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Recently I published my book Matters To A Head: Cannabis, Mental Illness & Recovery as a contribution to the public debate on the place of cannabis in our society. My own experiences with using the drug, and the mental illness that incapacitated me in my mid-twenties led me to believe that there is insufficient recognition of cannabis as an addictive and sometimes harmful drug. My family and I also discovered how little information there was available on the relationship between cannabis and mental illness, and that there has been a lack of appropriate treatment and service provision to people who suffer with a dual diagnosis.
My favourite quote in my book comes from my father, who made the potent observation that the problem with cannabis is that “some people can get away with smoking marijuana and some can’t. But by the time you find out you’re a can’t, it’s already too late”. That was certainly my experience.
The perception in our society of cannabis as a ‘soft’ drug does not factor into the equation any of the myriad human complexities that influence the effect the drug may have upon an individual. Especially when smoking starts at a young age and becomes a regular habit or an addiction. Through my time spent as a patient in a psychiatric hospital I discovered that there were many young people admitted with what seemed to be the pre-conditions for being in the ‘can’t’ category: regular cannabis use + early uptake of cannabis + experiencing a life crisis = onset of significant mental health crisis.
In New Zealand we have been debating drug law reform at the parliamentary level. To my mind, the legal discussion is secondary to the more pressing issue of the difficulties faced by the ‘can’t’ sector of the population. How do we help or make provision for the people in our society who are experiencing significant harm from the drug, and will do so irrespective of whether it is legal or not? Our psychiatric hospitals and prisons contain many such people. Like tobacco and alcohol, changing the legal status of cannabis will not change the fact that many of our people are seriously affected by the drug and need a lot of support to move out of the cannabis way of life.
The recognition of ‘dual diagnosis’, sometimes termed ‘dual disorder’, is a recent acknowledgement by the psychiatric profession that an individual suffering both drug problems and a diagnosable mental illness presents with a unique and complex set of difficulties at the treatment coalface. In Matters To A Head I have tried to express and explain this dynamic to aid better understanding:
Addiction is a powerful physical and psychological demand that worms its way into the core of a person’s being and sets about to destroy that person’s spirit and personality. With ‘P’ [methamphetamine] the addiction appears to take hold rapidly and often dramatically. With cannabis this process is generally slower and initially more difficult to recognise. Eventually though with any addictive drug use, regardless of what the drug is the results will be more or less the same. Every dimension of that person’s being will become tainted in some way.
It’s a difficult process for a non-addict to understand. After all, we look pretty defective towards the end of our using lives, not much of an advertisement for the happy-go-lucky face of recreational drug use. So why can’t we just stop once the party’s over?
When I first started going back to recovery meetings, I would share about how cannabis had become a ball and chain around my ankle. The fun had long since gone. I felt like I couldn’t function without it. In the early days I had loved the feeling of freedom that drugs gave me, but now I was in more shackles than I ever imagined possible. I smoked dope just to feel normal, but it didn’t make me normal, far from it. And I had always believed the lie I told myself, that I would be worse off if I quit, that I couldn’t be happy or indeed cope with life without dope. Happy? I wanted to kill myself, you can’t get much more unhappy than that. Denial is that thick.
Is it crazy to call a cannabis addiction life-threatening? Different people react differently to the drug. Be your own judge. It can certainly be soul-destroying. For me, getting clean felt like it had become a matter of life and death. I reflect on all the near-misses that I survived. Near-car accidents where I could have been killed; the life-sucking demons of depression and insanity that may well have led to suicide sooner or later; the fact that my drug use had become increasingly risky in that I would take whatever was put in my hand; I’m probably not being too melodramatic when I say that the odds of me failing to see out my natural years were stacking up.
I began to see that I could not stay clean unless I was also managing the symptoms of the bipolar. The addiction and the mental illness had their tentacles wrapped tightly around each other. I know not what caused what, what came first, but it hardly mattered now. There is a powerful dynamic between these dual forces which cannot be broken by merely looking at one or other of these malevolent beasts.
When my bipolar was in it’s active phases, highs or lows, using drugs was intricately wound up in this. When I was high, the added euphoria attained from using drugs as well was intoxicating and highly addictive. When I was depressed and haunted by demons, smoking dope and drinking were the things I relied upon to bring relief. Receiving medical treatment for the mood disorder helped me reach a place of at least some emotional stability where I was not so much at the mercy of the mood swings. When I was ready to quit, that little foretaste of stability made the idea of being clean from dope seem vaguely possible.
Being stoned had for years given me the numbness and emotional distance I needed to live with my thoughts, feelings and fears. Socially, where I had always felt that I was so different from everyone else, an alien who had accidentally landed on this strange planet, when I was stoned I either didn’t feel it, or just didn’t care. Even though mentally and emotionally smoking dope was making things worse, I didn’t see it like that. Anyway, by this point the physical aspect of addiction had taken hold and the cravings would not allow me to let it go even if I wanted to. In those last few months of active addiction I smoked dope every two or three hours just to appease the hungry beast. I was virtually never straight. Every time I took a deep toke on that joint I was sucking all the colour from my existence. And every day was the same. Grey”.
Generally speaking, the people in the mental health system who are not getting better are the ones who have addiction problems co-existing with their mental illness. What came first, the drug and alcohol abuse or the illness becomes an irrelevant aside. As is debate over how much or how little it takes to trigger the sensitivity.
Cannabis is a greedy substance. Its active chemicals like to get all over the neurons and synapses in your brain, not just the selected ones that much modern psychiatric medicine adheres itself to. For example, many of the antidepressants available today work on increasing the re-uptake of the neurotransmitter serotonin by the associated neurons. Serotonin, related to depression and mood stability, and its companion dopamine which relates to schizophrenia, psychosis and mania are both active in the regulation of moods and are targeted for effect by psychiatric medications.
Cannabis, like the older-style medicines, isn’t fussy. Its active chemicals, the cannabinoids tetrahydrocannabinol, or THC, and cannabidiol are fat-soluble substances that stick to the brain’s neurons. Being fat-soluble means that these chemicals will hang around a lot longer in the brain than if they were water soluble, for example, as with alcohol and psychiatric medication. The neurons that the cannabinoids are latching onto are the same ones that the psychiatric medications are trying to latch onto. Clinical research confirms that
“absorption and clearance of other substances taken at the same time as marijuana are affected (slowed down)”. 1
That is to say, any psychiatric medication the user might be taking. The cannabinoids are also known to inhibit the metabolism of substances processed through the liver and hepatic system. That is mostly all psychiatric medications with the exception of lithium, which is metabolised through the kidneys.
To roughly translate, this all means that if a person on psychiatric medication is also using cannabis on a regular basis, the effectiveness and reliability of the medication will be compromised by the presence of the active cannabis chemicals literally sticking around in the brain. That is why you or your mentally ill family member or friend isn’t getting any better, even though they swear they are taking their meds and that the dope is helping them to manage their condition. It’s probably not.
Throw into the mix the growing awakening to the role cannabis plays in the onset of psychoses and schizophrenia. Whilst it has been difficult to distinguish whether regular cannabis use causes these conditions in itself, or whether it triggers episodes in people who would have had them anyway, there most definitely is a troublesome dynamic between cannabis and mental illness.
Using cannabis as part of a medicinal regime is hard to justify in relation to mental illness, although many of us have tried. For one, there is no way of regulating a consistent dose. I remember all too well that sickening, dizzying feeling of being too stoned, having smoked something way too strong or unsuspectingly smoking dope that had been doctored with other drugs. You feel as though you are being sucked into a hallucinatory vortex and then spat out the other end as you come down. It is not in any way a therapeutic experience and occurs randomly and unpredictably depending on the dope. Even plants from the same crop can have variations in strength. I suspect that most people who buy their dope through New Zealand’s cannabis economy have no idea where it has actually originated from, how many hands it has passed through and what if anything has been done to it to increase it’s potency or increase profit margins.
Generally speaking, cannabis grown in New Zealand today has been hybridised into a much stronger drug than it was in the past. The more dope I smoked, the more my tolerance built, the more I needed to get the desired effect. Following this progression, always seeking out the strongest dope I could find, the more likely it became that I would experience an increase in the drug’s negative effects. That’s just how drugs work.
In recovery I have discovered two things. Firstly, that psychiatric medication works a lot better when it is not competing for brain space with cannabis. And secondly, that the old adage is true: time is a great healer. Many of my psychiatric symptoms, such as panic attacks and severe anxiety, have diminished and largely disappeared over time. I have found too that non-medical stress management techniques work more effectively in the more balanced chemical environment that being clean has given my mind.
One of the difficulties with getting help for these issues is the way our health system has traditionally compartmentalised these conditions as separate entities. Drug addicts over here, and people with a mental illness over there. This is starting to change with the development of integrated services but as yet there does not appear to be a cohesive and credible treatment modality underpinning service delivery. This is hampered further by the Ministry of Health-funded service providers’ adherence to the harm reduction model. This adherence means that there is little political will or resourcing for encouraging people with mental illnesses to quit totally one of the biggest impediments to their wellbeing and recovery, their so-called ‘recreational’ drug and alcohol use.
The New Zealand government has driven a strong and persuasive public health campaign to warn people of the dangers of cigarette and tobacco smoking and of the highly addictive nature of the habit. It is generally accepted that the best advice is that people should quit smoking altogether if they can. The government-sponsored Quitline has been put in place in recognition of the fact that people need help and support to make the change. But these same government entities have largely failed to acknowledge publicly that the reality of addiction applies to other widely available drugs as well. It is a societal denial and is perpetuated by simply doing nothing.
You would be hard-pressed to find an inpatient service in New Zealand which seriously addresses and provides appropriate treatment for both a person’s addiction and their mental illness. But as we are increasingly seeing the effects of alcohol and drug-fuelled mental health issues amongst our population, the time for change has come.
My own story underlines how difficult these problems are to resolve. For an addict to stop using, we have to really want to, and it can be any number of dire circumstances that occur before we reach that rock bottom, that point at which there is no other option but to stop using the drugs. But in service provision we must keep trying. We must make the time, the facilities, the people and the money available to meet that need. We must be willing and able to catch people at that moment when they feel desperate enough to consider the possibility of quitting. That window often does not stay open for long, and there is no place for waiting lists in effective service delivery.
As a society we cannot afford to give up on people, no matter how long it might take them to get clean and to stabilise their mental illness. The social and economic costs of continued denial and inaction are too high. The only sane option that remains is to provide the necessary resources to give our addicted and ill members of society the optimum circumstances to find and begin recovery.
There is a way forward in creating models of practice that work for people with a dual diagnosis. A positive start has been made in developing and co-opting the ideas and initiatives of mental health service-user groups. The small but encouraging growth of peer support as a recovery principle and method of practice is a big step in the right direction. As I have reiterated throughout this book, often the best information, support and enlightenment comes from those who have been in the hell-hole and have found a way out.
There is a significant role for peer support services alongside or as part of the multi-disciplinary treatment team in areas such as advocacy, support work and crisis respite care. But first, people who are or have been in the mental health services have to get well enough to lead. And we need acceptance, co-operation, innovative thinking and courage on the part of the medical-model services to let us put our plans into action. Projects such as COMPASS and Kotuku in the Nelson region ably demonstrate that there is much to be gained from moving over and making room for mental health consumers as service providers. The blueprints are already there.
An act of political bravery is becoming urgent. That is, to deliver the challenge to alcohol and drug services to reconsider the wisdom of keeping the harm reduction model as the centerpiece of their modus operandi when working with dual-diagnosis clients. Clinging tightly to this model is holding back necessary funding and political will to explore other treatment options. We have a scarcity of abstinence-based treatment programmes still in operation after being hacked away at by politicians who thought it would save money to close them down. I think we’d all agree that didn’t pan out too well.
It is true though that the quantitative measures used by governments to assess the success of such programmes reveal that not many addicts and alcoholics get clean and actually stay clean. But we know more now. We know that if we treat the whole person, appropriately diagnosing and treating mental illness in concert with addiction treatment, we have a better chance of improving those rates.
It is not official policy, but some community psychiatric teams have adopted a zero-tolerance stance of refusing to respond to call-outs where the person displaying symptoms is under the influence of alcohol and/or drugs. Their argument is along the lines of that there’s nowhere to take the person; the mental health units aren’t pleased to see them so that leaves the police cells. They argue that it is not their job to put their staff at risk and continually tie up resources needed for the people that aren’t drunk and stoned or high on ‘P’.
To me, this begs the retort of ‘Well, somebody needs to go and get them.’ It is not really OK that there is nowhere to take this person. That is no longer an acceptable or tolerable situation. Any cry for help deserves a humane response.
So they don’t make it, they run off and bust? We keep trying. You never know what little miracle might occur in the midst of that person’s self-destruction to lead them back to attempt recovery again. I reflect upon my own story, and those of others I have met through recovery. We were the incurables, we were those whose conditions appeared hopeless. People thought we were doomed. We thought we were doomed. But we have been granted a second chance at life, or a third, or a fourth…and we are doing ok.
It is my view that we need a broader range of flexible, available, mental health and addiction services, especially at the inpatient level. One size does not fit all, but many of our worst sufferers are already in our prisons or psychiatric hospitals, so why not do more work with them there? Its a captive audience, so to speak, in the boredom and desperation of an institution. Its not like they’re too busy to attend.
Right now in New Zealand we are discovering that it is ultimately more costly not to treat these conditions. It is also inhumane. Untreated mental illness and psychosis is torture to the sufferer. With regard to our justice system, just because a person is a prisoner doesn’t make it right to deny or simply fail to provide appropriate assessment and treatment. Surely the outcomes are better for everyone if people who need it can receive this. For our hard-core population of chronic dual diagnosis patients we may be putting in their hands the tools for survival and hope. And maybe, just maybe, for a future. That surely is a gift worth giving.
Kate K is a New Zealand Registered Nurse and recovering cannabis addict/bipolar sufferer. She has been clean from alcohol and drugs and remained hospital-free for over ten years. Matters To A Head: Cannabis, Mental Illness & Recovery is her first book. You can buy the hard/paper copy through her website [linked in to the title above] or you can buy the Kindle version through CrimeTalk and Amazon, and thus support CrimeTalk, by clicking on the widget below.
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