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ADD / ADHD and cannabis

 

Some people with ADD / ADHD use cannabis regularly, and I have had patients who moved on to prescribed ADD / ADHD medication, finding it both more helpful and lower in unwanted effects than cannabis.

As the diagnosis of ADD / ADHD grows in the UK, I suspect this will become more of a factor in the debate about whether cannabis should be criminalised to a lesser extent, or even decriminalised altogether.

I don’t have a formal professional view either way on that issue, especially as I’m not a specialist in “Substance Misuse”. But I would say that the arguments of the leading UK advocate for reducing criminal sanctions on cannabis, Professor David Nutt, seem far from clear-cut.

On his Blog (http://profdavidnutt.wordpress.com), Professor Nutt suggests that the risk of increasing schizophrenia in young people, which could result from decriminalisation, is not of great concern. On his own figures, for every extra million young men using cannabis, about 200 might develop schizophrenia who wouldn’t otherwise do so.

His argument seems to be that alcohol use would probably decline (because of switching from alcohol to cannabis), and the benefits from that would outweigh any cannabis-related harms.

He might be right, but I think at least two aspects of the debate have not received as much attention as they should.

First, it does seem very difficult to compare the harm of an often devastating psychotic disorder, with alcohol-related problems. Is it really as simple as saying that improving and extending life for tens of thousands of people, by reducing their alcohol intake, logically outweighs the risk of “only” a few hundred people developing schizophrenia?

Secondly, I think the wider debate about “harm reduction”, and Professor Nutt’s related view that UK medical doctors should be able to prescribe cannabis (as they can elsewhere in Europe) would benefit from an acknowledgement that medical prescribing of some mind-altering substances has been, and remains, too lax.

When UK general practitioners, from the mid-1990’s, were widely encouraged to prescribe antidepressants after little more than a ten-minute consultation, this state-approved practice was never properly tested. The concerns about misuse and harms of Seroxat and other antidepressants followed.

Of course, as a specialist prescriber of mind-altering substances myself (hopefully, always as a reasonable therapy), I have a direct vested interest. But it does seem to me that promoters of medication, whether natural or synthetic, branded or generic, freely available or eye-wateringly expensive, would generally be more credible if they listened to my (free) advice.

A far far better ending for “A Tale of Two Cities”?

 

I am obsessed by the novels of Charles Dickens, although this is a mild-to-moderate rather than a severe obsession, because I have not read any of them more than two or three times. Nor have I properly read more than a small fraction of the dozens of biographies and book-length critical studies published since Dickens’ death in 1870.

The recent riots in London, after the riots in Paris of a few years ago, got me thinking about Dickens’ descriptions of mob violence and mob rule in A Tale of Two Cities. The capture and execution of French aristocrats by the revolutionary Government provides an opportunity for the alcoholic and morally ambiguous lawyer, Sydney Carton, to do something unselfish for once.

I usually disagree with the view that Dickens is an overly sentimental writer of fiction, in the sense of false or distorted emotions being used for propaganda (for example, to promote a non-progressive view of the role of women). But this charge may be correct when it comes to Carton’s fate in the novel: in helping an aristocrat (who he happens to physically resemble) to escape, he deliberately gets himself imprisoned.

On his way to the guillotine, he speaks one of Dickens’ best-known lines: “It is a far far better thing that I do, than I have ever done”.

But is it? Carton’s supposedly noble action can be seen as promoting the idea that alcoholics are inferior beings who cannot change their personalities or behaviour, and do the rest of us a favour when they choose to die. Such was the hybrid of mistaken science and morality which developed in the last decades of the nineteenth century, and went even further in twentieth-century Nazi Germany.

The novel could easily have been written differently, with Carton revealing his true non-aristocratic status, backed up with a hidden physical attribute or some other identifier. Dickens had been the leading English novelist for decades, and had the skill to produce any number of original, plausible and memorable plot-lines based on Carton’s keeping, or at least trying to keep, his head.

 

This post was drafted by 2nd September, and published at DrNMblog.wordpress.com on 6th October

 

Raise your glasses

 

England have today won the Ashes in Australia for the first time since 1986. The media have contrasted the travelling England supporters’ cheerful optimism through the last two dozen years, with the fair-weather Australians, who deserted the stands as this Tour played out.

Like the “Tartan Army” who support the Scotland football team, many of England’s cricket supporters abroad are said to drink heavily and yet stay good-humoured. This “Barmy Army” has attracted the attention of academic sociologists, who suggest that they have created “a new form of English national identity” (1).

“Barmy” of course means “mad” or “insane”. As far as I know, no charity or professional group has censured the “Barmy Army” for the name they have chosen for themselves. To do so would itself be seen as crazed political correctness, which shows the importance of context for language like this (2).

English, (mostly) male sports fans who have been drinking: the more usual image is of football supporters facing off against baton-wielding European riot police (3). Both the Barmy and Tartan Armies show that it is not alcohol itself that inevitably leads to public disorder (4): for that to happen there has to be an advance expectation of hostility and violence. Perhaps the message in the “Barmy” name is that expectations can be changed.

So if toasting England’s Ashes victory tonight, pay attention to context and expectations; before downing those units of fizzy chardonnay, Aussie or otherwise.

 

 

(1) Parry M, Malcolm D (2004) England’s Barmy Army: Commercialization, Masculinity and Nationalism. International Review for the Sociology of Sport. March 75-94. I have only read the abstract, at: http://irs.sagepub.com/content/39/1/75.abstract

(2) See ‘ “Nutters”, “Fruitcakes” and “Loonies” ‘, 30th April 2010: https://drnmblog.wordpress.com/2010/04/30/nutters-fruitcakes-and-loonies/

(3) Documented in Bill Buford (1990) Among the Thugs

(4) A recent article in the Bulletin of the World Health Organisation seems rather confused. Despite the title – Governments confront drunken violence –implying a strong causative role for alcohol, the experts quoted appear to differ widely about social factors. Just one example: France is stated to have a growing problem, but the overall consumption of alcohol in France has continuously fallen in recent decades. 
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2930368/pdf/BLT.10.010910.pdf?tool=pmcentrez 

Published at www.DrNM.org.uk on 7th January 2011; transferred to DrNMblog.wordpress.com on 9th October 2011

The Call of the Bottle

 

Books “should, like alcohol, dissolve barriers”, according to the literary academic and journalist John Sutherland, who explored the early history of Alcoholics Anonymous (AA) in a short programme last week on Radio 4 (1).

But for some people (including Professor Sutherland himself, sober only through two decades of attendance at AA meetings) alcohol has the opposite effect: “drinking recreated the conditions of childhood. Solitude; myself alone” (2).

Of these two apparently contradictory explanations for excessive drinking (alcohol dissolves interpersonal barriers; alcohol creates an interpersonal barrier), the first has been widely held for decades. “Social anxiety” was seen as a cause of alcoholism (3), and a problem in itself, well before pharmaceutical companies supposedly invented it in the 1990’s (4).

Anyone with the slightest interest in English Literature is likely to have read at least one of Sutherland’s reviews, books, or introductions to classics by authors such as Wilkie Collins and Anthony Trollope. They are invariably well-organised and structured, with a light touch but not at all “dumbed-down”, so achieving their aim of engaging academics and the general reader.

Alcoholics Anonymous has the reputation of having a rather black-and-white view of addiction. This is probably helpful, even necessary, for many people with severe problems, especially those in the early stages of “recovery”.

But this academic abstainer is not afraid to explore complexity or uncertainty. For example, in his Introduction to Jack London’s ‘Alcoholic Memoirs’, he suggests that the “chronic boozer” London later brought his own alcohol intake under control “easily enough”, and then continued to drink in part “socially”, but also because of the creative possibilities gained from alcohol withdrawal (not intoxication) (5).

Therefore, for anyone looking to remove or reduce moderate or mild addictions, a period of solitude spent reading Sutherland’s extensive works is highly recommended, and is unlikely in my view to have any harmful effects.

 
(1) Available on the BBC’s iPlayer only until 14th November: http://www.bbc.co.uk/iplayer/episode/b00vr78f/The_AA_Bible/

(2) Both quotations are from Professor Sutherland’s British Council Biography: http://www.contemporarywriters.com/authors/?p=auth519D1A75056591DEA5JxLj47A89F

(3) http://www.ncbi.nlm.nih.gov/pubmed/4394734

(4) http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)60470-5/fulltext

(5) The whole Introduction can be read with Amazon’s “Look Inside” facility. The book’s full title is John Barleycorn: ‘Alcoholic Memoirs’.

This post was published at www.DrNM.org.uk on 12th November 2010, and transferred to DrNMblog.wordpress.com on 7th October 2011

The beautiful game: Americans can play (and watch) too

 

Writing in The Huffington Post, an American novelist has stated that football* will never catch on in the United States, because it is too boring to watch (1). “American sports fans…crave the excitement presented by the chance of a score on every play.”

One of his European readers responds by suggesting that high rates of ADD / ADHD might account for this drive towards instant gratification. But is it true, anyway, that people in the United States generally lack restraint, live more “in the moment”, thoughtlessly follow their impulses and desires?

If so, the US would, for example, have higher rates of alcohol and substance misuse compared with other cultures. Recent large-scale studies do not confirm this (2). The best physical indicator of alcoholism, cirrhosis of the liver, is still much more common in supposedly non-impulsive France (3). Moreover, despite a steady fall in the real price of alcohol, and relentless promotion (not least within sporting events) both overall alcohol use and misuse have declined in the US over recent decades (4).

The sport of the aspiring American businessman is golf, and US television ratings for major tournaments indicate an abundance of patience to follow such events over four days, far in excess of a ninety minute football game.

This Sunday the world cup climaxes. If the USA team had gone even further than the last sixteen (drawing against England), if they were playing against the current European champions, Spain, in the final, would football have become more of a credible spectator sport for Americans? I think so.

 

 

* This blog is primarily for UK readers, so “football” means “association football”. Note added 10th October 2011

(1) http://www.huffingtonpost.com/richard-greener/why-americans-dont-like-s_b_632880.html

(2) McBride et al (2009): Further evidence of differences in substance use and dependence between Australia and the United States. Drug and Alcohol Dependence

(3) World Health Organisation (2004 figures – published 2009)

(4) Zhang et al (2008): Secular Trends in Alcohol Consumption over 50 Years: The Framingham Study. The American Journal of Medicine. This study found that “heavy” use had declined, but not alcohol dependence.

Published at www.DrNM.org.uk on 9th July 2010; transferred to DrNMblog.wordpress.com on 10th October 2011

Vincent Van Gogh: did he have ADD / ADHD?

 

In a letter, written in English and currently on display in London, Van Gogh describes procrastination and hyperfocusing:

“My dear Russell…for ever so long I have been wanting to write to you – but then the work has so taken me up. We have harvest time here at present and I am always in the fields…when I sit down to write I am so abstracted by recollections of what I have seen that I leave the letter. For instance at the present occasion I was writing to you and going to say something about Arles as it is…instead of continuing the letter I began to draw on the very paper the head of a…little girl I saw this afternoon whilst I was painting a view of the river with a greenish yellow sky.”

There is also a suggestion of the regret and self-blame which many adults with ADD / ADHD experience:

“I enclose the slip of scribbling, that you may judge of my abstractions and forgive my not writing before as such.”

Van Gogh calls his subjective inability to control and focus attention his “abstractions”, and he refers to this again towards the end of the letter:

“I must hurry off this letter for I feel some more abstractions coming on and if I did not quickly fill up my paper I would again set to drawing and you would not have your letter.”

Biographies of Van Gogh do not provide much detail of his earliest childhood years, but in his late teens and twenties he certainly showed a restlessness and impulsivity in work and relationships which would be compatible with ADD / ADHD. A more difficult question is whether treatment, in perhaps enabling him to combine his artistic talents with just a little commercial success in his lifetime, would have dulled his creativity. I don’t think so, because that is not what ADD / ADHD treatment appears to do, when used properly.


 

This letter to John Peter Russell, written in April 1888, was on display at the Royal Academy in London when this piece was written. The exhibition was called The Real Van Gogh: The Artist and His Letters.

The letter can be viewed online at Amsterdam‘s Van Gogh Museum site: http://vangoghletters.org/vg/letters/let598/letter.html 

This post was published at www.DrNM.org.uk on 5th February 2010, and transferred to DrNMblog.wordpress.com on 7th October 2011

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