Wednesday, March 25, 2009


Weave a circle round him thrice,
And close your eyes with holy dread,
For he on honey-dew hath fed,
And drunk the milk of Paradise.

"Kubla Khan"

1. Referrals to the clinic in the last few months have suggested an uptick in heroin availability, relatively cheap and "high-quality" stuff, in this area. Hard to resist, apparently, at least when you're young, bored, and have few prospects. It brings to mind Mexican drug violence, which has been in the news more lately and which for me had come appallingly to life in Robert Bolano's fictionalized account in 2666. It makes me wonder, with any given person, what awful things happened so that this guy could get his fix?

Folks in Mexico complain that the real problem is demand north of the border--is this due to our uniquely depraved American culture, or merely disposable income enabling the potential depravity of human nature? As a moral argument this is terrible; a prostitute could similarly say, "Well, the guys want it and will pay for it, so what's a gal to do?" Worse than vice is the inciting of vice in others. Purely as a practical argument, though, it does pay to arrest the Johns too. And the flood of American guns to Mexico sounds like another good reason for gun control to me. But I'm just a Liberal with a crush on Obama.

2. What is one to make of marijuana habits? It's illegal, it's bad for the lungs, and some studies suggest long-term cognitive damage with extended and heavy use. Rarely, it makes someone psychotic. But the problem is that in some areas, such as the ones I've worked in, its occasional use is endemic, and if one focuses on that with everyone who uses it a few times per month, one would never talk about anything else. And the evidence for marijuana as a "gateway drug" or as a cause of other mental disorders is pretty flimsy.

I don't use it and as a physician I don't condone it, but psychiatry doesn't seem to be too worked up about it. My current Textbook of Psychiatry (American Psychiatric Publishing, Inc.) devotes about one and a half out of nearly 1800 pages to cannabis. My Textbook of Substance Abuse Treatment (also APPI) devotes separate chapters to alcohol, nicotine, opioids, cocaine, stimulants, sedatives, and hallucinogens, but not to cannabis. Patients are surprisingly forthcoming about their marijuana, as if they not only don't see it as a problem, but can't imagine that even a stuffy shrink would either.

3. In Psychology Today Stephen Mason, Ph. D. makes a questionable attempt to revive the generally discredited notion of the "addictive personality." But the concept has all kinds of problems, including its tendency to overdefine a person and the splitting of folks into addicts and non-addicts. If one considers behaviors like eating, sex, the Internet, and gambling, I'm not sure there is even a consensus on what qualifies as addiction, much less any coherent construct of an addictive personality.

"Addicts" comprise a surprisingly diverse group and a wide spectrum of severity. Those who really will use any psychotropic substance within reach are rare. It is far more common to see the pure alcoholic, or the opioid abuser with no taste for cocaine, or the cocaine abuser with no taste for opioids. There are, to be sure, people whose impulsivity and whose need for external rewards put them at risk for problematic behaviors--I'm thinking of a former patient who was morbidly obese (largely due to binge eating) and who also had a pathological shopping habit, but she didn't abuse substances. It is hard to see how the notion of "addictive personality" is really helpful, unless it amounts to a global admonition like "If you drink or use drugs you will go to hell." On the contrary, individualize, individualize, individualize...


Retriever said...

Great post, refreshingly free of the usual Recovery Lite lingo.

The correlations between mood disorders and addiction interest me. Most of the addicts or alcoholics I have known have also had mood disorders, and in fact the only ones who stayed sober or clean or both were those who got lots of very expensive treatment (long term usually) for the preexisting mood problems. This despite the usual AA propaganda that meetings can do it.

Also, tho AA is great when it works, there are many, many people for whom it doesn't work at all, hence the value of those in your profession paying attention to addiction and not simply saying "Yuck! I don't do that! Just go to AA. "

On addictive personalities, I think it cheapens the concept of addiction, but I think that there are certain personalities that are more susceptible to certain pathological behaviors. I think it probably has more to do with mood disorders than a separative addictive tendency.

In raising a kid with PDD (or whatever diagnosis of the month his MD attaches to him) I see a degree of obsession with a changing array of things (soda, chips, chocolate, video games, whatever) that make me think more than hypomania may be involved in things like your patient's sprees or binge eating. Perseverative behaviors in autism, OCD, these involve doing things that the person knows consciously to be bad for them. People end up drinking and drugging in the same way, even if initially they enjoyed it.

I've been told around here one big market for heroin is anorexic teenaged girls who value its appetite suppressant effect. Don't know if this is really true. Parents typically discover it when the careless kid drives their car (they have too much money) and the parents see that EZ pass paid on the route to the S Bronx at 2 am which is kind of a dead giveaway.

Around here, I see a lot of late teen, early college age kids who have been on meds for "ADHD" (which I generally suspect to be mood disorders, but the parents don't want the stigma) for ten years or so now, who a) start to abuse them and their mom's Oxycontin which many moms here abuse "for migraines" or the ever useful even if real "Back pain" and b) who just move on to heroin. Telling them not to do drugs is sorta futile when they have been managing their moods and focus for years on drugs.

On weed I am fairly rabid as I know very few kids who can maintain a decent GPA in high school if they smoke a lot, so it will have lifelong consequences far worse even than booze. Plus it is far more dangerous for teen drivers, and a factor in many accidents.

I suspect that many parents are still smoking weed (I don't and never did ) and getting drunk at home in front of their kids (we don't), and that this sets a bad example.

I also think that parents and kids alike are about 3 times more stressed than our parents' generation and so I do not mean to sound a judgmental jerk. The pressures on our kids to compete and be better than their friends are vicious.

Anonymous said...

Studies have shown that cannabis is excellent for chronic pain when traditional pharmaceuticals fail. It relieves Crohn's disease and Irritable Bowel Syndrome symptoms; MS symptoms; and cancer patients not only get pain relief but reduced anxiety also. Although benefits are most probably optimally derived from cannabis extract rather than the regular stuff smoked/inhaled, and with less side effects. So it has its uses beyond the recreational.

On 'addictive personalities' : I've heard that susceptibility to addiction is linked to relative dopamine receptor profusion - people with a relative scarcity are more likely to become addicted due to inadequate production of dopamine required to create a buzz and so are physiologically forced to take more of the rewarding substance to make up for the shortfall and achieve the same pleasurable levels of 'normal' people on lesser amounts. And of course the more they take - tolerance, dependence, addiction.... yeah, blame it on the brain. Incidently, extreme sport 'addicts' supposedly have the same neurological problem and are biochemically driven to ever more extreme behaviours to achieve that dopamine buzz - an intensity of desire/reward seeking that defies the normal fear response parameters of regular grounded people.

Maybe obsessive people in general are more prone to addiction; obsession by definition is a rarefied intensity of focus typically to the exclusion of much else, so therefore addicts tend to be purists in terms of choice of poison?

While on dopamine...apparently, studies have demonstrated that cold showers stimulate dopamine production (think of Scandanavians with their hot birch-slapping saunas followed by a murderous plunge into icy cold winter waters - invigorating!). How about that? Cocaine is definitely overrated...

Anonymous said...

Very interesting abd informative post. Thanks for sharing.

Leon's current assignment said...

Excellent post. Much to think on.

Sidebar three cents from my experiential chair:

I have found most patients do not openly disclose current marijuana use though will acknowledge some previous lifetime activity during the initial assessment period. Ongoing psychotherapy--the depth of the alliance over time--yields different results. Naturally.

I have encountered more than a few medical professionals who get their knickers in a bunch when learning of a patient's marijuana choices. I am not one of them. I see way too many "heads" with improved depressive, anxious and pain symptomology to hold a rigid stance. (I do a lot of work with the chronic pain population: "failed" surgeries, MS, cancer and on and on.) I am not saying I advocate for its use, I am saying it is not a battle I choose to fight: I have bigger fish to fry.

Dollars to donuts, patients share more of their reality with me than the clinicians whose judgments they detect on subtle, and not so subtle, levels.

Anonymous said...

I see way too many "heads" with improved depressive, anxious and pain symptomology to hold a rigid stance.

This speaks to me. I have used marijuana off and on to alleviate depression. Last summer, after ending a relationship (also the source of my supply), I have not had access, nor have I pursued a new source. I, like a previous poster in the discussion of DFW, have only ever been helped by MAOIs, which I have not had for five or so years. Last week I made an appointment to see someone about prescribing parnate again. I think the fact that I am not self-medicating, forces me to seek relief in the pharmaceutical. The clinic where I am going has mediocre therapists, and of course, a prescribing psychiatrist. I had given up on the profession, but alas, here I am again. I love your blog, and I wonder if you have discussed how one goes about finding better than mediocre care.

Anonymous said...

Nice post, and the comments here are adding a lot. Good work inspiring responses!