Dr. Anna Fels recently saw a patient who had an interesting method of self-medication. The psychiatrist wrote up the experience in the New York Times:
We talked for a long time about why she had come to see me. Then, as is my practice with a new patient, I asked what, if any, psychiatric medications and nonprescription, psychoactive substances — legal or illegal — she had used. Her answer was a new one for me. She stated that she chewed approximately 40 pieces of nicotine gum per day and had done so for well over a decade.
Responses to this question are often illuminating and can be rather humbling. Although doctors are trained to focus on prescription medications, there are and have always been nonprescription “remedies” for psychiatric conditions. And people’s preferences for one type of substance over another can give a glimpse into their symptoms and even their brain chemistry.
If a patient tells me he falls asleep on cocaine, I wonder if he might have attention deficit disorder. A patient who smokes marijuana to calm down before important business meetings leads me in the direction of social phobia or other anxiety disorders. I often wonder if people who take ketamine recreationally might be depressed, since this anesthetic has been shown to have antidepressant effects and is, in fact, being investigated for potential therapeutic use.
But tobacco is terrible, right? We’re all aware of the lung cancer risks of smoking and the various mouth cancers that strike people dipping Copenhagen. These dangers are real, but what causes cancer is not the nicotine but the tar and various chemicals found in the tobacco.
Nicotine is tobacco’s addictive component, which is why so many smokers wean themselves off those smelly old coffin nails with a nicotine patch, gum, or e-cigarettes. This gives them their fix without the serious cancer risks that come from tar.
Sorting through patients’ uses of psychoactive substances, from cocaine to alcohol to coffee, leaves me with an appreciation of the wildly different neurochemistry of people’s brains. One person will drink alcohol and feel euphoric, witty and extroverted, and the next will be logy and nauseated. In one patient, marijuana sharpened his focus and made it possible to pay attention in class, hugely improving his grades. Another felt paranoid and a third used it as a sleep aid. And presumably these substances all hit the same brain receptors in each of them.
My new patient explained that in her sophomore year at college she had started smoking. The effect, she said, was like “a key that fit perfectly into a lock.” Her brain felt clearer, her thoughts were more coherent, her mood and energy improved. Not wanting to damage her lungs, she soon switched over to nicotine gum and had been taking the same amount of it for well over a decade — a pattern of stable “dosing” that I discovered is typical in long-term nicotine users.
…But as I thought about our conversation later, I found her image of a key in a lock particularly striking; it was the very same one that psychiatrists and neurophysiologists use to describe the interactions in the brain between neurotransmitters and their receptors. And in fact, neurons do have receptors into which nicotine neatly fits, mimicking the actions of the brain’s own molecules.
Dr. Fels looked up some research and found that isolated nicotine does create positive effects in some people. It can improve brain functions, memory, and mood, and perhaps even decreases the potential for Parkinson’s disease. Eager to test these findings, she tried nicotine gum herself, but it only made her shaky and nervous. For her, the key didn’t fit the lock.
As you can see from my profile picture, my drug of choice is caffeine. If I don’t have a jolt of coffee first thing in the AM, I’m dragging through meetings, I think at half speed, and I’m distracted by nearly everything. By mid-afternoon, I get an all-over headache which is my brain’s way of reminding me to stop what I’m doing and guzzle a cup or three of joe. On the other hand, a Coke or cup of tea seems to tire me out, even though both have caffeine.
I’ve met people who use marijuana to enhance their creativity or just take the edge off (lots of comedians and musicians fit this profile), others who need a stiff drink at the end of the day to calm themselves, and others who can’t function without a constant supply of black tar heroin (your secret is safe with me, Peter Robinson).
I’m curious: Do you have a minor (hopefully legal) drug of choice that helps you function better?