Addicted to Bad Reporting

How should we cover drug dependence?

Journalists usually learn it early: Drug stories are crime stories. Articles about alcoholism and assorted “hard” drug addictions are typically sourced by law enforcement, and the frequently lurid results tend to dump recreational, illegal, and prescription drugs into the same stew.

This is a particular problem for patients on opioid substitution therapy, who take maintenance drugs such as methadone and buprenorphine (Suboxone). Both drugs are the subject of black markets the size of which is difficult to pin down, but the vast majority of users take the drugs under medical supervision in government-supervised health and social programs.

According to the World Health Organization (WHO), it is in everybody’s interest to get this straight. The U.N. agency reports that every dollar spent on drug treatment results in a savings of $7 in health and social costs. Treatment of opioid addiction with methadone or buprenorphine is now possible in 63 countries. “Substitution maintenance therapy is one of the most effective treatment options for opioid dependence,” says WHO. Such therapies reduce “heroin use, associated deaths, HIV risk behaviors and criminal activity.”

Nonetheless, the tendency among news writers to use phrases like “fake heroin,” “drug-using criminals,” and “giving drugs to drug users” led the International Harm Reduction Association (IHRA), with sponsorship from Schering-Plough, makers of the addiction treatment drug Suboxone, to suggest media reporting guidelines in a white paper issued earlier this year. In “Addicted to News: A Guide to Responsible Reporting on Opioid Dependence and its Treatment,” the authors reviewed 53 English-language articles about substitution therapy and discovered a continuing trend toward “sensationalist ‘tabloid’ stories’” leading to a “backlash against people with the condition, or an increase or exacerbation of the problem if it is glorified or publicized by a celebrity.”

Specifically, the IHRA identifies the following problems:

--Exaggerated terminology (“magic bullet,” “junkies,” “pharmaceutical narcotics”).

--Depiction of patients as criminals rather than people with a serious condition often requiring medical treatment.

--Undue emphasis on criminal activity related to substitution therapies.

--Assumption that the treatment has failed unless the patient is drug free.

--Portrayal of medical anti-craving drugs as indistinguishable from recreational drugs.

So what can a serious journalist do about it? IHRA is glad to provide some suggestions:

DO:

--Ask yourself, “what if this was me or someone close to me?’

--Use factual and correct terminology.

--Include balanced, up-to-date local statistics on treatment programs.

DON’T:

--Depend entirely on law enforcement as story sources.

--Use exaggerated or derogatory descriptions of patients in treatment.

--Try to localize a national or international story without close attention to its relevance to the local community.

--Allow celebrity news to warp the reporting of treatments available for this serious condition.

As the IHRA tirelessly points out, when patients are effectively treated, everybody benefits.

Graphics Credit: http://asp.cumc.columbia.edu

Drugs and Prison

The American Disgrace.

For years, drug policy discussions have foundered on a fundamental dilemma: If illegal and addictive drugs are freely available in the nation’s prison system—and there is no one who says otherwise—then how can we as a society expect to control the consumption of drugs outside the prison walls? Moreover, should people be jailed at all for simple possession?

In 1982, President Ronald Reagan inaugurated the “war on drugs." From 1980 to 1997, writes Glenn C. Loury in his book Race, Incarceration, and American Values, the number of people in prison for drug offenses increased more than 1,000 %. Only one out of five drug convictions involved any sort of distribution beyond simple possession, says Loury, although there is often dispute about these numbers and how they are derived.

In “Can Our Shameful Prisons Be Reformed?” which appeared in the November 19 issue of the New York Review of Books, David Cole argues that African-Americans “have borne the brunt of this war.” While white drug offenders in prison increased by more than 100 % from 1985 to 1991, the prison population of black drug offenders soared by 465 %. Citing figures from The Sentencing Project, Cole asks whether we are willing to accept “a system in which one out of every three black males born today can expect to spend time in jail during his life?”

America’s prison disgrace is everyone’s problem, however. Cole informs us that a new prison is opened in the U.S. every week, and that imprisoning someone costs $20,000 a year and up. We spend $7 billion on jails in 1980. Today, writes Cole, the figure is $60 billion.

Where are we going wrong? The answer is straightforward, and unavoidable: The War on Drugs. According to FBI crime statistics cited by Cole, the U.S. last year arrested 1.7 million people for drug crimes. “Since 1989, more people have been incarcerated for drug offenses than for all violent crimes combined,” writes Cole. “Yet much like Prohibition, the war on drugs has not ended or even significantly diminished drug use.” In addition, “about half of property crime, robberies, and burglaries are attributable to the inflated cost of drugs caused by criminalizing them.”

At the heart of the problem lies a long-standing dilemma. The American prison system does next to nothing for drug addicts, except assure them of a steady supply. The justice system does not systematically help drug addicts avoid prison, or reintegrate them into society when they get out. And, since a high number of chronic drug abusers also suffer from other mental disorders, the lack of consistent, well-funded, effective programs for ex-offenders virtually guarantees a revolving-door cycle of repeated incarcerations. For those drug felons who are not themselves addicts, and who are in prison due to simple possession charges, a program of mass parole would ease prison crowding significantly. There is really no reason why many of the prisoners in this class should have been locked up at all, but for draconian legislation passed in the heat of passion—like New York’s Rockefeller laws--about one drug “epidemic” or another.

In addition to converting the swords of the drug war into the ploughshares of job programs, education, and housing assistance, we need to recognize and act upon the obvious fact that young people who are in school are far less likely to end up in prison. Schools are a far more cost-effective solution than prisons. In addition, a RAND Corporation study cited by Cole concluded that treatment is "fifteen times more effective at reducing drug-related crime than incarceration."

In the end, the need for action is undeniable. As Cole writes, “The very fact that the US record is so much worse than that of the rest of the world should tell us that we are doing something wrong.”

Graphics Credit: http://correctionsproject.com

Marijuana Withdrawal: A Survey of Symptoms (Part 2)

By Dirk Hanson

[Originally published in The Praeger International Collection on Addictions. Ed. by Angela Browne-Miller. Westport, Connecticut: Praeger, 2009. Vol. 2 Ch. 7 pp.111-124.]


Results

All of the following comments can be found at the Addiction Inbox post on Marijuana Withdrawal. The unnumbered messages on the Web site are dated, and appear in chronological order.

Cave. (2008, February 8):

“Well I just stopped smoking pot after 4 years of everyday use, 5 days ago. I am feeling the withdrawal symptoms ridiculously hard. No appetite, slight nausea, extreme insomnia.”

Anonymous. (2008, February 26):

“My boyfriend (of 6 years) has been a smoker for approximately 16 years. He has tried to give up a few times seriously before but has never quite gotten there yet. His behavior is almost unbearable when he does. It really takes a toll on our relationship. I never realized that it could be so bad and that his actions are so exaggerated by withdrawal.”

Anonymous. (2008, February 26):

“I’m a 30-year-old man and have been a heavy cannabis user (3 to 4 joints per day, every day) since I was 19. . . . I’ve been through intense anxiety, depression, restlessness, lack of appetite. I can’t sleep for more than a few hours at a time and when I do, I sweat buckets. I have a terrible appetite, I’m cold all the time, like I can’t regulate my temperature.”

Anonymous. (2008, February 27):

“I thought I was going crazy because all other sites told me that there were no withdrawal symptoms from pot, I can’t think or eat and when I do finally get something down my gullet I get the runs straight after. . . . I feel like I have been hit by a truck and it has only been a week since I gave up.”

Anonymous. (2008, March 1):

“I am 31 and a heavy smoker of 10 years. . . . What is really troubling me, however, is the excessive dreaming. . . . The dreams are vivid and strong, enough to wake me up sometimes.”

Anonymous. (2008, March 3):

“This idea of ‘intense dreaming’ is very real and for the first 5 or 6 days after quitting I experienced life-like dreams/nightmares (99% nightmares), which would wake me from my sleep. . . . This idea of breaking out in cold sweat is also very real and quite scary when [it] occurs as [it] got me worried there was something else wrong with me.”

Scott. (2008, March 3):

“I was blown away when I saw ‘excessive sweating’ as I have been experiencing that for a few days. . . . If I could cut back drastically, that would be the ideal situation. But I know from experience that I can’t just smoke pot ‘a little bit.’ If I’m going to reduce, it’s going to have to be all the way to zero.”

Anonymous. (2008, March 7):

“I’m on day seven of abstinence and boy, do I feel lousy. Night sweats, anxiety, extreme insomnia, and loads of irritability/anger problems. . . . It’s a bit like when you have a bad flu. You plain feel rotten. Anything stress-related is magnified ten-fold.”

Bob. (2008, March 7):

“I’m 38 years old and have been using weed now daily for almost 21 years. . . . I’ve been ‘clean’ now for 4 days and so far it has obviously been difficult, but already I’m showing signs of improvement, the first two days I had no sleep at all. . . . My withdrawal symptoms: Loss of appetite, sweating, irritability, sudden crying fits.”

Anonymous. (2008, March 8):

“I am a 25-year-old female and I have been smoking pot since I was 13. I have NEVER stopped even a day that I can remember. Not unless I couldn’t get it. I have recently started to realize that it is a drug addiction. I was always on the ‘it’s not addictive’ side. I get very anxious if I think I’m not going to have any. . . . It is out of my control I think, and now I’m starting to not feel high. I REALLY wanna stop, but am so scared of the symptoms. I think I need help.”

Anonymous. (2008, March 18):

“Having read all of these comments and questions I no longer feel so abnormal. I have been experiencing most of these symptoms including vivid dreaming. . . . I have been a smoker since I was 15, every day smoking about 2–3 joints.”

Anonymous. (2008, March 24):

“I am a 25-year-old female. I started smoking at 18. . . . I quit a few weeks ago. . . . I can’t focus on anything. I can’t make myself do anything. . . . I snap at everyone, including my boyfriend who has been complaining about my excessive sweating. I didn’t even think of the sweating as a symptom until I read the other posts here.”

Anonymous. (2008, April 2):

“I just wanted to say I’m glad I found this site because as many people have noted the common wisdom is that there are few, if any, symptoms of withdrawal. . . . I’ve noticed the irritability and mood swings, which I expected, but didn’t make the connection between the vivid and frequent dreams and waking at night until I read all the other comments.”

Anonymous. (2008, April 8):

“I finally feel sane again after reading these postings. I am a 48-year-old male who has been smoking weed since 1975. Anywhere from 2–6 joints per day of good quality pot for the last four years. Decided to quit about a week ago and my life has been a living hell since. . . . Haven’t eaten a full meal in a week, very tired and depressed, stomach in knots.”

Anonymous. (2008, April 25):

“I quit weed 46 days ago. . . . pretty similar symptoms as everyone else and the most severe anxiety and depression I have ever known. . . . I can’t concentrate or focus, I can’t seem to forget about what has happened even though I want to, it feels as though my brain keeps reminding me about the ‘situation’ or some general anxious or negative thought just pops into my consciousness . . . like it’s never going to end, like my thoughts are caught in a vicious circle.”

Richard. (2008, May 3):

“It’s not suicidal ideation but it’s the feeling that life will just never ‘be right’. . . . when you suffer from symptoms that you’ve been told don’t exist, you are left looking for the wrong cause. So, if you’re told that marijuana withdrawal does not increase anxiety, anger, or ‘hopelessness,’ you want to look for a cause of those things. . . . I went through withdrawal periods where I was inappropriately angry at the wrong thing, thinking that specific PEOPLE were upsetting me when they were not.”

Discussion

The U.S. government’s essentially unchanged opposition to marijuana research has meant that, until quite recently, precious few dollars were available for research. This official recalcitrance is one of the reasons for the belated recognition and characterization of marijuana’s distinct withdrawal syndrome. According to research undertaken as part of the Collaborative Study of the Genetics of Alcoholism, 16 percent of people with a lifetime history of regular marijuana use reported a history of cannabis withdrawal symptoms (Schuckit et al., 1999, p.41). In earlier research, Mason discovered that those seeking treatment for cannabis addiction tended to cluster in two age groups—college age and mid-50s (Somers, 2008).

Budney et al. (2004, p. 1973) write:

Regarding cross-study reliability, the most consistently reported symptoms are anxiety, decreased appetite/weight loss, irritability, restlessness, sleep problems, and strange dreams. These symptoms were associated with abstinence in at least 70% of the studies in which they were measured. Other clinically important symptoms such as anger/aggression, physical discomfort (usually stomach related), depressed mood, increased craving for marijuana, and increased sweating and shakiness occurred less consistently.

Today, scientists have a much better picture of the tasks performed by anandamide, the body’s own form of THC. Among the endogenous tasks performed by anandamide are pain control, memory blocking, appetite enhancement, the suckling reflex, lowering of blood pressure during shock, and the regulation of certain immune responses. This knowledge helps shed light on the wide range of THC withdrawal symptoms, particularly anxiety, chills, sweats, flu-like physical symptoms, and decreased appetite.

Furthermore, we can look to indications for which marijuana is already being prescribed—anxiety relief, appetite enhancement (compounds similar to anandamide have been discovered in dark chocolate), suppression of nausea, relief from the symptoms of glaucoma, and amelioration of certain kinds of pain—for more insight into the common hallmarks of cannabis withdrawal.

What treatment measures can help ameliorate marijuana withdrawal and craving in heavy users who wish to quit? The immediate threat to any decision in favor of abstinence is what might fairly be called the “hair of the dog” effect. Note the findings of a 2004 paper in Neuropsychopharmacology: “Oral THC administered during marijuana abstinence decreased ratings of ‘anxious,’ ‘miserable,’ ‘trouble sleeping,’ ‘chills,’ and marijuana craving, and reversed large decreases in food intake as compared to placebo, while producing no intoxication” (Haney et al., p. 158).

Moreover, “Overall withdrawal severity associated with cannabis alone and tobacco alone was of a similar magnitude. . . . cannabis withdrawal is clinically important and warrants detailed description in the DSM–V and ICD–11” (Vandrey, Budney, Hughes, & Liguori, 2008, p. 48). It is possible that many more people are trying—and failing—to quit marijuana than researchers have previously suspected. Daily use of marijuana may be driven in part by the desire to avoid or eliminate abstinence symptoms (Haney, Ward, Comer, Foltin, & Fischman, 1999, p. 395).

To date, there is no effective anticraving medication approved for use against marijuana withdrawal syndrome. More than a decade ago, Ingrid Wickelgren wrote in Science: “For instance, chemicals that block the effects of CRF or even relaxation exercises might ameliorate the miserable moods experienced by people in THC withdrawal. In addition, opiate antagonists like naloxone may, by dampening dopamine release, block the reinforcing properties of marijuana in people” (1997, p. 1967). Since stimulation of THC receptors has homologous effects on the endogenous opioid system, various investigators have speculated that naltrexone, the drug used as an adjunct of heroin withdrawal therapy, may find use against symptoms of marijuana withdrawal in people prone to marijuana dependence (Tanda et al., 1997, p. 2049). Further research is needed on the reciprocal relationship between THC and opioid receptor systems.

Serzone (nefazodone), an antidepressant, has been used to decrease some symptoms of marijuana withdrawal in human subjects who regularly smoked six joints per day (Haney et al., 2003, p. 157). Anxiety and muscular discomfort were reduced, but Serzone had no effect on other symptoms, such as irritability and sleep problems.

Preliminary studies have found that lithium, used to treat bipolar disorder, curbed marijuana withdrawal symptoms in an animal study (Cui, Gu, Hannesson, Yu, & Zhang, 2001, p. 9867). Another drug for mania and epilepsy—Depakote—did not aid significantly in marijuana withdrawal (Haney et al., 2004, p.158).

Since difficulty sleeping is one common symptom of withdrawal, common prescription medications might be indicated for short-term use in the case of severe marijuana withdrawal. Some researchers have reported that even brief interventions, in the form of support group sessions, can be useful for dependent pot smokers (Copeland, Swift, & Rees, 2001, p. 45).

It is also plausible to suggest that the use of marijuana by abstinent substance abusers may heighten the risk of relapse. In a study of 250 patients at a psychiatric/substance abuse hospital in New York, “Postdischarge cannabis use substantially and significantly increased the hazard of first use of any substance and strongly reduced the likelihood of stable remission from use of any substance” (Aharonovich et al., 2005, p. 1507). However, the researchers found that cannabis posed a greater risk to cocaine and alcohol abusers. For heroin, “cannabis use after inpatient treatment did not significantly affect remission and relapse.”

It is surprising to note the relative paucity of previous clinical data the researchers had to work with in the case of alcohol and marijuana. “The gap in the literature concerning the relationship of cannabis use to the outcome of alcohol dependence was surprising,” according to Aharonovich and colleagues. “We were unable to find a single study that examined the effects of cannabis use on post-treatment outcome for alcohol dependence, despite the fact that the majority of patients now in treatment for alcoholism dependence also abuse other drugs. Clearly additional studies of this issue are warranted” (2005, p. 1512).

Addiction researcher Barbara Mason of the Scripps Research Institute of La Jolla, California, is overseeing a four-year study of the neurobiology of marijuana dependence under a grant from NIDA. The comprehensive project will involve both animal and human research, and will make use of state-of-the-art functional brain imaging. The federal grant will also be used as seed money for the new Translational Center on the Clinical Neurobiology of Cannabis Addiction at the Scripps Institute (“Scripps Given,” 2008).

Above all, it is time to move beyond the common mistake of assuming that if marijuana causes withdrawal in some people, then it must cause withdrawal in everybody. And if it doesn’t, it cannot be very addictive. This thinking has been overtaken by the growing understanding that a minority of people suffer a chemical propensity for marijuana addiction that puts them at high risk, compared to casual, recreational drug users. The fact that most people do not become addicted to pot and do not suffer from withdrawal is no more revealing than the fact that a majority of drinkers do not become alcoholics.

The idea of marijuana addiction and withdrawal remains controversial in both private and professional circles. For an unlucky few, a well-identified set of symptoms characterizes abstinence from heavy, daily use of pot. In this, marijuana addiction and withdrawal does not differ greatly from alcoholism—the vast majority of recreational users and drinkers will never experience it.

For those that do, however, the withdrawal symptoms of marijuana abstinence can severely impact their quality of life.

Note: Sources and references can be found at the end of Part 1 below.

Marijuana Withdrawal: A Survey of Symptoms (Part 1)

By Dirk Hanson

[Originally published in The Praeger International Collection on Addictions. Ed. by Angela Browne-Miller. Westport, Connecticut: Praeger, 2009. Vol. 2 Ch. 7 pp.111-124.]

(See also Marijuana Withdrawal Post)

More than 14 million Americans smoke marijuana regularly, making it the most commonly used illicit drug in America. In 2006, marijuana was the only drug used by 52.8 percent of illegal drug users (U.S. Department of Health and Human Services, 2006).

Over the past 15 years, as addiction researchers have been busily mapping out the chemical alterations in the human nervous system caused by alcohol, cocaine, nicotine, heroin, and tranquilizers, America’s most popular illegal drug has remained largely a scientific mystery. Marijuana, the drug millions of Americans have been using regularly for years, is the least studied drug of all.

Why has cannabis research lagged behind that of other drugs of abuse? For decades, the prevailing belief among users and clinical researchers alike was that marijuana did not produce dependency and therefore could not be responsible for major withdrawal symptoms. This thinking is based, quite understandably, on the widespread observation that most marijuana users do not have difficulty going without marijuana, either by choice or by necessity. However, marijuana withdrawal effects are frequently submerged in the welter of polyaddictions common to active addicts. The withdrawal rigors of, say, alcohol or heroin tend to drown out the subtler manifestations of cannabis withdrawal. As Barbara Mason, director of the Laboratory of Clinical Psychopharmacology at Scripps Research Institute, has explained: “People are deciding every day whether to use or not to use marijuana, for medical purposes or otherwise, and there is little scientific information to advise this decision” (2008).

Marijuana withdrawal, which typically affects only heavy smokers, has not been well characterized by the research community. Until recently, there was scant evidence in animal models for marijuana tolerance and withdrawal, the classic determinants of addiction. Now, however, several researchers have identified the existence of symptoms brought on by the abrupt discontinuation of regular marijuana use in both animal and human studies (de Fonseca et al., 1997, p. 2050). A growing body of evidence supports the existence of a clinically significant marijuana withdrawal syndrome in a subset of marijuana smokers. The syndrome is marked by irritability, restlessness, generalized anxiety, hostility, depression, difficulty sleeping, excessive sweating, loose stools, loss of appetite, a general “blah” feeling, and a mental state that has been described as “inner unrest.”

Recent clinical research, combined with anecdotal field reports collected by the author, demonstrate the existence of marijuana withdrawal and the consistency of the most common symptoms of withdrawal and detoxification.

Background

In 1992, molecular biologists identified the elusive brain receptor where THC, the primary active ingredient in marijuana, did its work. Shortly after that discovery, researchers at Hebrew University in Jerusalem identified the body’s own form of THC, which uses the same CB1 receptors as THC. They christened the internally manufactured substance anandamide, after the Sanskrit ananda, or “bliss” (Fackelmann, 1993).

Anandamide has a streamlined three-dimensional structure that THC mimics. Both molecules slip easily through the blood brain barrier. Some of the mystery of marijuana’s effects was resolved after researchers demonstrated that marijuana definitely increased dopamine activity in the limbic area of the brain. Tanda, Pontieri, and Di Chiara demonstrated that dopamine levels in the nucleus accumbens doubled when rats received an infusion of THC (1997, p. 2048). It appears that marijuana raises dopamine and serotonin levels through the intermediary activation of opiate and GABA receptors (Wilson & Nicoll, 2001, p. 588). THC may perform a signaling function in neurons containing GABA and glutamate.

THC and its organic cousin, anandamide, make an impressive triple play in the brain: They effect movement through receptors in the basal ganglia, they alter sensory perception through receptors in the cerebral cortex, and they impact memory by means of receptors in the hippocampus. It is clear that some of the effects of cannabis are produced in much the same way as the effects of other addictive drugs—by means of neurotransmitter alterations along the limbic system’s reward pathway.

A great deal of the early research was marred by inconsistent findings and differing definitions of addiction and withdrawal. Most recreational marijuana users find that too much pot in one day makes them lethargic and uncomfortable. Self-proclaimed marijuana addicts, on the other hand, report that pot energizes them, calms them down when they are nervous, or otherwise allows them to function normally. Heavy marijuana users claim that tolerance does build. And when they withdraw from use, many report strong cravings.

Work by Jones, Benowitz, and Herning had helped establish certain baseline symptoms—irritability, insomnia, and lack of appetite—as early as 1981 (p. 143). Studies by Budney, Novy, and Hughes in 1999 further outlined the syndrome in heavy daily marijuana smokers (p. 1311). But the abstinence effects were often inconsistent, and frequently hard to measure. Moreover, their clinical relevance was not always evident.

For marijuana withdrawal to be considered a clinical fact, several criteria had to be met. First, the typically transient pattern of withdrawal effects must be distinguishable from rebound effects. (A rebound effect is defined as the reappearance of a preexisting symptom, and is thus not considered a true withdrawal effect.) In addition, the symptoms must occur reliably, as demonstrated by comprehensive prospective studies (Budney, Hughes, Moore, & Vandrey, 2004, p. 1970). The symptoms under consideration must also be considered clinically significant. Finally, there needs to be a clear and repeatable timeline in evidence for the withdrawal effects.

It has been suggested that the reported symptoms of abrupt marijuana cessation do not rise to the level of withdrawal typically associated with drug detox. It is now possible to lay out the neurochemical basis of marijuana withdrawal, and to demonstrate that marijuana acts on the brain in a fashion similar to other addictive drugs.

There is solid experimental evidence that chronic, heavy cannabis users develop tolerance to its subjective and cardiovascular effects. “In summary,” Budney et al. write, “cannabis withdrawal effects clearly occur in the majority of heavy, daily users” (2004, p. 1974). As a rough estimate, approximately 10 percent of marijuana users are at risk for dependence and withdrawal, the classic determinants of drug addiction (Joy, Watson, & Benson, 1999, p. 92). There is clinical and epidemiological evidence that some heavy cannabis users experience problems in controlling their cannabis use, and continue to use the drug despite experiencing adverse personal consequences of use (Hall, Solowij, & Lemon, 1999). Moreover, there is strong clinical evidence that some users experience a withdrawal syndrome upon the abrupt cessation of cannabis use. The timeline is similar to withdrawal from other addictive drugs.

In 2004, a group at the University of Vermont, funded by the National Institute of Drug Abuse (NIDA), undertook a critical review of all major relevant studies of the validity and clinical significance of marijuana withdrawal (Budney et al., p. 1967). The review of studies demonstrated with certainty that there are people with a propensity for heavy marijuana use who suffer a clearly delineated, verifiable, and frequently vivid set of withdrawal symptoms when they try to quit. One of the most striking pieces of evidence for this is the similarity of symptom sets emerging from the clinical studies to date. The most common “reliable and clinically significant” effects of abrupt withdrawal in heavy pot smokers, according to the University of Vermont research group, included “severity of craving and sleep difficulty, decreased appetite, and increased aggression, anger and irritability” (Budney, Hughes, Moore, & Novy, 2001, p. 917; Kouri, 2002, p. 30).

As another study author concluded: “Marijuana withdrawal doesn’t include dramatic physical symptoms such as the pain, nausea, heavy sweating, and cramps associated with opiate withdrawal. Nevertheless, the symptoms of marijuana withdrawal appear clinically significant” (Zickler, 2002).

A recent comprehensive outpatient study (Kouri & Pope, 2000, p. 483) with prewithdrawal baselines showed greater levels of anxiety, negative mood, physical discomfort, and decreased appetite during abstinence but not at baseline, compared with two control groups. Moreover, in a “home environment” study, researchers worked with marijuana users who provided self-ratings during marijuana withdrawal; these users smoked an average of 3.6 times daily, did not use other drugs or abuse alcohol, and were free of major psychiatric disorders. The same symptoms predominated, and onset of symptoms occurred reliably within 48 hours of cessation. Moreover, “telephone interviews with collateral observers living with the participants confirmed participants’ reports of increased irritability, aggression, and restlessness during abstinence. . . . [T]he validation of symptoms by home-based observers suggested that the effects were of a clinically significant magnitude” (Budney et al., 2004, p. 1971).

Other studies by Budney and colleagues expanded on the list of symptoms that changed significantly from baseline during withdrawal: “anger and aggression, decreased appetite, irritability, nervousness, restlessness, shakiness, sleep difficulty, stomach pain, strange dreams, sweating, and weight loss” (2003, p. 393; 2004, p. 1972). Although most effects were transient, generally lasting no more than two weeks, “strange dreams and sleep difficulties showed significant elevations throughout the study” (2003). Budney et al. conclude that, since most symptoms returned to baseline levels in the former users, “these findings were not rebound effects indicative of symptoms that existed before the use of cannabis” (2004, p. 1972).

More recent studies by Haney and others “controlled for potential confounders by using placebo conditions and excluding persons who abused other substances, had an active psychiatric disorder, or were taking psychoactive medication” ().

Overall, the research cited above confirms that the most common marijuana withdrawal symptom is low-grade anxiety and dysphoria. Anxiety of this sort has a firm biochemical substrate. A peptide known as corticotrophin-releasing factor (CRF) is primarily responsible. Neurologists at the Scripps Research Institute in La Jolla, California, found that CRF levels in the amygdalas of animals in marijuana withdrawal were as much as three times higher than the levels found in animal control groups (Wickelgren, 1997, p. 1967). Long-term marijuana use alters the function of CRF in the limbic system in a manner similar to other addictive drugs (de Fonseca et al., 1997, p. 2051). (CRF receptors in the amygdala also play a direct role in alcohol withdrawal.)

Method

Personal observations and selected case histories of frequent marijuana users were gathered from anonymous, unedited comments posted on a blog site maintained by the author. Punctuation, capitalization, and spelling have been normalized in the excerpts included here. Most of the people who have posted comments thus far (more than 100) arrived at the site by means of the search term marijuana withdrawal. This may indicate that a large number of posters are heavy smokers seeking information about abstinence symptoms. The popularity of this search phrase on the Google search engine seems to suggest an interest in, and a need for, scientific information about marijuana withdrawal.

What has surprised many observers is that the idea of treatment for marijuana dependence seems to appeal to such a large and diverse group of people. NIDA has been able to find a cohort of withdrawal-prone smokers with relative ease. According to the principal investigator of one NIDA marijuana study, “We had no difficulty recruiting dozens of people between the ages of 30 and 55 who have smoked marijuana at least 5,000 times. A simple ad in the paper generated hundreds of phone calls from such people” (NIDA, 1999). This would be roughly equivalent to 14 years of daily pot smoking.

Comments gathered from anonymous users at an open Web forum created for the discussion of marijuana withdrawal symptoms cannot be controlled for confounding variables such as other addictions or psychological disorders. The comment section of the Web site is open to anyone. What such surveys can accomplish, however, is the demonstration of parallels, or lack of them, between findings in an experimental setting and anecdotal reports from the field. Survey studies cannot offer indisputable proof. Nonetheless, when combined with the results of formal clinical studies, such surveys offer a window into real-world experience, thus complementing the growing scientific data concerning marijuana withdrawal syndrome.

The comments were generated in large part by heavy, regular smokers who either recognized or have begun to recognize in themselves an addictive propensity toward marijuana. As a group, they have great difficulty—and suffer similar symptoms—whenever, and for whatever reason, they choose to abstain.

Perhaps, most important, the present survey adds to the growing documentation of the contention that withdrawal symptoms are a frequent cause of relapse in marijuana smokers attempting to achieve abstinence.

Cont. in Part 2.

References

Aharonovich, E., Liu, X., Samet, S., Nunes, E., Waxman, R., & Hasin, D. (2005). Postdischarge cannabis use and its relationship to cocaine, alcohol, and heroin use: A prospective study. American Journal of Psychiatry, 162(8), 1507–1514.

Budney, A. J., Hughes, J. R., Moore, B. A., & Novy, P. L. (2001). Marijuana abstinence effects in marijuana smokers maintained in their home environment. Archives of General Psychiatry, 58(10), 917–924. Retrieved February 27, 2008, from http://archpsyc.ama assn.org/cgi/content/full/58/10/917?cknck

Budney, A. J., Hughes, J. R., Moore, B. A., & Vandrey, R. (2004, November). Review of the validity and significance of cannabis withdrawal syndrome. American Journal of Psychiatry, 161, 1967–1977. Retrieved April 21, 2008, from http://ajp.psychiatryonline.org/cgi/content/full/161/11/1967

Budney, A. J., Moore, B. A., Vandrey, R., & Hughes, J. R. (2003). The time course and significance of cannabis withdrawal. Journal of Abnormal Psychology, 112, 393–402.

Budney, A. J., Novy, P. L., & Hughes, J. R. (1999, September 1). Marijuana withdrawal among adults seeking treatment for marijuana dependence. Addiction, 94, 1311–1322.

Copeland, J., Swift, W., & Rees, V. (2001, January). Clinical profile of participants in a brief intervention program for cannabis use disorder. Journal of Substance Abuse Treatment, 20(1), 45–52. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/11239727

Cui, S. S., Gu, G. B., Hannesson, D. K., Yu, P. H., & Zhang, X. (2001, December 15). Prevention of cannabinoid withdrawal syndrome by lithium: Involvement of oxytocinergic neuronal activation. Journal of Neuroscience, 21(24), 9867–9876. Retrieved April 27, 2008, from http://www.jneurosci.org/cgi/content/abstract/21/24/9867

de Fonseca, F. R., Rocío, M., Carrera, A., Navarro, M., Koob, G. F., & Weiss, F. (1997, June 27). Activation of corticotropin-releasing factor in the limbic system during cannabinoid withdrawal. Science, 276, 2050–2054.

Fackelmann, K. A. (1993, February 6). Marijuana and the brain: Scientists discover the brain’s own THC-delta-9-tetrahydrocannabinol. Science News. Retrieved March 28, 2008, from http://findarticles.com/p/articles/mi_m1200/is_n6_v143/ai_13434805/pg_1

Hall, W., Solowij, N., & Lemon, J. (1999). The health and psychological consequences of cannabis use. (National Task Force on Cannabis Australia, Monograph Series No. 25). Sydney, NSW: University of New South Wales, National Drug and Alcohol Research Centre. Retrieved February 3, 2008, from http://www.druglibrary.org/schaffer/hemp/medical/home.htm

Haney, M., Hart, C. L., Vosburg, S. K., Nasser, J., Bennetti, A., Zubaran, C., et. al. (2004). Marijuana withdrawal in humans: Effects of oral THC or divalproex. Neuropsychopharmacology, 29, 158–170.

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Photo Credit: http://hubpages.com/

Does Brain Research Worsen the Addiction Stigma?

“Once an addict, always an addict.”

When it comes to the neurobiology of addiction, the research community has made great strides in a few hectic years. However, as addiction counselor William White wrote in 2007, are we lacking a comparable neurobiology of addiction recovery?

White, a senior research consultant at Chestnut Health Systems/Lighthouse Institute, warns that in the past, campaigns seeking to reduce the stigma of mental illness by educating the public about “brain disease” have often inadvertently backfired, and invoked, instead, “harsher behavior toward the mentally ill.”

White states the matter starkly: “The vivid brain images of the addicted person may make that person’s behavior more understandable, but they do not make the person whose brain is being scanned more desirable as a friend, lover, spouse, neighbor, or employee.”

Furthermore, writes White, emphasizing the “chronic” part of a chronic brain disease can mislead the public into believing, “once an addict, always an addict.”

What can be done to balance out the downside of public perceptions related to the brain disease of addiction? White suggests that what is missing is what he refers to as the neurobiology of addiction recovery. When we convey to people that addiction is a brain disease that “alters emotional affect, compromises judgment, impairs memory, inhibits one’s capacity for new learning, and erodes behavioral impulse control,” we are not always helping to reduce the stigma of the disorder.

This state of affairs will continue, says White “unless there are two companion communications: 1) With abstinence and proper care, addiction-induced brain impairments rapidly reverse themselves, and 2) millions of individuals have achieved complete long-term recovery from addiction and have gone on to experience healthy, meaningful, and productive lives.”

White points out the lack of a specific research agenda in the field of addiction science that focuses on the “prevalence, pathways, styles and stages of LONG-TERM recovery.” Specifically, a comprehensive research agenda would need to include answers to question such as:

--“To what degree does neurobiology influence who recovers from addiction and who does not achieve such recovery?”

--“What is the time period over which such pathologies are reversed in recovery—days, months, years?

--What role can pharmacological adjuncts, social support and other services play in extending and speeding this process of brain recovery?”

--“Are there critical differences in the extent and timing of neurobiological recovery related to age of onset of use... age of onset of recovery, gender, genetic load for addiction, developmental trauma”, and other factors?

White’s paper, “In Search of the Neurobiology of Addiction Recovery: A Brief Commentary on Science and Stigma,” is available HERE.



Photo Credit: http://brain.utah.edu/

The Dutch Smoke Less Pot

One of those inconvenient truths.

Government drug policy experts don’t like the numbers, which is one of the reasons why you probably haven’t seen them. Among the nations of Europe, the Netherlands is famous, or infamous, for its lenient policy toward cannabis use—so it may come as a surprise to discover that Dutch adults smoke considerably less cannabis, on average, than citizens of almost any other European country.

A recent report by Reed Stevenson for Reuters highlights figures from the annual report by the European Monitoring Centre for Drugs and Drug Addiction, which shows the Dutch to be at the low end for marijuana usage, compared to their European counterparts. The report pegs adult marijuana usage in the Netherlands at 5.4 %. Also at the low end of the scale, along with the Netherlands, were Romania, Greece, and Bulgaria.

Leading the pack was Italy, at 14.6 %, followed closely by Spain, the Czech Republic, and France.

While cannabis use rose steady in Europe throughout the 1990s, the survey this year says that the data “point to a stabilising or even decreasing situation.” The study by the European Monitoring Centre did not include figures for countries outside Europe.

According to the Dutch government, Amsterdam is scheduled to close almost 20 per cent of its existing coffee shops—roughly 50 outlets--because of their proximity to schools. However, some local coffee shop proprietors maintain that far fewer shops, perhaps no more than 10 or 20, will actually be required to close.

What are the Dutch doing right? Are coffee shops the answer? It may be prove to be the case that cannabis coffee shops can’t be made to work everywhere—that the Dutch approach is, well, Dutch. However, the fact that it works reasonably well, if not perfectly, in the Netherlands is strong testimony on behalf of the idea of harm reduction.
Here are some excerpts from a flyer given out at some Dutch coffee shops by a group of owners known as the BCD, or Union of Cannabis Shop Owners:

--Do not smoke cannabis every day.
--There are different kinds of cannabis with different strengths, so be well informed.
--The action of alcohol and cannabis can amplify each other, so be careful when smoking and drinking at the same time.
--Do not use cannabis during pregnancy!
--Consult your doctor before using cannabis in combination with any medications you may be taking.
--Note that smoking is bad for your health anyway.
--Do not buy your drugs on the street, just look for a coffeeshop.

Customers must be over the age of 18, and in most coffee shops, as in bars and restaurants in the Netherlands and elsewhere, cigarette smoking is no longer allowed.

Photo Credit: www.us.holland.com

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Needle Exchange in America

AIDS/harm reduction activists press Obama.

First, the good news: After 20 years, the U.S. Congress has voted to remove the funding ban on syringe exchange programs designed to combat AIDS and to bring hard drug users within the orbit of the medical health community.

Now, the bad news: Conservative legislators have managed to insert a provision in the bill prohibiting needle exchange centers within 1,000 feet of schools, day care centers, colleges, playgrounds, youth centers, swimming pools—and just about any other institution you care to come up with. In short, the legislation would make it virtually impossible to operate a viable needle exchange program, even if sufficient levels of federal funding can be obtained. As one harm reduction activist put it in the Seattle Stranger: The only place you could put a federally-funded needle exchange program in the entire city of Chicago... is O’Hare Airport? Gee, it’s almost like Democrats aren’t really serious about allowing funding live-saving needle programs at all.”

Clearly, needle exchange activists are still waiting for an unambiguous sign from the White House that Obama plans to uphold his campaign promises in this regard. Obama’s go-slow policy on needle exchange has frustrated AIDS activists in particular.

Physicians for Human Rights, a group that supports clean syringe exchange programs, made October 14 a National Call-in Day, noting on its web site that “Senators need to hear from President Obama that his Administration supports syringe exchange. Now is the time to urge President Obama to fulfill his campaign promise to end the ban and to urge the Senate to act.”

In a post in January of this year, I wrote: “Obama’s agenda, as spelled out at Whitehouse.gov, calls for rescinding the ban in an effort to save lives by reducing the transmission of HIV/AIDS. ‘The President,’ according to the agenda, ‘supports lifting the federal ban on needle exchange, which could dramatically reduce rates of infection among drug users.’"

Syringe exchange programs, Physicians for Human Rights declares, “do more than provide clean syringes and properly dispose of used ones; they link people into the health care system and drug treatment programs that save lives.”

In short, says the group, “the presence of syringe exchange programs in communities does not increase rates of drug use, nor does it lead to a rise in crime. What it does do: decrease transmission of HIV, Hepatitis C and other diseases.”

Moreover, during his confirmation hearings drug czar Gil Kirlikowske said that “a number of studies conducted in the US have shown needle exchange programs do not increase drug use.”

It’s a confusing picture in the field: Needle exchange programs exist, in San Francisco, Toronto, New York and other major metropolitan areas, because county and other local and regional officials have authorized it, even when funding was precarious. Alongside these programs, a plethora of illegal needle exchange operations is also in place. The Drug War Chronicle quoted the Western director of the Harm Reduction Coalition: “We need to get legislation authorizing syringe exchanges on a statewide level.... Requiring local authorization means we have to deals with 54 jurisdictions instead of just one.”

Back in May, Maia Szalavitz reported in Time that the president was planning to move deliberately as part of a broader HIV/AIDS strategy, even though groups from the World Health Organization (WHO) to the American Medical Association have gone on record with the view that giving clean needles to drug addicts is a successful strategy to reduce the spread of HIV disease. Studies by Don Des Jarlais of Beth Israel Hospital in New York suggest that infection rates in New York’s drug addict population may have dropped more than 75 % over the last few years as clean needle programs became increasingly available.

In a report last month by the Drug Reform Coordination Effort (DRCNet), a spokesperson for the AIDS Action group was determined to remain positive. “I have a pretty good feeling about this,” he said. “I’m hopeful this is the year.”

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