ADDICTION GATEWAY OR SAFE EXIT?
In the early twentieth century, there was ongoing pressure on the United States government from the Temperance movement, a loosely based social activist network aimed at eliminating alcohol from society as a whole.
The movement gained support at the federal level when organizations such as the Committee of Fifty for the Investigation of the Liquor Problem and the Anti-Saloon League of America began to suggest policy reforms to the way that liquor was both administrated and permitted in public places. These organizations were supported by the corporate and social elite and gained momentum in the middle classes, because there was a perceived threat to the economy when alcohol use was pervasive, especially during working hours.
The immediate difficulty faced was that Prohibition law was almost impossible to enforce, and that continued to be the case throughout its course, because of the sheer volume of people who had to be policed. The rationale for this policy was based in a new way of thinking about one’s life and livelihood based on Protestant values and work ethic; if it took hold on a cultural level in the United States, the movement could be successful. With such a broad immigration policy prior to this time period, and increased fears about immigrants and their social norms after the First World War among a vocal segment of the population, Prohibition seemed to ensure that everyone was on the same page, so to speak, in terms of what they valued and how they acted.
Controlled and constrained
A control mechanism like Prohibition felt safe to the American public.
Even though Prohibition was put in place in order to reduce crime and corruption, solve social problems, reduce the tax burden created by prisons and poorhouses and improve health and hygiene, the opposite seems to have happened. Prohibition resulted in a massive increase in cross-border and in-city trafficking of alcohol, which, some say, led to the rise of the mafia in certain areas of the United States. In addition, the consumption of alcohol actually went up during the years of Prohibition, in that annual per capita consumption and the percentage of annual per capita income spent on alcohol had been steadily falling before Prohibition, and annual spending on alcohol during Prohibition was greater than it had been before.
In fact, Prohibition created a disconnect between the needs and interests of the population and the police. This in turn led to the creation of a large black market, different forms of law under the mafia, increased murder and other crimes associated with trafficking and a massive increase in the prison population. What this suggests is Prohibition’s extended enforcement may have shaped the current standards of conflict between the police and communities, which we continue to see in the present day.
We know that this “noble experiment” of Prohibition failed, almost from the time of its in institution in 1920 as the Eighteenth Amendment to the Constitution, under the Volstead Act, until it ended in 1927.
Prohibition of the use of psychoactive drugs is likely to fail as well.
That doesn’t mean we can’t look at how to manage the steady rise in addictive behaviors in our communities. I would argue that we ought to address addiction, just as we ought to address other debilitating health issues, but not for the moral reasons that are aligned with Prohibition.
Cannabis is seen by many as a so-called gateway drug, which seduces people into becoming drug addicts over the long term. To that end, CBD is often seen as deeply problematic because of the fact that it makes cannabis seem less of a problem, less of a risk.
The inherent lack of risk in cannabis use
What if cannabis was, instead of a gateway drug, an exit drug from addiction and addictive behaviors? As the scientific research literature suggests, it may be just that.
The gateway drug hypothesis has long played an important role in shaping drug use policy, and it has been called upon from the time of alcohol prohibition to the modern war on drugs as a justification for the time, money and moral justice efforts spent on policing our use of cannabis.1 This is not just an oversimplification of the issue of drug use, but it has been actively harmful from the point of view of health care.
“Far from being a so-called gateway to the use of harder drugs such as cocaine and heroin, marijuana is, for most people who try it, not even a gateway to more marijuana use,” according to William Martin, PhD, director of the Baker Institute drug policy program at Rice University, and his fellow researchers.2
Martin’s research, looking back at more than fifty years of cannabis use statistics in every part of the country, has shown that the average psychoactive cannabis user in the United States does not make smoking pot a habit. It’s clear that this substance doesn’t come close to meeting our expectations for what can be defined as addiction. In fact, the opposite is true. Researchers from other institutions also agree with this hypothesis. A study sponsored by the National Institutes of Health concluded that there is no evidence that the effects of marijuana are causally linked to the subsequent abuse of other illicit drugs, and that the risk was much higher for people who are prescribed sleeping pills or even Tylenol from their general physician.3
So, if cannabis is not generally found to be a gateway drug, then what, if anything, does it have to do with addiction? And why do I think that codifying cannabis as addictive is actively harmful from the point of view of health care?
We're so very, very wrong about addiction
We can’t just start with the roots of addiction. We have to start with our assumptions because, well, they’re wrong.
In the United States, the areas with the highest numbers of addicts aren’t city centers. Yes, you’ll see addicts in every major city. Like you, I’ve witnessed the living conditions of homeless addicts on the streets of places like San Francisco and New York. I’ve talked with some of them and heard their stories. But they’re not representative of the biggest masses of addicts in our country.
Where are our addicts?
West Virginia. New Mexico. New Hampshire. Kentucky. Ohio. According to researchers at the Baker Institute drug policy program, most of America’s addicts live in flyover states, in small towns and in rural areas. Addicts live in towns that are affected by high poverty and low economic stability. These are people who are seeking out illegal opioids or prescription drugs that are being resold. These are the same regions where there is a vast discrepancy in the availability of and access to health care; in the Deep South, Appalachia, along the Mississippi River, in the Southern Plains and in Texas, life expectancies are decreasing and the life expectancy gap is growing between rich and poor in this country.4
“Those who are addicted are significantly more likely to have had a traumatic childhood experience, to have a mental illness or to be facing economic insecurity,” Martin writes. “These are far stronger predictors of opioid dependence than the availability of heroin coming across the Mexican border or the street price for OxyContin.”
Addicts want drugs in order to feel better about the challenges that they face in their lives. But, perhaps even more likely, they soon need drugs. Opioids temporarily numb pain until a rapid desensitization process kicks in, driving an elevated dosage level by users, intense physical addiction—and eventual death in far too many cases.
The opioids inside us
Let’s talk about the opioid system in the body and how it relates to the endocannabinoid system.
We all produce our own opioids, just as we produce CBD. Think about the last time you felt angry. Maybe you were cut off on the highway, or maybe you lost out on landing a partnership at work. Maybe you were woken up in the middle of the night by an inconsiderate neighbor, and you had to get out of bed to bang on the wall. How did you calm yourself ?
The most likely thing that you did first was to take a deep breath.
Breathing fast acts to flood your blood stream with endorphins and adrenalin, so that you can react quickly to any additional challenge you face. When you feel safe, breathing slowly works to slow down your heart rate and stop these chemicals from moving through your body. Next, your gut produces serotonin, which moves through your bloodstream to your brain and finally to your liver. Serotonin acts to modulate what you see, hear and feel, so that you can move into a calmer state. Many more chemicals are released in the process, such as neuropeptides. These decrease physical and mental pain and allow your body to return to a state of homeostasis. You may directly aid in this process by slowing your breathing deliberately, but the body does its own internal “breathing” to make sure you’re safe.
But why does this happen?
Opioid receptors in your brain are present in order to absorb these chemicals and to interact with your physical and mental pain sensors. Not only do these receptors exist in the nervous system, but they’re also present in your heart, lungs, liver, gastrointestinal and reproductive tracts.5
“We have our own opioid system just like our own endocannabinoid system,” Dr. Andrea Furlan, associate professor in the department of medicine at the University of Toronto and a staff physician and senior scientist at the Toronto Rehabilitation Institute, explains. “It is our way of producing our own substances more potent than morphine but released in tiny doses in specific areas.”
Think about endorphins. We’ve all heard about what they do, and we talk about them all the time. We get what we call an endorphin “high” when we go for a run or go dancing. The reason we get this high is that, once they’re released, our opioid receptors are allowing these chemicals to move through our brains.
For some people, those receptors don’t open.
Here’s why. Social and personal stressors affect our brain function. We’ve already talked about the neuroplasticity of the brain, and the fact that when we have a high level of stress affecting us, we aren’t able to find a sense of calmness and safety in our body and mind.
In adults, a prescription for opioids doesn’t make this stress better, nor does it make pain go away.
“If you put someone on opioids it will depress, even totally surpass their own opioids,” Furlan tells me. “They are drowning their opioid system. It’s like hormones: if you take thyroid hormones, your thyroid stops making its own. So it takes a long time to rebuild it. It is my opinion that some patients will never be able to have their own opioid system again.”
The addiction cycle that Furlan describes is the one with which we are most familiar: someone gets into a habit of taking a drug, whether by a doctor’s prescription or just for the fun of it, but in either case, they are left with a crippled opioid system, which isn’t able to be fixed.
But there’s another, perhaps more devastating, opioid crisis, and that is based on what happens to infant children who are affected by a great deal of stress. What happens when this stress takes place while children’s brains are still developing?
It’s a complex scientific conundrum, but stay with me here. This story is worth your while.
Parents who are stressed out or don’t have enough money coming in are not likely to spend as much time with their children. This may be from the simple fact that they are working more than one job, and they have to count on a relative or neighbor for childcare when they do so. It may also be due to the fact that they are too exhausted or overwhelmed by stress to spend happy quality time with their children when they are at home. These parents may also suffer from addiction or social withdrawal.
But here’s the crux of the matter: children who experience a great deal of separation distress and a lack of attachment as infants may not develop opioid receptors at all. They will not physically develop the capacity to actually stop stress from happening on a neurological level.6
The reason is that these children have never learned how to calm themselves and force a rush of positive opioids through their central nervous systems in the way others have.7 They are physically incapacitated as a result, just like Furlan’s adult patients whose opioid systems have been destroyed from drug use. When these children, from the Midwest and the South and other parts of the country where parents are very vulnerable to stress, reach adulthood, they are at high risk for addiction and related mental health disorders. People with an opioid receptor disorder cannot produce their own chemical mix to self-soothe, and so they seek out chemicals that their bodies need.8 People need opioids, and their bodies will supplement these naturally; if they can’t access them naturally, people will supplement them through pharmaceuticals or street drugs.
When addicts are only treated by medication, they develop an increasing and addictive pharmaceutical dependence. This is why opioid medications are so problematic. Research has shown that what is known as neuroaffective therapy, which is actually a kind of talk therapy combined with somatic breathing exercises, can help the brain develop the capacity to create its own neurochemicals. It can actually fix some of these blockages and rebuild a portion of the body’s opioid receptors. This is a more substantive and effective approach that frees addicts from a heavy reliance on pharmaceutical forms of care. But our health care system doesn’t pay for therapy and, in most cases, doesn’t see the value in doing so.
Finding our equilibrium: The ideal of homeostasis
We need to come to terms with each individual’s level of vulnerability, but our assumptions are always that addiction is a moral choice. We think that people choose to take drugs, when, in many cases, our bodies are simply crying out for what we need to survive.
We have to understand the role of homeostasis in creating safety for people affected by addiction. We started to unpack this process earlier in the book, but let’s break it down even further so that we understand where CBD comes into the mix.
Homeostasis is the equilibrium of all of the major systems in the body so that our primary functions can be maintained: how we manage blood pumping through the body, our brain consciousness and body temperature, how we process food and water and our metabolism.9 For example, if our heart muscles aren’t working correctly, this can result in high or low blood pressure, high or low temperature, as well as heart issues like internal clotting or clogged arteries that might lead to a stroke or embolism. When we don’t drink enough water, our electrolyte balance may be off, and this can lead to low blood pressure, dizziness, kidney problems or even shock or stroke. Similarly, an imbalance in the way that we eat, or how our pancreas works, can result in an imbalance in insulin that could lead to diabetes. When one system goes of balance, there is the potential for an impact on another system. The maintenance of homeostasis is fundamental to who we are and our survival.
As Dr. Reggie Gaudino explains, this is where CBD does its best work, and if you look at the chemical makeup of CBD, you’ll see why. “Based on its structure, CBD actually looks very much like a corticosteroid, which is very important for our homeostasis in the body,” Gaudino says. “It also looks a lot like melatonin, the sleep chemical, which is probably why it helps with sleep as well. That’s exactly how the cannabinoids work. They actually act on those same systems to produce a homeostatic condition in the body.”
Our systems work together to maintain what is known as homeostatic control. For example, our chemical systems aim to regulate the amount of energy in each cell, while our hormonal systems regulate how we eat and move to balance our energy use.
As Steve DeAngelo points out, “No matter who we are, our purpose remains the same, and that is to maintain or restore homeostasis. Homeostasis is a fancy way of explaining the body’s natural balance. It means that you need to maintain a stable internal environment no matter what the external influences are.”
Perhaps most important, however, in maintaining homeostasis is the role of our central nervous system. The central nervous system is the connective group of nerve fibers that operate throughout the body, aligning both cognitive and intrinsic bodily needs and functions between the brain, the spinal cord and nerves, and the nerves that extend through each limb. The role of the nervous system in the maintenance of homeostasis is that the autonomic nerves control unconscious processes such as breathing, the heartbeat and digestion. The central nervous system is responsible for movement. The sympathetic nervous system allows us to process emotions on a somatic level. For example, the sweat glands are controlled by the sympathetic nervous system, so moments of strong emotion can be an indication of psychological or physiological arousal.10
The maintenance of homeostasis is made possible by the regulation of, most significantly, the autonomic nervous system, but it is also affected by the way in which the body responds to stimuli through its nervous system responses. Systems work together to maintain homeostatic control especially when the level of stress, either psychological or physical, put on the body is high. When we have excess hormonal and chemical stress, this can lead to a lack of homeostasis.
Solving pain and addiction
A lack of homeostasis is a direct path to disease, and here’s where CBD comes into the picture.
“This is the reason that cannabis is effective for so many seemingly unrelated diseases,” says DeAngelo. “Because in every case, what cannabis does is it restores homeostasis, it restores the natural balance. It seems that our bodies have evolved to work with cannabis. We wouldn’t all have an endocannabinoid system if we weren’t meant to engage with phytocannabinoids.”
DeAngelo isn’t wrong about the way our endocannabinoid system has developed, which we’ll discuss in more detail later in this book, but the premise that addiction is amoral really starts to break down when you look at the way our bodies process CBD. We don’t just use it to make ourselves feel better; we actually need it to survive, in the same way that we need opioids.
Mike Clemens, a scientist and principal at Guild Extracts in the San Francisco Bay area, explains why. “Homeostasis is maintained by a balance of the nutrients and minerals we need to be alive,” Clemens says. “It’s crazy how Western medicine will treat some other manifestation of the actual problem and that has worse effects than the problem. The endocannabinoid system supports that homeostasis that we need to be healthy—sleep, diet, inflammation, pain. Pain is a way of self-communicating harm. Pain is your body’s way of telling your brain something is wrong.”
What scientists like Clemens can do with CBD in order to create homeostasis and mitigate the effects of addiction is remarkable. One of Guild Extracts’ new efforts is to create a Bluetoothenabled device that will measure people’s pain and responses to vaporized CBD and THC so that they get the right dose when they need it, thus preventing overdose.
“If you use the device, we know the temperature the vape pen was used at, and how much product was used, and how long you used it,” Clemens explains. “Based on your phone use, we can also then see pupil dilation and use GPS to see if a patient moves or is physically still. What is their behavior after they use the product? If you have Parkinson’s, for example, have your tremors reduced? Then we can put it all into a deep learning neural network that compiles the data, and at the end of the day we crowdsource wisdom about how to best manage people’s medical needs.”
This new focus on CBD and carefully measured doses is something that Furlan knows a lot about. “Not everyone who is on opioids and wants to stop will be able to,” Furlan says, “but when they can, they have to do it through microtapering.”
Microtapering, Furlan explains, is a way of slowly getting opioid drugs out of the system and replacing them with CBD. This helps the body to not only repair its central nervous system so that homeostasis can be regained, but it also decreases the physical and mental pain of opioid detoxification.
“The most common symptom of getting off opioids is extreme anxiety; almost everyone will have it,” Furlan says. “They feel agitated, they can’t sleep or relax, concentrate; they have psychomotor agitation and they can’t stop moving their arms or legs, and it can last a couple days, weeks or months. It depends on how long they have been on opioids and how strong. Symptoms also include diarrhea, because opioids are constipating, and muscle pain. It hurts everywhere and nausea, vomiting, headaches and even sweating—profuse sweating—are common.”
Using CBD as a slow replacement for opioids works because it eases all of these symptoms while opening up endocannabinoid receptors so that the body can rest, relax and heal itself.
We’re not all the way there yet, however, in knowing exactly how to treat people affected by this kind of pain. “It is much more complicated than we ever understood and the field is still evolving and new studies are coming every day,” Furlan says. “Even the CBD system is still being discovered as we speak, and the receptors able to activate it.”
Despite this lack of clarity, Furlan and her team are trying to change the way that doctors look at pain, addiction and mental health issues linked to opioids and to consider a cannabis-based solution. In fact, not only is Furlan the author of Canada’s national opioid guidelines, she’s working to change legislation in her province of Ontario in order to make sure that doctors know how to shift their thinking. Furlan also worked to create an app, My Opioid Manager, to help doctors ensure that their patients can microtaper with confidence.
“We are investing a lot of time in an education project, Project Echo, providing information for primary care providers funded by the Ontario Ministry of Health,” she says. “We use telemedicine— we are twelve professors around the table every week, connecting with anyone in Ontario to discuss their cases. We’ve trained more than three hundred professionals across the province: occupational therapists, physical therapists, nurses, pharmacy operators, chiropractors. It’s very intensive. By educating primary caregivers, they can manage their patients better.”
Let's end our moral panic
A moral panic is a form of mass hysteria that is linked to fear and media urgency about a public issue. It includes a common concern, evidence of hostility, consensus in the media, a disproportionate level of response and volatility in terms of the way that the public engages with the issue. It provides a simplistic explanation for an issue in order to give the public a justifiable reason for something that has gone wrong. In other words, a moral panic can cause undue concern about an issue in the public eye, even if it is not necessarily something that will cause a long-term social or economic problem.
Moral panics can lead to rapid demonization of specific ideas, issues or people, such as the demonization of narcotics in the United States. It’s easy to blame those who are ill. It’s harder to come up with a valid solution for illness.
We can see the forest for the trees here. If Canada can create a foundation for re-educating doctors on how to use CBD, then the same has to be true for the United States.
What Prohibition and its effects have shown us is that the broad application of moral standards to a diverse population is likely to have negative effects. This is especially true in a country where our personal freedoms are highly valued. A moral high ground is not possible when people do not all believe the same thing about how life ought to be lived. And, in fact, the historical evidence shows the difficulty in trying to impose values and ideals: it makes a population question why that imposition is necessary.
The reality of our collective psychology is that we, as human beings, want to push back against government controls over what we ought to do. But perhaps even more important is the fact that we try to use moral arguments to talk about physical illnesses that are not the fault of patients. The moral regulation of what we believe to be our vices, like the use of opioids, is directly tied to our American expectations of assimilation, to the enforcement of conformity.
Instead of judging people with addiction issues, we need to get to the heart of the problems that bind our decisions as medical professionals, as politicians and as consumers. We need to look at what our bodies need to find homeostasis so that there is a forward shift. We also need the stigma of addiction to dissipate so that we can stop eliminating solid, scientifically valid solutions like CBD.
1. [Kleinig, J. (2015). Ready for retirement: the gateway drug hypothesis. Substance Use & Misuse, 50(8–9), 971–975.]↩
2. [Martin, W. & Neill, K.A. (2016). Drugs by the numbers: the Brian C. Bennett drug charts. Issue Brief 08.01.16. Retrieved from http://www.bakerinstitute.org/research/drugs-by-numbers/]↩
3. [Philipsen, N., Butler, R. D., Simon-Waterman, C., & Artis, J.]↩
4. [Sack, K. (2008, April 27). The short end of the longer life. The New York Times. Retrieved from http://www.nytimes.com/2008/04/27/weekinreview/27sack.html?_r=1]↩
5. [Feng, Y., He, X., Yang, Y., Chao, D., H Lazarus, L. & Xia, Y. (2012). Current research on opioid receptor function. Current Drug Targets, 13(2), 230–246.]↩
6. [Panksepp, J., Knutson, B. & Burgdorf, J. (2002). The role of brain emotional systems in addictions: a neuro-evolutionary perspective and new “self-report” animal model. Addiction, 97(4), 459–469.]↩
7. [Zellner, M.R., Watt, D.F., Solms, M. & Panksepp, J. (2011). Affective neuroscientific and neuropsychoanalytic approaches to two intractable psychiatric problems: why depression feels so bad and what addicts really want. Neuroscience & Biobehavioral Reviews, 35(9), 2000–2008.]↩
8. [Maté, G. (2008). In the Realm of Hungry Ghosts: Close Encounters with Addiction. Toronto: Knopf.]↩
9. [Colbert, B., Ankney, J., Lee, K., Steggall, M. & Dingle, M. (2012). Anatomy and Physiology for Nursing and Healthcare Professionals (2nd ed.). London: Pearson. ]↩
10. [Clancy, A. & McVicar, D. (2009). Physiology and Anatomy for Nurses and Healthcare Practitioners. New York: Hodder Arnold. ]↩