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UK: Cannabis: Dr Thomas Stuttaford answers your questions
The Times Wednesday 08 Jun 2005 Q: Our 25-year-old son has been smoking cannabis since he was 16. When he was 17-18 he began self-harming and was treated with Prozac for six months to a year; he also spent about a week in hospital. He ignores any suggestion that he should give up cannabis and probably wouldn't read your article if we gave it to him. Can you suggest any literature that would help him realise what he is doing to himself and advice as how we can encourage him to give up? Marion and Roger Townshend, Trowbridge A: I am very sorry to hear about your son. Obviously we can't discuss his own case in detail, as I haven't met him, but we can draw general conclusions from the points you raise. These may not all apply directly to your son. I would always be very careful about treating a patient with possibly psychotic symptoms, and a heavy cannabis smoker and therefore in danger of having a psychotic breakdown, with Prozac. In these cases I feel that the treatment should have at least an element of antipsychotic therapy. SSRIs, of which Prozac is one, can precipitate psychotic symptoms in vulnerable patients. In the recent Panorama programme on the effect of SSRIs on some patients who were depressed, the conclusion of the experts who analysed the cases was that when there had been disaster it wasn't so much the drug, but its misprescription, that was at fault. I took part in the discussion after the programme and it was worrying that so many patients in whom the depression was part of the negative symptomatology of a psychosis were treated with an SSRI without any thought of providing an antipsychotic. Little wonder that occasionally people had become aggressive or suicidal. I can't advise you on literature. However one of the best pamphlets on cannabis was produced by the National Institute of Public Health in Sweden - Adverse Health Consequences of Cannabis Use, A survey of scientific studies into the range of damage to health caused by cannabis. It was produced by Socialstyrelsen, The National Board of Health and Welfare in Sweden. It has been translated into English. Q: My boyfriend smokes cannabis every night to help him "relax". I always tell him how bad it is for him; it has caused many arguments and almost broken us up many times. He tells me I should stop trying to control him but he obviously has a psychological (if not physical) addiction both to the cannabis and the tobacco he mixes it with, and he=92s been smoking more and more since he moved in with his current flatmates. He is doing a fantastic PhD but he is going into work less and less because he feels lethargic in the mornings. He is blaming the PhD, saying it is boring. How do I make him see it's the weed causing the problem and not the PhD? Kate Palmer, London A: Nobody doubts that cannabis gives rise to psychological dependence. There is discussion about the degree of physical dependence, but no argument that heavy use of it leads to tolerance. There are withdrawal symptoms when cannabis is discontinued. These include irritability, sweating, headache and abdominal upsets. I would suggest that the first move is to encourage your son to leave his present flat. It is hard to renounce any habit if all those around you are carrying on with it. The more I talk to schoolteachers and university lecturers, the more often I hear the story of the bright student whose performance falls away as the result of heavy cannabis smoking. A problem is that a cannabis smoking student rarely has insight, and either ignores his deteriorating performance or blames other factors. Girlfriends are about the only close friends and relatives who might have the power to persuade him to change. Q: I am a migraine sufferer and for ten years I took paracetemol plus antihistamine before bed, which prevented me from having disturbed sleep and waking with a migraine in the morning. I don't know the danger of doing this for ten years; my GP says it's OK but I have reservations. I started to use cannabis instead, eating 2g of buds before bed. It worked a treat and after nine months my supplier went away and I was about to go back on the paracetemol but the symptoms had gone. Of course this may have been spontaneous and I make no claims about the efficacy of cannabis. It is the relative risk between cannabis and paracetemol that I am interested in. Alastair McGowan, Cardiff A: Some migraines will improve with a tranquilliser and analgesic, whether paracetamol plus anti-histamine or cannabis. I would agree with your GP that the anti-histamine and small dose of paracetamol wouldn't do any long-term harm, although sedative anti-histamines tend to give rise to a slight hangover the next day, so that you may feel depressed. The risks of a daily dose of cannabis are considerably greater. Cannabis risks can be divided into two, the physical and mental. The worst mental risk is that it will cause breakdown in someone who has a genetic vulnerability to schizophrenia or bipolar disorder (manic depression). This recent research has shown that this genetic liability affects one in four of the population, but the chance of this susceptibility being unmasked varies according to the dose, the genetic make up of the person and other factors. Regular cannabis taking even without producing a psychotic reaction may induce a cannabis smoker=92s personality =AD being excessively laid back, casual, forgetful, unambitious to an unusual degree and, in fact, generally idle but self-satisfied! Cannabis smokers are much more liable than other smokers to develop cancer of the lung, head and neck (including the mouth), and less frequently some other malignancies. There have been several reports for adverse effects on the cardiovascular system, long-term ill effects on vision, damage to sperm and to pregnancies. In addition to the factors you mentioned, psychosis caused by cannabis use carries the stigma of mental illness and is something that individuals and families may want to put behind them rather than shout about. Also, they are too knackered dealing with the problem to campaign. Q: Our student son had a manic episode last summer, quite possibly triggered by cannabis. What can we do to help publicise this? Are there any campaigns we can add a voice to? Name and address withheld A: A very good point. Parents may well want to keep quiet about the whole business. I should write to your MP. It is very interesting to study the background of the people appointed by this government to the advisory council for the misuse of drugs. It is quite extraordinary how many of them have been openly in support of the liberalisation of the laws relating to cannabis. It is equally extraordinary that none of the great experts on schizophrenia have been included in the committee even though it and crack are the two most common causes of acute psychotic breakdown. As well as writing to your MP, it would be as well to write to your local paper. Q: If there is a link between cannabis and mental health, why has there no been an increase in cases to match the increase in cannabis use we've seen over the past 40 years? In South London (Maudsley), Zerrin Atakn claims to have observed a doubling in this time, but that is nothing like the increase in the rate of cannabis use. There are many other variables which could have caused it. Derek Williams, Norwich A: There has. The incidence of psychotic disease is under-rated, as there is, not unreasonably, a reluctance to give someone a diagnosis that, regrettably, still has a stigma attached to it. Furthermore, if lesser conditions are exacerbated, or induced, by cannabis, so that the patient suffers from (for example) a schizotypal personality disorder rather than schizophrenia, this wouldn't be recorded. The evidence that cannabis is involved in psychotic breakdown is now so strong (it has been around for at least 40 years), that even the Department of Health has acknowledged it. Q: Do you think that, given the evidence of liver damage and other sicknesses, that cannabis causes more damage than alcohol? As cannabis can be taken safely by some individuals, what do you think the impact is of criminalizing millions of people for their choice of recreational drugs? Is the government not grossly out of touch? Name and address withheld A: Both an excessive alcohol intake and cannabis smoking may cause lasting physical and mental ill-health. If alcohol is to cause permanent damage to the drinker it usually has to be taken for many years. Heavy cannabis smoking can cause psychotic breakdown in a genetically vulnerable person just after one or two episodes. I have seen this happen. Although cannabis, unless taken in very large amounts, may not cause psychotic breakdown in those not genetically vulnerable, it does give rise to a certain personality type. Whereas it is right and proper that people=92s lives are their own, it is unfair for people to adopt a habit that in many cases leads to the development of a lifestyle that demands financial support from the rest of the community. Q: What anti-smoking campaigners fail to recognise is that people who need their nicotine fix will assuredly find something to replace it. At least the Quakers, concerned about too much drink, had the good sense to offer something else - chocolate. Cigarettes may cost the NHS but the taxes levied more than offset this. Cannabis and its friends cost the community both in NHS treatment and in more direct ways, such as theft. Can we have some lateral thinking? Ross Coad, South Petherton, Devon A: This problem has often struck me. What are the nicotine-addicted going to do when they can no longer smoke? I have just returned from a visit to Scandinavia, where many of the doctors are critical of our condemnation of taking nicotine through the cheeks (teabag nicotine). These bags were heavily criticised by British doctors when they were introduced into this country about twenty years ago. However the Scandinavian experts I spoke to said that no research had actually shown an increase in head and neck cancer in those who like to have a nicotine packed teabag nestling and leaking between their cheek and gums. Q: Is there any evidence that cannabis is harmful if ingested or smoked without tobacco? I'm talking about physical dangers, not mental risks - which I have no doubt are very real. Iain Dobson, Edinburgh I am afraid so. There is even a risk of psychotic changes in patients who have been given cannabis as a medicine in the trials of its use for the treatment of intractable pain. Physical side effects, as well as these mental ones, are also found, but in these cases the risk-benefit equation might make it worthwhile. Cannabis has an effect on the cardiovascular system, on the eyes and lungs. Q: I have been a regular dope smoker for about five years. My intake varies from 5-10 joints a week to that amount in one night. I do feel it has negative effects on me - memory and slight dopiness, usually after a heavy night. I also feel it affects my nervous system. I take daily vitamins and Vitamin C when feeling low, work out in a gym and eat as much fruit as possible. I have an ongoing battle to give up smoking tobacco, but my intake is, on or off, a pack a day for a few weeks and then none for months. Is there anything else you can recommend, a supplement or actively I could try to help maintain my immune system? Name and address withheld A: Thank you for writing. I am interested to hear that you have noticed the development of a cannabis personality, poor memory, slight dopiness, etc, as well as some adverse physical effects. I would certainly recommend a good quality multivitamin and mineral supplement and should take two, rather than one tablet a day. I would also discuss your problem with your own doctor as he, or she, might be able to obtain cognitive therapy to help you to give up both the cannabis and the nicotine. Continue with your excellent diet. Q: My son, aged 33, smoked cannabis and is now schizophrenic. It is quite likely that he was genetically susceptible. He is under the local equivalent of a mental health act section order, being treated with respiradon. He continues to harbour a variety of delusions, but absolutely refuses to accept that he is delusional. The psychiatrist's only answer seems to be to increase the dose and the GP has no alternative suggestions. My son is articulate and intelligent, but is becoming increasingly depressed and doesn't venture out of the house. Are you aware of any other treatment that we could try? Name and address withheld A: I am sorry for you. I know the difficulties you must have suffered and are continuing to suffer. Risperidone is only one of many of the new generation of antipsychotics. There are many others. Very often it is a matter of choosing the right one to suit the patient. The very small differences in the atypical antipsychotics may be just enough to help the patient. There have, for instance, recently been good reports of Abilify aripiprazole.
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