DOCTOR DRAWS ON PAST TO TREAT ADDICTIONS

He Argues Tobacco And Marijuana Are The Toughest Drugs To Kick

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. Its clients include Air
Canada, the College of Physicians and Surgeons of B.C., the Washington
State Bar Association, and Corrections Services Canada. However,
Baker--who, since starting his clinic in 1993, has spoken at hundreds of
conferences across North America and testified in British Columbia Supreme
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 B.C., 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 behaviour,
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 counsellor recommended he go to a treatment centre 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.

MATTHEW, A 33-YEAR-OLD local carpenter, doesn't smoke cigarettes but will
have a joint or two almost every night after work. (Despite the fact that
B.C. has a large population of marijuana smokers, not a single user
contacted by the Straight--except high-profile pot advocate Marc Emery--was
willing to have his or her full name published.) 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."

Emery, who heads the B.C. 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, however, 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. The health network says that people who smoke pot and
tobacco may develop lung, neck, and head cancers at a younger age than
those who smoke cigarettes only. The independent Washington, DC-based
Institute of Medicine of the National Academies states that even medical
marijuana should not be smoked on a long-term basis (more than six months)
because of potential lung damage, cancer risk, and poor pregnancy outcomes.

The Canadian Health Network also states that regular pot use in adolescence
may have a detrimental effect on brain development, especially in the area
that provides the ability to concentrate. The Canadian Centre on Substance
Abuse claims that the use of cannabis may bring about the onset of
schizophrenia in some people with a predisposition. Regular use may impair
male fertility; scientists from the University of Buffalo School of
Medicine in New York presented research at the 2003 annual meeting of the
American Society of Reproductive Medicine showing that the sperm of pot
smokers travel in fewer numbers than those of nonusers.

Although the so-called gateway effect--which has it that marijuana use
(particularly in adolescence) leads to the consumption of other, harder
drugs--is hotly contested, even by groups like the Institute of Medicine,
it's one theory that Baker believes in. "Show me an adult with a cocaine
habit and I'll show you someone who was 84 times as likely to have abused
marijuana," he says. "Does everyone who smokes marijuana in adolescence go
on to use cocaine? No, of course not, just as not everyone who goes in the
water drowns. But with increased exposure and usage, the prevalence of
substance dependence goes up.

"If people develop an addiction, they generally don't stay with marijuana,"
Baker adds. "They might go back to alcohol or add pills or they'll chip
away at marijuana then replace it with something else, like gambling, the
Internet, sex, shopping. It's like changing seats on the Titanic."

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 mould, 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 B.C., 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 antismoking laws,
as local writer Barbara McLintock describes in her new book, Smoke-Free:
How One City Successfully Banned Smoking in all Indoor Public Places
(Granville Island Publishing, $19.95). Now, the Canadian Cancer Society's
B.C. 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
on-line smokers' association called mychoice.ca. The group claims that
adult smokers are tired of social stigmatization, never mind 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 flavoured cigarettes, like Winter MochaMint and Warm
Winter Toffee.

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 centre, 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, Maryland-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 "costbenefits 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.