Reprinted from Journal of American Medical Association 201 (August 7, 1967): 368-71, with the permission of the publisher. This statement was prepared by the American Medical Association's Committee on Alcoholism and Drug Dependence and approved by the Council on Mental Health.
Unlike narcotics, barbiturates and other sedatives, and amphetamines and other stimulants,1-3 cannabis (marihuana) has no known use in medical practice in most countries of the world, including the United States. Despite this fact, the practicing physician should understand the nature of cannabis and psychological dependence on it, as well as the treatment of persons involved who may become his patients.
While there is no accurate measure of the prevalence of nonmedical use of cannabis and its preparations, it is clear that they are widely used in many parts of the world, including the United States. Those who utilize cannabis in one form or another include various personality types in diverse socioeconomic and cultural circumstances. In the United States, attitudes of rebellion against authority and thrill seeking are not uncommonly found among marihuana smokers.
HISTORY AND GENERAL BACKGROUND
As early as 1200 sc the hemp plant, Cannabis sativa, was described as a source of long textile fibers, and its "narcotic" properties were documented in Chinese writings by 200 AD. Its numerous derivatives, which can be smoked, eaten, or drunk, have become known throughout the world by a variety of names, including hashish, bhang, ganja, dagga, and marihuana. Traffic in and use of cannabis derivatives now is restricted in practically every civilized country in the world, including those where custom has allowed its introduction into religious rites.
India, where the intoxicating properties of ganja were generally recognized by about the tenth century, has undertaken a phased program for the reduction of the use of cannabis in the various forms of indigenous medicine, which will hopefully lead to the eventual elimination of such use.
Despite almost universal prohibition, cannabis use is still socially acceptable in certain parts of the world, though there is a trend away from such acceptance. The principal areas of the world involved in the nonmedical use of cannabis preparations are the Middle East, the African nations, and the Americas, including the United States.
The migratory course of marihuana to the New World is an interesting historical development. Apparently originating in Asia and the Eastern Mediterranean basin, the drug spread via Africa and South America to Mexico. Only within the past 60 years has marihuana been used in the United States. In spite of the proximity of Europe to the Mediterranean, its use there had little significance until recently, when it was imported to England and France as the American "vice."
Wide differences in the volume and form of use are evident despite the absence of hard data on the amount by country. Some authors believe that marihuana smoking is on the increase in the United States. Again, there are no data to prove or disprove this belief because there is no base line from which to make a judgment. Increasing or not, use is substantial and represents a problem with medical, social, and legal implications.
The term "cannabis" is used in international language according to these definitions:
"Cannabis" means the flowering or fruiting tops of the cannabis plant (excluding the seeds and leaves when not accompanied by the tops) from which the resin has not been extracted, by whatever name these parts may be designated.
"Cannabis plant" means any plant of the genus Cannabis.
"Cannabis resin" means the separated resin, whether crude or purified, obtained from the cannabis plant.
The term "marihuana," used primarily in the Americas and in England, refers almost exclusively to the preparations of the leaves and flowering tops of the cannabis plant, which are dried, sometimes mixed with tobacco, and then typically smoked in cigarettes. In the vernacular of the street, they are called "reefers," "joints," or "sticks" containing "hay," "grass," "pot," "weed," or "tea." The inhaled smoke has increased effect when the cigarette is reduced to a short "butt," because the active ingredients concentrate there during smoking.
Legally, the preparations of cannabis are dealt with in international treaties and in the western countries, including the United States, in the same general manner as the narcotics. In the United States, they are controlled under the Marihuana Tax Act, administered by the Federal Bureau of Narcotics.
PHARMACOLOGY AND BIOCHEMISTRY
The female cannabis plant develops a resinous material which incorporates the active pharmacological principles. This resin can be extracted from the base of cannabis confections, beverages, and medicaments, or from the dried tops of the plant, leaves, and flowers, and may be pulverized and smoked with or without admixture with tobacco. The inhaled smoke is irritating, and long continued exposure to it induces chronic respiratory disorders.
The principal active ingredients of cannabis resin are cannabinols, especially tetrahydrocannabinols, which are now known to exist in several isomeric forms. Many cannabinols have been isolated, but it is not yet known what their exact state or proportion is in the resin which brings about the typical effects of the drug as a whole in man.
A tetrahydrocannabinol has been synthesized recently, and its identity with a product of a natural origin established. In addition, many cannabinol derivatives have been prepared, utilizing, for the most part, starting materials of natural origin. Extensive animal and clinical trials of these substances are adding much to our knowledge of cannabis action.
The actions of cannabis are exerted primarily on the central nervous system, but their modes of action are poorly understood. Their effects, through smoking, are felt in a very few minutes and may persist for as long as 12 hours.
CANNABIS DEPENDENCE AND ITS CONSEQUENCES
No physical dependence or tolerance has been demonstrated. Neither has it been demonstrated that cannabis causes any lasting mental or physical changes; comments by physicians who have recently visited colleagues in Africa suggest a need for more intensive study of this possibility.
Persons who use marihuana continually and as the symptomatic expression of a psychological conflict, a means of gaining social acceptance, or a way of escaping painful experiences of anxiety or depression, may be said to be psychologically dependent on the substance. Continuous use may be associated with the development of psychiatric illness, although few chronic users are admitted to psychiatric inpatient facilities. Chronic marihuana users often are lethargic, neglect their personal appearance, and occasionally may experience a deep sense of failure after believing they are capable of accomplishing great things. The extent of psychological dependence on marihuana in the United States is not known, but such dependence may reasonably be presumed to be less than that to narcotic drugs on the grounds that the satisfactions obtained from marihuana by drug dependence-prone individuals are insufficient to meet their psychological needs.
Of greater interest than psychological dependence on marihuana is the casual, episodic, noncontinuous use of the substance by adolescents and young adults in and around urban centers and college towns, and indications that its use among high school students may be spreading. Such experimental use, if it does not lead to intoxication or frequent use and dependence, may not be medically dangerous. However, it is of concern as a medicolegal problem because marihuana is a drug, because its possession and distribution violates federal and many state laws, and finally, because its use is probably disproportionately higher among young persons with developing psychiatric problems than among those without them.
It is in the nature of adolescence to seek new and exciting experiences, to question self, family, and society, to try on and discard new guises of behavior, to reconcile opposing pulls and strains, and to act like child and adult. Such experiences contribute to personal growth and ultimately to intellectual development and social progress, though in some instances the behavior may appear to some viewers as thoughtless, irresponsible, or rebellious. The kaleidoscopic activity of adolescence assumes forms and patterns unique to each generation of adolescents, each having its own values, totems, and taboos. The content of an adolescent's experiments depends on many variables related to the cultural patterns and mores of his area, his own psychological development, and if marihuana is involved, on its availability.
Urban areas, with their concentrated population, and college towns within a two- or three-hour driving range of cities attract those who participate in drug traffic; although in college towns, marihuana suppliers are most often students who purchase the drug from a city "pusher" and then bring it into the college community. The number of young persons who become psychologically dependent on marihuana or progress from marihuana to drugs that produce physical as well as psychological dependence is not known. It is likely that those who do become dependent on marihuana or other drugs are psychiatrically disturbed and that drug use is but one of a complex of psychological and behavioral symptoms manifested by them.
Most experimenters either give up the drug quickly or continue to use it on a casual basis similar to the social use of alcohol. Those experimenters who find the effects of the drug unpleasurable, or at least not worthwhile for them, are the ones who immediately forego further use.
Most persons who experiment with and many who become dependent on marihuana do not go on to stimulants, narcotics, or hallucinogens, such as lysergic acid diethylamide (LSD). It is a fact, however, that persons physically dependent on other substances, such as heroin, almost always have had experience with marihuana, although not necessarily prior to experiences with so-called hard drugs.
Another area of society in which marihuana use has been observed for many years is the urban ghettos where feelings of hopelessness, powerlessness, oppression, and futile dissatisfaction provide fertile soil for cultivating the growth of such use. The use of marihuana among Puerto Ricans and both southern and northern Negroes is reputed to be high. In all likelihood, marihuana use among the poverty-stricken urbanite is concomitant with use of other dependence-inducing substances and a broad range of asocial and antisocial activity.
CHARACTERISTICS OF CANNABIS INTOXICATION
Subjectively, the user experiences one or more of the following effects: a feeling of well-being, hilarity, euphoria, distortion of time and space perception, impaired judgment and memory, irritability, and confusion.
After repeated administration and high dosage, other effects are noted, such as:
lowering of the sensory threshold, especially for optical and acoustical stimuli, thereby resulting in [a feeling of] intensified appreciation of works of art ...; hallucinations, illusions and delusions that predispose to antisocial behavior; anxiety and aggressiveness as a possible result of the various intellectual and sensory derangements; and sleep disturbances.
In the psychomotor sphere, hypermotility occurs without impairment of coordination. Among somatic effects, often persistent, are injection of the ciliary vessels and oropharyngitis, chronic bronchitis and asthma. These conditions and hypoglycaemia, with ensuing bulimia, are symptoms of intoxication, not of withdrawal.'
While some persons assert that marihuana improves artistic and other creative endeavor, there is no evidence that this is so.
There is little difficulty in recognizing the intoxication of a person who has smoked a significant amount of marihuana in the preceding few hours. If the physician has an opportunity to smell the smoke of a "reefer," a characteristic acrid odor will be noted. Federal, state, and local narcotic enforcement officers and certain clinical laboratories may be helpful in identifying the odor or the dried marihuana preparation, should the latter come into the physician's hands.
The problem of recognizing a nonintoxicated marihuana-dependent person or experimenter is quite difficult. As indicated earlier, there is no physical dependence, and hence, no withdrawal syndrome. A careful longitudinal history from the patient and from his close friends and relatives regarding his behavior and associates may be productive. This history should be obtained in a nonjudgmental manner. Such a history, even when marihuana use has not been admitted, coupled with a careful mental-status examination may indicate the possibility of such drug use. If the patient demonstrates a psychopathological condition of such nature which could make him vulnerable to experimentation with drugs or to their abuse, positive confirmation of marihuana or other drug abuse should not be considered a prerequisite for treatment of his condition. Such treatment is indicated whether or not he experiments with or has become psychologically dependent on marihuana.
Drug dependence is a multifaceted problem, embracing not only medical issues but almost every aspect of our culture and socioeconomic system. Obviously, there is no simple solution. The treatment and rehabilitation of the person with psychological dependence on marihuana ordinarily will require the attention not only of the physician but also of many others concerned with the problem. There will be complicating legal, emotional, social, moral, or religious issues which require special skills not ordinarily possessed by the physician, and he may well find it necessary to enlist the services of those who do possess them.
Because marihuana abuse does not result in physical dependence, the physician need not apply himself to physical complications of withdrawal. He must, however, determine at the onset of treatment whether other drugs are being taken simultaneously whose withdrawal requires careful management. This is frequently the case.
Ordinarily, minimal protection during the period of acute intoxication is all that is required, beyond providing appropriate measures for correcting any concurrent physical illnesses, including malnutrition. During the initial phase, ambulatory treatment of the person with psychological dependence (as contrasted with the experimenter) is generally not satisfactory because of the tendency to relapse. At least brief hospitalization is usually recommended to separate the patient from his supply, establish relations, and initiate treatment. Complete cessation of the use of the drug is necessary, and circumstances may require the family or others to seek legal means by which the patient can be brought to treatment, in those states where this is possible.
The major focus of effective treatment cannot be on the repeated drug abuse alone, because psychological dependence is almost universally symptomatic of serious underlying personality problems, severe neurotic conflicts, or psychotic reactions. The task of the physician is to learn from the patient what really bothers him at both conscious and unconscious levels, and what needs are being spuriously met at both these levels by taking marihuana.
It is also the physician's task to help the patient come to such a full comprehension of his intrapsychic and interpersonal problems that they can be eliminated. Short of this, the physician may have to give longterm supportive therapy that will enable the patient to live as productive and satisfying a life as possible with his psychic handicaps and in a drug-free state. The physician, of course, cannot change real vocational, family, social, and other environmental problems contributing to the patient's difficulty merely by treating his intrapsychic disorder. For this, as noted above, collaboration with others possessing additional pertinent skills is essential.
The physician who does not have sufficient professional training to equip him to handle these difficulties may wish to make early psychiatric referral. When psychiatric resources are not available, the physician may be called upon to provide limited individual, group, or family therapy over an extended period of time. In such cases, it is particularly important to seek additional help in the community from the appropriate agencies, interested lay organizations, or concerned professionals who can add substance to the treatment program.
The physician's attitude will influence his approach to the patient. It is important for the physician to remember that a person who has a psychological dependence on marihuana is sick and deserving of understanding and treatment, even though he may have been involved in unlawful activity.
A concomitant consideration is that, through the use of marihuana, a behavioral pattern often has been established in which the patient has experienced rejection by the wider society and acceptance perhaps only by those with similar problems. He may therefore have alienated himself from more desirable associates and family, or perhaps never have achieved a period of reasonably satisfactory adjustment to which he may return. Rehabilitation may require concerted community support, with simultaneous efforts to provide housing, employment, spiritual assistance, and other aids.
Each patient represents a unique therapeutic problem calling for ingenuity on the part of all who endeavor to help. The prognosis for persons psychologically dependent on marihuana, and particularly for experimenters, is good in most cases.
Legal control is one of the most important and effective aspects of prevention. Federal control of marihuana is the responsibility of the Federal Bureau of Narcotics under the Marihuana Tax Act of 1937 (US Code Title 26, sections 4,741-4,776).
The basic features of federal control are to make marihuana dealings visible to public scrutiny, and to render difficult the acquisition of marihuana for nonmedical and noncommercial purposes.
The act requires all persons with legitimate need to handle marihuana to register and pay an occupational tax, requires that all marihuana transactions be recorded on official forms provided for that purpose, makes transfers to a registered person subject to a tax of $1 an ounce, and makes transfers to an unregistered person subject to a prohibitive tax of $100 an ounce.
The controls over marihuana under the federal and state laws are dissimilar. Under the federal law, marihuana is not considered a narcotic drug. On the other hand, many states have covered marihuana by including it within the definition of "narcotic drug" since adoption of the Uniform Narcotic Drug Act in 1932. Marihuana is equated in many state laws with the narcotic drugs because the abuse characteristics of the two types of drugs, the methods of illicit trafficking, and the types of traffickers have a great deal in common.
THE PHYSICIAN-CITIZEN'S ROLE
Only an aroused and concerned public can create, mobilize, and implement resources to deal adequately with as serious a problem as drug dependence in all its forms. The proper stimulus must come from citizens who are community leaders aware of these needs and from professionals who apply themselves to these needs.
Frank and forceful public discussions, focusing on the futility and inherent dangers in experimentation with drugs such as marihuana and the consequences of any subsequent psychological dependence, can act as deterrents.
Expanded counseling services in schools could present more effective and more suitable alternatives to young people for dealing with their problems.
Continuing emphasis on the incompatabilities between a primarily punitive approach toward those who experiment with or become psychologically dependent on marihuana and modern concepts of treatment and rehabilitation could lead to further improvement of legislation and enhance the opportunities for the drug-dependent person to obtain treatment. The Narcotic Addict Rehabilitation Act of 1966, which went into effect Feb 6, 1967, was a substantial step in this direction at the federal level.
Persistent vigilance by law-enforcement agencies in eliminating illegal sources of the drugs needs public support and sufficient means with which to do the job. Real crusading may be required before adequate amounts of public funds are devoted to creating and operating affective treatment facilities and programs for the afflicted and for the control of illicit drug use.
Finally, only community understanding, compassion, interest, and active aid will enable the rehabilitated drug-dependent person to find a satisfactory place in society.
Marihuana is centuries old, but it represents a constant danger. The responsibilities of the citizen, including the physician, are clearly defined. The time to begin is now.
1 American Medical Association's Council on Mental Health and National Academy of Sciences—National Research Council's Committee on Drug Addiction and Narcotics: Narcotics and Medical Practice: The Use of Narcotic Drugs in Medical Practice and the Medical Management of Narcotic Addicts, JAMA 185:976-982 (Sept 21) 1963.
2 Dependence on Barbiturates and Other Sedative Drugs, Committee on Alcoholism and Addiction and Council on Mental Health, JAMA 193:673-677 (Aug 23) 1965.
3 Dependence on Amphetamines and Other Stimulant Drugs, Committee on Alcoholism and Addiction and Council on Mental Health, JAMA 197:1023-1027 (Sept 19) 1966.
4 Eddy, N. B., et al.: Drug Dependence: Its Significance and Characteristics, Bull WHO 32:728-729 (No. 5) 1965.