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Stands for Problems
“Any downsides from smoking? Unintended consequences?” I asked.
“The only bad thing about smoking,” Delilah said, “is that my parents are
always on my back. If they would just leave me alone, there wouldn’t be any
downsides.”
I paused to notice the sun glinting on her hair. She was the picture of health
despite the fact that she was ingesting more than a gram of cannabis a day.
Youth, I thought, compensates for so much.
—
The p in DOPAMINE stands for problems related to use.
High-dopamine drugs always lead to problems. Health problems.
Relationship problems. Moral problems. If not right away, then eventually.
That Delilah could not see downsides—except the mounting conflict between
her and her parents—is typical for teenagers . . . and not just teenagers. This
disconnect occurs for a number of reasons.
First, most of us are unable to see the full extent of the consequences of our
drug use while we’re still using. High-dopamine substances and behaviors
cloud our ability to accurately assess cause and effect.
As the neuroscientist Daniel Friedman, who studies the foraging practices
of red harvester ants, once remarked to me, “The world is sensory rich and
causal poor.” That is to say, we know the doughnut tastes good in the
moment, but we are less aware that eating a doughnut every day for a month
adds five pounds to our waistline.
Second, young people, even heavy users, are more immune to the negative
consequences of use. As one high school teacher remarked to me, “Some of
my best students smoke pot every day.”
As we age, however, the unintended consequences of chronic use multiply.
Most of my patients who come in voluntarily for treatment are middle-aged.
They seek me out because they’ve reached a tipping point where the
downsides of their use outweigh the upsides. As they say in AA, “I’m sick
and tired of being sick and tired.” My teenage patients, by contrast, are
neither sick nor tired.
Even so, getting teenagers to see some negative consequences of their use
while they’re still using, even if it’s only that other people don’t like it, can
be a point of leverage for getting them to stop. And stopping, even just for a
period of time, is essential for getting them to see true cause and effect.
A Stands for Abstinence
“I do have an idea about what might help you,” I said to Delilah, “but it will
require you to do something really hard.”
“What’s that?”
“I’d like you to try an experiment.”
“An experiment?” She tilted her head to the side.
“I’d like you to stop using cannabis for a month.”
Her face was impassive.
“Let me explain. First, treatments for anxiety are unlikely to work while
you’re smoking that much cannabis. Second, and more importantly, there’s a
distinct possibility that if you stop smoking for a whole month, your anxiety
will get better all on its own. Of course, at first you’ll feel worse due to
withdrawal. But if you can get through the first two weeks, there’s a good
chance that in the second two weeks you’ll start to feel better.”
She remained quiet, so I continued. I explained to her that any drug that
stimulates our reward pathway the way cannabis does has the potential to
change our brain’s baseline anxiety. What feels like cannabis treating anxiety
may in fact be cannabis relieving withdrawal from our last dose. Cannabis
becomes the cause of our anxiety rather than the cure. The only way to know
for sure is to lay off for a month.
“Can I stop for a week?” she asked. “I’ve done that before.”
“A week would be good, but in my experience, a month is usually the
minimum amount of time it takes to reset the brain’s reward pathway. If you
don’t feel better after four weeks of abstaining, that’s also useful data. That
means the cannabis isn’t driving this, and we need to think about what else is.
So what do you think? Do you think you would be able and willing to stop
cannabis for a month?”
“Hmmm. . . . I don’t think I’m ready to try quitting now, but maybe later.
For sure I’m not going to be smoking like this forever.”
“Do you still want to be using cannabis like this ten years from now?”
“No. No way. Definitely not.” She shook her head vigorously.
“How about five years from now?”
“No, not in five years either.”
“How about a year from now?”
Pause. Chuckle. “I guess you got me there, Doc. If I don’t want to be using
like this in a year, I might as well try to stop now.”
She looked at me and smiled. “Okay, let’s do this.”
In asking Delilah to consider her current behavior in light of her future self,
I hoped that quitting smoking would take on new urgency. It seemed to have
worked.
—
The a in DOPAMINE stands for abstinence.
Abstinence is necessary to restore homeostasis, and with it our ability to
get pleasure from less potent rewards, as well as see the true cause and
effect between our substance use and the way we’re feeling. To put it in
terms of the pleasure-pain balance, fasting from dopamine allows sufficient
time for the gremlins to hop off the balance and for the balance to go back to
the level position.
The question is: How long do people need to abstain in order to experience
the brain benefits of stopping?
Think back to the imaging study by neuroscientist Nora Volkow, showing
that dopamine transmission is still below normal two weeks after quitting
drugs. Her study is consistent with my clinical experience that two weeks of
abstinence is not enough. At two weeks, patients are usually still
experiencing withdrawal. They are still in a dopamine deficit state.
On the other hand, four weeks is often sufficient. Marc Schuckit and his
colleagues studied a group of men who were drinking alcohol daily in large
quantities and also met criteria for clinical depression, or what is called
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