barriers and facilitators to cannabis treatment

Barriers and facilitators to cannabis treatmentdar_313 311..319

PETER GATES1,2, JAN COPELAND1,2, WENDY SWIFT2 & GREG MARTIN3

1National Cannabis Prevention and Information Centre, University of New SouthWales, Sydney, Australia, 2NationalDrug and Alcohol Research Centre, University of New SouthWales, Sydney, Australia, and 3Health Services ResearchCentre,Victoria University ofWellington,Wellington, New Zealand

AbstractIntroduction and Aims. Despite its continued widespread use, relatively few individuals with cannabis use disorders presentto treatment services.There is a dearth of research examining the reasons for this observed underutilisation of treatment.Theaim of this paper is to examine barriers and facilitators to entry into cannabis treatment. Design and Methods. Threesurveys of regular cannabis users in treatment (n = 100), in the community (n = 100) and from a widespread Internet sample(n = 294). Results. Perceived barriers included: not being aware of treatment options; thinking treatment is unnecessary; notwanting to stop using cannabis; and wanting to avoid the stigma associated with accessing treatment. Perceived facilitatorsincluded: improving available information on treatment; keeping treatment specific to cannabis; offering additional services,such as telephone support; and simplifying treatment admission processes. Discussion and Conclusions. Participant’sperceptions differed significantly depending on their age, gender and treatment status. Participants in treatment typicallyreported barriers intrinsic to the individual while participants from the community reported barriers relating to the treatmentavailable. Reported facilitators were more homogenous and most commonly related to availability of information. [Gates P,Copeland J, Swift W, Martin G. Barriers and facilitators to cannabis treatment. Drug Alcohol Rev 2012;31:311–319]

Key words: cannabis, treatment, barrier, facilitator, marijuana.

Introduction

In comparison with other illicit drugs, cannabis use inAustralia remains high [1]. In the 2007 National DrugStrategy Household Survey, 9.1% of Australians aged14 years or older indicated using cannabis in the pastyear, of which an estimated 14.9% reported using can-nabis on a daily basis [1]. Similarly, in the 2007National Survey on Drug Use and Health, 10.1% ofAmericans aged 12 years or older indicated using can-nabis in the past year, of which an estimated 14.2%reported using cannabis daily or near daily [2]. This isconcerning given that greater frequency of use is asso-ciated with increased risk of physical and mental healthproblems, and the development of dependence [3,4].The 1997 Australian National Survey of Mental Healthand Wellbeing found that, among those who had usedcannabis at least five times in the previous year, 21%met DSM-IV criteria for cannabis dependence [5].

While effective treatments for cannabis use disordershave been developed, longitudinal research has shownthat only approximately one to three out of 10 depen-dent cannabis users will seek treatment within a givenyear [6–8].

The proportion of individuals entering treatment forcannabis use is significantly less than the proportionthat would benefit by doing so [9]. Attempts to explainthe disproportionately low rate of treatment uptakeconsider the characteristics of individuals seeking andattending treatment, treatment effectiveness, attitudestoward treatment, structural barriers to accessing treat-ment such as cost and transport, and also factors thatmilitate against facilitators to treatment.

Identifying relevant differences between individualswith cannabis use disorder who seek treatment, andthose who do not, may help explain the low numbersentering treatment. A large study in Denmark showeda high prevalence of previous psychiatric admissions

Peter Gates BSc Psych, Senior Researcher, Jan Copeland PhD, Professor,Wendy Swift PhD, Senior Lecturer, Greg Martin PhD, Senior ResearchFellow. Correspondence to Mr Peter Gates, National Cannabis Prevention and Information Centre, University of NSW, Sydney, NSW 2052,Australia. Tel: +61 2 93850269; Fax: +61 2 9385 3333; E-mail: [email protected]

Received 13 December 2009; accepted for publication 27 February 2011.

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R E V I E W

Drug and Alcohol Review (May 2012), 31, 311–319DOI: 10.1111/j.1465-3362.2011.00313.x

© 2011 Australasian Professional Society on Alcohol and other Drugs

(typically depression, personality disorders and schizo-phrenia), and frequent use of alcohol, amphetamineand ecstasy, in a sample of 1439 heavy cannabis usersseeking treatment for their cannabis use [10]. Thesecharacteristics are in contrast to the lower levels ofpsychiatric admission and less common use of alcohol,amphetamines and ecstasy in the cannabis-using popu-lation as a whole [5]. However, several studies haveshown that individuals with cannabis dependence whoseek treatment and those who do not are similar interms of demographics [9–13]. Thus, identified objec-tive differences appear to be limited to factors associ-ated with cannabis use including other substance useand mental health issues.

An individual’s subjective perception of cannabistreatment may better explain their choice to enter treat-ment or not. In particular, treatment may be avoided dueto the perception that it is ineffective or unnecessary.Pilot studies, trials and evaluations of brief cannabistreatments have shown utility in cognitive behaviouraltherapy, motivational enhancement therapy inter-ventions and contingency management interventions,as well as combinations of the three [14–19]. However,the availability of illicit drug treatments is not wellknown to drug users [20,21]. Further, as there is noavailable pharmacotherapy or well-promoted cognitivebehavioural therapy package [3,22], many cannabis-dependent individuals may believe that no suitable effec-tive intervention is available.

Cannabis treatment may also not be sought outbecause it is not necessary. A 1 year follow-up study of200 long-term cannabis users reported that one in fivehad markedly decreased their use, the majority doing sowithout entering treatment [8]. Additionally, studies ofcannabis-using individuals, including some with can-nabis dependence and others facing custody, exhibitlow levels of perceived treatment need [23,24]. Further,at least one study has compared the levels of perceivedtreatment need between cannabis and cocaine treat-ment seekers with equivalent levels of drug-relatedproblems and highlighted a greater ambivalence towardtreatment by cannabis treatment seekers [25].

Reviews of the literature on barriers to substance usetreatment generally cite a lack of interest in, knowledgeof or motivation toward treatment, a lack of treatmentplaces, long waiting times, the prohibitive expense oftreatment, problems with meeting program eligibilitycriteria and transport [20,21,26–29]. The most fre-quently reported social barrier to treatment entry isthe stigma associated with being labelled as an illicitdrug user and associated concerns over privacy[2,20,21,27,30]. Unfortunately, there is a dearth ofresearch regarding barriers specific to cannabis treat-ment and what can be done to facilitate treatmententry. Instead, problems associated with other drugs are

typically seen as more pressing to researchers and treat-ment providers [31]. In one of the few studies specificto cannabis treatment, Ellingstad and colleagues [32]interviewed 25 long-term daily cannabis users, whostopped using cannabis for at least 1 year without treat-ment. Respondents most commonly reported that: can-nabis use was not enough of a problem or did notwarrant treatment (80%); treatment was not needed toquit (76%); and wanting to avoid the stigma of beinglabelled a drug user (48%) [32].

Given the underrepresentation of individuals withcannabis-related problems in specialist treatment ser-vices, it is vital to further identify barriers to treatmentseeking and facilitators of entry into treatment. Thispaper reports on the perspectives of cannabis users intreatment, and those in the community, on barriers toand facilitators of engagement in cannabis treatment.

Methods

Three methods were developed to capture a range ofopinions regarding perceived barriers and facilitators tocannabis treatment. Two studies using face-to-faceinterviews were conducted with: 100 individuals in can-nabis treatment (CT group), and 100 individuals not intreatment who used cannabis at least weekly (NTgroup). A final study was conducted to obtain a morewidespread and rural sample from across Australia andincluded 294 individuals who used cannabis at leastweekly and completed a survey via the Internet (ISgroup).

Inclusion criteria for NT and IS groups (the non-treatment groups) were: (i) being aged at least 16 years;(ii) using cannabis at least weekly; and (iii) a lack ofcannabis treatment within the month prior to interview.Inclusion criteria for the CT group were: (i) being agedat least 16 years; and (ii) current attendance in can-nabis treatment. Recruitment was stratified such that,no more than approximately 30% of participants wereeither: (i) using any other illicit drug more than 3 daysper week; (ii) drinking more than eight standard drinksof alcohol per day; or (iii) in current methadone main-tenance treatment. Information regarding how manyindividuals were interested but were excluded due toeligibility criteria mismatch was not able to be accu-rately collected due to difficulties in treatment settingswhere multiple staff assisted with recruitment and thelack of applicability to an Internet sample.

Recruitment

Ethical approval was gained from the New South WalesUniversity Human Research Ethics Committee, andthe Northern Sydney and Central Coast Area HealthHuman Research Ethics Committee.

312 P. Gates et al.


The face-to-face interviews were conducted by twotrained social science graduates from August 2007 toJuly 2008. Purposive sampling was used to recruit NTparticipants through advertisements via the popularpress and local mail drop. Approval was gained torecruit the CT group from within 12 metropolitan non-government drug and alcohol treatment agencies,including: outpatient counselling (n = 4), residentialcentres (n = 3), detoxification (n = 1) and crisis (n = 1)units and therapeutic communities (n = 3) in Sydney.NT and CT participants provided consent after beinginformed of the nature of the study and that informa-tion provided was to be confidential.

The IS group (n = 294) was recruited through the useof a commercial survey company (Survey SamplingInternational) with access to a representative sample of90 000 Australians. A total of 8295 people accessed theInternet and were presented with the survey over aperiod of 5 weeks. Of those, 7631 did not meet eligibilityquestions and were not asked further questions. Afurther 157 people did not complete the survey due tolosing connection to the Internet, leaving the finalsample of 294.This group was utilised in order to accessa more rural population and to include respondents in allstates of Australia. The IS group were informed of thenature and confidentiality of the study before providingconsent by activating a link to the survey.

Assessment

The CT and NT groups were asked to detail theirdemographic background, treatment history, aspects ofcannabis use, opinions on treatment and scales ofphysical and mental health (a 5-point Likert scale andthe Kessler 10) [33]. Although the IS group wereinformed in writing of the confidential nature of thestudy, they did not receive the same assurance that wasafforded to face-to-face groups.That is, the face-to-facegroups signed a consent form detailing confidentialityin view of a researcher while the IS group simply acti-vated a link after being informed of confidentiality. Forthis reason, and because funding for increasing surveylength was limited, the IS group were not asked toprovide details regarding their demographic back-ground, treatment history, aspects of cannabis use(beyond indicating at least weekly use) or aspects ofphysical or mental health. Of interest in this currentpaper were the questions asked of all participants:(i) ‘In your opinion, what are the major barriers togetting cannabis users to enter treatment for their can-nabis use?’ and (ii) ‘What kinds of things would havehelped or encouraged you to enter cannabis treatment?’(for the CT group: ‘to have entered treatment earlier’).The researcher then indicated which barriers and facili-tators best matched the participant’s response from a

predetermined list, while participants completing thesurvey online were asked to use tick boxes. If the par-ticipants’ response was not listed, the response wasrecorded verbatim as qualitative data.

Data analysis techniques

The qualitative data were coded and organised intocategories using open coding techniques fromgrounded theory whereby similar responses weregrouped according to identified themes [34]. Partici-pant group comparisons were made between: (i) male(n = 286) and female (n = 206) participants; (ii) partici-pant’s age, (iii) frequency of cannabis use; and(iv) participants entering treatment from police orcourt systems (referred to as ‘mandated to treatment’)(n = 25) and those volunteering to treatment (n = 75).Between group analyses employed c2-tests (or Waldstatistic for categorical variables) and generated oddsratios (OR) with details interpreted via binary logisticregression. As participant’s age was a skewed non-parametric variable it was analysed by testing five par-ticipant age groups (stratified to have approximatelyequal numbers) in rank order. No Bonferroni adjust-ments were made as the evaluations were exploratory.Data from the IS participants were manually reviewedto prevent multiple responses. All analyses were con-ducted using spss (Version 13.0; SPSS Inc., Chicago,IL, USA).

Results

Characteristics of the CT, NT and IS groups

The total sample (n = 494) was mostly male (58%;excluding two missing data). There was no significantdifference in the proportion of male or female partici-pants between the NT and CT groups, with their com-bined total (n = 200) being mostly male (70%).The ISgroup (n = 294) had approximately equal numbers ofmale to female participants (49% male compared to50% female, and two missing data).

The IS group featured a large rural sample (40%)and respondents from each Australian state and terri-tory (31% New South Wales, 26% Victoria, 15%Queensland, 13% South Australia, 11% Western Aus-tralia, 2% Australian Capital Territory, 1% Tasmaniaand 1% Northern Territory).

Details of participant demographics and age groupsare shown in Table 1. The NT and IS groups hadapproximately equal percentage of participants in eachage group. However, these two groups were shown tohave significantly (c2 = 20.76, P < 0.001) more 45- to89-year-old participants than the CT group.

Barriers to cannabis treatment 313


No more than 27% of either participant group wereusing an illicit drug other than cannabis at least weekly(27% of the CT group, 16% of the NT group and 27%of the IS group).

The NT group reported using cannabis a median of69 days (range = 2–90 days) out of the 90 days previ-ous to interview.This frequency of use was significantly(Z = -3.5, P < 0.002) less frequent than recent can-nabis use by the CT group (median of 86.5 days,range = 0–90 days).The majority (68%) of CT partici-pants had previously sought treatment for theircannabis use and were twice as likely [OR = 2.12(1.20–3.77), P < 0.02] to have done so than the NTgroup (50%). Similar to the demographic questions,the IS group were not asked for the same detail regard-ing their cannabis use beyond reporting at least weeklyuse.

Barriers to treatment

As shown in Table 2, the barriers most commonly iden-tified by all participants were: (i) the feeling that treat-ment is not necessary to reduce cannabis use; (ii) userswould not be ready to stop; (iii) a lack of treatmentoption awareness; and (4) a preference for avoiding thestigma associated with accessing treatment.

Differences between treatment and non-treatment groups.The analyses regarding differences between participant

groups are depicted in Table 3. The CT group was themost likely to mention that people would not be readyto stop using, and that treatment is too difficult. TheNT group was the most likely to mention confidential-ity issues.The IS group was the most likely to mentionthat cannabis treatment is not thought to be necessary.

Differences between genders and selected barriers totreatment. Female participants were significantly(Z = -2.11, P < 0.04) more likely than male partici-pants to report that people may feel seeking cannabistreatment is not necessary when reducing [58% com-pared to 48%; OR = 1.48 (1.03–2.12)]. Male partici-pants were significantly (Z = -2.16, P < 0.04) morelikely to mention that it would be hard to admit you hada problem with cannabis due to a perception that it is aharmless drug [8% compared to 3%; OR = 2.53 (1.06–6.0)]. No interactions between gender and participantgroup were shown to significantly moderate barrierchoice.

Differences between age groups and selected barriers totreatment. The analyses regarding the differencesbetween participant age groups are depicted in Table 4.Those in the 16–23 year age group and the 30–44 yearage groups were significantly more likely than24–29 year and 45–89 year age groups to report thatcannabis users may not be ready to stop using.Those inthe 45–89 year age group were significantly less likely

Table 1. Participants’ demographics displayed by participant group

NT group(n = 100) %

CT group(n = 100) %

IS group(n = 294) %

Total sample(n = 494) %

Age group16–23 years 20 29 14 1824–29 years 18 29 21 2230–36 years 19 17 21 2037–44 years 21 19 23 2245–89 years 22 6 20 18

IncomeFull-time employment 24 21 — 23Part-time employment 21 13 — 17Temporary benefit 43 57 — 50Other income 12 9 — 10

Living arrangementAlone 32 26 — 29Partner 24 18 — 21Parents 15 20 — 18Friends 16 13 — 14Other 13 23 — 18

ResidencePrivate 28 27 — 27Rented 59 60 — 60Other 13 13 — 13

314 P. Gates et al.


than other age groups to report a lack of treatmentoption awareness. Participants aged between 37 and 89never referred to a lack of motivation as being a barrierto seeking treatment and only 3% of the remainingsample selected this barrier. No interactions betweenage group and participant group were shown to signifi-cantly moderate barrier choice.

Differences between those mandated to treatment andvolunteers and selected barriers to treatment. One-

quarter of the CT group reported being mandated totreatment. No significant differences were found in bar-riers mentioned within the CT group between thosemandated to treatment and those who volunteered.

Differences between frequency of cannabis use and selectedbarriers to treatment. Frequency of cannabis use wasanalysed for CT and NT groups (n = 200) for eachbarrier and was shown to moderate the frequencies towhich some barriers were reported. With each addi-

Table 2. Barriers to cannabis treatment depicted by participant group

Stated barrier to cannabis treatmentNT group(n = 98) %

CT group(n = 98) %

IS group(n = 294) %


Treatment is unnecessary 44b 36b 61a 53Not ready to stop using 14c 34a 23b 23Unaware of options 22a 17a 9b 14Treatment stigma 22a 13a 8b 12Hard to admit problem 13a 17a 0b 6Few specific treatments 11a 8a 7a 8No out of office hours 2a 2a 4a 4Unfavourable reports 8a 8a 3b 5Access problems 6a 5a 4a 5Treatment too difficult 5b 13a 0c 4Confidentiality issues 14a 1b 0b 3Prior commitments 2a 3a 4a 3Motivation issues 5a 6a 0b 2Protest from friends 4a 8a 3a 5Other 5 13 1 5

Column percentages total beyond 100% as participants could select more than one option. ‘a’, ‘b’ and ‘c’ denote significantdifferences between the percentages for each participant group. That is, any percentage noted with ‘a’ refers to the significantlylargest percentage, ‘b’ the next largest, and ‘c’ the smallest. Any case where ‘a’ or ‘b’ are noted in more than one group shows thatthere is no significant difference between them. Alpha levels for these comparisons are shown in Table 3.

Table 3. Significance testing between participant groups and odds of selecting a particular barrier

Stated barrier tocannabis treatment

Mann–Whitney (Z)(n = 490)

NT compared to CTOdds ratio (95% CI)

IS compared to CTOdds ratio (95% CI)

IS compared to NTOdds ratio (95% CI)

Treatment is unnecessary -3.00** 1.41 (0.79–2.50) 2.84 (1.77–4.57)*** 2.02 (1.27–3.21)**Not ready to stop using 4.79*** 0.33 (0.16–0.66)** 0.58 (0.35–0.96)* 1.77 (0.95–3.32)Unaware of options 3.03** 1.38 (0.68–2.79) 0.48 (0.25–0.93)* 0.35 (0.19–0.65)**Treatment stigma 2.63** 1.89 (0.89–4.02) 0.58 (0.28–1.19) 0.31 (0.16–0.58)***Hard to admit problem -6.99*** 0.73 (0.33–1.60) 0.83 (0.76–0.91)*** 0.87 (0.80–0.94)***Few specific treatments -1.07 1.42 (0.55–3.71) 0.78 (0.33–1.84) 0.55 (0.25–1.19)No out of office hours -1.37 1.00 (0.14–7.25) 2.22 (0.49–10.02) 2.22 (0.49–10.02)Unfavourable reports -2.65** 1.0 (0.36–2.78) 0.32 (0.12–0.86)* 0.32 (0.12–0.86)*Access problems -2.92 1.21 (0.36–4.11) 0.72 (0.25–2.14) 0.60 (0.21–1.66)Treatment too difficult -5.88*** 0.35 (0.12–1.03)* 0.87 (0.80–0.94)*** 0.95 (0.91–0.99)***Confidentiality issues -3.01** 16.17 (2.08–125.54)** 0.33 (0.02–5.34) 0.02 (0.00–0.16)***Prior commitments -0.60 0.66 (0.11–4.04) 1.2 (0.34–4.51) 1.87 (0.41–8.57)Motivation issues -4.09*** 0.82 (0.24–2.80) 0.94 (0.89–0.99)*** 0.95 (0.91–0.99)***Protest from friends -1.72 0.48 (0.14–1.65) 0.40 (0.15–1.03) 0.83 (0.25–2.70)

*P < 0.05; **P < 0.01; ***P < 0.001.



tional day of cannabis use the likelihood that partici-pants reported concerns regarding: treatment stigma[OR = 0.98 (0.97–1.0), P < 0.009]; and confidentialityconcerns [OR = 0.98 (0.97–1.0)] increased by 2%(0–3%). No significant interactions between cannabisuse frequency and participant groups were found.

Facilitators to treatment

As shown in Table 5, the facilitators most commonlyidentified by participants were: (i) improving theamount of information available on cannabis treatment;(ii) including separate services that are specific for can-nabis; (iii) making additional treatment services avail-able, such as telephone counselling; and (iv) makingtreatment admission an easier process.

Differences between participant groups and facilitatorsselected. The analyses regarding differences betweenparticipant groups are depicted in Table 6. The CT

group was the most likely to report a need to selectivelymarket treatments to adolescents.The NT group was themost likely to report a need to improve the availableinformation on treatments and perceptions that treat-ment is confidential. The IS group was the most likelyparticipant group to report a need for including separateservices for cannabis users and to offer help with travel.

Gender differences in facilitators mentioned. Male par-ticipants were significantly (Z = -2.18, P < 0.03) morelikely than female participants to report a need forcurrent treatments to provide additional help with lifeskills [9% compared to 4%; OR = 2.34 (1.07–5.10)].No interactions between gender and participant groupwere shown to significantly moderate facilitator choice.

Differences between age groups and those mandated totreatment and volunteers. The analyses regarding thedifferences between participant age groups are depictedin Table 7. Those in the 24–29 year age group were

Table 4. Significance testing regarding participant age groups and choice of treatment barrier

Stated barrier tocannabis treatment

c2 Logistic regressiona

(n = 490) 24–29 years 30–36 years 37–44 years 45–89 years

Not ready to stop using 13.95** 0.48 (0.25–0.93)* 0.58 (0.30–1.12) 0.95 (0.52–1.74) 0.32 (0.15–0.69)**Unaware of options 12.68** 1.44 (0.64–3.23) 1.98 (0.90–4.39) 1.01 (0.43–2.37) 0.27 (0.07–0.99)*Lack of motivation 17.11** 0.41 (0.07–2.27) 1.17 (0.30–4.50) 0b 0b

*P < 0.05; **P < 0.01; ***P < 0.001. aComparisons shown in this table were produced utilising the 16–23 year group as reference.bNo participant in this age group mentioned this particular barrier to cannabis treatment.

Table 5. Facilitators to cannabis treatment depicted by participant group

Stated facilitators to cannabis treatmentNT group(n = 92) %

CT group(n = 87) %

IS group(n = 294) %


Improving available information 45a 32a 25b 30Cannabis-specific services 7b 1b 24a 16Additional options such as telephone counselling 1b 12a 15a 12Making admissions easier 4b 10a 14a 11Improve education 20a 21a 0b 8Offer additional life-help 3a 5a 10a 7Offer help with travel 1b 2b 11a 7Help with childcare 0b 3a 5a 4Market treatment to adolescents 2b 17a 0c 4Make treatment optional 7a 10a 0b 3Improve confidentiality 8a 1b 0b 2Other facilitators 19 21 11 14

Column percentages total beyond 100% as participants could select more than one option. ‘a’, ‘b’ and ‘c’ denote significantdifferences between the percentages for each participant group. That is, any percentage noted with ‘a’ refers to the significantlylargest percentage, ‘b’ the next largest, and ‘c’ the smallest. Any case where ‘a’ or ‘b’ are noted in more than one group shows thatthere is no significant difference between them. Alpha levels for these comparisons are shown in Table 6.

316 P. Gates et al.


most likely to report that opening treatment centresoutside of office hours or introducing alternative ser-vices, such as telephone services would be beneficial.Those in the 45–89 year age group were the leastinclined to report either of these facilitators.

Differences in frequency of cannabis use. Frequency ofcannabis use was analysed for CT and NT groups(n = 200) for each facilitator and was shown to moderatethe frequency to which only one facilitator was reported.That is, frequency of cannabis use significantly(Z = 9.15, P < 0.003) moderated the frequency to whichparticipants reported a need to improve the perceptionthat treatments are confidential [OR = 0.96 (0.94–0.99)].That is, with each additional day of cannabis use,participants were 4% (1–6%) less likely to select thisfacilitator. No significant interactions between cannabisuse frequency and participant groups were found.

Discussion

Previous studies have identified barriers to cannabistreatment, although few have investigated differencesbetween subgroups of participants. The identified bar-riers were consistent with the existing literature high-

lighting a lack of interest in, knowledge of andmotivation for treatment, and concern about treat-ment stigma [20,21,26–29]. Among the total sampleof participants, the most commonly reported barriersto cannabis treatment were: (i) the feeling that treat-ment is not necessary to reduce cannabis use (com-monly mentioned by participants in the community,particularly female participants); (ii) the opinion thatcannabis users are not likely to be ready to stop theiruse (commonly mentioned by participants in cannabistreatment, and younger participants); (iii) a lack ofawareness of treatment options (commonly mentionedby older participants); and (iv) preference for avoidingthe stigma associated with being labelled a drug userin need of treatment (commonly mentioned by thoseusing cannabis more frequently). No significant differ-ences in the perceived barriers to treatment men-tioned were found between participants who weremandated to treatment and those who volunteered.

More generally, participants who were interviewedin treatment tended to focus on barriers intrinsic tothe individuals (such as motivation, not being readyto stop and difficulty in admitting problems), whileparticipants not in treatment tended to focus on barri-ers intrinsic to the treatment itself (such as availability,

Table 6. Significance testing between participant groups and selection of particular facilitators

Stated facilitators to cannabistreatment

Mann–Whitney (Z)(n = 473)

CT compared to NTOdds ratio (95% CI)

CT compared to ISOdds ratio (95% CI)

NT compared to ISOdds ratio (95% CI)

Improving available information -2.73** 1.69 (0.92–3.12) 0.68 (0.41–1.15) 0.40 (0.25–0.67)***Include separate services -5.69*** 6.00 (0.71–50.90) 26.37 (3.61–192.88)*** 4.40 (1.84–10.50)***Additional options such as

telephone counselling-2.40* 0.85 (0.11–0.68)** 1.39 (0.67–2.89) 16.45 (2.2–121.05)***

Making admissions easier -1.76 0.39 (0.12–1.33) 1.37 (0.63–2.94) 3.47 (1.21–9.96)*Improve education -7.84*** 0.93 (0.45–1.94) 0.79 (0.71–0.88)*** 0.80 (0.73–0.89)***Offer additional help -2.12* 0.70 (0.15–3.22) 2.18 (0.75–6.41) 3.12 (0.93–10.52)Offer help with travel -3.45** 0.47 (0.04–5.25) 5.01 (1.17–21.37)* 10.73 (1.44–79.70)**Help with childcare -1.41 0.97 (0.93–1.01) 1.40 (0.39–4.99) 1.05 (1.02–1.08)*Market treatment to adolescents -6.49*** 0.11 (0.02–0.48)** 0.83 (0.75–0.91)*** 0.98 (0.95–1.01)*Make treatment optional -5.24*** 0.61 (0.21–1.78) 0.90 (0.84–0.96)*** 0.94 (0.89–0.99)***Improve confidentiality -2.77** 7.08 (0.85–58.81)* 0.99 (0.97–1.01) 0.92 (0.87–0.98)***

*P < 0.05; **P < 0.01; ***P < 0.001.

Table 7. Significance testing regarding participant age groups and choice of treatment facilitator

Facilitator

c2 Logistic regressiona

(n = 473) 16–23 years 30–36 years 37–44 years 45–89 years

Out of hours 11.92* 0.47 (0.17–1.28) 0.65 (0.27–1.58) 0.32 (0.11–0.94)* 0.08 (0.01–0.60)*Telephone service 12.19* 0.51 (0.22–1.20) 0.75 (0.35–1.59) 0.58 (0.27–1.27) 0.11 (0.03–0.48)**

*P < 0.05; **P < 0.01. aComparisons shown in this table were produced utilising the 24–29 year group as reference.



accessibility or associated stigma and confidentialityconcerns). This trend in the barriers mentioned high-lights that increasing the accessibility of treatmentsalone will not necessarily increase treatment access.That is, there are underlying issues relating to the can-nabis user’s motivation and fear toward seeking treat-ment and difficulty in admitting problematic use thatneed to be addressed.

Among the total sample of participants, the mostcommonly reported facilitators to cannabis treatmentwere: (i) improving the amount of information availableon cannabis treatment; (ii) including separate servicesthat are specific for cannabis; (iii) making additionaltreatment services available, such as telephone counsel-ling; and (iv) making treatment admission an easierprocess. These facilitators were each commonly men-tioned by participants in the community, particularlythose interviewed online. However, these facilitatorswere found to be mostly consistent across participantgender, age groups and between participants who weremandated to treatment and those volunteering.

The trend in facilitators mentioned highlights knowl-edge of current treatments by participants in the com-munity who believe that improvements are requiredand by participants in treatment who believe that infor-mation on treatments needs to be better disseminated.By far the most commonly mentioned facilitator wasimproving available information. There is some limitedevidence that by implementing educational and infor-mational campaigns, attitudes and motivation towardhelp-seeking behaviour can improve. That is, someauthors have shown that treatment advertisements cansuccessfully increase access rates and education on theharms of continued use and increase motivation toattend treatment [11,13,21,23,35,36].

The other common facilitators reported suggest thatthe provision of a separate additional treatment service,such as a telephone-based helpline, would best facilitateaccess to treatment. A single Brazilian study has shownthat a cannabis-specific telephone-based service caneffectively operate as both an information service and ascannabis treatment [37]. Callers were reportedly 1.6times as likely to achieve cannabis abstinence over6 months compared to a control group given referencematerial only. No further study has been publishedregarding the influence of cannabis-specific telephone-based services on help-seeking behaviours.

The present studies had a number of limitations.First, participants not in treatment were recruitedmainly from inner city or metropolitan locations.However, the rural component of the IS group wassufficiently large that the total sample (24% rural) actu-ally overrepresented rural residents according to Aus-tralian census estimates (7% including inner regionalAustralia) [38]. Secondly, when participants were

responding to the barrier and facilitator questions,there may have been an inconsistency regarding theirreferent for their response. That is, some participantsmay have referred to their own experience while othersmay have referred more generally to a more or lessproblematic cannabis user than themselves.Thirdly, themajority of participants in treatment were recruitedfrom inpatient facilities. Thus, outpatient treatments,which are known to be the most commonly utilisedform of treatment for cannabis use problems in 2007,were underrepresented [39]. Fourthly, caution shouldbe taken regarding comparisons between the NT andCT groups and the IS group given the difference inrecruitment methodology. That is, the IS group wereinterviewed online and not afforded the same guidancewith questions as the face-to-face groups and were alsonot asked as many questions regarding their cannabisuse. For this reason, differences between the IS groupand other groups may be partially explained by theunrecorded frequency to which they used cannabis use.Finally, the assessment did not include a measure ofdependence on cannabis but rather looked at frequencyof use in the past 90 days and only for participantsinterviewed face-to-face. Individuals with greaterdependence on cannabis could arguably be less likely tomention the barrier that cannabis treatment is thoughtto be unnecessary. However, the percentage of partici-pants reporting this barrier presently was similar toprevious study [21].

Results confirmed previous research highlighting thatthe typical cannabis user believes treatment for can-nabis use to be unnecessary, would not be ready to stopusing and would feel stigmatised when accessing treat-ment. Participants reported that if better informationand education on treatment options were available, andif cannabis-specific services were available, entry intocannabis treatment could be facilitated. Differences inthe perceived barriers and facilitators to cannabis treat-ment were observed between participants within oroutside of treatment and between gender and agegroups. However, the reported barriers and facilitatorswere consistent between participants who were man-dated to treatment and those who volunteered. In orderto fully understand these differences further researchincluding measure of cannabis dependence and fre-quency of use in a population with diverse patternsof use is required. Additionally, further research isrequired to assess the appropriateness of implementingany identified facilitators to treatment, such as thedevelopment of telephone-based treatments.

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