Medications vs. Substances

by Steven Sobel, M.D.*

Taking a medication generally connotes a positive means of maintaining one’s health. Using a substance, on the other hand, is a pejorative term, implying reliance on chemicals as a means of escape. Yet the boundary between substance and medication defies facile demarcation.  Our labels can be arbitrary and even hypocritical.  One person’s medication is another person’s substance.  A chemical used as a substance in one situation is considered a medication when used somewhat differently. The distinction shifts along with cultural norms and the passage of time.

We might reach a consensus that penicillin is a magic bullet medication, a specific, effective antidote to an identified pathogen such as streptococcus, working via a known mechanism of action to destroy the bacterial cell wall. But penicillin is not a “psychotropic.” Nobody uses penicillin to get high.

What about morphine? For the individual in the throes of agonizing pain due to a kidney stone, this medication is a godsend.  When taken in high doses for nonmedical purposes, it morphs into a life-threatening substance. Heroin, which is converted to morphine in the body, elicits sinister images of desperate junkies to Americans, but is prescribed for acute pain and as opioid maintenance treatment in the United Kingdom.

Ritalin (methylphenidate) is a first-line treatment for ADHD. Valium rapidly ameliorates acute symptoms of an anxiety disorder. Both are substances of abuse when used at excessive doses recreationally.  Methamphetamine is another stimulant prescribed for ADHD, while its chemical cousin crystal meth is a generally considered a substance.

Perhaps we might choose to distinguish chemicals used to fight disease (medications) from those used for spiritual growth or an enhanced sense of well-being (substances).  Beginning in the 1960s, Harvard psychologist Timothy Leary promoted the possible therapeutic effects of LSD in combating psychiatric illness while also espousing the wonders of “acid” in expanding one’s consciousness, thus straddling both purposes. Carlos Castaneda described spiritual journeys abetted by peyote. But how significantly does this contrast with the cosmetic pharmacology described by Peter Kramer in “Listening to Prozac” in which he lauds the medication’s potential to improve certain personality traits such as social inhibition.

A chemical’s credentials as a medication are enhanced when it is viewed as a specific cure for a narrowly defined disease. Thus we saw “major tranquilizers” –an accurate descriptor of their effects, become rebranded as “antipsychotics” –an aspirational, but misleading label as we know neither the cause of psychosis nor the exact manner in which antipsychotics work.  Furthermore these chemicals have a broad impact on brain functioning, with effects sometimes helpful, sometimes detrimental, and sometimes neutral. Might one claim that substances can have a similarly vast spectrum of effects on the brain?

Or should we consider only the source of the chemical?  Morphine, heroin, valium and amphetamines are medications when picked up at a pharmacy. Those same chemicals bought on the street from a drug dealer are substances, yet we have not changed its chemical composition by moving it  from the pharmacy to the street.

The route of administration might offer us something to hang our hat on when it comes to the substance vs medication dilemma.  When administered by IV or snorting or smoking, we must be speaking of substances.  Not so fast—IV morphine is a pain medication.  Asthma medications are often taken by inhalation. Fluticasone is a nasal spray.  Intranasal administration of pain medications and anticonvulsants is occasionally  done “off-label” (without specific FDA approval). Surely physicians wouldn’t recommend smoking. Alas, the medication/substance boundary proves permeable again, as smoking of medical marijuana is prescribed, albeit still controversial.

Freud touted the many benefits of cocaine use, initially attracted to what he hoped would help his friend, Dr. Fleischl Marxow overcome his morphine addiction. The treatment turned out to be worse than the disease when his friend developed cocaine-induced psychosis. Freud also considered cocaine to be a useful antidepressant, but moved on to other theories as its addictive nature became more evident.  Are the current reports of IV ketamine’s benefit in treating depression a case of déjà vu all over again?  Couldn’t IV cocaine also lift one’s spirits temporarily? If ketamine’s effects last longer, perhaps a week, does that qualify it to be termed a medication rather than a substance?  Should we include alcohol in the medicine cabinet, reasoning that it can reduce the illness of social anxiety? Hallucinogenic mushroom (psilocybin) has been reported to show promise as a treatment for anxiety and depression, while ecstasy is being studied for PTSD.

Today, of course, we have marijuana banging on the gate to the medication realm. Marijuana use as a medication actually dates back to ancient times. It had been a common component of various nostrums in the U.S. prior to being outlawed. In the 1800s, Irish physician, William Brooke O’Shaughnessy studied its use for muscle spasms and pain. Clearly it can also be used as an escape from mundane reality, as a means to get “high.” If psychiatry has pathologized normal suffering, then perhaps medications also often serve as an escape, and, if so, is that to be judged harshly? Marijuana’s use has been linked to adverse effects on the brain. Antipsychotics, too, have been linked to cerebral atrophy (shrinkage of the brain), so apparently causing brain damage is not sufficient evidence to cast a chemical into the substance category. Medical dispensaries sell marijuana as a medication, but the science underpinning its use as medication is in its infancy at best. Are we letting facts get in the way of a good theory posited by its many proponents who sing its virtues with almost religious zeal? Or are doctors becoming the new drug dealers? Its promotion as a medicine might be premature and dangerous or, according to others, unfairly hindered due to lack of Big Pharma backing.

The boundary between medication and substances is a murky one, shifting with time, setting, dosage, route of administration, cultural perceptions, source of supply, and purpose of use.  A reasonable definition of an ideal medication might be a chemical which has a specific, known mechanism of action enabling it to cure a known disease without causing serious adverse effects. When those chemicals have the potential to induce nontherapeutic psychiatric effects, we are left with no clean line upon which to build our border fence, but rather a fickle seascape of unruly, turbulent waters.

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