I understand addiction. After “retiring” from a 35 year career in emergency medicine several years ago, it was only a few months before I was back picking up random shifts with my old group. I don’t know if the best term for my behavior was relapse or recidivism. The point is I know what it is to want to “get that feeling back.” Even though I was frequently exhausted walking out of the ER after a long night shift, there was a deep sense of well being that would come over me. It was a feeling I didn’t get from many other activities.
That’s why I was intrigued when I was approached a few years ago to think about changing gears and working with opioid addicted patients. I had seen the illnesses, the injuries and the social devastation caused by the opioid epidemic for all those years. But it all seemed to whiz by me so fast that I didn’t have time to really get at, much less understand, its cause.
When I finally got into it, I came to recognize two fundamental truisms. First, they were the same patients I had been treating for the last several decades. Second, they all had the same desires and hurdles that I did. In other words, we were all addicted to something in some way. Something gave us that “feeling” of well being. Whatever its origin, the final mediator of that great feeling of well being was dopamine bathing the frontal cortex. And once you got it, you wanted to keep it as long as you could. The big difference was that these patients got that feeling of well being from something that was destroying them, their families and their communities.
What does that have to do with “a little harmless pot?” My OUD patients are not addicted to pot. They have much bigger fish to fry. But about every other patient I see has a urine drug screen that is positive for THC. It’s called a “dirty urine” in street vernacular. For many of them, a joint is seen as no more harmful than the evening cocktail that I enjoy almost every night. “It helps me sleep,” many say. And then they wait cautiously for my response.
I want them to trust me. I don’t want to be seen as a naive prude who can’t relate to their lives. I want them to stay focused on the job of recovery from opiates. Some will tell me that it helps them with their anxiety. And since I really don’t want them taking benzodiazepines and opioids I just shrug and let them know that basically I’m not going to get excited about it. I want my reaction to be nonjudgmental, but I really do have opinions about the safety of marijuana use.
The first concern — and one that has been voiced many times over the years — is that marijuana is a “gateway drug.” This always made intuitive sense to me, even if I didn’t have statistics to prove it. Now, I’m hearing patient after patient tell me that their opioid use started with marijuana. During a recent intake interview I asked, “How did you start taking opiates? Were they prescribed to you or did your opioid use start recreationally?”
One thing did surprise me. Due to a naive sense of denial, I used to think that most opioid users did not start with prescription opioids. Or if they did start with prescription drugs, it was someone else’s prescription that they got a hold of for recreational use. I’m disappointed to report that my belief in the integrity of the medical system was misplaced. Over 80% of my patients report that their addiction started with a real injury or surgery that was followed by prescribed opioids for pain relief. Some will admit that they got more than just pain relief and that was what hooked them. But they wouldn’t have taken the opioid without a doctor’s prescription in the first place. And what’s worse, when their doctor realized that their patient was addicted, they simply cut them off or punted them over to pain specialists whose hands were largely tied at that point.
Returning to the intake questions, my patient detailed deep dive into heroin that seemed to come out of nowhere. But when I questioned him further, he responded that “of course” this was all preceded by a long history of marijuana and then cocaine use. This doesn’t prove anything except that it is common knowledge among OUD patients that marijuana is how they got started. They just don’t want to throw away this crutch.
My next warning is about the use of marijuana in a household containing children. Colorado has seen a fivefold increase in pediatric marijuana poisoning in recent years. My real concern, however, is the emergence of marijuana paranoia or marijuana psychosis that has been noted on the rise in Colorado. I’ve even read reports of increases in violent behavior that stemmed from the marijuana using patient believing that they were at risk from the person that they were attacking.
How does this happen? I’m no neurologist or psychiatrist, but I have some ideas that I would like to throw out for discussion. It has to do with “reality testing.” Generally speaking, if a person thinks something is real that is not true, we conclude that they are failing at reality testing. My psychiatrist mentor used to tell the story of the schizophrenic going down the road who started to hit the green lights with perfect timing. At the first light he was delighted. At the second, he was beginning to think that someone was changing the lights to please him. And by the third light, he was convinced he was the king and the lights were being changed by the central government.
Normal thinking people encounter thousands of mental inputs each day that must be interpreted by the inhibitory and modulating effect of thoughts and experiences contained in other areas of our brain. It is this analysis that allows us to determine what is “real.” What if the neurons connecting the parts of the brain doing this analysis are impaired or destroyed? In some situations one might feel that all is well, when it is not. One might also conclude that he or she is in danger because the inhibitory thought is suppressed. I’ve asked some of my patients who actually enjoy using marijuana daily if they have ever seen this effect. And even those who enjoy daily use will admit that they have seen paranoia in others.
When I bring this up with my friends who want to promote recreational and medicinal marijuana we often times slide into a needlessly antagonistic discussion. They remind me of the dangers of alcohol abuse. And they are absolutely correct. We warn people of the dangers of alcohol abuse. We punish those who abuse the privilege and step over the line to the detriment of others. Can’t we do the same with recreational use of cannabis? Probably so. But I wonder if, like my opioid dependent patients who don’t want to give up their nightly joint, we want this to be more benign than evidence suggests.
I was fooled once about the potential for harm in prescription pain relievers. A decade from now I would hate to see the medical community look back and say that they were fooled into complacency a second time.