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 Acknowledge It.

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, stable patterns.

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 make sense.

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
unobtrusively.

Study Population

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.

Age

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.

Gender

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.

Race/Ethnicity

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 avoid them.

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 1/2 ounce or more were more apt to either
grow it themselves or have access to a friend who did.

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
research.

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 find them.

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.

Paternal Influences

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 listed below

Paternal Factors Associated With Adolescent Use of
Cannabis

Early Death (before age 6)

Early Divorce

Alcoholic Father

Workaholic Father

Elderly Father (over 40 when patient born)

Invalid Father

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.

School Careers

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 long-acting amphetamines.3

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 friends.

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) diseases.6

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
application.

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 by cannabis .

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 origin.

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 involved.

In a context where most of the somatic conditions were clearly
additive in that the applicants had aleady 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 condition.

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 of 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 penalties.

Summary

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
effective medicine.

Beyond that concern, the increasing enthusiasm for drug testing and
punishing those who test positive for cannabis wth 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.

References

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 S.
Attention deficit disorder in adults. Ann Clin Psychiatry. 2002
Jun;14(2):105-11

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 Psychiatry. Aldyne De Gruyter New York 1992

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