Patient Network http://www.ohiopatient.net/
Pubdate: Fri, 01 Apr 2005 Source: O’Shaughnessy’s (CA)
Copyright: 2005 California Cannabis Research Medical Group
Author: Tom O’Connell, M.D.
(Cannabis - Medicinal)
CANNABIS USE IN ADOLESCENCE: SELF-MEDICATION FOR ANXIETY
Data From the Author’s Practice
Show That Many Californians Use Cannabis to Treat Emotional Conditions.
Government Studies Obscure This Reality and Some Reformers Seem Reluctant to
In response to TV news footage of able-bodied young men
buying cannabis in Oakland, city
officials voted in 2004 to limit the number of dispensaries. The politicians were exploiting (and
re-enforcing) a misconception that California’s
medical marijuana law applies only to those with serious physical illnesses.
Many of my own patients are seemingly able-bodied young
men. Their histories reveal problems that are indeed serious (impaired
functionality at school and/or work, use of addictive drugs) and that are
treated effectively with cannabis.
I began screening Californians seeking a physician’s
approval to use cannabis in November 2001. Although the reference in
Proposition 215 to a doctor’s “recommendation” of cannabis implied that some
applicants would be seeking to use it medicinally for the first time, the
applicants I encountered, almost invariably, had been using it in non-addictive,
Use of cannabis typically preceded
-often by years-the onset of whatever physical symptoms they were citing to
justify their use.
These patients were among those identified as criminals
and deviants for decades by government propaganda. The idea that they were
criminals who belonged in jail or addicts requiring “treatment” simply didn’t
Never in history has such a large collection of admitted
illegal drug users been so willing to present themselves
for unbiased examination.
Developing Research Tools
Although basic demographic data could be obtained by
questionnaire, I developed a detailed interview to examine pertinent areas of
personal history. Systematic exploration of prior drug use revealed that nearly
all had tried alcohol and tobacco aggressively about the same time they tried
pot. Many had then tried a variety of other drugs.
My patients’ drug-initiation patterns suggested they had
been addressing similar needs. Herein, I realized, might be a key to defining
the “medical” use of cannabis and perhaps to better understand its appeal as a “recreational”
agent. I adapted my interview accordingly, as I learned more.
The discovery that most were using cannabis to treat
insomnia suggested self-medication of anxiety or depression -so I expanded that
portion of the interview dealing with psychotropic symptoms. Upon learning that
many of the younger males had already been labeled with ADD, I sharpened my
focus on school and family histories.
The finding that a large percentage had been raised by
single mothers and that many biological fathers of intact families were either
heavy drinkers or preoccupied with work suggested a common etiology for the
symptoms exhibited in adolescence.
By June 2002 I had a standardized list of questions on a
form that doubled as a cue sheet and a place to record answers efficiently and
A total of 3,815 patient encounters between mid-November
2001 and December 1, 2004
have been recorded. Of those, 2,799 were evaluated with the structured
interview. An earlier group of 1,016 had been screened with a more traditional
history and physical. Approximately two thirds (1,850) of the 2,799 structured
interviews were first-timers; the rest were ‘renewals’ of patients seen at
least once previously.
The applicants were seen at several different venues in
the Bay Area and many had traveled from other parts of the state-sometimes
hundreds of miles Virtually all of my original patients had been made aware of
my availability through word of mouth spread through the loose network of
buyers’ clubs, which had -over the first five years of Prop 215- become
concentrated in the few Bay Area counties where they were tolerated by local
governments. Presumably they knew that I was pro-cannabis, but not that I
looked favorably on its use as a treatment for depression and anxiety.
This article relies on detailed data from 790 patients and
demographic data from an additional 364 patients.
Only 3.6% (34/937) were older than 60 when first seen.
5.5% were born before 1946.
16.4% born 1946 - 1955
15.4% born 1956 - 1965
28.0% born 1966 - 1975
35.6% born 1976 - 1985
Those who initiated cannabis use in the 1960s are now in
their fifties and sixties. Most have been using cannabis on a regular basis for
decades, others have resumed after periods of abstinence. The sharp cut-off in
the upper age limit of this population is evidence that an illegal mass market
for “marijuana” really didn’t begin until large numbers of vulnerable
adolescents were exposed to it.
Of 1118 applicants, 236, or 21.1% were female, a 4:1 ratio
which has obtained throughout the three years of the study. The same 4:1 ratio
of males to females seems to apply to all racial groups.
Applicants were assigned to four rather arbitrary
categories on the basis of race. When there was doubt about which category was
most appropriate, they were asked their preference. The only observed areas of
significant racial differences were in drug initiation rates. Although the
rates at which Black cannabis smokers try illegal drugs other than cannabis are
considerably higher than the those reported in annual
national surveys, they are considerably lower than among White pot
smokers-especially for psychedelics, methamphetamine and heroin (see table at
top left, next page).
Patterns of Use
Patients report that in terms of potency (although not
variety), the cannabis found “on the street” in Northern California
is comparable to that available in clubs.
Although the vast majority were
experienced, chronic users, their knowledge of cannabis lore varied widely and
seemed mostly to reflect individual differences in curiosity. Some were very
knowledgeable about strains and delivery systems, others extremely naive. Very
few were using edibles on a regular basis-many had either experienced or heard
about the extended cognitive effects that can follow ingestion of innocuous
appearing baked goods, and -although not clear on the reasons-preferred to
Overwhelmingly, the mode of ingestion favored by
applicants was smoking. Knowledge of
vaporizers is beginning to spread, thanks to the cannabis clubs that sell them.
Younger patients seem more inclined to use them on a regular basis. Some older
users express resistance -the best vaporizers are expensive and old habits hard
to change. Several complained that taste and aroma were lacking.
Late afternoon and evening are the favored times to use
cannabis. Early morning use is favored by those with ADD type symptoms and is
discussed more fully under that heading. Almost all patients have fairly
consistent schedules for their use of cannabis; it is generally solitary and
private unless trusted friends are around. Most people did not tempt fate by
smoking at or near work.
Consumption, measured in ounces per week, varied from as
little as 1/16 to well over an ounce, with 70% reporting they use between 1/8
and1/4 ounce. People smoking ½ ounce or
more were more apt to either grow it themselves or have access to a friend who
My impression is that the extreme variations in amounts
consumed are more a reflection of different sensitivities to cannabis than to
any greater desire to get “stoned.” In fact, the impression one gets from
discussing cognitive effects in general is that almost all find excessive
effects undesirable and try hard to avoid them (which is the main reason
inhalation is favored over oral ingestion).
Alcohol & Tobacco Use
The most obvious relationship between alcohol, tobacco,
and cannabis is that nearly all those who try cannabis have either tried the
others or will soon do so. That linkage -first noted in the mid-1970s1- was
amply confirmed by the present study: 100% of applicants had tried cannabis by
attempting to get “high,” usually as adolescents (about 30% either failed on
their first attempt or weren’t sure). 99.3% had also tried alcohol by getting
drunk (many were also monumentally sick) and 93.7% had tried tobacco by
inhaling at least one cigarette.
Repeat use of both alcohol and tobacco tended to be
aggressive. More than half had binged in high school or as young adults; 35%
had experienced alcohol black-outs; and 12.5% had received DUI citations. Yet
essentially all who have continued to use cannabis on a regular basis
subsequently moderated their alcohol consumption. Few are teetotalers, but
nearly all who still drink do so moderately. Most have reduced alcohol
consumption to 20% of their peak levels -or less.
Cannabis also has enabled patients to reduce tobacco use.
Although 68.1% of cannabis applicants became daily cigarette smokers for a
while, over half (53%) of the smokers have since been able to quit and almost
all the rest are trying. Even inveterate tobacco smokers (those unable to
remain abstinent) uniformly relate their cigarette consumption to both stress
and access to cannabis: when the former is high and the latter is low, they
tend to smoke a lot more tobacco.
I can recall only two applicants who said they enjoyed
smoking cigarettes and had no intention of quitting.
Initiation of Other Drugs
An individual’s first use of a drug is important for the
obvious reason that drugs never tried never become
problems. However, mere trial of an agent does not signal that repeat use will
follow or what its pattern might be if it does. How chronic use of one agent
might ultimately affect use of others is largely ignored by conventional
While children as young as nine occasionally initiate
drugs, the greatest incidence is from 12 on.2 Since most people have tried all
the drugs they will ever use by age 25, adolescence and young adulthood are
clearly important areas for any drug policy to focus on. At first glance, the
high initiation rates for other drugs observed in this population (table at top
of next page) would seem to support the hypothesis that cannabis is a “gateway”
to use of other drugs.
A more detailed evaluation discloses that relatively few
episodes of problem use or “addiction” ensued. Those whose use became
problematic were generally able to solve their problems without professional
help. Discussing those issues with
applicants left a strong impression that continued use of cannabis had played a
significant role in helping them control not only alcohol and tobacco, but
illegal drugs as well.
Their aggressive trials of psychedelics can be seen as a
manifestation of the same curiosity exhibited for other agents and presumably
impelled by the same symptoms which had led them to try alcohol, tobacco and
cannabis in the first place. The response of many to being questioned about
peyote and mescaline was that they would have tried them had they been able to
The fact that white cannabis users tried psychedelics at
more than double the rate of blacks is startling and remains unexplained.
Availability in their respective communities is probably a factor.
In attempting to determine the origin of the symptoms
motivating this population’s aggressive adolescent drug sampling, the most
obvious place to start was family background. A common element was the absence
of their biological fathers from their early lives -either physically, through
early death or divorce, or emotionally, through a variety of other mechanisms
Paternal Factors Associated With Adolescent Use of
Early Death (before age 6)
Elderly Father (over 40 when patient born)
The role played by insecurity and low self-esteem during
applicants’ school careers became increasingly transparent. One
or more of the above situations obtained in nearly all patients.
Pre-school day care, kindergarten and primary school are
the first opportunities for most children to socialize outside the family.
Being different for any reason - too short, too tall, unfashionable attire,
unusual name, etc.- can quickly become something one
is teased about. Intrinsic shyness and
sensitivity to teasing can make the school setting difficult to bear.
Applicants are now asked to rate their experiences in
primary, junior high and high school as “happy,” “unhappy.” or “mixed.” After
emotional tone is registered, they are asked if they were ever “class clowns”
or considered disruptive by their teachers. They are also asked if descriptions
of “Attention Deficit Hyperactivity Disorder” apply to them.
ADHD and ADD are diagnostic labels increasingly applied to
school children exhibiting behaviors that irritate and frustrate their
teachers. The concept that the condition frequently persists throughout life (“Adult
ADD”) has been endorsed by the medical establishment, and increasing numbers of
patients are being treated with Adderall and other
Although the behaviors had long been noted among educators
and pediatricians, a unifying diagnosis seems to have originated in the late ‘60s
with Paul Wender, a child psychiatrist at the University
of Utah.4, 5 Treatment of affected
children with stimulants, primarily methylphenidate (Ritalin), began in the
1970s and has become both increasingly common. The ADD/ADHD diagnoses are now
codified in the American Psychiatric Association’s Diagnostic and Statistical
Manual of Mental Disorders.
ADD has been associated from the beginning with dyslexia
and several other so-called “learning disorders.” Among my male patients, the
diagnosis of ADD was either made or suggested for some 10-15% while they were
in school. Nearly as many were diagnosed
as adults, or the diagnosis was applied informally by family members or close
The ADD diagnosis is associated in conventional literature
with both “substance abuse” during adolescence and low self-esteem. The ratio
of boys to girls diagnosed with ADD has remained at about 4:1. As the diagnosis
is made more frequently in adults, it has been noted that fathers with ADD are
more apt to have sons with the condition (and vice-versa). This is a pattern
one might expect in a highly competitive, male dominated society.
The idea that “self-esteem” is both important to a child’s
early success and strongly influenced by the biologic father is certainly not
new. Single mothers, low self-esteem, and a proclivity to try multiple drugs in
adolescence have all been reported as common in children diagnosed with ADD.
The term “attention deficit disorder” is clearly a
misnomer. These individuals are not inattentive; rather, their problem seems to
be that they are so aware of other stimuli around them that they have trouble
remaining focused on the chore/problem at hand. There is universal agreement
among applicants who have been diagnosed with and/or treated for ADD that
cannabis helps them achieve and retain focus. They also are the ones most
likely to use cannabis early in the day.
Cannabis as Palliative
ADD and other psychiatric conditions are defined by the
DSM without reference to the objective
external standards which Anatomic and Clinical Pathology readily provide for ‘somatic’ (physical)
Upon closer analysis, modern “mood” and “behavioral”
disorders represent various combinations of symptoms either observed in-or
reported by-those said to be afflicted. The symptoms include chronic insomnia, dysphoria, depression, anxiety, excessive
anger, difficulty in focusing, agoraphobia, and morning appetite inhibition.
These symptoms abound in the chronic cannabis users I have
interviewed. They had usually been
present since adolescence and predated whatever somatic symptoms the patient
could cite -with varying degrees of credibility- as their reason for seeking an
Prop 215, the state initiative that legalized the medical
use of marijuana, refers to “seriously ill patients.” Why would applicants
prefer to cite somatic symptoms instead of emotional ones? Several explanations
can be offered:
Many male adolescents feel that a “macho” image allows for
physical injury and pain, but not for emotional impairment.
Medical marijuana advocates, in seeking to maximize public
support for their cause, often invoke “the dying.”
Law-enforcement opponents of medical marijuana, starting
with former state attorney general Dan Lungren, have
sought to trivialize mood disorders and assert that they are not properly
treated by cannabis. Former Drug Czar Barry McCaffrey, in his first public
response to California’s new law,
ridiculed the inclusion of chronic insomnia on a list of conditions treatable
There is general agreement by all but the most doctrinaire
opponents of medical use of cannabis that it effectively palliates a wide
variety of symptoms produced by an even wider variety of named diseases. The
most common symptoms are chronic pain both of neuritic and musculo-skeletal
The effectiveness of cannabis in treating two “functional”
disorders, migraine and asthma - which are classically exacerbated by but not
thought to be caused by emotions-was well established before the Marijuana Tax
Act of 1937. Cannabis also helps control chronic diarrhea produced by Crohn’s
Disease, Ulcerative Colitis, or Irritable Bowel Syndrome. Its effectiveness in
controlling the tenesmus and cramping of the latter
condition also suggests a spasmolytic mechanism is
In a context where most of the somatic conditions were
clearly additive in that the applicants had already been using cannabis to
manage emotional symptoms, the expenditure of scarce assets to “confirm” what
amounted to a somatic excuse for their pot use did not seem reasonable; particularly
when the underlying psychotropic reasons for its use were deemed adequate and a
detailed history had shown they fit the “profile.” There is also a relatively
small subset in whom more sporadic and casual use of
pot had become far more regular after the patient developed a new somatic
The Gateway Hypothesis
Drugs are initiated in sequence. Prior to the late 1960s,
alcohol and tobacco were primary agents tried by adolescents. When researchers began
studying the phenomenon of youthful cannabis initiation they reported that nearly
all their subjects had already tried both alcohol and tobacco- and that many
had subsequently tried several other agents. Their assumption that cannabis was
a “gateway” from legal to illegal drugs became the prevailing explanation.7
The presumption that all drug use is both hedonistic and
harmful added conviction to that interpretation. Data showing that most heroin
addicts had used cannabis before heroin bolstered the gateway theory, and it
seems to have gone unchallenged for 30 years even though it never met a basic
theoretical test of “causality.”
Evidence that cannabis is capable of benignly and
effectively palliating the psychotropic symptom complexes so often encountered
in juveniles and young adults was clearly beyond the scope of any research
funded-or even permitted-by NIDA. That such symptoms tend to persist into
mid-life for many who suffer from them is now endorsed in psychiatric
literature and has spurred development of a host of pharmaceuticals intended to
treat them. Yet most applicants for whom
these pharmaceuticals were prescribed report that cannabis provides more
effective and durable relief.
A little-noticed 2002 paper by Morral
et al demonstrated that a theoretical “common factor” could provide a better
explanation than “gateway” for the initiation patterns observed.8 My data
suggest that the common factor is adolescent angst.
The previously unrecognized role of cannabis as effective
self-medication for symptoms experienced by adolescents also explains why so
many adults have continued to use it despite potential social and legal
Proposition 215 encouraged many individuals who had been
considered “recreational” users of cannabis to apply for “medical” status.
Interviews placing their cannabis use in broader context showed that it is
frequently an alternative to the use of alcohol, tobacco, and “harder” drugs.
The federal government, by imposing a Prohibition based on
biased, inadequate studies, is depriving the American people of a safe and
Beyond that concern, the increasing enthusiasm for drug
testing and punishing those who test positive for cannabis with either criminal
or social sanctions is destructive to the large -but at this writing unknown
-number of Americans treating emotional symptoms with what may be, for them,
the best agent available.
1. Kandel, DB, Editor. Examining the Gateway Hypothesis; Stages and Pathways of Drug
Involvement. Cambridge University Press 2002.
2. Guo, JieHill,
Karl G.Hawkins, J. David Catalano, Richard F. Abbott,
Robert D. Journall of the American
Academy of Child and Adolescent
Psychiatry, July, 2002
3. Pary R, Lewis S, Matuschka PR, Rudzinskiy P, Safi M, Lippmann
Attention deficit disorder in adults.
Ann Clin Psychiatry. 2002
4. Wender, PH Minimal Brain
Dysfunction in Children. Wiley New York1971.
5.Wender, PH ADHD;
Attention-Deficit Disorder in Children and Adults Oxford,
2000 University Press.
6. Kirk, SA & Kutchins, H.
The Selling of DSM; the rhetoric of science in
De Gruyter New York
7. Kandel, DB, Logan, JA.
Patterns of Drug Use from Adolescence to Young
Adulthood: I. Periods of Risk for
Initiation, Continued Use, and
Discontinuation AJPH 74 (7) 660
8. Morral AR, McCaffrey DF,
Paddock SM. Reassessing the marijuana Gateway
Effect Addiction. 2002, 97 1499