Zilos

A Vancouver doctor who draws on his own past to treat addictions says tobacco and marijuana are the toughest habits to kick.

Zilos-note: Warning -- Reefer Madness!

Richmond doctor Ray Baker is best known for his work in addiction medicine. He designed the first such program at UBC's medical school – but his knowledge is not all academic.

Eleven years ago Baker founded HealthQuest Occupational Health Corporation, which treats people with substance-use disorders. However, Baker – who, since starting his clinic in 1993, has spoken at hundreds of conferences and testified in court on the medical, neurobiological, psychological, and pharmacological effects of nicotine and mood- and mind-altering substances – also knows all about addiction first hand.

As a med student at the University of Western Ontario and during his first decade as a family and emergency-room doctor in rural British Columbia, Baker was hooked on tobacco, marijuana and alcohol. Although he thrived on the demands of a busy practice and the chaos of the ER, he was increasingly exhausted and his marriage was in trouble. But he didn't think he had a problem.

"I was driven, compulsive, conscientious," Baker says in a sunny-morning interview over coffee. "People see addicts as a certain type. I was addicted as a 17-year-old. I supplied half my class at med school with pot I grew on my farm. ...The interesting thing – and this is not atypical – is that with the shame and guilt, I felt worse and worse about my behavior, so I would achieve more and more. I was class valedictorian in medical school. ... For many professionals with addiction, their attention, their performance is just fine; if anything, it's superior.

"I was doing a damn good job," he adds of his work in Logan Lake. "I knew there was a problem when I walked out the back door of my clinic in 1984 with 10 people waiting for me. I was burned out, but I didn't know what was wrong."

It was only after a counselor recommended he go to a treatment center that Baker realized he was addicted. That's when he became passionate about learning more about the condition and helping others. With their relentlessly seductive effects, Baker says tobacco and marijuana are among the hardest drugs to quit smoking, as anyone who picked those as their New Year's resolutions knows.

In the past 10 years, Baker has treated more than 5,000 people with substance-use disorders, some addicted to heroin, others to cocaine, and still others to tobacco.

"The worst is nicotine," he asserts. "The reward for a dose of nicotine is powerfully reinforced. The release of the pleasure hormone dopamine is very sharp and very quick.

"If you're injecting heroin, you might shoot up four times a day and have four spikes – from euphoria to discomfort to withdrawal. With crack, you might do it 10 to 20 times a day. If you smoke 20 cigarettes a day, and every time you inhale you get a dose, that could be as many as 200 per day. And it's the same with any substance that's smoked."

Granted, pot has value when used medicinally, and there are those who argue that marijuana – whose primary psychoactive ingredient is the chemical THC, or delta-9 -Tetrahydrocannabinol – isn't addictive. But even casual smokers of pot or tobacco face health consequences.

Like a Fine Cabernet

Matthew, a 33-year-old local carpenter, doesn't smoke cigarettes but will have a joint or two almost every night after work. Matthew, who's been using pot regularly since his early 20s, is reluctant to say he's addicted, comparing his love of home-grown marijuana to another's appreciation of a fine Cabernet.

"Being in Vancouver, not smoking pot would be like living in France and not drinking the wine," he says in a phone interview. Smoking pot helps him relax and have peaceful sleeps, he says, but he admits he worries about the long-term health effects.

"Obviously being in that state provides some kind of comfort, or else I wouldn't keep going back," Matthew says. "But smoking anything, even in moderation – I don't care if it's organic or not – over a long period of time does concern me. I feel good when I'm not smoking, no question. I have more energy; I'm more on the ball. It does slow you down a bit; the high-grade stuff dulls the mind. You get a residual hangover."

Marc Emery, who heads the British Columbia Marijuana Party and says he consumes about four grams of pot a day via joints or a bong, stresses that he has no health concerns whatsoever.

"I haven't seen any negative ramifications, and I've been smoking for 26 years," Emery says in a phone interview. "When doctors say, falsely, that THC leads to cancer, there is no empirical evidence.

"The only downside," he adds, "is that if I smoke late at night, it makes me hungry, so I can't get to sleep very readily."

According to the Canadian Health Network, smoking marijuana can lead to chronic coughing and lung infections. The May 15, 1997 issue of Annals of Internal Medicine reported that marijuana contains about 480 substances, including tar and other chemicals and irritants; some say the carcinogens in marijuana are stronger than those in tobacco, while others argue the opposite.

Other potential health consequences come from the toxins some marijuana growers use to eliminate pests and prevent plants from rotting. According to Marijuana-Seeds.Net, fungicide is frequently used to combat mold, while the best way to get rid of spider mites, which are the most common plague in marijuana cultivation, is with insecticides. "Always stop using pesticides a few weeks before harvest, otherwise, you'll be smoking some of the poison later," the site says. To this possibility, many smokers are oblivious.

By contrast, the harmful additives and carcinogens in cigarettes are well-known. They include formaldehyde, hydrogen cyanide, carbon monoxide, ammonia, nitrogen oxides, and benzene. The Canadian Cancer Society states that more than 47,000 Canadians, including 5,600 people in British Columbia, die each year as a result of tobacco-related illnesses such as lung, throat, and oral cancer, stroke, heart disease, and emphysema.

Matt Pinch, who works as a promoter in the music industry, started smoking when he was 14; by 16 he was up to two or three packs a week. Now 29, he stopped smoking, for the third time, last August. He says daily tasks like writing or driving are among the triggers that make him want to reach for a smoke.

"I would say that from that very first cigarette, nicotine had a hold on me," Pinch says in a phone interview. "Not a single day goes by that I don't have a physical craving.

"In my early 20s, I started to look at mortality a little differently," he adds. "I started to see I could die from this. And the government raising taxes really helped me. I was up to three-and-a-half, four packs a week; at eight bucks a pack ... Then there's coughing up phlegm and all the stuff that comes out of your chest.

"When you wake up and realize that this thing, this stick, is controlling your life, that's wrong."

Pinch is quick to emphasize that his opinions on quitting smoking are just that: opinions. He says he hates it when nonsmokers force their views on other people. And there's no question that smoking is a politically-charged subject.

Victoria was the first city in Canada to pass aggressive anti-smoking laws. Now, the Canadian Cancer Society's British Columbia and Yukon branch is urging the Liberal government to implement a provincewide ban on smoking in public areas – a move that Alberta Premier Ralph Klein flat-out refuses to consider in his province.

Last September, the Canadian Tobacco Manufacturers' Council funded an online smokers' association called mychoice.ca. The group claims that adult smokers are tired of social stigmatization, nevermind increasing taxes.

Tobacco giant Philip Morris, which sells cigarettes in more than 160 countries, has developed a youth-prevention program. "Because of the serious health effects of our products, we believe we must stop children from smoking," the company's web site says. But most manufacturers' selling tactics are focused squarely on young people. Girls are especially vulnerable because so many use smoking to lose or maintain weight. Camel has even introduced flavored cigarettes, like Winter MochaMint and Warm Winter Toffee.

Pieces of the Puzzle

Baker describes addiction as a brain disease, an "invisible disability" that has biological, psychological and social components. Making matters more challenging is that people with substance-use disorders often have other conditions, like chronic pain, depression, or sleep disturbances. "These are all fixable," Baker says. "You just have to find what pieces of the puzzle are missing for each individual."

A common myth about people who can't quit their drug of choice is that they are noncompliers with personality problems, Baker says. Contributing to his own addiction was never having learned how to resolve conflict or express or experience emotions like fear and anger.

"People who develop addictions aren't good at comforting themselves," he explains. "At the treatment center, I learned a lot from other people. Show me someone with addiction and I'll show you someone who doesn't know how to set boundaries."

A study conducted by the Bethesda, Md.-based National Institute on Drug Abuse and published in the February 2004 issue of Cognitive Brain Research found that people prone to anger and aggression may be predisposed to develop a nicotine addiction and to express more of the mood consequences involved in quitting than those with more relaxed, happy personalities. Genes could also play a role. Headed by California Institute of Technology scholar Andrew Tapper, a study published in Science last November found that a mutation in a particular nicotinic-acetylcholine receptor in the brain lowered the threshold of nicotine dependence in mice.

When it comes to cigarettes, there are all kinds of approaches to quitting, from hypnotherapy to acupuncture. Newer local initiatives include the Canadian Gay, Lesbian, Bisexual and Transgender/Transsexual Mass Media Tobacco Reduction Campaign, which is operated by the West Coast Gay Men's Health Project and Vancouver Coastal Health and which targets 19- to 35-year-olds. On May 3, the Knowledge Network will launch Kick Butt, its own reality series that will follow five smokers in their attempts to quit.

Baker maintains that the more a patient likes and trusts his doctor, the better his adherence to treatment will be. Clearly, part of what sets him apart from health professionals who have never experienced addiction themselves or who have little patience for those who struggle with it is empathy.

"I was very annoyed at my medical training," Baker says. "No one had explained the neurobiological aspect of addiction, the cognitive distortions, treatment, what one has to do to recover, relapse prevention."

According to Baker, chances of recovery are best when treatment combines pharmacological approaches (like the nicotine patch, gum, or bupropion), psychotherapy and social and family support. Quitting cold turkey has the lowest success rate.

However, determination also plays a crucial role. "Ninety percent of people quit using willpower," Baker says. He encourages those wanting to stop to do a "cost-benefit analysis" of smoking versus not smoking. "Until the costs outweigh the benefits, they won't do it." He adds that when it comes to giving up nicotine, the first two weeks are the toughest.

"The brain is going to resist brutally. Your IQ temporarily drops; you're irritable; it interferes with judgment and thinking."

But simple steps will take cravings away, like taking a deep breath; chewing on "low-cal, crunchy things"; keeping something in your mouth, like a piece of a cinnamon stick; or having a drink of cold water. Exercise helps too, because it releases endorphins.

"You'll feel terrible, but it's only temporary," Baker says of cravings. "Within 24 hours of quitting, your cardiovascular disease risk decreases." Within 72 hours, lung capacity increases; within two weeks to three months, circulation improves and lung function increases; and within six months, coughing, sinus congestion, fatigue, and shortness of breath improve.

Baker says giving up marijuana can be more complicated, given the commonly held notions that the substance is neither harmful nor addictive.

"An adult who continues smoking marijuana is saying, 'My drug is so important to me that I will risk my job, my reputation, my ability to leave the country, my relationship with my wife and family.' That level of compulsion requires more extensive help, but treatment is essentially identical."

For tobacco and marijuana smokers, Baker encourages going to 12-step programs and support groups. He'd like to see family doctors play a more active role in helping patients quit and offering follow-up visits. And he advises smokers to follow this acronym: CARESS, which involves developing coping skills, including learning to set boundaries; being accountable (especially to others, so tell friends and coworkers about your plan to quit); taking responsibility (instead of denying you have a problem or blaming others for it); education; social support; and spirituality.

And this is coming from someone who's been there.

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