on it or judging the emotion as wrong or shameful.  Similarly, an individual with a drug addiction may relapse every time he passes by a location where he previously used substances that taps into the feelings he used to associate with substance abuse. With mindfulness training, an individual becomes keenly aware of his body and mind, noticing that as he passes a certain area their pulse begins to increase and a somewhat nervous sort of feeling arises. An individual can label this feeling as a craving, observe that it will pass just like any other feeling, and allow it to do so without acting on it or judging the craving.

Traditionally used as a component of meditation, mindfulness is employed in clinical settings as a technique for reducing stress and managing cravings (i.e., Anderson, Lau, Segal, & Bishop, 2007; Witkiewitz, Marlatt & Walker, 2005). Mindfulness-based meditation (MBM) practitioners are able to assess consciously drug-related cravings and motivations for engaging in substance use, thereby allowing them to respond without succumbing to cravings. Although situational cues to cravings are typically included in relapse prevention programs, the addition of mindfulness base meditation better allowed participants to increase their awareness and self-monitoring of cues to use substances. While increasing their awareness, participants become more present-oriented (by releasing obsessions with the past or future, as well as continually observing the present environment), and decrease impulsivity through being aware and thoughtful of their motivations. Mindfulness base meditation also seemed to increase self-efficacy through its use as a challenging skill, and may be useful as an alternate behavior to substance use. Witkiewitz and colleagues (2005) commented that by practicing mindfulness skills during high-risk situations, the reinforcing qualities previously associated with the addictive substance are counter-conditioned. By focusing on the present moment, clients are not less likely to ruminate and feel guilty about past occasions they have used in that situation, nor do they think about the future gratification of using a substance.

Engaging in thought suppression, such as attempting to ignore all thoughts related to drinking in order to curb alcohol consumption, can have deleterious consequences. Researchers have linked thought suppression to increased substance use in individuals trying to maintain sobriety (Bowen, Witkiewitz, Dillworth, & Marlatt, 2007). Mindfulness base meditation decreases the avoidance of difficult thoughts and events because it involves accepting all thoughts into consciousness, regardless of their acceptability or associated discomfort. Furthering Witkiewtiz and colleague’s (2005) findings, Bowen, (2007) examined the role of MBM in thought suppression using a population of incarcerated males. The MBM helped decrease thought avoidance and contributed to an overall decrease in alcohol use and alcohol-related deleterious consequences during a 3-month period after release from jail. Murray and Leigh, (2005) found MBM to work though similar mechanisms (metacognition, acceptance of thoughts and emotions, etc.) as a tool for decreasing avoidance-coping strategies in teaching participants to discontinue the use of escapism to tolerate negative events.

The posited protective role of spirituality is a well-known phenomenon that has been associated with substance use and misuse (Mohr & Huguelet, 2004; Kendler , Liu, Gardner, McCullough, Larson, & Prescott, 2003; Booth & Martin, 2001). There is no doubt that spirituality has become an important topic in today’s world (Avants, Marcotte, Arnold, & Margolin , 2003).  Among the general public a new sense of spiritual freedom, openness to eastern religions, to new age approaches, to alternative therapies, and to Native American and other spiritualties has added great variety to the spiritual landscape of America (Doubleday, 2005).  Introspection, self-help movements, pursuit of the inner child, and various 12 Step approaches has also had a widespread impact.  Surveys reported in the popular news media indicate that nearly 80% of Americans believe in the power of prayer to improve the course of illness (Wallis, 1996).  Likewise, health care workers also strongly believe in the power of spirituality to influence the course of medical and psychological interventions as well as the rate of recuperation from chronic illnesses (Piedmont, 2001).

For many of those who work in the addiction treatment field, the use of spiritual concepts in the treatment of alcohol and drug addiction is seen as the clearest demonstration of the value of spirituality and this construct is seen as the central curative factor in recovery (Piedmont, 2001).  Other research has shown that increased spiritual practices have been associated with improved addiction treatment outcome (Carter, 1998), that spirituality has played a role in maintaining treatment gains (Koski-Jännes & Turner, 1999), and that recovering individuals apparently show more evidence of spirituality than those who relapse (Jarusiewicz,  2000).  Although the word ‘spirituality’ has been used increasingly in the literature of the medical and social sciences, the variations in how this word is defined and measured are highly problematic in making sense of the results.

Human beings are a composite of essential parts—physical, emotional, social, and spiritual, working interchangeably to comprise balance and harmony in the whole person (Fiske, 2002).  The term spirituality generally refers to the human longing for a sense of meaning and fulfillment through morally satisfying relationships between individuals, families, communities, cultures, and religions. Although often viewed in a religious context, spirituality is not necessarily about being religious.  Spirituality is about responding to the deepest questions posed by an individual’s existence with a whole heart.  Religion refers to organized structures that center around particular beliefs, behaviors rituals, ceremonies, and traditions (Canda & Furman, 1999).

During the last five years, several expert committees from the addiction/health fields have grappled with a scientific conception of spirituality (Larson, Swyers, & McCullough, 1998; Miller& Thorensen, 2001; NIAAA, 1999 as cited in Miller, 2003a).  Miller (2003a) summarized the findings of these committees into several working assumptions about spirituality: Spirituality is not interchangeable with religion; it is one principle area of concern for religion, but religions also have other non-spiritual goals and purposes. Spirituality is best understood as a characteristic of individuals.  It includes the individual’s “religion” or religiousness, but is not defined in relation to religion.  Spirituality is not a commodity that is present or absent, or one that is possessed in amount.  Spirituality is multidimensional and is best understood as comprised of multiple dimensions including: behavior and practices; beliefs; motivations and values; and, subjective experience.  Every person can be located somewhere within the multidimensional space of spirituality.  The assessment of spirituality has to do with understanding the person’s location along the multiple dimensions.

Furthermore, those who prayed and read the bible several times a week were 42% less likely to have a diagnosis of an alcoholic disorder within the prior six months as compared to the rest of the sample (Koenig, George, Meador, Blazer, & Ford, 1994). The practice of transcendental meditation is associated with lower risk of substance use (Aron & Aron, 1980). Lower risk of alcohol use disorders has been associated with private practices of prayer and scripture reading (Koenig et al., 1994). More than a dozen studies have found that alcohol/drug abuse is associated with a lack of sense of meaning, on the Life Purpose Scale, relative to control samples (Crumbaugh & Maholick, 1969; Black, 1991). In a study of over 2,000 female–female twins, Kendleretal,  (2003) reported that current drinking and smoking as well as lifetime risk for alcoholism and nicotine dependence were inversely associated with personal devotion (such as frequency of praying and seeking spiritual comfort), fundamentalist Christian beliefs, and conservative religious affiliation. It was reported, in a study assessing  spirituality  among opiate or cocaine users seeking treatment, that frequent time spending on spiritual activities showed significantly better outcomes in terms of subsequent drug use and treatment retention (Heinz, Epstein, & Preston, 2007). Spirituality is significantly related to use and attitudes towards marijuana by serving as a protective factor. In another study, Connors, (2003) found that higher scores on several measures of spirituality predicted higher rates of abstinence at the six-month follow-up.  Avants, et al, (2003) found that perceived support and comfort from spiritual beliefs positively influenced recovery from addiction.

Statement of the problem

Cannabis use in the Nigeria society has become an issue of serious concern and constitutes one of the most important risks taking behavior among young adult. Despite worldwide concern and education about cannabis use, many only have limited awareness of their adverse consequences (Eneh, 2004).

Cannabis has been used to reduce nausea and vomiting in chemotherapy and people with HIV/AIDS, and to treat pain and muscle spasticity (Borgelt, Franson, Nussbaum &Wang, 2013). According to Borgelt and colleagues, (2013) Safety concerns regarding cannabis include the increased risk of developing schizophrenia with adolescent use, impairments in memory and cognition, accidental pediatric ingestions, and lack of safety packaging for medical cannabis formulations.

Similarly, Gordon, Conley, and Gordon, (2013) reported that exposure to marijuana had biologically-based physical, mental, behavioral and social health consequences and was associated with diseases of the liver (particularly with co-existing hepatitis C), lungs, heart, and vasculature.

Numerous studies have been conducted (e.g Eneh, 2004; Borgelt, Franson, Nussbaum &Wang, 2013; Gordon, Conley, & Gordon, 2013) to unravel the etiological complexities of cannabis use in an attempt to search for effective prevention programs. However, it is evident from studies done that a variety of factors account for frequent use of cannabis in our society. Some of these factors include family and peer-group influence, exposure to mass media content, and low level of self-esteem. The present study intends to address the following problems.

  1. Would dispositional mindfulness significantly influence readiness to change cannabis use?
  2. Would spirituality significantly influence readiness to change cannabis use?

Purpose of the study

The purpose of this study is to:

  1. Examine whether dispositional mindfulness will influence readiness to change cannabis use.
  2. Investigate whether spirituality will influence readiness to change cannabis use.

Operational Definitions of Terms

Mindfulness: This means maintaining a moment-by-moment awareness of  thoughts, feelings, bodily sensations, and surrounding environment as measured by Five Facet Mindfulness Questionnaires (Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006).

Spirituality: This is more of an individual practice and has to do with having a sense of peace and purpose as measured by Spiritual Experience Index-Revised (Genia, 1997)

Readiness-to-change: This is a motivational state that is strongly influenced by cognitive, affective, environmental and interpersonal events as measured by the Stage of Change Readiness and Treatment Eagerness Scale (SOCRATES 8D) (Miller & Tonigan, 1996).

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