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August 29, 2011

Annals of Self-Medication

Psychoactive drugs that can be ingested as a vapor gain immediate access to the pulmonary (lung) blood flow, travel almost immediately to the left atrium and are then pumped to the brain; thus allowing their pharmacologic effects to be perceived with the first “toke” almost in real time. Experienced cannabis smokers are unanimous that what they feel is an almost immediate sense that the world is a more friendly place than it had been just seconds earlier. The immediacy and unique quality of that response confirms the presence of cannabinoids. Typically, experienced users then take additional tokes, each representing an incremental increase in dose, until there is one that doesn’t change the way they feel- a signal they are “high.” Most stop there because they recognize it as a refractory period and realize that more tokes at that time would simply be a waste of money.

Thus the inhaled marijuana “high” is a unique alteration in mood usually characterized as “relaxation” by users. The necessary dosage is unique for each individual and is reflected by the number of tokes required to produce it. Although there are considerable differences in potency from one strain to another, user memory is what allows them to get the dose right; a process called titration. A corollary is that those who have never experienced the inhaled marijuana “high;” yet insist it is both criminal behavior and analogous to alcohol intoxication, literally do not know what they they are talking about. The whole subject becomes even more complex when one realizes that at least half of all would-be cannabis initiates did not get high on their first attempt and many were forced to try several times before they succeeded. That phenomenon was well described by Harvard psychiatrist Lester Grinspoon. Cannabis seems to be the only drug that tests its prospective users; a phenomenon I recognize, but cannot claim to understand.

The state of relaxation represented by the “high” was described as “anxiolytic,” by the makers of Valium in the early Sixties.. Actually, the first anxiolytic to reach the market was probably meprobamate, a carbamate “tranquilizer” marketed as Miltown in the early Fifties. Then came the phenothiazines later in the same decade. Thorazine became the most famous and is still widely used, along with Sparine, Compazine, and Phenergan. Finally, the benzodiazipines arrived in the early Sixties. Other widely used “benzos” are Librium, Ativan, Versed, and Xanax. In general, the availability of drugs that could moderate disturbed behavior is what allowed the states to do away with the expensive state hospital systems that had been necessary to manage disturbed patients with “mental illness in the first half of the Twentieth century. Patients on oral agents could be managed much more cheaply as outpatients. Unfortunately, those who were less compliant- or who preferred to self-medicate with inhaled cannabis- have been remanded to the criminal justice system for treatment through the efforts of Richard Nixon and John Mitchell, since 1970.

The high produced when “marijuana” is smoked is pharmacologically unique; primarily because its effects can be precisely titrated by the user, a process made possible by the fact that smoking allows its incremental effects to be measured almost immediately following each toke.

To add to the complexity of the clinical pharmacology of cannabinoids, "edibles" behave so differently from smoke that they almost require a separate category. Although many users have discovered those differences and are able to take advantage of them, I have yet to encounter one who could provide a lucid explanation of the relevant anatomy and physiology; nor have I found one in the “literature,” either professional or informal. Most damning of all is the total absence of experimental data that would document the key clinical differences: inhaled cannabinoids are used primarily for their anxiolytic properties while “edibles” are used less often overall and are most prized for pain control, rather than for the anxiolytic effects provided by smoke.

More on this later.

Doctor Tom

Posted by tjeffo at August 29, 2011 09:24 PM