14. Conclusions: Asking Better Questions in Cannabis Research
P. H. Connell, Bethlem Royal and Maudsley Hospitals, London. N. Dorn, Evaluation and Research Unit, ISDD, London.
It was noted in the introduction to this book that the Planning Committee had arranged the proceedings in such a way that participants were not forced into summaries, statements or blue-prints for the future. The Editors, therefore, decided to make an attempt to cull out the proceedings' recurrent themes; to highlight areas where there appeared to be general agreement and to examine and make explicit themes that seemed inherent
in the material presented. The interpretations offered (for which we take full responsibility) do not necessarily reflect the views of all the participants and are largely a result of our study of the proceedings, our subjective impressions, and our assessment of the meaning of the Conference viewed in the context of research over the past years.
The aims of the Conference were to attempt an overview of the present state of knowledge; to discuss conceptual and methodological problems; to bury dying issues and to point the way to future avenues of worthwhile research. In the event, the Conference seemed to have been successful except in the attempt to bury dying issues. This failure to realise this aim is partly due to the free and undirected discussion but also to other factors which will be discussed later and which involve trends which may bode well for future research.
Some participants were concerned that the advent of soluble preparation of cannabis and of delta tetra-hydrocannabinnol and other preparation of active principles might materially and perhaps dramatically alter the whole picture.
Although this contribution is partly based upon the discussions, it is in no way intended to be comprehensive and exhaustive. The reader is referred to the summaries of discussion to gain a more detailed overview.
A major part of the time in discussions was devoted to consideration of methodology. After all, in cannabis research there is as yet no laboratory test which can determine the presence of cannabis in biological fluids outside the very specialised research laboratory (of which there are few) so that whether or not an individual has taken or is in fact taking cannabis cannot often be determined. Nor can the dose which is actually absorbed be determined (taking into account the method of use in which inhalation is wasteful in terms of absorption into the body of active substance) even though the dose of cannabis supplied is known. It is therefore impossible to construct accurate dose-response curves for inhalers and impossible, in the area of field surveys, to know beyond doubt that the person is actually taking cannabis. Thus, however good the methodology of a field study or a clinical study, the pharmacological state of the subject is unknown or relatively unknown.
In the study of individuals from the clinical and psychological viewpoint, it was repeatedly pointed out that there was an urgent need to define symptoms and signs; to create check lists of items which could be validated and could be applicable to different cultures
and to employ measures which could be used internationally. The need for standardized interviews was also stressed.
From time to time, the question of effects of motivation on drug effect was raised and the need to evaluate this factor in cannabis studies emphasized.
These are just a few examples of the general concern of participants about the inadequacy of tools for research and the need to concentrate on this general area in the future.
Certain areas for urgent study were proposed and certain priorities were suggested in the discussion of Dr Miller's paper and in the paper itself. There seemed to be some agreement that the following areas should be included and emphasised in future research:-
1. The development of tests for the determination of the presence of cannabis in body fluids and in particular roadside tests of use in driving research and the evaluation of accidents. Such research would be unlikely to produce results for some years.
2. Research into the effect of cannabis on driving and wider research into driving accidents in relation to other drugs taken and the general 'epidemiology' of driving accidents (including research into the background and meaning of minor damage to cars such as bumps, scratches etc.)
3. Research of populations where cannabis use is the sole drug used before these populations become multiple drug use societies with consequent confusion and blurring of the role of cannabis.
4. Longitudinal surveys in which individuals are assessed regularly over a long period of time rather than cross sectional studies at a given moment in time.
S. Cross cultural researches both nationally and internationally.
6. Research into the chronic effects of cannabis use.
7. Research into patterns of use of cannabis and other drugs in geographical areas at different times when the availability of cannabis varies.
8. Research to define dose-response curves whether using inhalation or other methods of use of the drug such as ingestion or even injection of suitable preparation of cannabis or its active principles.
9. Research into what users consider they gain from cannabis use.
10. Research to reassess cannabis in terms of possible use in therapeutics.
DIFFERENTIATION OF HYPOTHESES
The history of cannabis research is littered with threatening question marks. Does cannabis cause brain damage, madness, heroin addiction, violent crime, degeneration of the body and spirit, etc? are examples. Two characteristics can be identified in these hypotheses. Firstly, their ready appeal to a general audience and secondly, their global, undifferentiated or 'total' quality. These two characteristics are clearly associated. It is easier to think of brain damage than of specific deficit; of madness than of specific clinical signs; of escalation to heroin addiction than use of other drugs, and of overall degeneration than of change of lifestyle. Furthermore, there is no question of brain damage, madness, addiction, crime and degeneration being other than a bad thing.
It seemed, however, that recently there had been a change of style in cannabis research away from the hypothesis of generalised negative effects towards hypotheses of clear, delineated and operationally defined specific effects that were no longer automatically regarded as negative or bad.
Cannabis has been the bogy of drug research because of the difficulty of finding scientific evidence (as contrasted with moral emotional and political belief systems) adequate to justify prohibition and because of the difficulty in finding scientific evidence clearly and indisputably proving cannabis to be of no danger to humans. The result would seem to have been a rather panicky attempt to discover something really 'nasty', and has directed attention away from investigation of carefully defined hypotheses and toward the really spectacular, but relatively less likely hypotheses. The end result would seem to have been 'bad' research since one can hardly do good research on hypotheses that are so wide and ill-defined as to be virtually untestable. Thus, data collected in selective ways from particular or peculiar samples, or even subjective impressions, were presented as expert knowledge.
Such a reaction to cannabis is understandable when viewed in the context of other drugs. Alcohol, nicotine, barbiturates, amphetamine and opiates, for instance, all have clear dangers such as brain damage, cancer, bronchitis, overdose potential and dependence potential etc. Once a danger is identified the drug is felt to be 'known' and relaxation and action concerning the drug takes place. In the case of cannabis, however, (and this applies to some extent to LSD) there is extreme anxiety because it is difficult to identify the threat which is felt must be there. In the absence of a clearly identifiable threat, a phantasy arises as a focus for anxiety. Thus, paradoxically, extreme and general dangers are hypothesised because it is not possible to locate any moderate or specific danger. This situation seems now to be passing. The scientific community is overcoming its phantasy of cannabis to confront the more complex reality. The greatest improvement in research seems to lie not only in better research design but in cannabis researchers' blossoming willingness to ask more relevant and less ambitious questions.
Returning, now, to the intended purpose of this Conference, it is possible to understand why there was little explicit sealing off of dead issues. Global and unsubstantiated hypotheses seem to have given way or been divided up into a greater number of more clearly defined questions. Thus, there is a retreat from the hypotheses of generalised irreversible brain damage to questions such as to what medium and long term cognitive effects of chronic use can be directly attributed to cannabis use, and whether effects, if present, are reversible. The question as to whether tolerance occurs gives way to questions concerning to which specific effects tolerance and reverse tolerance occur. In terms of acute effects questions are now asked as to which kinds of performance in stated conditions are inhibited and which facilitated. These precisely formulated questions seem to lead to answers or potential answers in a way that is impossible if wider questions are asked. So, rather than sealing off dead issues, research would seem to be concerned with subdividing issues to a point where they become more amenable to scientific enquiry.
These development have drawbacks. Thus, there is the danger that in building up knowledge in small bits rather than in large chunks, researchers will become exclusively test-minded and select only those areas that can be researched with existing test instruments and procedures or developments of these. If this tendency takes hold one will be left with a ragbag of atomistic findings devoid of unifying principles. There is thus a need for a series of well-articulated and comprehensive theoretical models that generate mutually exclusive and readily testable hypotheses. These models or systems could be derived from the wider literature in the clinical and social sciences, as well as from the literature on cannabis research itself. A model that ostensibly explains the behaviour of a cannabis user but does not account for the behaviour of the person building the model is a poor model, given that both activities can be regarded as deviant, as purposive and as meaningful in terms of the person's perception of himself to his reference group!
It seems to follow, therefore, that in retreating from the vague and almost untestable, ill-defined hypotheses of yesterday, the researcher should resist the attraction of a-theoretical empiricism and base his research on hypotheses derived from theoretical working models. Thus, confirmation or disproval of a hypothesis will have implications for a whole model or explanation, rather than just for the acceptance or rejection of that hypothesis, which may be of little interest of itself.
THE PERSON AS AN AGENT
A theme of the Conference was the interest in the user's subjective reports of the state of acute intoxication and in his accounts of the reasons for his behaviour. When cannabis use was regarded as a kind of disease there were no grounds for taking the perspective of the user seriously since it was assumed that he was not capable of insight into his own experience. More recently, subjective reports of users are coming to be seen to be as valid a source of research hypotheses as the subjective impressions of observers of users. A remaining problem would seem to be that reports of users are always made in relation to and in response to a particular enquirer or social situation, and that, furthermore, subjective experience is itself the result of the interaction of the user with a particular social system and set of expectations and constraints. Stripped of a social context, the user would not exist: embroiled in a social context, be it that of the street or the laboratory, the user constructs his experience in terms of that context. Thus in regarding subjective reports of research data, it is important to acknowledge its social specificity.
It would seem imperative, therefore, to draw attention to the importance of relating theoretical models to both individual and social systems. There is an apparent move away from perception of the drug as the agent of drug use, through an appreciation of the power of the person's environment and of the social forces that act upon him, and towards a perception of drug use in which the user himself is re-invested with the power to define the meaning of his behaviour. It is becoming apparent that different persons within a culture take drugs for many reasons and with a variety of intentions, and that the intentions of the user are important in shaping the acute drug effects and may have an influence on some longer-term potential outcomes.
This summary and discussion raises a number of practical and theoretical issues. It seems apposite to close by suggesting, as did one Conference participant, that clinical and psychological cannabis research is becoming more and more a study of 'Life'. The implication is that cannabis research must from now on be judged by the normal criteria of the clinical, behavioural and social sciences. Thus, more imaginative and comprehensive types of theoretical explanations and higher standards of empirical evidence are called for. But, in the last analysis, success will rest on our ability to ask the right questions.