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.
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