Should Weed Be Used to Treat Eating Disorders?

Anna Demarco was 21 the first time she smoked weed. She was having an anxiety attack in the car with her friend Patrick, who had a habit of burning while cruising, and he passed her the bowl to try to help calm her down. Anna didn't know what else to do, so she took a hit.

Anxiety was a regular thing for Anna, who had been anorexic for as long as she could remember. She weighed less than 100 pounds until her junior year of high school; by the time she turned 20, she was fluctuating between 115 pounds and a dangerously-low 85 pounds. The anxiety seemed to feed her eating disorder, and sometimes manifested itself in throttling attacks like the one she felt that day.

In the car with Patrick, she coughed a few times, the unfamiliar smoke curling in her lungs. Then she sat back and realized she felt… calm. Her breathing steadied, and her anxiety began to melt away. She was relaxed. She was free.

She was hungry.

Five minutes later, Anna called her mom and said she was trying to decide where to eat. Her mom started to cry. When Anna and Patrick went to a buffet for lunch, Anna ignored all of her usual rules about eating food—the kind of compulsive, compartmentalizing rules that mark an anorexic—and made it all the way to the end of the buffet, where they kept the soft serve.

For the first time in her entire life, she felt normal. She loaded up her plate with a slice of pie and a scoop of soft serve and sat down to eat.

By the estimates of the National Eating Disorder Association, there are 30 million people in the United States living with an eating disorder. Finding adequate treatment can be difficult, since the illness is both psychological and physical, it often occurs in conjunction with other disorders, and the relapse rate is high (about one-third of anorexic patients remain chronically ill, some of whom eventually die). Treatment often involves some combination of cognitive-behavioral therapy and medication, but since the source and symptoms of an eating disorder are highly individualized, treatment options are not one-size-fits-all.

Of the 23 states with medical marijuana programs, only five of them include anorexia nervosa on the list of conditions eligible for medical marijuana cards (none of them include bulimia or unspecified eating disorders). Neither the Academy for Eating Disorders, an organization responsible for developing research and best practices for eating disorders, nor the National Eating Disorders Association acknowledge cannabis as a viable treatment option (both also declined to comment on this story).

Eating disorders have a high degree of comorbidity, which means they're often fueled by underlying problems like anxiety, depression, and body dysmorphia. This can complicate treatment options, since without dealing with other issues, eating problems rarely go away. Currently, over 50 percent of those diagnosed with anorexia nervosa are also prescribed psychotropic drugs as part of their therapy. Those drugs go toward treating the related disorders—but they don't always work.

After Anna had been hospitalized for her eating disorder twice—once at age 13, and again at age 17—she was prescribed a cocktail of pills. Every night, she took an SSRI and a sleeping medication; benzos to allay her anxiety attacks; trazedone, an anti-psychotic medication; and a special medication to block out the anxious nightmares that often shook her awake at night.

Despite all the medications, she still wasn't functioning. For many eating-disordered patients, this is not uncommon.

The American Psychiatric Association offers a 128-page document outlining guidelines for treating patients with eating disorders, which rattles off an extensive list of psychiatric medications that might aid in recovery—benzodiazepines, SSRIs, anti-psychotics, topiramate, lithium. Marijuana is not on the list. Of the medications listed, the guide acknowledges a litany of possible problems: Malnourished patients tend to have worsened side-effects from antidepressants and anti-psychotic medications, both of which are commonly prescribed. Patients taking anti-psychotic medication need to be monitored for akathisia, a type of corollary distress from the meds. Certain antidepressant (like bupropion) come with a black-box warning because in underweight people, there is an increased risk of seizure. Benzodiazepines can become highly addictive. Other medications can cause "insulin resistance, abnormal lipid metabolism, and prolongation of the QTc interval," which can lead to heart problems.

Dr. Beth Braun, a psychologist in Los Angeles who works specifically with eating disordered patients, says she's seen greater success with her clients who smoke weed than those who take psychotropic drugs. Dr. Braun doesn't recommend pot to her patients, since she can't legally prescribe drugs (she's a psychologist, not a psychiatrist) but she says if it works for her patients—if they feel better and it helps them start eating—then she supports it.

There's always a risk that marijuana can negatively affect younger patients, whose brains and bodies are still developing, but Dr. Braun points out that practitioners already "give kids benzodiazepines, Valium, and Xanax." Those drugs can have lasting effects on kids, too, and the side-effects are way more dangerous than weed.

Other experts disagree. Dr. Kim Dennis, CEO and Medical Director of Timberline Knolls, a leading residential treatment center and partner with the National Association of Anorexia Nervosa and Associated Disorders, pointed out that while marijuana may be seen as a more natural alternative to psychotropic drugs, marijuana is also virtually unregulated compared to the pharmaceutical drug industry, meaning it's hard for patients to choose the right dose or the right strain. She also said that 50 percent of those with eating disorders also have substance abuse problems, and worries about creating dependency on the drug. A mental health counselor in a well-known center for the treatment of eating disorders in Massachusetts added that "with a lot of these kids, their cardiac system is compromised. When you smoke weed, your heart rate can spike." She says there was a 14-year-old in her center who was sent to the hospital for symptoms of a heart attack—something that would only be exacerbated with weed.

And since marijuana induces "the munchies," it can increase the risk of binge-guilt—the feeling of shame and regret after an eating-disordered person consumes food—leading to greater purges later on. For bulimic patients, this is a major risk.

To be sure, marijuana is not a panacea. Kaitlyn Jones, who had been restricting food since she was 16 and purging since she was 19, felt consumed by her disorder and smoked weed occasionally as an escape. But when she did, she told me she became "hyper-critical of my body and the food I was eating. Most of the time, I would just not eat." She said her obsessive-compulsive disorder would kick in tenfold when she was high, and instead of relaxing her, weed made her tense up—almost as if she was overcompensating for feeling out of control.

Dr. Braun says that a successful eating disorder treatment depends on the individual, and marijuana doesn't work for everyone. But when smoking weed does help some of her patients get on the road to recovery, she doesn't see anything wrong with it. After all, she says, it's the same idea as taking a psychoactive drug.

"So which is worse—the benzodiazepine or the marijuana? I guess medical research would have to show that."

Except, the research on marijuana and eating disorders is scant. The US Department of Health & Human Services budgets $30 million for the research of eating disorders each year, which comes out to about $1 per person living with an eating disorder. By contrast, the department budgets $81 million for research on post-traumatic stress disorder (about $16 per person), $259 million on schizophrenia (about $74 per person), and $404 million on depression (about $122 per person).

It's not just that eating disorder research receives less research money per person—it's that eating disorders affect more people in the United States than PTSD, schizophrenia, and depression combined. Eating disorders also have the highest mortality rate of any psychological illness, and they are the only one from which the actual symptoms can cause death.

One of the few researchers who's studied the relationship between marijuana and eating disorders fairly extensively is Dr. Alin Andries, a physician at the University of Southern Denmark. Dr. Andries has so far published three peer-reviewed studies about the relationship between cannabinoids and anorexia—one looking at changes in physical activity, another measuring changes in body weight, and another tracking hormonal changes.

"There are many studies revealing the appetitive effect of cannabis and its synthetic derivates. This effect occurs rapidly after ingestion and is known as 'the munchies,'" Dr. Andries told me via email. "We thought that this aspect could be further investigated in anorexic patients, due to the impaired relationship between appetite and weight gain"—that is, anorexia patients won't eat or gain weight, even if they're hungry. Plus, anorexia nervosa offered the "purest study environment," since the disease's causes are exclusively psychiatric, unlike previous research on cannabinoids and weight gain among cancer, AIDS, or Alzheimers patients.

Previous research has suggested that people who suffer from eating disorders may have a variation of the CB1 receptor gene, which creates a type of cannabinoid resistance. A study published in the journal Biological Psychiatry found deficits of this receptor in the brains of anorexic and bulimic patients, which can affect "body perception, gustatory information, reward, and emotion," according to Dr. Koen Van Laere, the lead author of the study. Prior research also suggested that by creating a compromised endocannabinoid system in rodents, researchers could simulate anorexic symptoms. Dr. Andreis' expected to find similar conclusions in humans.

In each of Dr. Andries's studies, he gave patients either capsules of synthetic cannabinoid called dronabinol or placebo pills. He found that the cannabinoids seemed to have stress-relieving effects ("our pateints were less perfectionistic and keen to lose weight," Dr. Andries told me), and there were modest increases in body weight after four weeks of dronabinol therapy. But there was also a small increase in physical activity—something the researchers didn't expect—which is associated with "activity anorexia," or a way to expend calories besides not eating. And while the therapy proved to be safe and generally well-tolerated, the research noted no change in the patients' eating disorder-related psychopathology. In other words, the cannabinoid therapy didn't relieve the body dysmorphia, the concern about weight, and the fear of eating food that all characterize an eating disorder.

In the end, none of Dr. Andries' patients overcame their eating disorders.

Still, one promising part of Dr. Andries research was his three-year clinical study on cannabinoids and weight gain, which found that anorexic patients who took the synthetic THC pills for four weeks gained about a pound and a half more than anorexic patients who took placebo pills. A pound and a half might not seem like much, but for someone who is drastically underweight, it can be the difference between life and death.

When you're starving, weird things happen to your brain. A famous study, known as the Minnesota Starvation Experiment, found that when people lost 25 percent of their body weight, they experienced severe emotional distress and depression, but also severely compromised cognitive abilities. Participants were unable to concentrate, their judgment was poor, and some experienced hallucinations or a desire to self-harm. (Diagnostically, anorexics are more than 15 percent below normal body weight.)

When your body is in a period of starvation, it uses the fattiest tissue first—which, in the absence of body fat, is the brain. The brain is literally broken down, piece by piece, causing mental fogginess, lack of concentration, and an inability to focus. For eating-disordered patients, this can feed into the cycle of body dysmorphia and the strange logic of eating disorders. As little as five pounds can make a huge difference in how people think—especially about themselves and their disorders.

Many eating disorder therapies focus on raising patients' body mass index, both because it lessens the risk of death and because weight gain is one of the only ways to reframe patients' thinking about their own disorders. Successful treatments focus on rebuilding patients' brains as much as they focus on rebuilding their bodies.

So if cannabis can help patients keep a few extra pounds on their bodies, it makes sense that some people credit it as their gateway to recovery. In the course of reporting this story, I spoke to over a dozen people who had self-medicated their eating disorders with marijuana—and while their stories included varying degrees of success, many of them told me that weed was the one thing that made them believe they could get better.

One man in his mid-20s, who struggled with restrictive eating throughout his teenage years, said he turned to weed for a "necessary cognitive break from the misery I felt." He toked up when things got really bad, and found that it could provide the relief he needed. "Of course, this was no magic solution, but it really helped in those stupefied hours," he said. Smoking weed was "subversive enough to demonstrate that another life was both possible and desirable."

One person remembers how, the first time she was high, she forgot how many calories she had eaten that day—something that she had tracked compulsively. Forgetting felt like a burden was lifted off her shoulders, and reminded her that a life without constantly tracking her nutrition was possible. Another person told me that "it was probably a combination of things that helped me get back to a healthy weight, but I always figured smoking pot is what tipped the scales and made me [hungry] those two or three first times."

Then there was Christopher, who told me at his lowest he weighed about 70 pounds. He used marijuana as a coping mechanism during his early recovery, as a way to quell his depression, anxiety, and stress, as well as stimulate an appetite that he had long ago lost. For the first time since his eating disorder began, he was able to shift his mental focus from calories to other things, like watching a television show or having a normal conversation.

The most surprising thing he said was not that the marijuana made him feel calmer, or hungrier, or even less anxious. It was that he finally saw himself in the way that other people saw him.

"When I was high, the thoughts that told me I was an awful piece of shit got a bit quieter," he said. When he was high, he could see himself as he really was—frighteningly, rail-thin—rather than the distorted image of himself he saw when he was sober.

"Marijuana," another person told me, "opened parts of my mind that allowed me to find control. It was as if I didn't have access to these parts [of my mind] prior."

It's been five years since Anna Demarco smoked for the first time, and she now considers herself in recovery from her eating disorder. She smokes about three times a day—before meals, and before bed—and she's able to eat normally.

Dr. Kim Dennis, the Medical Director at Timberline Knolls residential treatment center, does not consider this to be true recovery. "If a person becomes dependent on marijuana to manage her eating disorder, she doesn't have the freedom that a person in recovery has. The person in recovery has done work to uncover and heal the underlying issues."

Anna also worries that she's become dependent on the drug. "I can't eat without smoking, because my anxiety is constant and my stomach is always in knots," she said. She's gone through periods where she tries to smoke less, but whenever she does, she loses her appetite and her anxiety spikes. Once, when she quit smoking for three weeks, she caught herself "obsessively watching my figure everyday and weighing myself any place I found a scale."

With marijuana, Anna says she feels more normal. "Without it, I am not a functioning person."

Marijuana isn't a "cure" for her eating disorder, and she knows that weed is not a permanent fix. But she says it's part of what's keeping her alive, and there's no shame in surviving.

If you are suffering from an eating disorder, please visit the National Eating Disorder Association.

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