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    The double-edged sword of marijuana self-medication

    Counselors often see the people who don't seem to benefit from marijuana. Can legalization put a different light on the drug?
    Photo: Unai Mateo

    Photo: Unai Mateo

    A marijuana plant growing in a national wildlife refuge.

    A marijuana plant growing in a national wildlife refuge. U.S. Fish and Wildlife Service

    On the night of Dec. 6, as hundreds of pot smokers were celebrating the passage of I-502 by lighting up en masse for the second night in a row at the Space Needle, I wondered if any of my former clients were there. I could imagine the relief some of them might feel at being able to smoke in public, not at the margins but right in the thick of a crowd of like-minded others.

    During my training some years ago at a community counseling center, I got to know people whose relationships with marijuana seemed to straddle a hard-to-navigate line between addiction and self-medication. I remember people who couldn’t afford to buy vegetables — or to pay $15 for a therapy session with a trainee  — who managed to come up with $300 per month for their dealers.

    Typically, the people I worked with at the counseling center felt a fondness for marijuana that they did not feel for prescribed psychiatric medications. Zyprexa and Lamictal were difficult facts of life, but pot was a friend.

    Many said they found cannabis relieved their anxiety and depression, made it possible for them to leave the house and face the world. Judging by my own experience and that of many of my colleagues, as well as a host of online message boards, marijuana is one of the most popular and widely-used unprescribed treatments for mental health problems, ranging from anxiety and depression to attention-deficit and bipolar disorders.

    Yet using marijuana is also considered a diagnosable mental-health disorder. In the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (the DSM-IVTR), use of a substance is considered to be “abuse” if the user engages in risky or self-damaging behavior in order to use it. By definition, using an illegal substance is risky. And other risks have been identified, including that the main psychoactive compound in marijuana may induce or worsen psychosis.

    Now that marijuana is at least a big step closer to being legal in Washington — legal by state law, with federal authorities deciding which if any steps to take to enforce federal prohibitions — is it any closer to becoming a recognized treatment for depression, anxiety or other mental health conditions? And should it be? Does marijuana have the potential to serve as a valuable, reasonably safe addition to the available medications for mental health?

    This question is, in part, being fought out in the political process, where advocates make their cases in black and white. Meanwhile, those of us who work in the mental-health profession are considering it in the same way we are trained to approach most questions: by trying to be thoughtful, trying to allow for reasonable doubts and concerns, aiming for a more complete understanding of a complex reality. When I talk with colleagues about the question of marijuana as a treatment for mental-health conditions, I don’t hear any easy answers.

    Therapy is a conversation between a person who is there to voice needs, fears and desires, and another person whose job is to be a benign skeptic, listening with an active interest in the other’s well-being but without personal agendas or judgments.

    In my role as a therapist, I see reasons to doubt the claims of political advocates on either side of the marijuana debate. My counseling-center clients who used marijuana typically suffered from side effects, but then the same was true for many who took prescribed medications.

    Some things are known about marijuana’s effects on the human nervous system. Its main psychoactive compound, called THC, closely mimics a neurotransmitter called anandamide, which is named for the Sanskrit word for “bliss.” THC molecules attach to anadamide receptors in various parts of the nervous system, including the dopamine-generating so-called “pleasure center,” the nucleus accumbens.

    Depending on many intricate and unpredictable factors, the THC-mediated boost in dopamine activity can make a person feel imaginative, brilliant, comfortable, painless — or it can fuel paranoia and set the heart racing. Or interfere with memory. Other compounds in marijuana are thought to have anxiety-quelling tendencies to counter THC’s anxiety-provoking effect, and marijuana dispensaries advertise unverifiable claims as to the potency and pharmacological effects of different cannabis cultivars.

    Ed Mosshart, LMHC, a Seattle therapist and substance-abuse expert, who has worked as a clinical director in both outpatient and residential treatment programs, told me in a recent conversation:

    I think [medical marijuana] can be legitimate, but like many medicines, in fact many medicines for anxiety have significant side effect profiles. I don’t think it’s a panacea and I don’t think people should go into it thinking that it’s going to be some medical revelation, because its use is problematic.

    He cites some of the most common side-effects seen with marijuana use: reduced motivation, short-term memory loss and withdrawal from relationships. “In my experience, people who smoke on a daily basis get out of touch with reality and have memory problems. They can’t see the destruction they’re causing their family by checking out on them,” Mosshart said.

    Other colleagues who did not want to be named in this article had similar concerns. Two therapists I know, both of whom have been practicing for over 20 years, told me that they have seen long-term frequent marijuana use interfere with their clients’  ability to realize their hopes for their own lives.

    “I’ve seen it again and again,” one of them told me. “Really bright people, but they just never get around to doing the things they want to do.”

    On the other hand, a third highly experienced colleague told me that she is cautiously optimistic about one client’s use of marijuana as medication for post-traumatic stress disorder.

    “Right now, he’s using it just to help him sleep,” she said. “It seems to be helping.”

    Mosshart said that he too had seen some cases where people self-medicated with marijuana and on the whole felt that it helped enough to be worth the side effects.

    “One thing I would say,” he added, “is that it’s not so much about the substance, it’s about how the person uses it, what’s their relationship to it. Alcohol, for example, is legal and in grocery stores, and more people die of alcoholism every year than all other addictions combined. Alcohol is the big offender. I hate to see marijuana vilified when alcohol is more devastating, I see marijuana as being relatively benign, compared to alcohol.”

    In practical terms, the line between addiction and self-medication is murky. Once viewed as a moral weakness, addiction is now understood as a neurobiologically complex condition in which the underlying problem is chronic emotional pain. Dr. Gabor Maté, author of In the Realm of Hungry Ghosts: Close Encounters with Addiction, is one of the leading advocates today for a more neurobiologically sophisticated and empathetic approach to treating addiction. In a 2007 article in the Globe and Mail, he wrote:

     Addictions always originate in unhappiness, even if hidden. They are emotional anesthetics; they numb pain.  The first question — always — is not ‘Why the addiction?’ but ‘Why the pain?’

    Increasingly, neuroscience is offering models for understanding why some people suffer more than others do from emotional and psychological pain. The idea of the unconscious is being reinterpreted in terms of the limbic system and the autonomous nervous system, powerful shapers of our emotional lives that operate outside our conscious control. An overactive amygdala, an underdeveloped orbitofrontal cortex — these are the kinds of models researchers are identifying as likely causes of chronic emotional dysregulation.

    It is a humbling shift from an earlier generation’s belief that if a problem was “all in your head,” that meant it could be dealt with by a dose of vigorous commonsense thinking.

    Today, we often treat pain in the mind with medications that appear to alter levels of key neurotransmitters, including dopamine and serotonin. These medications often come with side-effects, and individuals’ experience with their effectiveness varies. Clearly, we do not yet know enough about the extremely complex neural activity involved in any mental illness, let alone how best to treat it.   

    According to Washington state law, marijuana is authorized as a medication for a limited number of medical conditions, including “Intractable pain, limited for the purpose of this chapter to mean pain unrelieved by standard medical treatments and medications.” The law does not specifically exclude emotional pain, so it is understandable that people suffering from mental illness have asked the state to grant them the legal right to use marijuana to self-medicate, if they find that it works better for them than other available treatments.

    So far, such petitions to the state Medical Quality Assurance Commission have been denied. Most recently, a 2012 petition to authorize medical marijuana for obsessive-compulsive disorder and attention-deficit hyperactivity disorder was turned down. While the commission reported that they found the testimony in support of the petition “courageous and moving,” they concluded that there was a lack of data to support the use of marijuana for these conditions, adding a call for such studies to be done.

    Research may indeed become more feasible in the future, if marijuana becomes legalized under federal as well as state law. Currently, federal law defines marijuana as a Class I controlled substance, which means that it has a high abuse potential and no accepted medical use — a designation which impedes research into its possible medical uses.

    In the meantime, it may not matter much to Washingtonians, who now have a choice whether to seek medical marijuana by prescription — which is easy to obtain — or simply to exercise their new right to use it for their own reasons, without needing a doctor’s permission.

    But those of us who work in the field of mental health will still be wondering. Should the way we think about marijuana abuse be revisited, now that using it is less legally risky? When is pain relief therapeutic, and when might it bring more suffering — for our clients themselves, or for the people around them — than it relieves? Are there good reasons for viewing marijuana more skeptically than prescribed psychiatric medications?

    Mosshart remarked, “A lot of people who get medical marijuana don’t have conditions that rise to the level of needing marijuana to medicate it. I think it’s misused, quite a bit, actually.”

    Perhaps the most hopeful view of current trends is that as marijuana becomes legalized, we may be able to gain a clearer, more objective and nuanced picture of its actual impacts and potentials, so that the line between use and misuse becomes a bit clearer for people trying to decide whether to use it.

    Carol Poole is a psychotherapist in private practice who also enjoys writing about depth psychology in popular culture. Her writing has appeared in BenBella Books' Smart Pop series.

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    Posted Thu, Dec 27, 8:47 a.m. Inappropriate

    I'm all for legalized marijuana and could care less about any medical benefits. Legalization will accomplish two things. First we'll not fill jails and prisons will people whose only crime is smoking a joint. Secondly the world won't end. Those who oppose legalization remind me of the believers in the Mayan calendar and we see how that worked out.


    Posted Thu, Dec 27, 12:03 p.m. Inappropriate

    The questions raised here are superb, including the observation that current Federal Law is obstructing research into a drug, in the right quantities, is beneficial to many, patients and non-patients.

    I believe the target result for these studies is the political and scientific determination of metabolite blood levels - certainly someone smoking enough to raise that level to an as yet undetermined threshold is likely suffering side effects.

    That said, for the chronic addictive multi-substance abuser alcoholic I'd bet marijuana usage, even unlimited, is a positive factor for reducing drug inspired violence.

    Posted Thu, Dec 27, 3:37 p.m. Inappropriate

    If you mean we might not see the level of crime and violence associated with getting money to obtain drugs, then I think you could very well be correct. However, being high doesn't rule out being violent. Cannabis was one of the main ingredients in the snuff that Zulu warriors used before going into battle. Thousands of GIs in Viet Nam used it, so there's a history associated with it and only time will tell.


    Posted Fri, Dec 28, 5:13 p.m. Inappropriate

    the 'Nam vets I knew at the time always said that they didn't get stoned when on patrol, for the obvious reasons. But once they were off . . .

    Steve E.

    Posted Thu, Dec 27, 11:15 p.m. Inappropriate

    I'm struggling to wend my way through the verbiage to find the writer's real message in this piece. I think it is basically a statement of concern that broader availability of marijuana may prove to further complicate the lives of some current (ab)users.

    That makes sense. The repeal of alcohol prohibition certainly led to more overuse, abuse, and dependence. And there are certainly DSM-IV diagnostic codes for alcohol-related problems as well as for overuse of marijuana and other drugs.

    Just as prohibition didn't prevent alcohol use, the prohibition of marijuana (probably the world's longest-used consciousness-expanding plant material) hasn't prevented humans from seeking it out. In both cases, there are people who can use with enjoyment and restraint, and some who just can't. In both cases, some people whose mental lives are disordered in some fashion (whether they are 'diagnosable' or not) may find that using complicates, rather than furthers, their attempts to find stability.

    The sporadic, small-scale efforts to legalize formerly prohibited substances is probably the beginning of a turnaround in a century-long political, legal, and cultural war. In my "partial libertarian" view, that's a good thing--and other consciousness-expanding drugs should also be legally available.

    But there's a cost and a down-side, and I think that's what the writer is musing about, with specific remembrance of those troubled people for whom weed means more trouble. I muse about it, too. The near certainty is that with marijuana more freely available, we'll see more of the dysfunctional effects mentioned in this article--and we'll see more auto accidents caused by misuse, and we'll see injuries and deaths. "And so on," as the late Mr. Vonnegut would say.

    This doesn't lead me to review my meager knowledge of neuroanatomy and neuroreceptors, but to rummage around in my meager knowledge of philosophy. In particular, I recall the thinkers who looked most intently at the joys, sorrows and potential of human existence--and concluded that life has no element of fairness and is best confronted fully and with such courage as each person can muster. That seems to be a good strategy for embarking on a world of greater freedom, risk, and possibility.


    Posted Fri, Dec 28, 5:18 p.m. Inappropriate

    “I’ve seen it again and again,” one of them told me. “Really bright people, but they just never get around to doing the things they want to do.”

    And as we well know, this doesn't happen to people who don't smoke or drink. LOL. How many memoirs are there from upstanding citizens, titans of industry, etc., who lament not climbing the mountain, trying to play music professionally, running the marathon, spending more time with the kids, etc.

    Steve E.

    Posted Wed, Jan 23, 6 p.m. Inappropriate

    i am bipolar and smoked marijuana for my symptoms for 20+yrs. it wasnt until i decided to try prescribed medications that i begun to have more serious problems. these drugs have almost killed me. they have caused me to try and almost succeed in killing myself twice in a yrs time. i did not have these issues before i started taking them. i want so badly to get off my prescribed medications and go back to smoking marijuana. i want to be ok again. but im considered a criminal if i do. marijuana makes me happy. it gives me energy to get up and do the things that need to be done. it helps me eat and sleep. the medications that i am on makes me unfunctionable and miserable. it also has an effect on my heart. they are not at all good, where as i believe that marijuana is good and the answer. it may be that it is not for everyone. nothing is. and as far as short term and long term memory, well, depression has a huge effect on memory. try drinking , which is very dangerous and legal. it can cause you to not be able to remember anything. anything can be abused. but i dont sit around on my rump getting stoned all day. i have a life, or i had a life before all these messed up prescriptions. my life is more meaningful when i smoke, whereas all i want to do most days now is die. but the government doesnt seem to care about the welfare of the people because i am not alone in my beliefs. the proof is out there. i just dont understand why it is a problem. i dont understand why the government depries innocent people of this GOD MADE MEDICATION.

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