Monday, July 20, 2009

This is Your Brain on Drugs

The debate over marijuana continues apace, with two new New York Times articles (here and here) discussing the increased potency of contemporary cannabis and its implications for addiction and speculative legalization. (Tellingly, these articles were in the "Fashion and Style" and "Opinion" sections, not "Health" or "Science").

I express no clinical or other opinion here about the issue, but merely report what I've observed about patient reports of marijuana in 15 years of general psychiatric practice, both inpatient and outpatient (I do not subspecialize in substance abuse issues, but the matter of substances comes up frequently in general practice).

In working with addicts one expects to encounter denial or, at best, ambivalence about the impact of substance use, but nonetheless I have met numerous patients over the years who fully acknowledge, whether spontaneously or when pressed, that their use of alcohol, cocaine, opioids, or amphetamine is problematic or destructive. However, I can probably count on the fingers of one hand the number of people I've worked with in 15 years who could be brought to see their marijuana use as dysfunctional (I mean, to really and painfully see it, not to vaguely humor me in considering the notion). To be sure, many patients suffer consequences from the drug's illegality, but that doesn't really count in assessing its dangerousness. Tobacco smokers on average are far more alarmed about their habit than pot smokers.

Again, I mention this not to condone its use, whether personally or professionally, but to wonder at what a strange drug it is. Its detrimental effects, such as they are, must therefore be insidious in the extreme, and not such as to disrupt life on a day-to-day basis. Indeed, more than with any other drug (even alcohol and tobacco), marijuana users tend to justify their habit as being calming and therapeutic (although some report that it makes them, if anything, more anxious). Many see it as a kind of alternative medicine, not so much different from taking St. John's Wort or other herbal preparations. If marijuana deprives its users of what would otherwise be a better pot-free life, it does so in such a way that they are unable to see what they're missing. To be sure, all addictive substances do this to a degree, but pot seems to do it more than most.

Laura Miller at Salon reviews a book by Ryan Grim called This is Your Country on Drugs: A Secret History of Getting High in America. I haven't read the book, but the article suggests that a central theme is the ubiquity of mind-altering substances throughout history and various cultures. This suggests that a central characteristic of consciousness is a desperate need to be other than it is; many accomplish this by means of other human beings, the arts, or God, but for many, directly biological self-management is too tempting to avoid altogether. Substances can and should be managed and regulated, but any attempt to suppress their use altogether may have unintended consequences, as the review suggests.


William said...

My former roommate uses pot as a way to control her psychiatrist-diagnosed OCD. It works well and has none of the side-effects that the legal psychotropics have.

Anonymous said...

Until you come across a patient
that is so terrified to even answer
the door from Pot induced paranoia
one might think it a harmless drug.
It is not and the new weed is beyond
the giggle grass of the 1950's in
producing this drug induced fear.

Novalis said...

Yes, I have come across that a couple of times, but it seems to be rare. I would be the last to consider marijuana "harmless," but it's hard to say whether it's more harmful, overall, than, say, alcohol or nicotine.

Retriever said...

It helps cancer patients suffering pain and nausea from their treatments, but otherwise I've have seen little good come of its use. It seems to me (as a boring fuddy duddy observer) that it just makes people think themselves witty, happy, relaxed, but act slow, stupid and get the munchies. The people I know now who are middle-aged and have smoked a lot of weed, all have coughs and more bronchitis and pneumonia (like longtime smokers, only worse, because marijuana is not filtered). I worry about how it affects people's driving (more dangerous effects on judgment and perception than alcohol).

I wouldn't presume to judge someone who smokes it at home and who really is helped (say, with anxiety calmed) by it, but I worry about any drug that helps normally contented people chill artificially. Almost no miseries and anxiety I know that can't be equally well soothed by hugging a loved one, or patting a faithful dog or cat. Or gardening, or exercising,or other activities, or taking photographs,or building something, or teaching a child something,or cleaning a closet, or reading, or cooking a good dinner, or blogging...

My own drug of choice is caffeine, which helps one concentrate on work, not tune out.

Anonymous said...

Whether drugs are regulated or not makes no difference to individuals' capacity to self-regulate - as with anything.

Insight into one's condition is inversely proportional to the degree of distractive hold the substance has on the individual (pot is not as easily assimilated into the daily experience of existence/living as tobacco is, and so its use necessarily assumes a more distractive quality); it could also have something to do with the constant ubiquitous public health information that amplifies consciousness of tobacco's specific ill effects, while pot has a more modest generalised, albeit demonised, profile (you shouldn't smoke pot because pot is...just bad!) - and generalistions are just too inclusive and diffuse to incite an immediate sense of threat in the individual; hence the subsequent lack of apparent concern of pot users.

Suppression is never a good thing. Humans need outlets/distractions. Some biological 'freaks' have a high functionality threshold in spite of drug use, while others disassemble at the drop of whatever.

Maybe pot users are in more of a hopeless/despairing existential fix than tobacco smokers - why care about damage when all is already damaged beyond supposed repair?

Like Retriever said about helping cancer patients for instance, it does have its positives beyond existential escape/alleviation; so for therapeutic use it should be regulated and stnandardised.

Anonymous said...

There's deifnitely an argument to be made for government regulation and decriminalisation of marijuana. It includes attempting to control the crime - crime - that often accompanies drug cultures. Prohibition strongly relates to increases in associated systemic crime. Increased price. Controlled supply may reduce possibilities of harm. If marijuana is available then perhaps users wont go looking for other stronger drugs in its absence. etc etc. But yes, this is off-set by various positive and negative health costs

Dr X said...

I know a few very successful, high-functioning, pot smokers. If they are impaired by their pot use or impaired in other ways, I sure don't see any evidence for it. I am sometimes baffled by their ability to smoke pot regularly, without any obvious ill-effects. We're talking about as much as 30+ years of regular use--people close to retirement. They are anything but stoners and not people struggling professionally or socially.

I've also known a few pot smokers who seem to be just struggling to get through life. One wonders, of course, about the extent to which pot is both medication for, and cause of their condition--or maybe neither. Don't troubled people have the need for recreation?

The other interesting dimension of pot is that many people say that they don't smoke because they find it disabling. Aside from the illegality, this would be the issue for me. I don't see how I could function smoking pot. It isn't about paranoia--I just find the experience disabling and mildly unpleasant, so I haven't touched it in decades.

We can try to force pot to fit our theories of addiction, but I'm not convinced that works very well. It's a complicated drug with widely varying effects on people. The meth user's pattern is more predictable. The tranq abuser's pattern is more The heroin user's pattern is more predictable.

Paul J. Richardson said...

This comment is directed to all the fear-mongering moral-high-ground political evangelists who generalize from personal experience, or mere heresay, to the broader population (as if that is going to be statically valid).

I've seen far more convincing peer-reviewed journal articles from the likes of 'The New England Journal of Medicine' proposing the RISKS AND DANGERS of high fat foods, untreated depression, genetically modified live stock, and household toxic pollutants. No, pot is mostly a door to heavy drugs (or other evils) by virtue of an artificial status as taboo, imposed culturally. Should we say the same of pornography, or 'dablings' with heathen religions?

Remove the taboo, and you will remove much of the "giggling" sneaky fun which so many of us correctly recognize as the beginning steps down the road of perdition for immature, hurt, and angry people (who will likely take that road with or without pot). Alcohol is glamorized all the time in commercials. It's humorized (think Captain Morgan here), and it's fiercely defended as an important part of tradition and culture. It certainly does have first movers advantage from the perspective of Porter's 5 (now 7) forces.

Oh the hypocrisy and idiocy of xenophobic conformity to scripted morality, void of uncommitted logic and the search for effective methods for truth testing.

I'd personally rather smoke a joint, than drive in rush-hour traffic in most major cities today, IN ORDER TO PROTECT MY HEALTH from the worse danger -- and I refer here as much to stressful intersections and fruitcakes with guns as any possible collisions. I smoked pot for years when I was single. I liked it, and I miss it, in the same way I miss diving boards at public swimming pools before ignoramuses decided that 1/100,000 idiots who broke their neck on them, was too high a liability, and so every body had to just give up all that fun, FOREVER.

Yes, we should all be alarmed and dread the 1/100,000 chance that we will be the one who hits the jackpot, reacting "adversely" to this or that. But for god's sake?!! Should we all just lock the freagin doors and hide from the harmful solar radiation?, or can we still try to just live life??

I'll take my chances, and enjoy my fatty hot dog, with extra chilly and cole slaw. You go ahead and eat your bland puffed rice cake, ok? It's rather ironic how easily the owners of the means to production manufacture consent, now that religion has been replaced by the much more efficient media of this century. And with patriotic, zealous consent, their distilleries and other heavy investments continue unabetted.

Anonymous said...

Yup firstly I am one of the anon. writers above speaking about pot induced paranoia,I live in New York City for almost 70 years,work in the arts ,where pot smoking could be normal for some and have really seen a lot of pot induced psychosis.Too much "Big Brother"
watching,listening,that sort of fear.Or fear of mugging,home invasion in actual doorman guarded

It could be smoking Pot in a rural or small city is different because the population and whom one might come across is sort of more controlled than in NYC with 9 million beating hearts here.
Flip side:
I also know long lived pot
smokers,who Drive ,have kids ,get Academy awards for their films or write great book reviews for major publications,only one died from
lung cancer as pot (to think of it)is full of carcinogens and tar.

For myself I had tried to smoke once in 1959 outside of the old
Jazz nightclub"Birdland" and all
I had was great sleep when I came home,I do remember the turntable
going round & round for the longest
time as an amusement.

As they say down the block here"Go Figure".