The impact of regulation on self-medication

September 04, 2017 The Noffs Team Comments

Humans have long used a variety of drugs to self-medicate. Alcohol and pharmaceuticals are the most common go-to drugs for self-medication, however the risk of dependency on these drugs is high, and the health risks from excessive use can be severe.  

Other drugs, such as MDMA, have been researched for their potential use as medicines for PTSD sufferers, and medicinal cannabis is now accepted in many jurisdictions as a legitimate remedy for those suffering pain related to terminal illness.   

The gradual shift in the legal landscape for certain drugs may change the way we self-medicate and cope with the various pressures and strains of past trauma, or even daily life. If more options for medicinal therapy become available, a dependence on the “go-to” substances - alcohol and certain opioids - may decrease.

WHY DO WE USE ALCOHOL?

Alcohol use is common across many societies. It is widely used socially and as part of celebrations, however it is also misused in many situations, and for a variety of reasons. 

There is a theory that our liking of alcohol is evolutionary, and originates from the development of primates as fruit eaters [1]. The fermentation of ripe fruit in warm climates stimulated the senses, and the alcoholic smell of the fruit would act as a guide to primates finding food sources. And just as the aperitif effect of alcohol stimulates eating amongst modern day humans, the smell of fermented fruit strengthened the appetite of our ancestors. 

Drinking out of curiosity remains one of the main reasons for alcohol consumption, especially amongst youth. Alcohol promotion is a huge part of life [2], and many young people become interested to find out what it feels like. Young people are also more likely to take risks [3], and drinking can be a risky behaviour, particularly if the young person in question is under the legal drinking age. 

Alcohol is seen as an easy way to alleviate stress [4]. The idea that alcohol is a stress reliever has some truth to it - alcohol is a depressant, and sedates the central nervous system. It actually has a similar effect to some anti-anxiety medications [5], and can improve mood and confidence. Alcohol is seen as part of the social fabric of society. It is often seen as a normal, essential part of social functions [6], and an easy way to break the ice when meeting new people. Alcohol is also widely used as an escape, especially amongst those attempting to numb the pain of a traumatic event in their lives [7]. 

However, it is widely established that alcohol is a highly inappropriate drug to use as a way of alleviating stress or trauma, and harmful alcohol use can have short-term effects such as loss of concentration, sleep disruption and emotional volatility, and liver damage, cancer and death in the long term [8]. 

OTHER DRUGS AS STRESS RELIEVERS

Can the argument be made that alcohol would be used less as a stress reliever if more jurisdictions had legal access to drugs such as cannabis? Given that very few jurisdictions grant legal access to any illicit drugs, it is difficult to say. In the two years since Colorado and Washington regulated recreational use of cannabis, alcohol tax receipts for both states show little change in the amount people are drinking [9],  suggesting people are still turning to alcohol regardless of having legal access to other drugs. However it is still too early to determine whether the newly legal status of cannabis will have a significant impact on alcohol consumption rates in the future. 

On the other hand, there is evidence to suggest medicinal cannabis is having an impact on harmful opioid use. Opioids, like alcohol, are also often used as a form of self medication, particularly for patients prescribed them for chronic non-cancer pain. One study [10] analysed the impact of medicinal cannabis laws on opioid analgesic overdose rates in certain US states over a 10-year period and found that, while further research was needed, medicinal cannabis laws are associated with significantly lower state-level opioid overdose rates. This suggests that legitimate patients with chronic non-cancer pain may choose alternative non-opioid treatments if they are available. Evidence such as this may be further supported by one US treatment centre’s claims that medicinal cannabis is helping patients tackle a dependence on illicit drugs such as heroin and cocaine [11], though more research is needed on this. Overall, however, based on preliminary evidence, we can make the educated prediction that rates of harmful alcohol use may also decrease when alternative therapeutic substances become more widely available. 

MDMA, another drug with a history of medicinal research, is currently being trialled as a therapy assistor to PTSD sufferers. There are trials taking place in the United States, Israel and Canada [12], and preliminary results have shown that incorporating MDMA alongside a psychotherapeutic treatment can help people recover from PTSD, that the drug’s facilitation of feelings of trust and compassion may be useful in this context. 

It is important, in this case, to distinguish between the clinical use of MDMA and recreational use of ‘ecstasy’, or ‘molly’ [13]. The MDMA used in clinical trials is pure, compared with what is sold on the street as ecstasy, which is marketed as containing MDMA but may also contain potentially dangerous adulterants [14]. 

When we consider the association between PTSD and problematic use of alcohol, namely that being diagnosed with PTSD increases the risk of developing an alcohol use disorder [15], we have to wonder whether exploring and providing better medical alternatives would help curb problematic drinking amongst the top percentile of heaviest drinkers - many of whom may be suffering from PTSD or a similar trauma-related disorder. 

CASE STUDY: THE NETHERLANDS AND MAINSTREAM CANNABIS 

The Netherlands is an interesting case where, despite prohibiting use of all illicit drugs, it remains the country most associated with regulated cannabis. Since 1976, despite the illegal status of cannabis, Dutch authorities chose to turn a blind eye to its use, giving rise to the establishment of the now famous “coffee shops” [16] and reputation of the Dutch as frequent and liberal cannabis users. While this reputation isn’t entirely accurate, and the coffee shops are now largely used by tourists, the Netherlands has long been seen as a country where cannabis use is as mainstream as drinking.

The Netherlands’ per capita alcohol consumption rate is also below the European average, at 9.9 litres [17], compared to 10.9 litres overall in Europe, although it is not the lowest on the continent. A study comparing alcohol laws in the Netherlands with that of Canada and the United States found the Netherlands to have the least strict enforcement, and a considerably lower drinking age [18]. It also found the Netherlands overall to have generally less strict cannabis laws, with a stronger sense of regulation as opposed to prohibition. However, youth drinking in the Netherlands is significantly higher than the US or Canada, and cannabis use is significantly lower amongst Dutch youth than the other two nations. This suggests Dutch youth have not substituted alcohol with cannabis despite living in a culture where cannabis use appears to be more widely accepted and mainstream. The study concluded therefore that there was little correlation between substance use and policy for the three jurisdictions, however alcohol enforcement may be more effective than cannabis enforcement.

CONCLUSION

Having examined the reasons for widespread and mainstream alcohol use, together with alcohol’s history and status as a normalised part of many societies, it can be argued that widespread alcohol use will continue as long as people associate it with socialising, celebrating, and self-medicating. It is too soon to determine whether jurisdictions such as Washington and Colorado, having only recently regulated recreational cannabis use, will see any change in drinking patterns, however indications elsewhere suggest the availability of medicinal cannabis has had an impact on overdose rates involving opioids, and we can theorise that it may have the same results for rates of harmful alcohol consumption. 

The research into MDMA as a therapy assistor for individuals suffering the effects of PTSD has been ongoing, and if nothing else could indicate that alternative medicinal therapies could see a reduction in harmful alcohol use amongst this group in the future. 

In the Netherlands, with its history of liberal cannabis use and regulation, drinking rates are lower than the European average, yet a comparative analysis of the Netherlands, the US and Canada found Dutch youth drink significantly more than American and Canadian youth, yet use far less cannabis. This suggests that the mainstream status of cannabis in the Netherlands has not sold it as an alternative to alcohol. The overarching conclusion can be made that, whilst alcohol and opioids continue to be the go-to drugs for self-medication, there are signs that, where alternative substances are available, there has been less problematic use, as has been the case in certain US states where medicinal cannabis is more widely available. As drug policy continues to reform into the future, the indications are there that methods of self-medication may also shift.

[1] http://www.huffingtonpost.com/robert-dudley/why-humans-drink-alcohol_b_4834110.html

[2] http://publichealth.hsc.wvu.edu/alcohol/effects-on-society/why-people-drink/

[3] http://www.druginfo.adf.org.au/fact-sheets/young-people-and-alcohol-web-fact-sheet

[4] http://publichealth.hsc.wvu.edu/alcohol/effects-on-society/why-people-drink/

[5] http://www.healthline.com/health/alcohol-and-anxiety#Overview1

[6] http://publichealth.hsc.wvu.edu/alcohol/effects-on-society/why-people-drink/

[7] http://www.dualdiagnosis.org/mental-health-and-addiction/post-traumatic-stress-disorder-and-addiction/

[8] http://drugabuse.com/library/the-effects-of-alcohol-use/

[9] http://www.thecannabist.co/2014/11/05/legal-weed-six-things-marijuana-legal-oregon-washington-dc-alaska/22642/

[10] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4392651/

[11] http://www.independent.co.uk/news/health/medical-marijuana-heroin-cocaine-addiction-treat-los-angeles-rehab-centre-high-sobriety-joe-schrank-a7748626.html

[12] www.maps.org/research/mdma

[13] http://bjp.rcpsych.org/content/206/1/4

[14] www.maps.org/research/mdma

[15] http://www.aaets.org/article126.htm

[16] http://europe.newsweek.com/marijuana-and-old-amsterdam-308218?rm=eu

[17] http://www.who.int/substance_abuse/publications/global_alcohol_report/profiles/nld.pdf

[18] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2790541/

 

 

 

 

 

 

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