Marijuana—it’s just a plant, right?

Well, yes and no. It’s probably the most controversial plant ever discovered by humans, who have used it around the world for thousands of years and for many reasons. The herb Cannabis sativa and its cousins harbor hundreds of chemicals, a couple of dozen of which fall into the category “cannabinoids”—some of those with psychoactive, or mind-altering, qualities. A vast body of research has been published about the chemistry—and effects—of consuming the plant by smoking or eating. Until recent years, there was considerable mystery about just how marijuana worked in the human brain, but there has been something of a revolution in that understanding in the past decade.

Politically, of course, marijuana is far more than any old plant. Arguments have festered for centuries about the good vs. bad effects of marijuana as used by humans for fun, health and profit. Over 76 million Americans—one-third of all adults—have smoked “pot” at least once. About 6 percent of Americans, or 14 million, currently smoke it, and at least 2.5 million of us try it for the first time each year. About two-thirds of those new users are under 18 years old, and by their senior year in high school, almost half of all teens have tried it. Considering our proximity to the nation’s largest illegal agricultural grounds in Mendocino and Humboldt counties, that proportion may well be higher here in Marin.

So is that really a problem? It depends on whom you ask. Marijuana is demonized as destructive to kids and portrayed as the main stepping-stone to “harder” drugs at the same time it is claimed to be harmless, or even a life-saving medication. California, particularly in the Bay Area, has become ground zero of the “medical marijuana” movement. Comics like Cheech and Chong make careers out of satirizing pot’s comedic elements. Archaic films like Reefer Madness are laughed at as failed dramatizations of the demon plant—but most official attempts at “educating” kids about marijuana have been not much more effective.

But the consequences of being caught with marijuana can be severe. It’s illegal almost everywhere and here in the United States more people are arrested and put behind bars for “pot” than for any other drug—perhaps not surprising, as pot is the most widely used of all illegal drugs. Almost 750,000 Americans are “busted” with pot annually—about half of all drug-related arrests—with up to one-third of those incarcerated for some period. Although many health and other experts have recommended that we not put marijuana users in jail, the ongoing “drug war” continues with countless lives affected and huge sums spent on enforcement of anti-marijuana laws. At a minimum, students can get in serious trouble at school, with a nationwide movement toward “zero-tolerance” policies that require expulsion for those caught.

What to make of this complicated and contradictory picture? Even if you ask your average doctor, he or she is unlikely to know much about marijuana. Mill Valley psychiatrist and addiction medicine specialist Timmen Cermak, M.D., however, has one of the most informed perspectives to be found anywhere. In addition to his private practice, where he sees many people of all ages with all manner of drug-related problems, he is medical director of a drug treatment program in San Francisco and has chaired committees and served on the governing board of the California Society of Addiction Medicine, the state organization of doctors of all specialties who also focus on drug issues. He completed his psychiatric training at Stanford, where he helped in creating the first therapy group for adult children of alcoholics.

“Tim Cermak is one of the leading experts on addiction in the United States” says Dr. David Smith, founder and president of the legendary Haight-Ashbury Free Medical Clinics and a past-president of the American Society of Addiction Medicine, the national association of addiction physicians. “He has made major contributions in helping our society better understand the complexities of marijuana, particularly as it relates to cannabis dependence in youth.”

Cermak’s latest book is Marijuana: What’s a Parent to Believe?, published by Hazelden books. He’s a busy man, and seems not too eager to appear in any limelight; but he agreed to talk about marijuana—a topic he feels is subject to many misconceptions.

Addiction medicine is still a relatively rare medical specialty—too rare, given how widespread drug problems are in our nation. How did you first get interested in issues of drugs and addiction?
I first got involved long before I became a physician—I was born into a family with an alcoholic father. That gave me a set of experiences that I didn’t really understand at the time, but later on in my training I learned more about the dynamics in an alcoholic family. Professionally that is what piqued my interest, in the sense that I learned about ways that I thought and acted that I had never discussed with anyone. I realized that there was something understandable and communicable about the way my mind worked—that I wasn’t unique. And I just had to study that.

And how about your interest in marijuana specifically?
My interest in that preceded my medical training for personal reasons. I’m of a generation where it was everywhere, but as I am almost 60 now and graduated from graduate school in 1967, it was after that when I had my first experiences. I was really quite taken by many of the mysteries and magic ascribed to marijuana at the time. Because my father was alcoholic, for me alcohol was sort of this thing I disdained as nothing that I would want to get involved in. But here was pot, which did not make you throw up and all that. So I used it. And I tried to understand exactly what this plant was doing to me, so I read a lot—particularly Andrew Weil, whose early book The Natural Mind made the most sense to me. I learned that the “magic” was not really “out there” in the plant, but that it was my brain that was producing all the experiences I was having. But at the time there was not all that much good research available.

In your book, the effects of marijuana on brain chemistry are central to your messages. So when did you really begin to learn about that science?
In addiction medicine there had not been that much attention paid to marijuana, as there are so many nastier drugs out there and we do not see people dying or lying in the street because of pot smoking. But I did come back to looking at marijuana when Proposition 215, the Compassionate Use Act for medical marijuana, passed here in 1996. When that was being debated, I was at a meeting of the California Society of Addiction Medicine and naively asked, “Shouldn’t doctors who are experts in drug issues have some opinion on this?” And of course I was asked to generate that opinion, and so I gathered a group of physicians to do a literature review of what was known about so-called medical use. And I’ll be honest with you, at the start I thought this was a ludicrous idea, that there was any possible medical use for marijuana. And I both have and haven’t revised my view.

We’ll come back to that. What did you learn about the effects on the brain?
My fascination was re-ignited by this effort. It was clear that we knew what marijuana does in the brain—there was an explosion of discoveries in the early to mid-1990s. I, and most people in addiction fields—let alone in the general public—were unaware of this research. It’s really an exact replication of the endorphin story. You take this plant which has some oils in it which contain chemicals like Tetrahydrocannabinol [THC], and get it into your body and it produces some effects, like the opiates do on endorphins. We already knew there are receptor sites for opiates in the brain that the drug bonds to—but they were not there for opiates, but for an opiate-like chemical made in our brain called endorphins—and those, in the proper amount, make us high. It’s the same story with marijuana—we now know there are receptors in the brain that THC latches on to—but again, those receptors were not put there for THC, but there are natural chemicals the brain produces as part of its mechanism for regulating a whole host of mental and physical functions. This “endocannabinoid” system of naturally produced brain chemicals includes several chemicals used as neurotransmitters, which help our brain function. Anandamide is the most widely researched but there are at least three or four others. And it’s remarkable that this system is at least 10 times larger than the endorphin system. So we have this major system within the brain that’s been discovered within the last 10-15 years. That’s like sending someone out to discover India and finding two major continents on the way. The main discoverer of this system feels that there are not any physiological functions in our body that are not affected by this endocannabinoid system.

So the implication is that altering this brain system via external cannabinoids, such as in marijuana, might have more impacts than we suspected before.
Right. We now know a lot, but there is a vast amount still to be learned.

Your focus is on young people—what is it that makes marijuana so attractive and seductive?
We first should consider where these brain receptor sites are. They are concentrated in the part of the brain that makes memories, so that if you flood it with THC it disrupts memories—which many people already know. But that’s not what makes it enjoyable. There are a few things to consider there. The primary one is the impact on the area of the brain, called the amygdala, which creates a sense of novelty—there are heavy concentrations of anandamide receptors there. So if we flood those sites with THC, it makes everything seem very novel, even things that we have gotten very used to and don’t usually notice. In a sense it “refreshes” our mind so that even mundane things can feel very novel—watching a Simpsons show for the fourth time and it feels like the first time you’ve seen it.

Oh, I can watch The Simpsons over and over without marijuana, no problem—maybe pick another example.
[Laughing] OK—but how about just a trip down the hall to the bathroom seeming like a fun journey, or seeing and being fascinated by every bubble in the soap in the kitchen—it’s what I call “virtual novelty.” Many people find it in listening to music. And the amygdala, when stimulated, can also generate a sense of awe—that may be part of our brain that’s active in spiritual experiences. So there’s often a sense of “wow,” of the ineffable, a numinous quality, of great meaning to what’s going on. And there is also often a sense of connectedness that is stimulated.

Much of these feelings or insights are often not very durable once the drug has worn off, right?
Right, usually not. But if you look at the research, you find that almost every animal with a nervous system has this endocannabinoid system—insects don’t have it, for some reason. And in humans, the time when we have the highest level of cannabinoids is as a fetus, right up to when we are born. If you give newborn rats a cannabinoid blocker at birth, they fail to suckle, and die. The whole system is part of being a mammal, in terms of suckling, of eating, of bonding and connecting to the mother—so when you stimulate that, you get a sense of connectedness, you get the “munchies,” you can get a sense of comfort and relaxation.

A few people get a sense of anxiety or even panic, which increases as people get older, but most don’t.

And why is this especially attractive to teens?
Look at what’s perhaps the most prominent characteristic in adolescence—boredom. A tremendous number of kids are easily bored. And virtual novelty is a great antidote to boredom. When they smoke pot, everything becomes more interesting. And here is where we start to get into difficulties—if you repeatedly flood those THC receptor sites, the brain begins to cut down on the number of them—by as much as 90 percent. So after the high, say when you get up in the morning to go to school, your sense of novelty may be sub-par. So even if something new is presented to you in school, it will be “boring, man.” So it’s a reinforcing cycle—later on you want to smoke again, to get that sense of novelty back. And you add to that the impaired memory and you have learning problems.

We hear a lot about THC and other drugs being stored in fat and “leaching out” when someone stops using—any truth to that, and does memory and other function return with stopped use?
I’ve looked for any convincing evidence of any clinical significance of the storage and leakage of THC from fat cells, but have not found one single piece of research which supports that. As for memory, the sense of mental clarity does seem to return sometime after stopping use, and it is very hard to demonstrate that there is any permanent impairment.

For teens, it’s clear that non-chemical factors are important too. Other than brain chemistry, why would kids be drawn to pot?
Many reasons. For one, it’s a very quick and seemingly successful way of carving out your own autonomous identity. With one joint, you’re suddenly very different from your parents, and connected to a whole new group that sees itself as being freethinking and different from the rest of the world. But in adolescence there are a whole series of challenges you have to confront and work out within yourself, to discover what your own set of values are. Getting really involved with pot can seem to provide a whole package of values without all that work. And you can find kids who have this whole set of values but don’t really know themselves at all.

So would you say it can provide an illusion of autonomy?
Yes, exactly. And life and development go very fast in adolescence—if you take a two-year hiatus from some of the tasks of adolescent development, you’re likely to be way behind, out of step with your peer group. It can take a lot of time and effort to make that up. Pot use can become a lifestyle that is justified by civil libertarian thinking, as in “I like to do this, it’s a natural herb,” and so on—I point out to people that death cap mushrooms are natural too, but not necessarily healthy—but what’s unfortunately happening in all too many cases is the real process of true psychological autonomy is being disrupted.

And the story here is both social and chemical as well, right?
Some of this does relate back again to brain development—there is a second period of explosive brain growth after our fetal and infant months, which comes around ages 11-12. You can think of the brain during this time like a bush in the spring—suddenly there’s a great flowering of extra branches, synapses, connections—followed by a natural pruning process where the useful connections are maintained which goes on from about age 12-24. And if you flood the brain during this time with external THC, I think you get an imbalance in the brain’s ability to mature fully. And we can measure this with EKG and neuropsychological tests. One problem is that it becomes more difficult to ignore irrelevant stimuli—to ignore the distractions and to focus. And the earlier someone begins smoking, the longer those changes will last.

One of the most useful messages in sex education is that it is healthy to delay the onset of sexual activity in teens as long as possible—it seems this work is leading to something similar with respect to drugs as well?
Yes. We now know that for those people who never smoked pot before they were 18, only about 10 percent of them will have problems with cannabis dependence and other problems. But below 18, and the younger you go the more this is true, the higher the percentage becomes of those problems.

You use the term “dependence” and there is a lot of debate about how that concept and that of “addiction” apply to marijuana.
I use the same criteria we use for any other drug, and I prefer Andrew Weil’s criteria for whether you have a healthy or unhealthy relationship with any drug: Do you have difficulty separating from it? When you use it do you have essentially the same experience as when you started using or have you developed tolerance to it and must use much more? Have you neglected responsibilities or had other problems related to using it? These are fairly commonsense ways of looking at it. But the question of whether it can lead to dependence is no longer debated among scientists. The changes in the reward center in the brain are the same as for other addictive drugs, and if you suddenly stop it, you get similar if milder effects—insomnia, restlessness, hostility and so on. It’s true that you don’t see people “jonesing” in the streets over pot, but it can pervade someone’s lifestyle just as much as other drugs. We see people who don’t know how to relax without it, who can’t cope with the stresses of life without it, and so on. That’s a seductive quality about it.

But for people who crave and need that novelty, and relaxation, what are the healthier alternatives?
Again, our natural cannabinoid system is the facilitator of many valuable experiences. Our lives have more vitality the more we are responding to the world as if it is fresh and new. The THC in marijuana may alert us to that experience, but if you rely on that, you have difficulty having such experiences without it—which can be inconvenient in many settings at a minimum. There are other ways of naturalistically tapping into the same experience—look at mindfulness meditation, for one example. You can learn how to enhance that fresh response to the world on your own, wherever you are, and without reducing your sensitivity. And I think one of the next frontiers in research is going to be about how do we find more ways to do that without drugs.

One of the warnings in the past was that chronic marijuana use could cause an “amotivational syndrome”—a lack of desire and ability to do anything productive. What’s the story here?
That term is not used much anymore by those who know the field. We have a hard time defining motivation, and a harder time measuring it. Again, there may be a “novelty deficit” and problems learning and with memory, but not much good evidence on motivation itself.

One warning we hear now is that marijuana is much more potent now than a generation ago and that this is responsible for many of the problems.
It’s simply not true that “it’s a different drug than it used to be,” as some people say. That’s a grossly misleading statement. Is vodka a different drug than beer? It is a different drug delivery system, but it’s still alcohol. So yes, you can become drunk or stoned faster, but it’s exactly the same THC with the same effects.

Another controversy concerns the “gateway theory,” that use of pot often leads to use of “harder” drugs. What’s the evidence for that?
There’s very little science to support the notion that using marijuana naturally leads to use of harder drugs. If you talk to people addicted to other drugs, they started with any number of things—perhaps most commonly alcohol and tobacco. Although you might find that most users of harder drugs have used marijuana at some point, most marijuana users do not in fact progress to other drugs. So causality is very hard to establish.

There has been research published in recent years suggesting that marijuana use, particularly in young people, can contribute to other psychiatric diagnoses like depression and even schizophrenia, and to physical problems like male infertility and even development of breast buds in male heavy users What’s your take on these concerns?
There’s not really that much that’s clear there. The science is mixed. I initially thought there would be more conclusive information regarding those links, but I’ve waded through the literature and I think they’re still open to question. There is some indication that for those already predisposed to those kind of mental problems, at least, marijuana use can trigger such problems sooner or more often.

How about impacts on the lungs from smoking it?
There has long been a feeling that marijuana is less harmful to the lungs than tobacco, but in fact the harmful chemicals in tobacco, with the one important exception of nicotine, are all there in marijuana too. People do tend to smoke less marijuana than tobacco but it turns out that some of the long-term effects on lungs, such as bronchitis and cancer, are present in longtime heavy marijuana users as well.

So there are defined negative impacts. Let’s talk about when a kid is known to be using. In your book, you write that it is not always bad to get the police involved if your kid won’t stop smoking pot.
Sometimes you need another authority to enforce the message that the child has a problem, and in kids under 18, you at least know that any legal record they might acquire then will later be erased.

How about “zero tolerance” policies in schools, where kids are kicked out if found with any drug?
That is too often counterproductive. You want to intervene in a way that will help, using counselors and parents and community resources. To remove them from school altogether risks driving them further into risky behavior. I might make an exception for someone who is an active drug dealer on campus, though.

Once someone has admitted to a real problem, what does “treatment” entail?
It’s not much different than for other drug dependency. Abstinence is important, and some people need a defined residential program to at least start that. And there are recovery groups focused specifically on marijuana, like Marijuana Anonymous.

So what’s your basic message to kids and their parents regarding marijuana use?
One thing we’ve learned, or should have learned by now, is that the scary, “reefer madness” approach is counterproductive—kids have a pretty accurate gauge of when they are being lied to, and once they find that out, you’ve lost them. So I try to keep the message connected to the data we have. One message is that “use equals risk.” And the more use there is, the more the risk. So let’s get away from the denial, thinking that there’s no risk involved. And risk varies with age, with family history of drug and alcohol problems, and so on. Also, addiction is real.

One of the most dreaded questions kids ask their parents is “Did you smoke it when you were my age?” How do you suggest parents respond to that?
The first issue is what age kid we’re talking about. Again, lying is problematic and likely counterproductive. So if the adult started smoking at an older age than that of their child, one thing to say is, “I did, but certainly I had not started at your age.” And then you can get into talking about what risks and experiences you had. If it’s true, you can say, “I did not do as well in school, or sports, or my career, as I might have if I was not smoking pot.” One thing of interest is that the cannabinoid system is actively involved in the forgetting of bad experiences.

So what happens to someone who gets picked up by the cops when they are stoned?
It’s likely that they will not remember that as negative an experience as it was at the time. So we end up with a kind of euphoric recall. I could tell you about the great Moody Blues concert I went to, but really have to think to recall the panic I felt while waiting in line and thinking that the person walking back and forth in line was a narc. And getting in trouble with the law is part of the picture here. So basically kids have to get a more balanced view of the risks they might be taking.

The bigger debate in society concerns the “drug war” and whether we should change the legal status and penalties for marijuana. What do you think?
It’s a legitimate question for adults to debate and come up with recommendations. I don’t think we should ever consider legalizing it for young people. The question is, if you legalize it for adults, would that mean more access and use by kids? And if that is the case, I believe constraining adult use is legitimate, for all the reasons we’ve discussed. We do know that legalizing it in the Netherlands did in fact lead to higher use among adolescents.

Let’s go back to the medical marijuana issue. You headed a committee of addiction specialists to sort out the facts. What is your take on the issue almost a decade after California liberalized the law?
There are a lot of medications that have first been discovered in the botanical world. Subsequently, with research, we isolate and extract the active essence of the plant and find ways to deliver it which minimize side effects and other problems. To me, to think that the best way to use cannabis to manipulate our cannabinoid system to fight disease is to burn it and inhale the ashes into our lungs is a real anachronism. We need to find other delivery systems. That’s where my opinion has not changed. But I do believe more in the known and potential medical uses. We’re already finding that it can have real use in controlling spasticity in multiple sclerosis, for example, but I suspect the greatest potential is for controlling pain. But there are many potential benefits—maybe not as many as some of the advocates say, but we’ll see.

What do you think of the “pot clubs” that have sprung up all over?
I think they are mostly about money—so far as I’ve heard, most of them charge the same or very close to street prices, which makes no sense if you look at it. I think there’s a lot of hypocrisy on the part of some medical marijuana advocates, unfortunately.

Finally, do you think there is anything unusual or even unique about attitudes towards marijuana here in Marin?
It’s not unique, but it seems there is no community consensus here. Many adults here are so ambivalent, as there has been and still is so much use among all types of adults, including doctors and lawyers and so on. So there’s no firm opinion.

There seems to be no problem finding marijuana here, for one thing.
There’s certainly plenty of access to marijuana here, but I don’t know if that’s more true here than elsewhere. Nationwide, since 1975 somewhere between 88-95 percent of high school seniors say that it is easy or very easy to acquire. Use, however has varied over the years, and that seems to be linked to perception of risk. So it is important for young people to know what the real risks are, and we are far from doing that well at this point.

Timmen Cermak will join other leading experts on marijuana for a free public forum Wednesday evening, April 20, at the San Francisco Medical Society. For information, call 415/921-4987 or see www.drugpolicy.org.