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Addiction (1998) 93(4), 493 503
RESEARCH REPORT
Marijuana use and treatment outcome among
opioid-dependent patients
ALAN J. BUDNEY, WARREN K. BICKEL & LESLIE AMASS
University of Vermont, Departments of Psychiatry and Psychology, 200 Twin Oaks Terrace,
S. Burlington, VT 05403, USA
Abstract
Aims. Information concerning the association between marijuana use and opioid dependence and its
treatment is needed to determine effective clinical guidelines for addressing marijuana use among opioid
abusers. Setting and participants. Marijuana use was assessed in 107 people enrolled in treatment for
opioid dependence. Design and measurement. Univariate comparisons of marijuana users and non-users
and multivariate regression analyses were performed to examine associations between marijuana use and
socio-demographic, psychosocial, medical and substance-use variables. The relationship between marijuana
use and treatment outcome was also explored in a subset of this sample who received treatment that included
buprenorphine detoxi cation and behavior therapy (N 79). Findings. Sixty-six per cent of participants
were current marijuana users and almost all (94%) continued to use during treatment. Users were less likely
to be married than non-users, and more likely to report nancial dif culties, be involved in drug dealing and
engage in sharing of needles (p 0.05). A unique effect of marijuana use on drug dealing and sharing needles
was retained after statistically controlling for the in¯ uence of heroin and alcohol use and other socio-demo-
graphic variables. No signi cant adverse relations were observed between marijuana use and treatment
outcome. Conclusion. Pending a more comprehensive understanding of the function and consequences of
marijuana use on psychosocial functioning, it appears that progress in treatment for opioid dependence can
be made without mandating that patients abstain from marijuana use.
Introduction
The majority of opioid-dependent individuals
who seek treatment in the United States are
polydrug abusers. Marijuana use is the most
prevalent type of illicit substance use among this
clinical population with estimates of concurrent
use ranging from 50% to 85% (Ball et al., 1988;
Saxon et al., 1993; Darke & Hall, 1995; Niren-
berg et al., 1996). Such high marijuana-use rates
raise at least two important clinical questions.
First, what types of impairment and adverse
consequences are associated with marijuana use
among opioid abusers? Secondly, does concur-
rent marijuana use present additional treatment
needs or affect outcomes? Scienti c information
addressing these issues is needed to determine
how to effectively approach marijuana use in
opioid-dependent patients.
Adverse effects associated with marijuana use
have been reported in diverse populations. Mari-
juana-related impairments in health, psychoso-
cial and psychiatric functioning in non-clinical
populations have been observed (Halikas et al.,
1983; Kandel, 1984). Substantial numbers of
Correspondence to: Alan J. Budney PhD, Department of Psychiatry, University of Vermont, 200 Twin Oaks
Terrace, S. Burlington, VT 05403, USA. Tel: 802-865-3333; Fax: 802-865-3396; e-mail: abudney@zoo.uvm.edu
Submitted 11th April 1997; initial review completed 28th July 1997; nal version accepted 10th October 1997.
0965 2140/98/0400493 11 $9.50 Society for the Study of Addiction to Alcohol and Other Drugs
Carfax Publishing Limited
494 Alan J. Budney et al.
individuals seek treatment for problems related
to marijuana use and the majority of such people
exhibit symptoms of marijuana dependence
(Stephens, Roffman & Simpson, 1993). Mari-
juana-associated impairment has been detected
even among individuals seeking treatment for
cocaine dependence (Budney, Higgins & Wong,
1996). The speci c types of marijuana-related
problems in these diverse samples include
impairment in memory, concentration, motiv-
ation, health, interpersonal relationships,
employment, as well as increased psychiatric
symptoms, lower participation in conventional
roles of adulthood and more participation in
deviant activities (Halikas et al., 1983, Kandel,
1984, Stephens et al., 1993; Budney et al., 1996).
In contrast, the few studies that have examined
the impact of marijuana use on health and psy-
chosocial functioning in the opioid-dependent
treatment population have not detected substan-
tial adverse effects associated with its use. One
study reported no detectable impact of marijuana
use on high risk behavior for contracting AIDS
(Saxon & Calsyn, 1992). A second study failed to
observe any marijuana-associated psychosocial
impairment among methadone-maintenance
patients except for the endorsement of more
items on the schizoid, schizotypal and psychotic
thinking scales of the Millon Clinical Multiaxial
Inventory and a greater ASI drug severity rating
(Saxon et al., 1993).
Two studies have speci cally assessed the
in¯ uence of concurrent marijuana use on treat-
ment outcome for opioid dependence. Saxon et
al. (1993) compared outcomes of marijuana
users and nonusers enrolled in methadone-
maintenance treatment and found no relation
between marijuana use and the use of opioids or
other drugs (cocaine or benzodiazepines) during
treatment. The authors noted that the aforemen-
tioned personality-style factors associated with
marijuana use may interfere with wider social
rehabilitation goals, although no data relevant to
this issue were available. A second comparative
study also reported no observable impact of
marijuana use on opioid or other drug use among
methadone-maintained patients (Nirenberg et
al., 1996). Consistent with these ndings, two
studies examining the in¯ uence of concurrent
marijuana use on treatment for cocaine depen-
dence also failed to show any observable effects
of marijuana use on treatment outcome (Budney
et al., 1996, 1991).

Research aimed at increasing our understand-

ing of this type of polydrug use appears war-
ranted given the high prevalence rate of
marijuana smoking among this dif cult clinical
population. Current opioid dependence treat-
ment philosophies in the United States range
from a mandated drug-free policy (i.e. all sub-
stances of abuse are equal and patients must
commit to remaining abstinent from all sub-
stances to remain in treatment) to a mainte-
nance-only approach (i.e. other drug use is
ignored and the patient is provided with metha-
done and minimal supportive therapy). The pur-
pose of the present study was to replicate and
extend the previous research on the impact of
marijuana use on opioid-dependent people and
the effect of such use on treatment outcome. We
examined marijuana-associated effects on a
broader range of socio-demographic, health, psy-
chosocial and psychiatric variables than have
been previously investigated. This study also
included a more diverse sample than previous
studies, which employed primarily male (99%)
Veterans Administration patients from urban
environments (Saxon et al., 1993; Nirenberg et
al., 1996). The current study included 37%
women and participants resided in a semi-rural
area. Many participants traveled 1 2 hours by
car because of the lack of other treatment ser-
vices in their local communities. In addition, we
explored the relation between marijuana use and
treatment outcome variables (i.e. drug use and
psychosocial changes) among patients receiving
buprenorphine detoxi cation and behavior ther-
apy in contrast to the methadone-maintenance
treatment environments examined in previous
studies. Buprenorphine is a partial MU-opioid
agonist currently being investigated as a replace-
ment medication for opioid dependence (Bickel
& Amass, 1995).
Method
Subjects
Subjects were 107 opioid-dependent adults
enrolled in our outpatient treatment research
clinic located in Burlington, Vermont, USA. All
clients met DSM-III-R criteria for opioid depen-
dence and Food and Drug Administration
(FDA) guidelines for methadone treatment (i.e.
a history of opioid dependence and either
signi cant current opioid use or signs of opioid
withdrawal). Clients were excluded if they were
Marijuana use and opioid dependence 495
pregnant, actively psychotic, at high risk for sui-
cide or had a medical condition that would con-
traindicate the administration of buprenorphine.
These clients were primarily Caucasian (94%)
males (63%) with a mean age of 34 years. Thir-
teen per cent were currently married and 66%
had the equivalent of a high school education or
less. Eighty-nine per cent reported life-time
heroin use and 67% reported i.v. use as their
current preferred route of administration.
The subsample used to examine the associ-
ation between marijuana use and treatment out-
come included only participants who received
buprenorphine and behavior therapy (N 79)
(Bickel, Amass & Higgins, 1995; Bickel et al.,
1998; see Bickel & Amass, 1995 for a review of
buprenorphine). These clients were selected
because all received similar treatment and thus
type of treatment would probably not confound
the interpretation of the outcome data. Also,
participants who dropped out during the rst 2
weeks of treatment (N 5) were excluded
because urine samples were not available to
accurately classify their during treatment mari-
juana-use status. Three of the ve dropouts
reported marijuana use during the 30 days prior
to treatment.
Intake assessment
Intake assessments were 3 4 hours in duration,
were conducted in a single session, and written
informed consent was obtained prior to study
participation. Assessments were conducted by
trained intake workers under the supervision of
a doctorate-level psychologist. All substance-use
diagnoses were reviewed by the psychologist
who re-interviewed the patient if the diagnosis
was unclear. The following instruments were
used in the assessments: (a) Psychoactive Sub-
stance Abuse Disorder sections of the DSM-III-
R Checklist (Hudziak et al., 1993), (b)
Addiction Severity Index (ASI) (McLellan et al.,
1985), (c) Michigan Alcoholism Screening Test
(MAST) (Selzer, 1971), (d) Beck Depression
Inventory (BDI) (Beck et al., 1961), (e) opioid-
related consequences checklist (51 items:
adapted from the Cocaine Consequences
Checklist: Washton, Stone & Hendrikson, 1989)
and (g) a socio-demographic and drug-history
questionnaire developed in our clinic. Intake
workers were trained to administer the ASI and
DSM-III-R checklist via manual review, obser-
vation and supervised practice interviews.
Treatment
Participants were enrolled in one of three ran-
domized, controlled clinical trials that examined
the ef cacy of buprenorphine detoxi cation
combined with behavioral therapies. The details
of these treatments have been described else-
where (Bickel et al., 1995; Bickel et al., 1998).
Brie¯ y, trial 1 was 26 weeks in duration and
compared two treatments: the Community
Reinforcement Approach (CRA) plus contin-
gency management (CRA CM) vs. standard
ª methadoneº counseling (Bickel et al., 1998).
Trial 2 was 32 weeks in duration and compared
two treatments: CRA plus enhanced contin-
gency management (CRA ECM) vs.
CRA CM. Trial 3 was also 32 weeks in dur-
ation and compared two treatments:
CRA ECM plus contingent pay for naltrexone
compliance vs. CRA ECM.
Counseling. CRA was implemented in 1-hour
individual sessions scheduled 1 3 times weekly
with the goal being to increase the availability of
natural sources of reinforcement for prosocial
behavior, including drug abstinence (Higgins,
Budney & Bickel, 1994). CRA sessions included
functional analysis training, detoxi cation skills
training, drug refusal training, social/recreational
counseling and, if indicated, vocational counsel-
ing, relaxation, assertiveness, problem solving,
time management, relationship counseling and
social skills training. Therapists also engaged in
extensive outreach efforts and scheduled addi-
tional sessions as needed to assist patients to
attend sessions and meet treatment goals. Stan-
dard methadone counseling (trial 1 only)
involved one 30 45-minute counseling session
per week focused on life-style management (Ball
& Ross, 1991).
Marijuana use during treatment was discour-
aged by providing a clinical rationale and rec-
ommendation for discontinuing marijuana use.
Therapists then assisted patients who were inter-
ested in reducing their marijuana use by
employing the same skills training and related
interventions noted above. Contingency-
management procedures were not affected by
marijuana use.
496 Alan J. Budney et al.
Contingency management. CM (trials 1 and 2)
procedures involved patients earning vouchers
for providing opioid-negative urine specimens
during weeks 2 24. Additional vouchers could
be earned for engaging in weekly prosocial activ-
ities that were approved by the therapists as
consistent with current therapeutic goals (see
Bickel et al., 1998 for details). Use of these
vouchers involved therapists and patients jointly
selecting retail items and activities (e.g. gift
certi cates to restaurants and the cinema, con-
tinuing education materials, sport equipment,
YMCA membership) to reinforce opioid absti-
nence and prosocial behavior.
ECM (trials 2 and 3) involved identical proce-
dures to those employed in CM plus additional
bonuses for each full week of opioid-negative
urine tests and contingencies on buprenorphine
dose. Opioid-negative urine specimens resulted
in the participant’s choice of alternate-day dos-
ing (Amass et al., 1994) or an additional non-
drug reinforcer valued at approximately $20.00.
Opioid-positive specimens resulted in a 50%
decrease in dose and forfeiture of the aforemen-
tioned bonus.
Buprenorphine. Participants received between a
1- and 10-week stabilization dose of 2, 4 or
8 mg/70 kg of buprenorphine. The stabilization
dose was determined during the rst week of
treatment based on pretreatment reports of opi-
oid use, observations of opioid withdrawal and
observed reaction to a 4 mg dose of buprenor-
phine. Participants received a 7 22-week
buprenorphine detoxi cation depending on the
trial and the buprenorphine dose received. Doses
were decreased at a rate of 10 15% per week on
average across the trials during the detoxi cation
phase of the treatment.
Urine testing. Urine specimens were collected
under staff supervision three times per week
throughout treatment. Specimens were screened
immediately via an on-site Enzyme Multiplied
Immunoassay Technique (EMIT, Syva Corp,
San Jose, CA, USA). All specimens were
screened for opiates, methadone and pro-
poxyphene and one randomly selected specimen
per week was also screened for cannabinoids,
benzoylecgonine (cocaine) and benzodiazepines.
Outcome measures. Treatment retention was
de ned as the number of weeks of treatment

completed. Opioid abstinence was de ned as the

longest period of continuous abstinence achieved
and was determined by the number of consecu-
tive, scheduled opioid-negative urine specimens
provided. Urine specimens not provided as
scheduled were counted as opioid positive.
Abstinence from marijuana, cocaine and benzo-
diazepines was determined by the percentage of
urine specimens collected that were drug-negative.
The ASI was re-administered at 12 months after
treatment entry to all participants who could be
located.
Data analyses
Comparative analyses. To examine associations
between marijuana use and socio-demographic,
psychosocial, medical and substance use vari-
ables, univariate comparisons between marijuana
users and non-users were performed on selected
variables collected at intake using 2 tests for
categorical measures and t-tests for continuous
measures. For these analyses, marijuana users
were de ned as participants who reported mari-
juana use during the 30 days prior to enrolling in
treatment or who provided at least one can-
nabinoid-positive urine specimen during treat-
ment. These liberal criteria were used so that all
participants who reported marijuana use or for
those for whom we had objective evidence of use
were included in the marijuana-use group. Ident-
ical comparative analyses were performed that
included in the marijuana-use group only those
who reported at least weekly marijuana use or
who provided at least 50% cannabinoid-positive
urine specimens during treatment (i.e. ª regularº
users). These comparisons permitted a test of a
ª regularº marijuana-use group to a group of
non-or light users. The two sets of analyses
yielded very similar results. Therefore, only the
former set of ndings are presented in this
report.
Multiple logistic regression was used to deter-
mine whether differences observed in the uni-
variate analyses remained signi cant after
adjusting for between-group differences in other
socio-demographic and drug-use variables. The
potential explanatory variables in the logistic
regression models were selected because they
either differed signi cantly between marijuana-
use status groups on the univariate analyses or
represented important subject characteristics
thought to be associated with the dependent
variables. The purpose of the regression analyses
Marijuana use and opioid dependence 497
Table 1. Comparison of subject characteristics
Marijuana user Non-user
(N 71) (N 36)
Gender (male)
a
69% 50%
Age
c
33.6 (7.8) 34.8 (8.0)
Race (Caucasian) 94% 94%
Education (high school or less) 68% 64%
Employment (full-time) 39% 42%
Income ($ per month) 1124 (1727) 1070 (1413)
Marital status
b
(currently married) 08% 22%
a
p 0.10;
b
p 0.05;
c
mean (standard deviation).
was not to develop predictive models or to
account for individual variability in the depen-
dent variables, but rather to examine whether the
signi cant univariate relation between mari-
juana-use status and the dependent variable was
solely or partially the result of confounding
between marijuana-use status and other subject
characteristics.
Outcome analyses. To examine the association
during treatment between marijuana use and
treatment outcome, preliminary 2 2 (treat-
ment marijuana-use group) ANOVAs were
performed on the outcome data for each of the
three clinical trials. Marijuana users were de ned
as those who provided at least one cannabinoid-
positive urine specimen during treatment. No
signi cant marijuana-group main effects or treat-
ment by marijuana-use group interaction effects
were observed in any trial for any of the outcome
measures. Therefore, data from the three trials
were combined for the analyses presented in this
report; t-tests were then performed to test for
differences between these combined groups
(marijuana users vs. non-users) on treatment
retention, documented opioid abstinence and
other drug abstinence. Treatment retention was
measured using percentage of treatment weeks
completed rather than number of treatment
weeks because of the difference in treatment
duration across studies. For all outcome analy-
ses, an intention-to-treat model was used and
missing urine specimens were treated as opioid
positives. For other substances (marijuana,
cocaine and benzodiazepines), only those urine
specimens collected were included in the com-
parative analyses.
Repeated measures analysis of variance was
used to examine changes from pre-treatment to
follow-up on the seven ASI composite scores for
those participants who completed the two ASI
assessments (N 53). The group time interac-
tion term was used to indicate whether the mari-
juana groups changed differentially over the
course of treatment and follow-up. Statistical
signi cance was determined at the 5% level for
all analyses in this exploratory study.
Results
Participant comparisons
Socio-demographic characteristics. Sixty-six per
cent of participants (71/107) met the criteria
speci ed above and were designated as mari-
juana users. The only socio-demographic vari-
able that differed signi cantly between marijuana
users and non-users was current marital status
(Table 1). A lower percentage of marijuana users
(8%) than non-users (22%) were currently mar-
ried, which appeared to be primarily accounted
for by differences in divorce rates between users
(44%) and non-users (28%). We also observed a
non-signi cant trend suggesting a greater per-
centage (69%) of males among the marijuana
users than the non-users (50%).
Substance use. Marijuana users reported an
average of 12.2 8.5 years of regular marijuana
use and smoking 10.3 11.6 days/month (Table
2). Twenty-eight per cent of the users were daily
smokers ( 20 days/month) and 17% met cri-
teria for current marijuana dependence. Mari-
juana users were more likely to report use of
heroin (97% vs. 78%) and alcohol (73% vs.
498 Alan J. Budney et al.
Table 2. Substance use comparisons
Marijuana user Non-user
(N 71) (N 36)
Current substance use
(% used during prior 30 days)
Heroin
a
97% 78%
Methadone
b
15% 33%
Other opioids 73% 81%
Alcohol
a
73% 36%
Cocaine 48% 44%
Sedatives 63% 50%
(no. of days used during prior 30 days)*
Heroin** 23.2 (8.9) 21.1 (10.3)
Methadone
c
4.4 (2.9) 9.4 (8.2)
Other opioids 15.0 (10.3) 15.1 (11.2)
Alcohol 13.3 (10.6) 8.2 (8.6)
Cocaine 8.2 (9.6) 6.0 (8.4)
Sedatives
c
9.6 (9.2) 14.5 (12.8)
Marijuana 10.3 (11.6) 0.0
$ spent on opioids
(prior 30 days) 351 (348) 294 (278)
Years of regular use
Heroin 7.8 (7.6) 6.5 (8.5)
Methadone 3.2 (12.1) 2.4 (5.1)
Other opiates 7.4 (7.2) 7.4 (8.7)
Alcohol
c
13.0 (8.5) 9.5 (8.6)
Cocaine 5.5 (6.7) 4.5 (6.0)
Sedatives 4.2 (5.8) 5.5 (8.5)
Marijuana
b
12.2 (8.5) 5.7 (8.1)
Life-time intravenous use (%)
b
94% 78%
Current preferred route
% intravenous 69% 63%
% intranasal 15% 14%
ASI drug score
b
0.40 (0.10) 0.35 (0.10)
ASI alcohol score
b
0.17 (0.21) 0.09 (0.17)
MAST score 17.6 (15.6) 16.0 (16.2)
Alcohol dependence (%) 27% 14%
Cocaine dependence (%) 32% 20%
Sedative dependence (%) 20% 19%
Marijuana dependence (%) 17%
Cigarette smokers (%) 87% 80%
No. of prior treatment attempts 3.0 (4.8) 3.6 (4.8)
*Includes only participants who reported use of each drug during the prior 30 days;
**mean (standard deviation)
a
p 0.01;
b
p 0.05;
c
p 0.10.
36%) during the 30 days prior to treatment.
scales. They were also signi cantly more likely to
Non-users were more likely to report illicit
report a history of intravenous use (94% vs.
methadone use (15% vs. 33%). Among users of
78%) than non-users and, among intravenous
each substance, frequency of use did not differ
users, to share needles (77% vs. 57%).
signi cantly between the two groups, although
non-signi cant trends suggested greater fre-
Adverse consequences comparisons. Substantial
quency of sedative and illicit methadone use
proportions of all participants reported various
among patients who did not use marijuana.
consequences related to opioid use on the
Marijuana users had signi cantly higher scores
adverse consequences checklist, but signi cant
on the ASI drug and the ASI alcohol composite
group differences emerged on only three
Marijuana use and opioid dependence 499
items. Marijuana users reported more nancial
problems (96% vs. 81%), more selling of drugs
(57% vs. 31%), and less experiences of panic
related to their drug use (21% vs. 40%).
Multivariate analyses. Stepwise logistic
regression was employed to determine if the vari-
ables that differed between marijuana-use groups
in the univariate analyses were the result of con-
founding between marijuana-use status and
other potential explanatory variables. Separate
logistic regression analyses were performed to
identify predictors of eight variables that differed
between the marijuana-use groups (i.e. heroin-
use status, alcohol-use status, history of intra-
venous use, needle sharing, marital status,
nancial problems, dealing drugs, experiences of
panic). The control variables examined in these
analyses were gender, age, heroin-use status,
alcohol-use status, methadone-use status and
history of intravenous use. The logistic
regression examining needle-sharing included
only participants with a history of intravenous
use (N 95); the other regression analyses
included all participants (N 107).
Marijuana-use status was selected into four of
the logistic regression equations indicating that it
was signi cantly related to heroin-use status
(coef cient of variation (cv) 2.29 0.82,
p 0.01, odds ratio (OR) 9.9), alcohol-use
status (cv 1.58 0.44, p 0.01, OR 4.8),
needle sharing (cv 0.94 0.47, p 0.05,
OR 2.5) and dealing drugs (cv 1.08 0.44,
p 0.02, OR 3.0) after controlling for the
aforementioned other variables. Marijuana-use
status was not selected into the four other
regression analyses, indicating that marijuana-
use status did not have a unique effect on marital
status, history of intravenous use, nancial
dif culties or experiences of panic after con-
trolling for the other variables.
Marijuana use and treatment outcome
Sixty- ve per cent (51/79) of patients (i.e.
buprenorphine and behavior therapy partici-
pants) provided at least one marijuana-positive
urine specimen during treatment. Marijuana
users provided, on average, 45% (SD 35%)
marijuana-positive urine specimens during treat-
ment. Only three participants who reported
marijuana use prior to treatment did not show
any evidence of use during treatment. Frequency
of marijuana use prior to treatment was
signi cantly associated with percentage of mari-
juana-positive urinalysis tests during treatment
(r(79) 0.64, p 0.001).
Comparisons between those who did and did
not use marijuana during treatment revealed no
signi cant differences on any of the treatment
outcome measures (i.e. treatment retention, opi-
oid, cocaine or benzodiazepine abstinence and
pre post changes on the ASI) (Table 3). Separ-
ate analyses by gender also did not reveal any
signi cant relations between marijuana use and
the outcome measures (data not presented).
Moreover, frequency of marijuana use during
treatment (% cannabinoid-positive urine speci-
mens) was not signi cantly correlated with
weeks of opioid abstinence (r(79) 0.07) or
percentage of weeks retained in treatment
(r(79) 0.21).
Discussion
The rate of marijuana use (66%) observed
among this sample is consistent with prior
reports documenting a high prevalence of mari-
juana use among individuals seeking treatment
for opioid dependence (Saxon et al., 1993;
Darke & Hall, 1995; Nirenberg et al., 1996).
This report documented concurrent marijuana
use among males and females residing in a rural
environment indicating that such use is common
in diverse samples of opioid-dependent patients.
Almost all marijuana users (94%) continued to
smoke while enrolled in treatment underscoring
the need for the development of empirically
based clinical strategies to address such use.
Marijuana use was associated with only a few
markers of psychosocial impairment in this
study. Users were less likely to be married and
reported more nancial dif culties; however, a
unique effect of marijuana use on these variables
was not retained after statistically controlling for
the in¯ uence of heroin and alcohol use.
Nonetheless, these types of problems are consist-
ent with ndings from general population and
clinical studies of marijuana users that note
lower participation and stability in conventional
roles such as marriage and employment among
marijuana users (Kandel, 1984; Stephens et al.,
1993; Budney et al., 1996). More notable was
the failure to observe differences between mari-
juana users and non-users on the many other
indicators of problem severity at intake. Such
500 Alan J. Budney et al.
Table 3. Opioid dependence treatment outcome
Marijuana user Non-user
(N 54) (N 25)
Retention* 65% (32) 60% (33)
(% of wks completed)
Opiate abstinence
(no. of continuous wks) 8.4 (6.5) 8.5 (7.2)
Other drug use
(% positive urine specimens)
Benzodiazepines 32% 40%
Cocaine 13% 14%
ASI composite change scores*
(intake 12-month follow-up)
Medical 0.07 (0.45) 0.09 (0.50)
Employment 0.05 (0.27) 0.06 (0.35)
Legal 0.03 (0.30) 0.15 (0.22)
Alcohol 0.05 (0.29) 0.10 (0.16)
Drug 0.24 (0.16) 0.20 (0.18)
Family social 0.11 (0.27) 0.21 (0.26)
Psychiatric 0.01 (0.30) 0.04 (0.24)
Includes only participants who received buprenorphine and behavioral
treatment. Excludes participants who dropped out during the rst 2 weeks
of treatment.
*mean (standard deviation); **raw change scores are presented to
preserve clarity. Only those who completed both ASI assessments are
included (n 53). ANCOVA analyses revealed no signi cant group time
interaction effects across subscales.
ndings are consistent with those of a similar
study that reported only a few differences
between marijuana users and nonusers (Saxon et
al., 1993). At least two potential explanations for
these ndings deserve comment. First, the
consequences of opioid dependence and its asso-
ciated life-style may obscure any effects of mari-
juana use. That is, the baseline level of severity
and types of problems experienced by opioid
abusers may be so broad and of such a large
magnitude that we could not detect any addi-
tional consequences of marijuana use. Secondly,
people who do not use marijuana may engage in
alternative substance-use behavior that has simi-
lar effects on psychosocial functioning. For
example, we observed a non-signi cant trend
suggesting that, among those who report use of
sedatives and methadone, non-users of mari-
juana reported more frequent use of these drugs.
Thus, non-users may simply have an alternative
choice of drug that results in comparable effects
or consequences.
Two other substance use-related differences
between marijuana users and non-users were
observed at intake. Users were more likely than
non-users to be involved in drug dealing and to
engage in sharing needles, two deviant behaviors
with signi cant medical and psychosocial risks.
Marijuana use retained its unique effect on these
high-risk behaviors after controlling for use of
other drugs (including the greater heroin and
alcohol use observed among marijuana users),
gender and age. The increased probability of
needle-sharing was in contrast to a previous
report that found high risk behavior for HIV
infection, including number of needle sharing
partners, to be linked to alcohol use among
intravenous drug users, but not marijuana use
(Saxon & Calsyn, 1992). Saxon & Calsyn (1992)
found that, among their intravenous drug-using
sample, those who used both alcohol and mari-
juana reported the highest rate of needle-sharing
and marijuana-only users reported the lowest
rate. We found equally high rates of needle-
sharing (75%) among those who used both
alcohol and marijuana and those who used mari-
juana only; both these groups reported higher
rates than those who used alcohol only (55%) or
those who did not use either substance (53%). A
number of differences between the samples and
measures used to examine needle-sharing could
account for these disparate ndings. The Saxon
Marijuana use and opioid dependence 501
study used a continuous measure of needle-
sharing, i.e. number of needle-sharing partners
in past 30 days, while the present study
employed a dichotomous measure, i.e. any his-
tory of needle-sharing. The marijuana-only sub-
jects in the Saxon sample were older on average
and more likely to be enrolled in methadone
maintenance than the other groups in their sam-
ple; both these factors could be related to less
engagement in high-risk behavior for HIV
(Darke & Hall, 1995). Additional research is
needed to understand better the relationship
between HIV-risk behaviors and polydrug abuse
among opioid-dependent individuals.
The present study found no adverse relations
between marijuana use and any of the treatment
outcome measures (i.e. retention, documented
opioid, cocaine or benzodiazepine abstinence or
ASI change scores). These results are consistent
with two previous studies that failed to detect an
in¯ uence of marijuana use on opioid or other
drug use among methadone-maintenance
patients (Saxon et al., 1993; Nirenberg et al.,
1996). Moreover, the inclusion of the ASI as an
outcome measure also showed that marijuana
use may not signi cantly affect treatment-related
changes in psychosocial function. Thus, the lack
of a clear association between marijuana use and
treatment outcome was replicated in and
extended to a rural, mixed-gender sample of
opioid-dependent patients receiving buprenor-
phine detoxi cation and behavior therapy.
The absence of an association between mari-
juana use and outcome has been observed only
in retrospective studies and has not been exam-
ined during post-treatment follow-up periods.
Prospective studies are needed to determine
more clearly how different treatment approaches
may impact marijuana use and treatment out-
come. Notwithstanding these limitations, the
extant ndings suggest that progress in treatment
for opioid dependence can be made without
mandating that patients abstain from marijuana
use. Treatment approaches to other drug use
among opioid-dependent patients may be best
developed within harm reduction models such as
those adopted in many European countries
(Marlatt & Taper, 1993). Others have suggested
that marijuana use in this population may serve
a function during the treatment process that
perhaps helps patients remain in treatment
(Shaffer & LaSalvia, 1992; Nirenberg et al.,
1996). For example, many opioid patients state
that marijuana helps them to deal with opioid
withdrawal symptoms. On the other hand, we
know that chronic marijuana use is associated
with impaired psychosocial functioning,
especially among users with a history of other
drug problems. In our clinic we currently advise
against marijuana use, but spend minimal time
addressing such use during treatment unless the
client expresses interest in setting a reduction
goal or we have information which clearly indi-
cates that marijuana is interfering with the
achievement of other treatment goals. A better
understanding of the function of marijuana use
in this population will provide information that is
important for determining whether or not, when,
or how to address marijuana use.
A number of limitations of these ndings
deserve comment. First, the use of the ASI as the
only outcome measure of psychosocial function-
ing and the relatively small sample size (N 53)
employed in those analyses warrants cautious
interpretation of the results that failed to show
an in¯ uence of marijuana use on psychosocial
change. For example, the observed associations
between marijuana use and needle-sharing and
drug-dealing suggest that future medical and
legal consequences may be more probable
among opioid-dependent marijuana users, yet
our global measures of functioning (i.e. ASI) in
these areas did not show any association to mari-
juana use. Future research should include more
comprehensive measures of psychosocial out-
come. Secondly, the likelihood of spurious
ndings in this study was relatively high because
of the large number of statistical tests conducted
between the groups. We chose not to control for
experiment-wise error rates due to the
exploratory nature of the study; thus, the unique
ndings of this study should be interpreted cau-
tiously pending replication.
Finally, the differential impact of the use of
other drugs of abuse on treatment process and
outcome among opioid-dependent patients war-
rants comment. The present study, along with
other previous studies, document the ubiquitous
nature of polydrug use among opioid-dependent
patients. As discussed elsewhere, the functional
relations between different combinations of
drugs of abuse may vary and require unique
clinical approaches (Bickel, DeGrandpre & Hig-
gins, 1995). This study is the third to document
the relative independence of marijuana and
opioid use in the treatment environment. An
502 Alan J. Budney et al.
analog study from our laboratory provided fur-
ther support for such functional independence
(Petry & Bickel, 1998). When asked to report on
how they would hypothetically allot their money
when given choices to spend it on different drugs
of abuse, opioid-dependent patients’ purchases
of marijuana were relatively independent of the
price of heroin, or at best a weak substitute. In
contrast, their decisions to purchase benzodi-
azepines and cocaine were signi cantly affected
by changes in the price of heroin. Valium was a
strong substitute for heroin (i.e. valium pur-
chases increased as the price of heroin
increased). Cocaine was both a complement and
substitute for heroin (i.e. when heroin prices
were low cocaine was purchased concurrently
with heroin; when heroin prices increased,
cocaine purchases increased). These ndings are
consistent with behavioral economic conceptions
of drug use and support clinical observations
that the use of benzodiazepines and cocaine are
related to opioid use during treatment for opioid
dependence (e.g. Des Jarlais et al., 1992; Darke
et al., 1993; Nirenberg et al., 1996). Alcohol
abuse among opioid-dependent patients is also
associated with negative outcomes such as
premature termination from treatment,
increased health risks and greater mortality
(Bickel, Marian & Lawinson, 1987; Bickel &
Amass, 1993). Similar ndings regarding the
differential impact of other drug use have been
reported in clinical samples of cocaine-depen-
dent individuals. Two studies have shown the
relative independence of marijuana and cocaine
use, while other studies have shown a positive
association between alcohol and cocaine use
(Budney et al., 1991, 1996; Carroll, Rounsaville
& Bryant, 1993; Higgins et al., 1993). These
ndings underscore the need to examine sepa-
rately the effects and function of various drug
combinations observed in the treatment-seeking
population. Effective treatment approaches will
need to acknowledge such differences and
employ clinical strategies based on such infor-
mation.
Acknowledgements
This paper was presented in part at the College
on Problems of Drug Dependence 57th annual
scienti c meeting, June 1996, San Juan, Puerto
Rico. This research was supported by National
Institute on Drug Abuse research grants R29-

DA08655, R01-DA06969, and T32-07242. We

thank Evan Tzanis for his assistance with data
analysis. Correspondence concerning this article
should be addressed to Alan J. Budney, Ph.D.,
Department of Psychiatry, University of Ver-
mont, 200 Twin Oaks Terrace, S. Burlington,
VT 05403. Leslie Amass is now with the Depart-
ment of Psychiatry, University of Colorado
School of Medicine, 4200 East 9th Ave, Box
C253, Denver, CO 80206
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