Good For Everything?
“It does everything,” my colleague explained. “It treats pain. It treats headaches. It treats depression and anxiety and epilepsy. They keep asking me for it, every day.”
A novel antidepressant? An extraordinary new anti-anxiety agent?
My internist friend is bombarded with requests to give the “good stuff” – “prescription grade” marijuana - to his patients. And marijuana is definitely getting more officially acceptable. Recently, the head of the FBI commented on the trouble finding talented hackers who do not use dope. Asked what a marijuana using hacker interested in working for the FBI should do, Comey replied "he should go ahead and apply."
The historical arc is moving quickly. As marijuana historically ascends from “reefer madness” to decriminalization to legalization, it’s really time to consider its effect on public health - what it does to all of us together.
Debate on this has many sides and many players. Lots of money - and many lives - are riding on f how legalization might ultimately be regulated. Like many of today's political/economic/health debates, it will be "informed" by ridiculous data, like this satire provided by Tyler Vigen demonstrating the inverse correlation between honey bee production and juvenile marijuana possession arrests (an "amazing" .933):
But the front line clinicians I talk to have their own take. They see varied populations where marijuana is not an easy, pleasant, sociable high but something much more complicated. Here are concerns that this clinician has, and which I also hear about from other clinicians and patients:
Murder and destruction are not the first things people think about when they consider marijuana. They should be near the top of the list.
Drug cartels in many nations have used marijuana – along with cocaine and opiates – to get very rich and powerful. Simultaneously they have suborned politicians, corrupted entire countries and massacred thousands of women and children. The number of murders in Mexico alone is staggering. Large parts of Latin America have been convulsed by the drug trade, which has done much to destroy communities and societies, and marijuana has played its part in league with other drugs. Preoccupied with the “drug war” and locking up what are now millions of drug offenders, Americans have paid insufficient attention to the death and destruction our drug habits produce internationally. No wonder the president of Uruguay, who spent much of his life incarcerated, has worked to legalize marijuana. More and more agree with him.
Yet a nation which often lets motorcyclists ride without helmets might reflect on what widespread marijuana use will do to motor vehicle – and other accidents. Who wants their kid taking out the new bike for a “fun spin” right after hitting her bhang? We know what alcohol does to drivers and workers. What will Americans do collectively to prevent accidents provoked by using legalized marijuana?
The Other Gateway Drug
The tobacco industry does not possess a high reputation. They hid their data about smoking's effects on health for decades – and paid hundreds of billions when caught out.
Now tobacco companies sense at least two new major opportunities.
One is e-cigarettes. Though people like myself have argued e-cigarettes may aid smokers to become ex-smokers, they can also addict kids to tobacco – aided by gorgeous packaging and tasty candy flavors.
So e-cigarettes will and should be differently regulated. And that will be a boon for Big Tobacco. It has already been making big moves into the e-cigarette industry. Its capital, political and marketing heft may allow it to take a large part of that burgeoning product.
And people may forget that marijuana legalization was also bruited about in the 1960’s. Reports of the time were that the major tobacco companies had registered a variety of trademarks – “Top Joint” and “High Joint” - to get into the coming “marijuana revolution.”
Expect them to try again. This time they tobacco companies may be incentivized – at least by memories of the past – to do things with more concern for societal effects.
But many people I know fail to see that marijuana – the so-called “gateway” to “harder drugs” – is also a gateway to tobacco use.
Supposedly about two thirds of American high school students have tried marijuana. Generally, they’ve smoked it. Often, it was their first experience smoking anything. Often they smoke marijuana with tobacco.
How many will become tobacco smokers? Whatever the number, the public health cost may prove high.
Addictionologists I speak to are unhappy about potential marijuana legalization. Certainly they see a select population. But they tell me they see many who are addicted to marijuana alone, as well as combined with other drugs.
But casual smokers of marijuana usually don’t know much about the tangled, often contradictory clinical literature on marijuana and psychiatric illness.
Recent data are not always encouraging. The group led by Hans Breiter at Northwestern has found that marijuana cognitively impairs young people in ways that may be different from adults. The latest findings from brain imaging studies are that the nucleus accumbens and amygdala change their form, format and shape in marijuana users aged 18-25. Since these regions are deeply involved with pleasure; sex; food; emotional response and arousal, this should raise concern.
Clinically, people have known for a long time that marijuana can precipitate clinical illness – like panic attacks and psychosis. People who “casually” imbibe suddenly find themselves feeling inchoate dread, sometimes a sense they are about to die. Others develop hallucinations that are far worse than a “good trip.”
How many of these souls would have eventually been afflicted if they never touched marijuana? That is hard to say - and hard for many "happy"marijuana users to believe. But quite a few imbibers got a lot more than they bargained for.
Psychiatrists I speak with complain that marijuana is used far too frequently by people with mood and anxiety disorders.
Just as people in manic states may self-medicate with alcohol, many folks with depression smoke dope. They feel better, they tell you. Some say it’s “the only thing” that really does make them feel better.
Others may be unaware that prolonged use may prolong their depressive episodes. Many patients over the decades have told me their depressions only lifted when they quit smoking.
For marijuana can produce something else besides pleasant mood, cameraderie and seamless happiness. It can produce cognitive impairment where people overestimate their abilities – like their capability to drive.
And it also induces in some despair, in others futility – the attitude of “whatever” or “it doesn’t really matter.” And that sense of futility can last, with regular use, for decades.
Perhaps we might say that marijuana may - in certain people - produce a state of cognitive despairment. That it may do so in a minority of people should not let those who happily imbibe disdain their fellows with negative results. Futility is a horrible feeling to carry day after day after day.
The Nature of Drugs
The public often has contradictory responses to drugs. Prescription drugs are theoretically “good” in that they’re pure, but also “dangerous.” All their side effects require strict government regulation.
Conversely, over the counter drugs, particularly “food drugs” like caffeine and alcohol, are considered “safe.” You don’t need to see a doctor to get them. They must be okay.
Except drugs are drugs. They do lots of things people really like – consider the many millions eagerly puffing on expensive, illegally sourced marijuana – and lots of things they don’t.
This “angel and devil” element exists in all drugs. Whether prescribed by doctors, tobacco companies, or “health dispensaries,” you want to know what you’re taking and what it might do – to you and others.
For drugs have population effects. They change death and morbidity rates. They shift attitudes and societal mores. They cost a lot directly and indirectly, from overall economic productivity to, in many cases, the costs of treatment and law enforcement.
Drugs deserve to be viewed comprehensively for all their effects – individually and collectively, nationally and internationally, on health, diseases, politics, power and the environment. That includes the many millions ruined and wrecked by the drug trade and the drug "war."
For drugs are a big part of public health. And it’s time to think about our public health first – well before our national obsession with our fouled-up medical care system.
Health care should be to provide health – physical, mental, social and spiritual wellbeing. And that includes the many different effects - positive and negative - of drugs.