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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.

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

Giving up EU subsidy: so hard to do

 

Are holidaymakers from the UK still seeing EU-subsidised tobacco growing in Southern Europe?

The EU’s website states that “In the interest of public health, direct tobacco subsidies were phased out by 2010.” But in February this year, UK members of parliament expressed “disappointment at the continuing subsidy…to the tune of some £260 million each year”.

I can report seeing just as much of the large-leaved crop this year in the part of South-West France I have visited every August since 2007, although a friend who knows a different area well says tobacco planting is much reduced.

Readers may remember the EU tobacco subsidy being a big focus of campaigning throughout the 1990’s. It was said that much of the tobacco was too low-grade to be smoked by Europeans, so it was dumped on non-EU countries at a loss, encouraging people on low incomes to become nicotine-addicted. If that is true, then stopping (or greatly reducing) the subsidy has taken a long time.

Tobacco is linked to ADD / ADHD in two ways. Symptoms in teenagers predispose to starting smoking, and also to difficulty in giving up later. This is often said to be due to risk-taking, but some of my patients report big improvements in cognitive function when they smoke. As mentioned two weeks ago, the UK-licensed smoking cessation drug Zyban (bupropion) can be effective in reducing ADD / ADHD features.

Secondly, children of mothers who smoke during pregnancy go on to develop ADD / ADHD more frequently. A recent study suggests this is more of a genetic than a brain-toxicity mechanism (1), but there is a wide range of other evidence which strongly indicates maternal smoking to be bad for the developing foetal brain.

Many people find a Southern European field full of mature tobacco, with white trumpet-shaped flowers rising several feet above the leaves, to be a beautiful thing. But it is a deadly beauty which we seem to be in no hurry to get rid of.

 

 

(1) http://www.ncbi.nlm.nih.gov/pubmed/20413131 

This post appeared late due to problems with technology and organisation

Published at www.DrNM.org.uk on 20th August 2010, and transferred to DrNMblog.wordpress.com on 10th 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

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