05/23/23

The Loophole with Delta-8

You may have seen storefront signs saying something like, “Delta-8 Sold Here”, and wondered what they could be selling. In states where recreational marijuana is not legal you would most likely think it certainly couldn’t be referring to that, and you would be right. It is technically not THC or delta-9-tetrahydrocannabinal, the main psychoactive ingredient in cannabis sativa. But according to the Agriculture Improvement Act of 2018, any part of the cannabis plant containing .3% or less of THC by dry weight is now defined as hemp. And there’s the loophole that has been exploited to permit delta-8 THC to be legally sold in markets that so far have restricted the legalization of marijuana.

In December of 2018, the Senate easily passed the Agriculture Improvement Act of 2018, 87 to 13. In, “How Delta-8 THC Works, and Why Experts Are Worried About It,” The New York Times reported that at the insistence of Mitch McConnell, the bill legalized industrial hemp as a crop. The hope was that hemp could be used for construction products and plastic composites and help vendors of CBD, a non-psychoactive compound found in cannabis sativa or “hemp.” But what happened was the 2018 Farm Bill allowed hemp to be used as a precursor for synthesizing delta-8-THC, which has a nearly identical chemical structure to delta-9-THC. And delta-8 is psychoactive, producing a “high” similar to delta-9. See the graphic below from “Marijuana Variant of Concern.”

Here is why designating hemp as cannabis sativa containing less than .3% in the 2018 Farm Bill was so significant. According to the pro-marijuana website Weedmaps, most cannabis plants contain negligible amounts of CBD, less than 1%. However, hemp plants average between 12% and 18% CBD. The Center for Disease Control and Prevention (CDC) noted that CBD does not produce a high as THC does. At this point in time, there is only one FDA approved medicine containing purified CBD from hemp, Epidiolex, which is approved to treat seizure disorders.

But the 2018 Farm Bill removed “hemp from the federal Controlled Substances Act, effectively legalizing CBD if it comes from hemp.” CBD is now marketed in many consumer products: foods, oils, lotions, capsules, and cosmetics. Science is still learning about CBD and the CDC said CBD products are not risk free. They can lead to liver damage, drowsiness or sleepiness, diarrhea or changes in appetite, and mood changes like irritability. They may also lead to serious side effects when used in combination with other medicines or drugs.

There is a lot we do not know about CBD. Currently, we do not know how CBD use affects a person over time. We also do not know how different modes of CBD use (smoking, vaping, eating, applying to skin, etc.) affect a person.

CDC released a Health Alert Network (HAN) Health Advisory in 2021 to inform consumers that CBD can be synthetically converted into Delta-8 THC, which is psychoactive and not well understood. This alert warns consumers about the potential for adverse events due to insufficient labeling of products containing THC and CBD.

THC most often refers to delta-9 THC, the most common THC isomer in cannabis. But there are several other isomers that occur naturally in cannabis, including delta-8 THC, which is estimated to be approximately 50-75% as psychoactive as delta-9 THC. The CBD-to delta-8 THC conversion process uses a solvent, acid, and heat to produce concentrations of delta-8 THC higher than those found naturally in the cannabis plant. “This conversion process, used to produce some marketed products, may create harmful by-products that presently are not well-characterized.”

The 2018 Farm Bill led to an expanding and unregulated market for delta-8-THC, according to Leas et al, which sought to measure public interest in delta-8. The researchers looked at the global rate of recommended searches that mentioned delta-8-THC from January 2011 through August 2021. The search trends were stable from 2011 through 2019. But they increased by 257% from 2019 to 2020 and 705% from 2020 to August 2021. The global trend of delta-8-THC searches was driven primarily by increases in the U.S., where the rate increased by 466% from 2019 to 2020 and by 850% from 2020 to August 2021. “By 2021, the rate of searches for delta-8THC in the US was at least 10 times higher than [the] rate of delta-8-THC searches in any other country or territory.”

The growth in searches following legalization of hemp in the US as well as the greater interest in US States with more restrictive delta-9-THC policies suggests that delta-8-THC may be meeting a demand for legal use of THC in markets that do not permit use of delta-9-THC. The one-year lag following the legalization of hemp could potentially be explained by a need for developing an infrastructure to produce and ship delta-8-THC products. For example, one manufacturer claims to have created “USA’s first federally legal THC-dominant product since cannabis prohibition started,” after it developed a method of synthesizing delta-8-THC in September of 2019. By 2021, hundreds of Delta-8-THC manufacturers existed throughout the US, and many offered to ship products to consumers and wholesale to retailers in states that did not permit use of delta-9-THC.

While public interest in delta-8-THC seemed to be concentrated in the US, some manufacturers have opened offices in Europe. One manufacturer, Just Delta, has offices in the UK. Leas et al said global and US jurisdictions should clarify whether methods of converting cannabinoids to THC compounds are legal under existing hemp and cannabis laws. They recommended a public-health-focused approach that clarifies definitions of THC compounds to include delta-8-THC and other THC isomers; and disallows the use of methods that convert CBD to THC, “at least until these can be determined to be safe.”

The NYT article, “How Delta-8 THC Works,” reported that a survey of delta-8 users said they were less anxious, less paranoid, and had a nicer high than with delta-9 THC. “The most common experiences when using delta-8 were relaxation, euphoria and pain relief.” There were reports of some difficulty concentrating, problems with short-term memory and an altered sense of time, but not to the same extent as with regular marijuana. The explanation for the differences between delta-8 THC and delta-9 THC is probably that there’s less delta-8 THC in the CB1 receptors, “so people are less likely to experience the more distressing symptoms” when they get too high.

Manufacturers of delta-8 products argue that delta-8 may chemically be THC, but legally it now is hemp. “Since you can extract CBD from hemp, and CBD is not THC, [then] it’s still considered hemp.” The lack of regulation around delta-8 in the US is the biggest concern of many public health experts. In a paper published in December of 2022, none of the delta-8 products tested contained the amount of delta-8 they claimed. All 27 had potentially harmful byproducts, presumably from the manufacturing process, including lead and mercury.

Between January 2021 and February 2022 national poison control centers handled over 2,000 calls about delta-8. Forty-one percent involved children accidentally ingesting products with delta-8. “One of those cases resulted in death.” Without federal regulation, 14 states have banned delta-8, or all unregulated forms of THC, including delta-10. Ironically, this includes several states where recreational marijuana is legal, including Colorado and New York. Delta-10 is illegal in Colorado and New York as well.

Eric Leas, the lead researcher in the above study that assessed public interest in delta-8-THC, said in “The Hemp Loophole,” that “the loopholes that allow THC compounds to be sold as hemp ought to be closed.” He said the regulatory system for recreational marijuana makes it a safer product than delta-8. The manufacturing quality checks and other regulatory requirements such as labeling rules about potency and licensing distributers act as important public health standards. None of these protections currently exist for delta-8. All the experts interviewed for “How Delta-8 THC Works,” including those supportive of legalizing marijuana, recommended against using delta-8. “There is no way to ensure its safety.”

03/14/23

Waiting Before Pennsylvania Goes “Full Colorado”

President Biden pardoned individuals convicted of marijuana possession under federal law and said marijuana’s classification as a Schedule I Controlled Substance—as is heroin—would be reviewed. The NYT reported the pardons will clear everyone convicted on federal charges of simple possession since it became illegal fifty years ago. They will not apply to individuals convicted of selling or distributing marijuana. Soon afterwards, the Pew Research Center conducted a survey in October of 2022 on whether or not marijuana should be legal for medical or recreational use. Not surprisingly, 59% of Americans thought it should be legal for medical and recreational use and 30% said it should only be legal for medical use.

The Pew article also noted two additional states legalized the use of marijuana for recreational use, bringing the total number of states to 21 which have already done so. There are clear differences demographically by age and party affiliation. Seventy-two percent of adults aged 18-29 favored legalizing medical and recreational marijuana, while only 46% of adults 65 and over did. Seventy-three percent of those who said they were Democrats or Democratic-leaning independents favored legalizing medical and recreational marijuana use, while only 45% of Republicans and Republican-leaning independents. See the following graph taken from the Pew article.

In Pennsylvania, the Democratic support to legalize recreational marijuana received a boost at the midterms, even though it was not one of the two states to legalize it. John Fetterman, who just won the Senate race of 2022, has been vocal about his support for legalization from the beginning of his tenure as Lieutenant Governor of Pennsylvania in 2019. He said on his web page, “Weed should be legal, nationwide.” He thought we needed to “move our views on this subject out of the Stone Age.” See “Should Pennsylvania Go ‘Full Colorado’ with Marijuana? Part 1.”

Rescheduling and decriminalizing marijuana are two reform measures that do not require Pennsylvania to also go “full Colorado” with legalizing recreational marijuana. Pennsylvanians should know that Colorado has had problems after legalization and passed state bill H 1317, which applied to the state’s marijuana industry. Note the measure passed with strong bipartisan support. Purchases of high-potency marijuana were limited to one-fifth the original level. “The bill requires warning labels, real-time monitoring of sales, and stiffened medical recommendations from physicians.” It also called for research into the mental and physical health effects of marijuana.

Supporters of legalization in Colorado said creating a regulated market would drive out the “criminal element” and end the violence driving the black market, but the opposite has happened. The Black market still dominates the marijuana business, “as has happened everywhere state have legalized marijuana, from California to Illinois.” It was supposed to end corruption, but actually spread it more widely. “Not only did the promised benefits, both financial and on behalf of public safety, not come to pass, but in multiples areas of daily life the metrics have worsened.”

Colorado traffic deaths have increased 24% overall. Deaths in which drivers tested positive for marijuana increased 135%. “The percentage of all Colorado traffic deaths that were marijuana related has risen from 15 percent in 2014 to 25 percent in 2019.” More marijuana calls are coming into poison centers. Adverse marijuana-only exposures have quadrupled since legalization. Emergency-department events and marijuana-related hospitalizations increased sharply.

As the years since legalization have passed, the public health and public safety impact has grown, year over year. The effect on families, on pediatricians, on educators, on emergency departments, on the workplace, on law enforcement, and indeed on the general quality of life in a once thriving state, has been strikingly negative.

We should not be surprised to learn that there is a high cost to making an addictive and dangerous substance a commercial product. Nor should we enable this public policy mistake to take root elsewhere. Taking stock, we can now say that the so-called legalization experiment has, at least, produced one positive impact—it has issued a clear warning about the path we are on.

Then there was the publication of a study published on November 15, 2022 in the journal Radiology that found airway inflammation and emphysema were more common in people who smoked marijuana and cigarette smokers and nonsmokers, “Chest CT Findings in Marijuana Smokers.” The lead author of the study was quoted in Medical News Today as saying, “93% of the marijuana smokers had emphysema rather than 67% of the tobacco-only smokers.” The researchers also found cannabis smokers had higher rates of airway inflammation. The CT imaging showed greater mucus buildup in the airways, thickening of the bronchial wall, and sometimes irreversible enlargement of the airways, all of which can lead to more congestive symptoms and infections.

While the public impression is that cannabis is relatively safe and may be safer than cigarettes, “the newly identified link between cannabis use and irreversible lung damage could mean that cannabis is potentially more harmful than many people may realize.” A possible explanation between marijuana and irreversible lung damage could be because marijuana is usually smoked unfiltered, where tobacco cigarettes are generally filtered. When marijuana is inhaled, more particulates are deposited in the airways, likely acting as irritants. Compared to tobacco, the way marijuana is inhaled (a longer time and a higher volume when holding your breath) may lead to microtrauma with the airspaces causing emphysema.

The researchers said the small sample size of their study (56 marijuana smokers, 57 nonsmoker controls, 33 tobacco-only smokers) precluded them from drawing strong conclusions from their findings. Nevertheless, the research may have implications for patients who smoke marijuana for pain relief and other reasons. A critical care medicine specialist and pulmonologist who was not involved in the study told Medical News Today:

The findings of the research point towards confirming a trend we have observed with younger patients presenting with more breathing difficulties. Any inhalation of particulate matter, whether tobacco smoke or marijuana, causes inflammation within the airways.

President Biden’s actions with marijuana are constructive and will allow solid scientific research into the adverse effects and the medical benefits of marijuana to move forward. Hopefully, the piece-meal, state-by-state backdoor way of legalizing recreational marijuana will slow down. Pennsylvania needs to wait and see what that research will show before it goes “full Colorado.” And it seems the evidence will be a mixed bag.

03/7/23

Marijuana Policy Has Run Ahead of Science

Senate Bill 3 was signed into law by Governor Tom Wolf on April 17, 2016, legalizing medical marijuana in Pennsylvania. The Governor anticipated signing the bill “will improve the quality of life for patients and their families throughout Pennsylvania.” Information on the PA Medical Marijuana Program indicated it would include funding for research to study “the use of medical marijuana to treat serious conditions.” There will also be an advisory committee “that will view these research findings and make recommendations to the legislature for changes to the act.” I’d like to suggest they start with a Harvard-based researcher who is concerned that “policy has outpaced science” when it come to making public health decisions about recreational and medical marijuana.

Staci Gruber is an associate professor of psychiatry at Harvard Medical School and the director of the MIND program (Marijuana Investigations for Neuroscientific Discovery). She has done research on the effects of both recreational and medical marijuana. In an interview with The Harvard Gazette, Dr. Gruber said the science on the health effects of marijuana is not yet settled. “When we think about legalization we always like to have science inform policy. In this particular case, it seems to me that policy has outpaced science.”

She added there is a lot we don’t know about the effects of marijuana. Most of what we do know comes from studies of “chronic, recreational marijuana users.” There are differences between recreational and medical marijuana use, for example with regard to what they use, and how they use. She said there has been well-founded excitement about the potential for medical cannabis use. “[But] there’s a striking paucity of research on the use of medical cannabis.”

Dr. Gruber and her colleagues discussed the findings in a study of theirs, “Splendor in the Grass?” that looked at the impact of medical marijuana on executive functioning. They acknowledged how the growing body of evidence shows recreational marijuana use adversely effects brain function, especially during adolescence, the critical period of neurodevelopment. But they also theorized the use of medical marijuana (MMJ) may not lead to the same adverse neurocognitive effects. Recreational users, seeking a euphoric, mood altering effect, use products with a high THC content. In contrast MMJ users seek medical relief and use products with a markedly different chemical composition than common recreational products. “These MMJ products are often (but not always) high in other cannabinoids, such as cannabidiol (CBD) which has been touted for its therapeutic potential, and which is not psychoactive.”

The study found that after three months of medical marijuana use, patients (who had previously not been exposed to marijuana) experienced some improvement, rather than the well-documented deficits. “They showed some improvements in measures of executive functions. They also had some improvements in sleep quality and some measures of mood and quality of life.” A subset of people who were using MMJ for chronic pain also reported improvements. Although it was a small sample size, there was a 42% reduction in opiate use. When they analyzed samples of their patient’s products, a number of them were using products high in CBD (cannabidiol) and other non-psychoactive cannabinoids.

Gruber thought there was hope for at least adjunctive therapy, “if not substitution therapy,” for cannabinoids or cannabinoid-based products for individuals currently using opioids. “We’ve seen individuals who’ve stopped using opioids altogether.” That won’t work for everyone. “But that doesn’t mean it’s something that shouldn’t be exploited and explored.”

While future studies are needed to further examine the impact of MMJ, research is impeded by a number of federal and state restrictions. It is imperative, however, that sound research, including well-controlled clinical trials of MMJ products, many of which are already widely used by patients, are thoroughly examined. As the “green rush” pushes forward, gaining momentum as states continue to adopt less restrictive policies, we cannot afford for research to continue to lag behind.

Dr. Gruber said her goal as a scientist was to provide truthful information so all people, regardless of their recreational or medical status, can understand what is in their cannabis or medicine. In pursuit of this goal, Dr. Gruber and her colleague Kelly Sagar continued a discussion of their research with “Marijuana on the Mind?” in Policy Insights from the Behavioral and Brain Sciences. You can also watch an archived webinar by Gruber and Sagar on the same subject, “Marijuana on the Mind: A Primer for Policymakers” on the website Social Science Space, where there are also written answers to some of the questions from the webinar. The presentation exists as an independent YouTube video as well. The audio cuts out a few times, but returns if you continue with the video.

In “Marijuana on the Mind?” Gruber and Sagar gave a helpful review of the history of medical use of marijuana, noting how it was included in the U.S. pharmacopeia (a list of medicinal drugs with their effects and directions for their use) until 1942. They also documented several areas of concern with marijuana, including its adverse effects on cognition, especially executive function and memory; brain development among adolescents; and safety concerns related to the frequency and magnitude of marijuana use as well as its potency.

Marijuana (MJ) use negatively effects executive brain functions (EF) such as attention, decision making, risk taking, inhibition and verbal fluency. An earlier age of onset in using MJ appears to be related to greater impairment on EF. “Several investigations have also noted that lower EF appears to predict increased MJ use.” Several aspects of memory are negatively effects by MJ use. Some evidence suggests increased use and higher exposure to MJ are related to slower psychomotor/processing speed.

The formation of grey matter and whiter matter in the brain is adversely effected by MJ use. Grey matter is responsible for information processing and decision-making. White matter has a critical role in promoting efficient communication within and between regions of the brain. Adolescent MJ users are particularly vulnerable to grey matter reductions; minimal further damage seems to occur after early adulthood. Lower white matter integrity is related to higher impulsivity scores, particularly with early onset MJ users.

MJ users with early onset (prior to age 16) reportedly use MJ nearly twice as often and more than 2.5 times as much relative to late-onset users. Overall, frequency and duration of use appear to be key factors in determining the extent of MJ-related impairment.

Safety concerns with MJ use are on the rise due to the increased potency of marijuana and the use of MJ concentrates. The potency of marijuana has risen nearly 200% since 1995. The use of concentrated MJ products, such as dabs, shatter, wax, budder and others can exceed 60% THC. “Furthermore, these products may also contain residual amounts of solvents (i.e., butane, hexane), often used to make concentrates, which are potentially toxic.” There has been very little research done on cognitive performance or measures of brain structure and function in humans with MJ concentrates. “This raises concern that adverse consequences associated with MJ use may be worse now than in the past, particularly among young users.”

Based upon their discussion, policy recommendation given by Gruber and Sagar include:

age restrictions based upon evidence highlighting the developmental trajectory of the adolescent brain;
restrictions on targeting youths in advertisements;
safe packaging guidelines to prevent the accidental ingestion of edible MJ products by children;
place limits on THC potency as well as minimums for potentially beneficial cannabinoids in marijuana, like CBD;
more research on the impact of medical marijuana, which will likely require a lessening of marijuana as a Schedule I substance

As the dialogue regarding legalization of recreational and MMJ continues, perceived risk of MJ use has fallen to an all-time low. Consequently, those with the highest neurodevelopmental vulnerability are using MJ more frequently than in previous years, posing a serious public health issue. A growing body of evidence indicates that relative to non-MJ users, heavy MJ users exhibit poorer performance on cognitive tasks, altered patterns of brain activity, and lower frontal WM coherence, which are highly moderated by age of onset of MJ use. Given the potential therapeutic benefits of MJ, however, it is important to weigh these risks with the benefits. Policy has outpaced science, and eased restrictions allowing citizens to use MJ, in some cases without the benefit of appropriate research. Additional investigation is warranted and necessary to guide informed policy decisions. As states consider legislation for MJ use, it is imperative to determine safe guidelines regarding the impact of MJ on the brain, particularly during critical periods of neurodevelopment.

Dr. Gruber’s research through the MIND program will be extremely helpful for the PA Medical Marijuana Program and state policy makers, such as members of the advisory committee, in making informed public policy decisions with the ongoing availability of medical marijuana in Pennsylvania. The review by Gruber and Sagar of the research relevant the influence of marijuana on cognition, brain structure and brain function in “Marijuana on the Mind?” can be helpful in making future public policy decisions with regard to medical marijuana in the state.

An article cited by Gruber and Sagar, “Cannabis for Medical Use,” should also be reviewed by policy makers, as it is a systematic review and meta-analysis of the benefits and adverse events of cannabinoids. The full text of the systematic review is available. What follows is from the article’s Discussion.

Most studies suggested that cannabinoids were associated with improvements in symptoms, but these associations did not reach statistical significance in all studies. Based on the GRADE approach, there was moderate-quality evidence to suggest that cannabinoids may be beneficial for the treatment of chronic neuropathic or cancer pain (smoked THC and nabiximols) and spasticity due to MS (nabiximols, nabilone, THC/CBD capsules, and dronabinol). There was low-quality evidence suggesting that cannabinoids were associated with improvements in nausea and vomiting due to chemotherapy (dronabinol and nabiximols), weight gain in HIV (dronabinol), sleep disorders (nabilone, nabiximols), and Tourette syndrome (THC capsules); and very low-quality evidence for an improvement in anxiety as assessed by a public speaking test (cannabidiol). There was low-quality evidence for no effect on psychosis (cannabidiol) and very low-level evidence for no effect on depression (nabiximols). There was an increased risk of short-term AEs with cannabinoid use, including serious AEs. Common AEs included asthenia, balance problems, confusion, dizziness, disorientation, diarrhea, euphoria, drowsiness, dry mouth, fatigue, hallucination, nausea, somnolence, and vomiting. There was no clear evidence for a difference in association (either beneficial or harmful) based on type of cannabinoids or mode of administration. Only 2 studies evaluated cannabis.There was no evidence that the effects of cannabis differed from other cannabinoids.

The authors noted there was moderate-quality evidence to support the use of cannabis to treat chronic pain and spasticity. However, the existing evidence suggesting improvements in nausea and vomiting due to chemotherapy, weight gain in HIV, sleep disorders, and Tourette syndrome was low quality evidence. Cannabinoids were also associated with an increased risk of short-term adverse events such as those noted in the above quote. Future studies with large random clinical trials were said to be needed in order to confirm the effects of cannabinoids with issues such as: weight gain in patients with HIV/AIDS, depression, sleep disorders, anxiety disorders, psychosis, glaucoma, and Tourette syndrome. Additionally, the lack of research into the effects and adverse events with cannabis point to the need of future studies in these areas.

Hopefully as medical marijuana becomes more widely available in Pennsylvania, the administrators of the Medical Marijuana Program and other state policy makers will pursue the recommendations suggested in the research reviewed here by Gruber and others who are concerned that “policy has outpaced science” when it comes to lawmakers making public health decisions about recreational and medical marijuana.

Originally posted on March 6, 2018.

01/31/23

Never Enough and Adaptation

In “Never Enough and No Free Lunch,” we looked at what Judith Grisel identified as the three laws of psychopharmacology from her book, Never Enough. She recalled a time when giving a brief lecture to a group of high school students on the opponent-process theory of Solomon and Corbit. A student leaped to his feet and cried out, “This changes my life!” She said she shared his sentiments and added that the theory was important because it largely “set the course” for how scientists think about and study addiction.

Richard Solomon and John Corbit proposed that every stimulus that disturbs the way we feel is counteracted by the nervous system in order to bring the body back to an emotional “set point” or homeostasis. In their description of the theory in a 1974 article for Psychological Review, “An Opponent-Process Theory of Motivation,” they said addiction did not differ in principle from any acquired motivational system. “We can easily describe opiate, alcohol, barbiturate, amphetamine, or cigarette addiction within the empirical framework of the analysis we have proposed.”

Grisel said Solomon and Corbit suggested that feeling states are maintained around a “set point” like body temperature is. Any feeling, such as being happy, depressed or excited, represents a disruption of the stable feeling state or homeostasis. The opponent-process theory suggests that “any stimulus that alters brain functioning to affect the way we feel will elicit a response by the brain that is exactly opposite to the effect of the stimulus.” The fact that our feeling states are so tightly constrained has important implications for understanding drug abuse. The brain learns by adapting to every drug that affects its function.

Some of these changes are relatively transient, like tachyphylaxis [an acute, sudden decrease of response to a drug after its administration, rendering it less effective] in an occasional drinker, but as learning is stronger with repetition, chronic exposure to a drug results in more lasting alterations. For some drugs, such as antidepressants, adaptation is actually the therapeutic point. Developing tolerance to selective serotonin reuptake inhibitors (SSRIs) may help to change a pathological affective “set point” so that being depressed is no longer the patient’s normal state. . . .As the brain adapts to a drug of abuse and the drug becomes less effective at stimulating dopamine transmission, a user must take more and more to produce the same high. Engaged in a futile attempt replicate the initial experiences, an addict repeatedly administering the drug ensures more and more adaptation.

In the following charts, the A process is what the drug does to the brain and the B process is the brain’s response or adaptation to the drug, as it attempts to return the brain to its neutral, homeostatic state. State A can be pleasant or unpleasant, but whatever it is, State B is the opposite. The set point is the line in the middle. Large doses of a drug produce large A processes, and long-lasting stimulations produce long-lasting A processes.

When the brain is first exposed to a drug, the high or A process is not initially dampened by the B process of the brain trying to return to a neutral, homeostatic state. This leads to an initial peak experience followed by a leveling off. The A process in the brain is always the same if the same amount of the drug is used, but this is not true for the B process. Generated by an adaptive nervous system, the b process learns with time and exposure. “Repeated encounters with the stimulus (or use of the drug) result in bigger, faster, and longer-lasting B processes that are better able to maintain the homeostasis in the face of further stimulation.” Another thing to know is the B process can be triggered by environmental cues that signal an A process is coming. In other words, it can trigger the A process.

After many times of getting high, an adaptation results and there is hardly a bump in the feeling (euphoric) state. The drug then functions primarily as a way to hold off withdrawal and craving in the b process, in the face of the brain’s ability to counteract the A process until drug use is stopped, then withdrawal and craving begins in earnest. The classic illustration of this is with opioids like heroin.

This model also explains why the states of withdrawal and craving from a drug are always exactly opposite to the drug’s effects. If a drug makes you feel relaxed like benzodiazepines, withdrawal and craving are experienced as anxiety and tension. If a drug helps you wake up like caffeine, adaptation includes a lack of energy and enthusiasm. If it reduces the sensation of pain like opioids do, feeling pains you didn’t know you had will happen.

The common symptoms of addiction are tolerance, withdrawal and craving, and they are embedded in the consequences of the B process. Tolerance occurs because more drug is needed to produce an A process capable of overcoming an increasingly stronger b process. Withdrawal happens because the B process outlasts the drug’s effects (see the charts above). Craving is almost guaranteed by the opponent-process model, because any environmental cue that became associated with the drug (through classical conditioning) can trigger a B process because the learning cycle or ritual that included the cue or trigger was repeated many times as the person used drugs.

This happens because of what Jeffrey Schwartz called the Quantum Zeno Effect, in You Are Not Your Brain. This means the brain areas activated by a drug are stabilized and held in place long enough so they can be wired together by Hebb’s Law. Hebb’s Law says neurons that fire together wire together. Once any sequence of neurons is wired together, the brain will respond to similar situations in a reliably “hard wired” way. So, any environmental cue that occurred repeatedly within the sequence of neurons or the ritual of “getting high” has the potential to become a trigger and initiate craving. In Never Enough, Judith Grisel gave a personal example of the incredible power of this cognitive memory process.

I was clean for close to two years and had been volunteering in my biopsychology professor’s laboratory to get some research experience. One part of the protocol required daily administration of an experimental drug into the subjects’ (rats) peritoneum, which is the sac that loosely constrains the abdominal organs. The standard procedure is to cup the rat gently in one hand, insert the needle with the other, and create negative pressure by pulling slightly back on the needle to be sure the injection isn’t going straight into a blood vessel. I thought I’d fully extinguished any personal associations by this time, but one day when I pulled back and the needle filled with blood, I heard clamorous ringing in my ears and a taste in my mouth that were characteristic of cocaine going into my vein. It was years later, in a completely different context, and I had not a whit of desire to use at that moment, but just seeing blood filling the syringe cause an instantaneous reaction. I let my colleague finish the injections and went back to my dorm sobered by the astounding power of memory.

The brain is so well organized to counteract things that cause it anxiety or unease, that it uses its learning skills to anticipate the disturbance a drug will cause rather than wait for the drug effects themselves. It starts a B process, from which you experience craving. In other words, the brain begins to dampen the drug effects before you even take the drug! So, there is a real potential for cue-induced relapse to occur and addicts need to become aware of this danger and develop a plan ahead of time, before the B process activates, to manage it if it occurs.

Originally posted on July 6, 2021

01/10/23

Common Grace & “The Triangle of Self Obsession,” Part 2

In “The Blame Game: Accepting Accountability” Gina M. asked how many times you have made a poor choice out of spite, or a defense mechanism, or in reaction to something done to you? She said it took her a long time to admit that she had been playing the blame game for much of her life. She said she had been living in the triangle of self-obsession—anger, fear, and resentment. More and more everyday she’s realized how often she uses the excuse of “what’s happened to me” as a cop-out for every poor choice she’s ever made.

But the reality is that I was just rewarding my self-pity, living in the triangle of self-obsession, finding every excuse in the book for my questionable behavior. I was playing the blame game just so I had a “reason to.” A reason to deceive myself. A reason to justify my poor choices…because it was too hard to accept the fact that sometimes I actually do make poor choices. And because those poor choices carried more shame, guilt and regret than I cared to admit, because I was a people pleaser who lacked self-love and self-respect, my fear of judgement led me straight into a triangle of self-obsession.

In Part 1, we pointed out how common grace and the triangle of resentment, anger and fear could be applied to the consequences of Adam and Eve eating of the tree which God commanded Adam not to eat. Recall that it was said NA literature was a common grace description of how God restrains drug addiction and alcoholism. Recovery is God’s bounty poured out on all people in order for them to recover, regardless of their faith in Him. It won’t save them from their sin, but it can prevent them from the further guilt, shame and unmanageability of an active addiction. Here in Part 2, we’ll unpack the common grace found in “The Triangle Self-Obsession,” where it said self-obsession was at the heart of addictive insanity.

Not realizing she had affirmed what I’ve called the common grace of recovery, Gina M. said it was not just addicts who could benefit from the self-discovery recovery brings. “You don’t need to be an addict to hold resentments, to be angry, or to feel fear.” She said she was “learning to replace anger with love, resentment with acceptance, and fear with faith.”

“The Triangle of Self-Obsession” said resentment is the way most addicts (or most people) react to their past. This resentment was reliving past experiences over and over again. Anger is how most people deal with the present. “It is their reaction to and denial of reality.” Fear is what we feel when we think about the future. “It is our response to the unknown.”

NA pictured the way we react to people, places, and things as follows:

All three of these things are expressions of our self-obsession. They are the way that we react when people, places and things (past, present, and future) do not live up to our demands.

In Narcotics Anonymous we are given a new way of life and a new set of tools. These are the Twelve Steps, and we work them to the best of our ability. If we stay clean, and can learn to practice these principles in all our affairs, a miracle happens. We find freedom—from drugs, from our addiction, and from our self-obsession. Resentment is replaced with acceptance; anger is replaced with love; and fear is replaced with faith.

Following the distinction between spiritual and religious made by AA, Alcoholics Anonymous, NA avoids beliefs or doctrines that it sees as institutional religion. NA and AA follow the thought of William James in The Varieties of Religious Experience, who saw institutional religion as worship, sacrifice, ritual, theology, ceremony and ecclesiastical organization. Personal religion or spirituality for James was “the feelings, acts and experiences of [the] individual . . . in their solitude, so far as they apprehend themselves to stand in relation to whatever they may consider to be divine.” In the broadest sense possible, this spirituality consisted in the belief that there was an unseen order to existence; where supreme good lay in harmoniously adjusting to that order.

“The Triangle of Self-Obsession” said seeking help from belief in a Power greater than yourself was a natural part of growing up, but here it stumbles. Belief in Adam and Eve, accepting the reality of the story of the birth of original sin and the promise of salvation in the protevangelium is theology—part of institutional religion—which it avoids. So, it must have a nonreligious explanation for why people become addicts. It does this by describing how when people are born, they are only conscious of themselves, “we are the universe;” we are self-centered. As we grow up, we realize the outside world cannot provide all our wants and needs, and we begin to supplement what is given to us with our own efforts.

As this dependency on people, places, and things decreases, we increasingly rely on ourselves to meet our wants and needs. We become more self-sufficient “and learn that happiness and contentment come from within.” As we grow and mature, we recognize not only our strengths, but also our weaknesses and limitations. And most people develop a belief in a “Power greater than themselves to provide the things they cannot provide for themselves.” Here is where addicts are said to “falter along the way.”

We never seem to outgrow the self-centeredness of the child. We never seem to find the self-sufficiency that others do. We continue to depend on the world around us and refuse to accept that we will not be given everything. We become self-obsessed; our wants and needs become demands. We reach a point where contentment and fulfillment are impossible. People, places, and things cannot possibly fill the emptiness inside of us, and we react to them with resentment, anger, and fear.

Without a belief in a Power greater than ourselves that can be trusted to provide the things we cannot provide for ourselves, the addict cannot grow out of childish self-centeredness. Their wants and needs of people, places, and things become demands that are impossible to fulfill. This leads to a negative reaction to that failure with resentment, anger, and fear. It cannot be a sinful reaction to not getting their wants and needs met, since sin is religious.

Instead of fallen, sinful human nature, NA says addicts have a metaphorical “disease” that forces them to seek help from a greater Power, one that Christians confess to be Jesus Christ, who is the same yesterday, today and forever (Hebrews 13:8). Relating Hebrews 13:8 to the above diagram from “The Triangle of Self-Obsession,” we’d say Jesus is the same in the past, present and future. “We are fortunate that we are given only one choice; one last chance. We must break the triangle of self-obsession; we must grow up, or die.”

To the Christian who believes in the truth and reality of the Genesis story of the Fall of Adam and Eve and the origins of sin, “The Triangle of Self-Obsession” will seem to be an incomplete explanation of how addicts “falter along the way.” But it can be used as a point of contact to explore a deeper, and truer sense of spirituality and religion beyond that of William James, NA, or AA. See “Is AA Religious?” and “Religious Alcoholics; Anonymous Spirituality” for a discussion of the differences between true religion and mere religion; true spirituality and mere spirituality.

01/3/23

Common Grace & “The Triangle of Self-Obsession,” Part 1

Adam and Eve could have used a good NA (Narcotic Anonymous) meeting after they ate of the fruit of the tree in the middle of the Garden. They used “what’s happened to me” as an excuse for their poor choice and the shame, guilt and regret that followed. They floundered in self-pity and let their self-centeredness lead the way into even more poor decisions. At a meeting, they would have learned they were living in the triangle of self-obsession, making excuses for their questionable behavior.

Let’s look at Genesis chapter 3 to see how this works out. The serpent tells Eve she won’t surely die if she eats of the fruit of the tree in the midst of the garden. She saw the tree was good for food, a delight to the eyes, and was desired to make you wise. So, she took the fruit and gave some to Adam, who ate it with her. They got what they had craved, but along with their eyes being opened to their poor decision, there were negative consequences for their actions.

They realized they were naked, and that they had impaired their relationship with God. They now saw their guilt before God (they were naked) and were ashamed. So then they sewed fig leaves together and made themselves loincloths (Genesis 3:4-7).

When God called to Adam and said “Where are you?”, He was calling on Adam to consider what he did wrong. A commentator observed that there is no possibility for reconciliation if the guilty are unwilling to confess their deeds. When Adam said he was afraid because he was naked, he was afraid to appear before God in his nakedness—he was ashamed of his disobedience. “Adam admits his sense of shame, which was motivated by his guilt.”

There were also problems from how they responded to God’s questions. When God asked if he ate of the tree which he was commanded not to eat from, Adam failed to take responsibility for his actions. He actually blamed both Eve and God, saying the woman that God gave him gave him the fruit and he ate. It’s like he’s saying, “I only too what she gave me!” Adam implied God was ultimately responsible for the success of the serpent and Adam’s eating the fruit. Here we see how by shifting the blame, Adam tried to evade accountability for his actions—and in the process alienated his relationship with Eve. In effect, Adam said, “The helper you gave me God, she’s responsible!”

When God asked Eve to explain what she had done, she also played the blame game, saying the serpent deceived her and she ate. Adam and Eve were trying to excuse their sinful behavior, but they were really deceiving themselves. And because of their failure to take responsibility for their actions, they experienced more shame and guilt, and were led straight into the triangle of self-obsession.

NA says self-centeredness is the core of their disease, their addiction. And as we saw above, it is the heart of all sin from the beginning. In “The Triangle of Self-Obsession,” it says:

Resentment, anger, and fear make up the triangle of self-obsession. All of our defects of character are forms of these three reactions. Self-obsession is at the heart of our insanity. Resentment is the way most of us react to our past. It is the reliving of past experiences, again and again in our minds. Anger is the way most of us deal with the present. It is our reaction to and denial of reality. Fear is what we feel when we think about the future. It is our response to the unknown; a fantasy in reverse. All three of these things are expressions of our self-obsession. They are the way we react when people, places, and things (past, present, and future) do not live up to our demands.

If Adam and Eve had been able to attend that NA meeting, they would have been introduced to a new set of tools— the Twelve Steps. However, God had a better plan than an NA meeting or the Twelve Steps for Adam and Eve. In His judgment against the serpent, God said there would be hostility between the serpent and the woman, between her offspring and the serpent’s offspring (Genesis 3:15). Christian tradition refers to God’s statement in Genesis 3:15 at the protevangelium, the first gospel. The New Testament presents Jesus as the Christ—the long-awaited Messiah and Savior predicted by the prophets and alluded to in God’s judgment against the serpent in Genesis 3:15.

However, the NA fellowship does not go there in “The Triangle of Self-Obsession.” Instead of Jesus Christ, the recovering individual is supposed to seek the help of a “Power greater than themselves.” Many Christians will have an automatic rejection of whatever NA says about recovery if that greater Power is not explicitly called Jesus Christ. But remember, “The Triangle of Self-Obsession” is not about salvation from sin, but recovery from addiction.

Jimmy K., considered to be the founder of NA, made a profound contribution to the fellowship when he successfully argued the NA First Step should say members were powerless over “our addiction” instead of alternatives like drugs, alcohol and drugs, or narcotic drugs. Instead of centering their institutional identity on a single drug, as AA did, NA focused its attention on the shared process of addiction. So, you won’t hear about the Fall, or Adam and Eve, or the protevangelium in “The Triangle of Self-Obsession.” But you will hear about faith, love and acceptance from the perspective of common grace:

Common grace is understood to be the unmerited favor of God towards all men whereby (1) he restrains sin so that order is maintained, and culture and civil righteousness are promoted; and (2) he gives them rain and fruitful seasons, food and gladness, and other blessings in the measure that seems to him to be good.

When you read any NA or AA literature, think of it as a common grace description of how God restrains drug addiction or alcoholism; how it is God’s bounty poured out on all men and women in order for them to recover, regardless of their faith in Him. With this in mind, we’ll continue to reflect on “The Triangle of Self-Obsession,” in part 2 and consider how the addict is given “a new way of life and a new set of tools.”

For more on Jimmy K. and NA, see “The Birth and Near-Death of Narcotics Anonymous” and Growing Pains with Narcotics Anonymous.”

12/13/22

Juul and the Fight to Regulate Vaping

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On June 23, 2022, the FDA ordered JUUL Labs Inc. to stop selling and distributing its products in the US. After reviewing the company’s PMTAs (premarket tobacco product applications), the FDA concluded the applications did not have sufficient evidence the Juul products would benefit public health, as claimed. Some of the company’s study findings had insufficient and conflicting data—“including regarding genotoxicity and potentially harmful chemicals” leaking from their e-liquid pods. The FDA Commissioner said, “Today’s action is further progress on the FDA’s commitment to ensuring that all e-cigarette and electronic nicotine delivery system products currently being marketed to consumers meet our public health standards.”

The FDA thought Juul’s application left regulators with questions about the chemical makeup of its vaping formulations, while Juul thought it submitted enough information and data to address all the concerns. The acting director of the FDA’s Center for Tobacco Products said,

As with all manufacturers, JUUL had the opportunity to provide evidence demonstrating that the marketing of their products meets these standards. However, the company did not provide that evidence and instead left us with significant questions. Without the data needed to determine relevant health risks, the FDA is issuing these marketing denial orders.

The next day the U.S. Court of Appeals placed a temporary hold on the ban, saying Juul’s application warranted “additional review.” Then the FDA announced on Twitter it would allow Juul’s vaping products to remain on the market while it reviewed the application for “scientific issues” unique to the Juul application.

The NYT said the decision to conduct an internal review moved the dispute out of the public eye of the appellate court and returned it to the agency’s private administrative process. The ban in June was celebrated by critics who thought the company should be held accountable for luring teenagers to use its flavored products. Others were critical, saying e-cigarettes are less toxic than traditional cigarettes. Juul argued that it had helped two million adult smokers quit traditional cigarettes. The company also said it had been singled out by members of Congress who influenced the agency to make the ruling.

Juul’s court filing said the agency contended “in more than two dozen places” that Juul did not provide enough data on four chemicals. But Juul said it did provide the data—6,000 pages of data. “Had F.D.A. done a more thorough review (like it did for other applicants), it would have seen data showing that those chemicals are not observable in the aerosol that Juul users inhale.”

Theodore Wagener, the director of the Ohio State University Center for Tobacco Research, said the original ban was surprising, given that independent research teams like his own found that Juul devices were far less toxic than traditional cigarettes. He said Juul aerosol has significantly lower-level and fewer toxicants than cigarettes; and lower chemical levels than other e-cigarettes. It seemed thing were beginning to go Juul’s way, and perhaps was a foreshadowing of the FDA decision.

Then on September 6^th Juul agreed to pay $438.5 million to settle a two-year investigation by 33 states into the marketing and sales practices they blamed for starting a national flood in teen vaping. The company did not acknowledge any wrongdoing in the settlement, but said it was trying to resolve past issues while it awaited the FDA decision on whether it would be allowed to continue to sell its products. Connecticut’s attorney general said they were under no illusions that it will stop teen vaping. “But we have essentially taken a big chunk out of what was once a market leader.”

Juul said the settlement aligned with its current business practices. “We remain focused on the future as we work to fulfill our mission to transition adult smokers away from cigarettes — the No. 1 cause of preventable death — while combating underage use.” Under pressure for it marketing practices of targeting youth, Juul revised its business practices and target audience to adult smokers in the fall of 2018. See “Not JUULing Around” and “The Armageddon of Juul.”

The agreement does not resolve all of the company’s legal battles. While Juul had previously reached settlements in lawsuits brought by attorneys general from North Carolina, Washington, Louisiana and Arizona, nine similar cases remain. Major lawsuits filed by New York and California are among those still pending. And about 3,600 lawsuits by individuals, school districts and local governments, have been consolidated in an action that is still wending its way through a California court.

A study done in 2018 and published in the journal Pediatrics looked at 4207 students in ninth-through 12-grades in the Pittsburgh Public Schools. The researchers showed an inverse correlation between protective factors, such as parental monitoring and future orientation and youth vaping. “The differential association of protective factors across tobacco products highlights the unique social and relational features of vaping.”

One of the study’s authors, Kar-Hai Chu, has been studying the evolution of e-cigarettes for the past ten years. He said his research team has done several studies on Juul’s presence on social media, finding at least 25% of Juul’s Twitter followers were under 18. He said their estimate was conservative, as the recent settlement noted above found the number could be as high as 50%.

The immediate and obvious concern was that so many adolescents were being exposed to Juul’s advertisements, but as behavioral scientists, we realized the problems didn’t end there. Not only were kids seeing the ads, but they were sharing them with their friends. In the world of Facebook, Twitter, and Instagram, sharing tobacco content was as easy as a single click.

He described how on Instagram they saw many different flavors of Juul products in colorful cartons. “Decades of research have found that colorful tobacco images are more appealing to younger teens; Instagram was just the latest platform for this strategy.” He then noted a post that made them laugh: “Why do people pee in the Juul room?” But there was truth behind the humor. For teachers and school officials that Twitter post defined the battles they were having.

Kids were using Juul devices in schools, in bathrooms (or Juul rooms), and even in classrooms when teachers’ backs were turned. Schools were desperate for solutions. School administrators had watched adolescent cigarette use decline over the past decade, but this was something new. Yes, it was still a tobacco product, but kids didn’t seem to understand the health impacts. These weren’t teens rebelling by using cigarettes, knowing they were harmful; instead, it was athletes, A-students, and others who believed that e-cigarettes were merely flavored vapor with no impact on their health.

But the golden days for Juul have faded. After Juul gave in to public pressure and stopped selling flavors that appealed to young people, it fell to the fourth favorite among students. Puff Bar, with its candy-and fruit-flavored vapes was first. Altria in December of 2018 bought a 35 percent share of Juul (See “Not JUULing Around”). In a recent filing to its investors, Altria said its share was now valued at $450 million.

Whatever the FDA decision is on Juul, the FDA is purposefully moving to regulate all vaping, all ENDS (electronic nicotine delivery systems). But vaping manufacturers won’t give up without a fight. In an attempt to evade FDA regulation, manufacturers of e-cigarette brands popular with kids have begun to use synthetic nicotine in their products.

However, a new federal law went into effect in April of 2022, clarifying the FDA’s authority to regulate tobacco products containing nicotine from any source. After July 13, 2022, “any new non-tobacco nicotine product that has not received premarket authorization from FDA cannot be legally marketed.” When companies are found to be illegally marketing non-tobacco nicotine products, the FDA will first issue warning letters to achieve voluntary compliance. But the agency will pursue enforcement actions such as civil money penalties, injunction, non-tobacco sales orders, or injunction.

11/8/22

Is AA Religious?

Roger C. announced in June of 2022 that his article, “The Last Post on AA Agnostica,” would be the final new article posted on the website. AA Agnostica would remain online, but there will be no more new articles. He said in the eleven years since it was launched, AA Agnostica has been a comfort for those who could not stand “all the God stuff at traditional AA meetings,” like ending with the Lord’s Prayer. “All the God stuff” makes AA religious.

Roger said he was treated with disrespect at traditional AA meetings because he didn’t believe in God and was told that without God, he would get drunk again. While that prediction did not come true, it seemed to motivate him to start the website, AA Agnostica. There are several resources in addition to its 746 other articles, including a listing of secular group websites, alternative 12 Steps and literature. There is also a link to a 2015 self-published book edited by Roger, Do Tell! Stories by Atheists and Agnostics in AA (available on Amazon). It contains thirty stories by people who do not believe that “an interventionist deity—a God—had anything at all to do with their recovery from alcoholism.”

In the first chapter of Do Tell! Stories by Atheists and Agnostics in AA, “Reshaping the AA Culture,” Roger C. pointed out that the fellowship and the book from which it gleans its name, Alcoholics Anonymous, was “mired” in the predominantly American Christian culture of the Thirties and Forties. He described how God was mentioned (in one way or another) in six of the 12 Steps. A section from “How It Works,” chapter five of the Big Book, is typically read at the beginning of an AA meeting. The reading says that “probably no human power could have relieved our alcoholism” but the God could and would do so “if He were sought.” A so-called “traditional” AA meeting ends by reciting the Lord’s Prayer.

The point he’s attempting to make is that despite various judicial decisions have found AA to be a religious organization, AA has failed to respond because it sees the rulings as “outside issues,” which he believes is incorrect. See “The Courts, AA and Religion” on the AA Agnostica website for the rulings.

He believes this is an “inside issue” that needs to be addressed by AA. However, Roger C. does not think the Big Book should be revised or rewritten. “It lays the foundation for what does work for alcoholics: the very human power of one alcoholic talking to another alcoholic.” This, he said, is what assists alcoholics in working towards “recovery from alcoholism and is the very essence of the fellowship of AA.”

It is true that U.S. Courts have ruled that AA is a “religion.” However, I think these rulings and Roger C.’s claim it is an “inside” issue to AA are based on an understanding of what constitutes a religion in modern culture that is different than what AA itself believes. Pointing to references to “God,” and saying the Lord’s Prayer as evidence that AA is religious stems from Edmund Tylor’s definition of religion as “the belief in spiritual beings.” AA seems to follow Emile Durkheim, who thought religion was a product of society and should not be defined just in terms of ideas of divinity or spiritual beings. AA also explicitly credits how its sense of religion and spirituality is drawn from William James in The Varieties of Religious Experience.

In “What Does Religious Mean?” I discussed how Tylor’s understanding seems to have influenced the legal decisions within American culture and the U.S. court system. Then I continued to unpack how William James influenced the spiritual, not religious understanding within AA in “Spiritual, not Religious Experience” and “The God of the Preachers.” I agree with AA that the Court decisions ruling that AA is religious is an outside, rather than an inside issue to the fellowship.

Some Christians, like Martin and Deidre Bobgan in 12 Steps to Destruction, make the same error, viewing AA as religious. They claim A.A. is a Christless religion, offering up a counterfeit salvation. “Because of the many versions of God represented in A.A., professing Christians are uniting themselves with a spiritual harlot when they join A.A.” In The Useful Lie, William Playfair claimed when Christians go to AA for help, they unwittingly side against Biblical Christianity.

In “Religious Alcoholics; Anonymous Spirituality,” I suggested a more helpful discussion would distinguish between true religion and mere religion; true spirituality and mere spirituality. Mere religion or mere spirituality are concepts consistent with Durkheim’s and James’ understanding of religion and spirituality (called personal religion in The Varieties of Religious Experience, VRE).

The emptiness of ritual or worship (mere religion) without a heart for God (true spirituality) is noted in Hosea 6:6, “For I desire steadfast love and not sacrifice, the knowledge of God rather than burnt offerings.” Again, the same contrast appears in Micah 6:7-8, “For You will not delight in sacrifice or I would bring it; you will not be pleased with a burnt offering. The sacrifices of God are a broken spirit; a broken and contrite heart, O God, You will not despise.” True religion always contains true spirituality.

At its best, Twelve Step spirituality rises only to the level of general revelation or common grace. There is a God and sobriety is better than drunkenness. True spirituality requires that we confess with our mouth that Jesus is Lord and believe in our heart that God raised Him from the dead (Rom. 10:9). True spirituality requires true religion. In his book, “True Spirituality,” Francis Schaeffer rejected the possibility of true spirituality devoid of biblical content. There cannot be a leap-in-the-dark faith for a Christian; there is no “faith in faith” encounter with the divine.

Twelve Step spirituality is nothing more than common grace or mere spirituality. Following the thought of William James in VRE, it rejects institutional religion, which he defined worship, sacrifice, ritual, theology, ceremony and ecclesiastical organization. Personal religion/spirituality for his purposes, was “the feelings, acts and experiences of [the] individual . . . in their solitude, so far as they apprehend themselves to stand in relation to whatever they may consider to be divine.” In the broadest sense possible, this spirituality consisted of the belief that there was an unseen order to existence, and supreme good lay in harmoniously adjusting to that order.

A higher power could be anything that was other than and larger than the person’s conscious self. Towards that end, James said that spiritual experience could only testify unequivocally to two things: the possible union with something larger than oneself and the great peace that was found within that union. Spiritual encounters would not unconditionally confirm a traditional belief in the one and only infinite God. James suggested that the practical needs and occasions of religion were sufficiently met by the belief that beyond each person, a larger power existed that was friendly to him and his ideals. All that was required was that the power should be both other than and larger than a personal conscious self. “Anything larger will do, if only it be large enough to trust for the next step. It need not be infinite; it need not be solitary. It might conceivably be only a larger and more godlike self.”

A.A. has consistently avoided an understanding of this higher power as G-O-D (as good, orderly direction) beyond the above discussion of William James in the Varieties of Religious Experience. Devoid of a true religious understanding of God and Jesus Christ, as we see in Romans 10:9, it is not a religion, as defined in the VRE. It won’t lead you to a relationship with Christ, but if you practice its 12 Steps, it may help you establish and maintain abstinence from alcohol.

10/18/22

Back to the Future with Psychedelics

© Zhuxi1984 | Dreamstime.com – Back To The Future Photo

“I am 100 percent in favor of the intelligent use of drugs, and 1,000 percent against the thoughtless use of them, whether caffeine or LSD.” (Timothy Leary, in Chaos and Cyber Culture)

We’re going “back to the future” with recent research into the therapeutic benefits of hallucinogens for treating alcoholism and mood disorders. (See additional stories here and here; and a previous blog, “As Harmless as Aspirin?”) Classical hallucinogens such as LSD, mescaline or psilocybin, and dissociative anesthetics such as ketamine and PCP might be “useful” in the treatment of major depression, anxiety disorders and OCD. A recent study concluded: “There was evidence for a beneficial effect of LSD on alcohol misuse.” A single dose of LSD was found to be associated with a decrease in alcohol misuse. Another longitudinal study suggested that: “hallucinogens may promote alcohol and drug abstinence and prosocial behavior in a population with high rates of recidivism [with individuals on probation or parole].”

An issue of Current Drug Abuse Reviews (volume 6, number 1, 2013) was devoted to the investigation of psychedelics and their potential as therapeutic agents in the treatment of addiction. Several different articles suggested the therapeutic benefits of a variety of psychoactive substances—some classics and some newer ones.

Rick Doblin, in “Psychedelic-Assisted Psychotherapy for the Treatment of Addiction,” said: “There are multiple frameworks for understanding how psychedelic therapy can alleviate substance abuse.” He noted that the idea that psychedelics can be helpful in combating drug abuse conflicts with “the notion that psychedelic drug use is inherently wrong.”

Michael Bogenschutz of the University of New Mexico Health Sciences Center suggested that sacramental use of classic hallucinogens, like the Native American Church’s use of peyote, “is strongly associated with decreased alcohol and drug use.”

Lisa Jerome and others lobbied for studies that tested MDMA-assisted psychotherapy in people with an active substance use disorder. “It appears that MDMA, like classic psychedelics, may have a place in addressing substance abuse or dependence, which could be linked to its pharmacology or its psychological effects.”

Ayahuasca, a psychotropic brew prepared from an Amazonian vine and bush, may be associated with reduced substance use and “improvements in several cognitive and behavioral states.”

Thomas Kingsley Brown reported that ibogaine, a psychoactive alkaloid found in a rainforest shrub of West Central Africa, helps with withdrawal symptoms and reduces drug cravings.

A study of ayahuasca-assisted treatment for substance use problems by Gerald Thomas and others suggested that it was associated with significant improvements in several factors related to problematic substance use. While this particular study occurred in Canada, ayahuasca has been used as a remedy to help overcome drug addictions in Peru and Brazil. “Although these programs claim improved health outcomes for patients who complete them, neither has been evaluated with sufficient scientific rigor to provide definitive evidence of the success of their approaches.”

Ibogaine is not used in the US to treat addiction because of its severe side effects, which include hallucinations, bradycardia (slow heart rate), whole-body tremors and ataxia (lack of muscle control during voluntary movements). It also had cerebellar toxicity with high doses in rats. Nevertheless, it is a growing form of treatment outside the US. A subculture of ibogaine clinics has sprung up in Mexico. Read about a trip to one here.

A synthetic derivative of ibogaine, 18-MC, has been developed and is said to show promise. It resulted in “a long-lasting decrease in ethanol, morphine, cocaine, methamphetamine and nicotine self-administration [in rats], and attenuation [decrease] of opioid withdrawal symptoms.” Significantly, it is not expected to have hallucinogenic effects and does not have the negative side effects noted above with ibogaine.

In 2012 Savant HWP, a privately-owned pharmaceutical company in California, received a three-year grant from the National Institute on Drug Abuse (NIDA) for the pre-clinical development of 18-MC. Stanley Glick, the scientific founder of Savant and a long time researcher with ibogaine, said: “18-MC is likely to be the first of a new generation of agents effective against a broad spectrum of addictions—from hard drugs such as heroin and cocaine, to alcohol, nicotine and even sugary, high-fat foods, possibly reducing obesity rates.” On September 23rd of 2014 Savant announced they had begun human safety clinical trials on 18-MC. “Savant HWP plans to develop 18-MC as a treatment for many forms of addiction and compulsive behavior, with an initial focus on cocaine and opiate dependencies.”

The so-called “psychedelic treatment” approach, based on the original work of Humpry Osmond, uses pre and post therapeutic sessions and one large dose of your hallucinogen-of-choice (LSD, ayahuasca, psilocybin, mescaline). The spiritual, therapeutic goal is captured here by Aldous Huxley’s description of his experience with mescaline in The Doors of Perception:

The man who comes back through the Door in the Wall will never be quite the same as the man who went out. He will be wiser but less cocksure, happier but less self-satisfied, humbler in acknowledging his ignorance yet better equipped to understand the relationship of words to things, of systematic reasoning to the unfathomable Mystery which it tries, forever vainly, to comprehend.

But we should also remember the warnings of Albert Hofmann, the inventor of LSD, who cautioned not to underestimate the potential negative consequences of a deliberate provocation of mystical experiences with hallucinogens like LSD. “Wrong and inappropriate use has caused LSD to become my problem child.” In the “LSD state” the boundaries between the self and the outer world effectively disappear. “A portion of the self overflows into the outer world. . . . This can be perceived as a bless[ing], or as a demonic transformation imbued with terror.”

Originally posted on December 22, 2014.

10/11/22

Striving After Wind with NPS

A few years ago, the problem with new psychoactive substances seemed to predict a dire future. The United Nations Office on Drugs and Crime (UNDOC) launched the Early Warning Advisory on NPS in June of 2013 to address the growing emergence of NPS at the global level. The term “new” can be misleading, as many NPS were first synthesized decades ago, but only recently became recreational drugs. As of December 2021, data reported to the UNDOC Early Warning Advisory 1,124 substances have been reported by governments, laboratories and partner organizations. All told, 134 countries and territories globally have reported one or more NPS.

NPS are not controlled under the International Drug Control conventions, so their legality can vary widely from country to country. By 2021, over 60 countries had implemented legal responses to control NPS. Many countries amended existing legislation, while others used innovative legal instruments. Several countries where a large number of NPS rapidly emerged, adopted controls on entire substance groups of NPS, or introduced analogue legislation that invokes the principle of “chemical similarity” to an already controlled substance explicitly mentioned within the legislation.

The World Drug Report 2021 (Executive Summary, Book 1) indicated these measures helped the number of NPS emerging on the global market to fall from 163 in 2013 to 72 in 2019. But this occurred primarily in high-income countries. “However, the NPS problem has now spread to poorer regions, where control systems may be weaker.” Seizures on synthetic NPS in Africa rose from less than 1 kg in 2015 to 828 kg in 2019. A similar trend was seen in Central and South America, where seizures rose from 60 kg to 320 kg over the same period of time.

Responses that have helped to contain the supply of NPS and reduce negative health consequences can be expanded to lower-income countries, some of which are increasingly vulnerable to the emergence of NPS. Those responses include early warning mechanisms that ensure a continuum of evidence-based measures from early detection to early action, post-seizure inquiries, including the formation of joint investigation teams, and training of emergency health workers on how to address cases of acute NPS intoxication. The expansion of services for people who use drugs and people with drug use disorders to people who use NPS can also help addressing the harm posed by those substances.

The use of NPS is often linked to health problems. Side effects range from seizures to agitation, aggression, acute psychosis and the potential for drug dependence. NPS users have frequently been hospitalized with severe intoxications. Information on long-term adverse effects is still largely unknown, and safety data on toxicity is limited or nonexistent. “Purity and composition of products containing NPS are often not known, which places users at high risk as evidenced by hospital emergency admissions and deaths associated with NPS, often including cases of poly-substance use.”

Effect Groups of New Psychoactive Substances

Up to December of 2021, there were six main pharmacological ‘effect’ groups of NPS: stimulants, synthetic opioids, synthetic cannabinoids, dissociatives, classic hallucinogens and sedatives/hypnotics. Stimulants (36%) and synthetic cannabinoids (30%) were the most common, while sedative/hypnotics, mimicking the effects of benzodiazepines (4%) and dissociatives (3%) were the least common. Synthetic opioids accounted for 8% and psychedelics or classic hallucinogens 15% of NPS. See the following graphic presentation of these groups.

Van Hout et al described health and social consequences of recent NPS use among a survey of 3,023 users in six European countries. Socially marginalized respondents (who are also high-risk drug users), were often unemployed, homeless and/or in care. They were the oldest, with an average age of 33.5 years. A substantial proportion of them lived in homeless shelters or hostels (32.3%) or other living arrangements (12.3%), including living on the streets. The education achievement of most marginalized respondents (55.2%) was only up to the equivalent of high school. Among marginalized respondents, 75.7% were unemployed or living on benefits.

The other two groups of those surveyed, nightlife NPS respondents and online respondents, tended to live with relatives or in rented accommodations. They were better educated and significantly less likely to be unemployed or living on benefits (10.8% and 8.1% respectively). Within all three subsamples, a majority of recent NPS users had experienced acute unpleasant side effects. See Table 4 in Van Hout et al.

In terms of reporting of acute side effects, experiences of increased heart rate and palpitation, dizziness, anxiety and horror trips and headaches were reported as most common across all three categories. The proportion who had experienced these effects was substantially larger in the marginalised sample (85.3%), than in the night life and online community samples (58.8 and 51.0%). When looking at the separate side effects, there are significant differences between the three groups in every symptom, with mostly much higher proportions of marginalised users reporting these effects. When comparing night life users and online community users, night life users reported more unpleasant effects, especially head and stomach aches and dizziness. However, in all categories, marginalised users show much higher rates than the two other groups. Increased heart rate or palpitation was the most reported side effect in all three samples.

Benzodiazepine-Type NPS

Benzodiazepines and benzo-type NPS, primarily etizolam, flualprazolam and flubromazolam are often detected in drug overdose cases and can contribute to serious adverse health effects, particularly when used in combination with opioids. “Current NPS threats”, vol. 3 reported that benzo-type NPS were identified in 48% of post-mortem cases as having been the cause of death or contributing to the cause of death.

The analysis presented here reveals that benzodiazepine-type NPS can play an important role in contributing to serious harm, either alone or in combination with other psychoactive substances. Thus, forensic laboratories should ensure that they have appropriate analytical methods available for their detection in case work.

NPS with Opioid-Like Effects

NPS opioids seem to be a fast-growing category of NPS over the past five years. They include a range of fentanyl analogues and research opioids that were developed by the pharmaceutical industry, beginning in the 1960s, as alternatives to morphine for pain management. “Some of these substances were not developed further and were subsequently considered ‘not suitable for human consumption.’” Some of these opioids have been rediscovered. Others have been developed by modifying their chemical structure, which creates a “new” chemical compound and circumvents existing legislation. While they are dissimilar in their chemical structure, the common action of NPS opioids is they act on the mu opioid receptor. The harms associated with NPS opioids other than fentanyls vary considerably.

NPS with opioid-like effects continue to emerge on illicit drug markets, and “Current NPS threats” highlighted three. Isotonitazene, a synthetic opioid has been seen in Europe and North America. Since June of 2019, there were eight incidents of fatalities associated with isotonitazene in the US reported to UNODC. In seven cases it was assessed to be the cause of death. Because of its novelty and opioid-like effects, it could have been misinterpreted as a heroin overdose, masking other cases of fatality.

Kratom, usually involving the concomitant use of other substances, has shown a potential to cause serious harm, including fatalities. Ninety percent of all kratom cases involved the concomitant use of other substances. Since July of 2019, at least 14 cases have been identified where kratom caused (n=7) or contributed (n=7) to a fatality.

Brorphine was first identified in the US recreational drug supply in July of 2020. Its emergence seems to be directly linked to the DEA’s scheduling of isotonitazene. It is commonly found with fentanyl and flualprazolam. “Current NPS threats” said it appears to have a long half-life and high potency when compared to medicinal opioids like hydromorphone. “Despite having structural similarities to fentanyl, brorphine differs in key aspects from fentanyl and falls outside the scope of generic legislation aimed at covering fentanyl analogues.” Between June and November 2020, 120 overdose deaths attributed to brorphine were reported in the US.

Reflecting on the evolving history of NPS, I’m reminded of the book of Ecclesiastes, which says: “Is there a thing of which it is said: ‘See this is new’?” It has been done already and is a vanity—a striving after wind.

What is crooked cannot be made straight, and what is lacking cannot be counted. (Ecclesiastes 1:15)

Faith Seeking Understanding

Charles Sigler, D.Phil.

Category Archives: Addiction & Recovery