Dependency and Cannabis by Tod Mikuriya, MD

This paper was written by Dr. Mikuriya in October ’99 with O’Shaughnessy’s in mind; but then I went to work for the San Francisco District Attorney’s office and we put off the launch of the paper. It was never published. Given the title he chose, I’ve moved the concluding section to the beginning (which is why the footnotes are out of order).  —Fred Gardner

American Drug Policy, Dependencies, and Cannabis

The complex interplay of cannabis use with physiology, psychology, and groups challenges research. Outcomes are combination of pharmacology, expectations, setting, personal and social forces. The contemporary ambiguity, a product of ignorance from deprivation of contemporary clinical experience, may be somewhat assuaged by two facts: Firstly, cannabis has been used for millennia by numerous cultures without serious adverse consequences.^xxii Secondly, neither the composition of cannabis nor the physiology of humans have changed since the drug was taken from the armementarium of medicine.

Perceptions of cannabis and its effects distorted by sixty years of prohibition are embedded in official policy^xxiii. The Controlled Substances Act of 1970^xxiv classifies cannabis as Schedule I: high potential for abuse, no currently accepted medical use, and lack of accepted safety. The 1999 Institute of Medicine report favorably compares the psychophysical profile of cannabis to other conventional medication in chronic pain and spastic conditions but avoids any recommendation of using cannabis for the treatment of alcohol and drug dependencies.^xxv

To circumvent prohibition censorship and dissimulation of contemporary official propaganda a review of medical and pharmaceutical literature prior to the passage of the Marihuana Tax Act in 1937 is mandatory. Cannabis was available and utilized extensively in medical practice until its removal from availability. There was an overall decline in its use with the development of newer synthetic sedative, stimulant, and analgesic drugs.

Criminalization of dependencies in the United States began in 1869 when the Temperance party became the Prohibition party. The ensuing state-by-state war of the drys against the wets culminated in national victory in 1919 with the passage of the Voalstead Act with Prohibition of alcohol.

The Harrison Narcotics Act of 1914 criminalized non medical use of opiates and cocaine. In 1921 the Federal Prohibition Commissioner criminalized the maintenance of unconfined narcotic addicts.^xxvi The subsequent demonization and persecution of physicians and narcotic addicts they sought to treat significantly limited treatment^xxvii. Methadone maintenance programs available since the 1970’s remain heavily bureaucratized and functionally rationed. Alcohol and drug dependency treatment remain frequently unavailable. The last to be funded, first to be cut from public budgets and often not covered by private insurance. In America drug policy is controlled by the Attorney General —not the Surgeon General. Drug dependencies are defined as moral defects and not medical problems. Police become the armed pharmacologists. DARE (“Drug Awareness and Resistance Education”) celebrated its 17^th birthday with uniformed police in the class rooms.

Meanwhile, television and print media tell us to ask your physician about Paxil® (paroxetine), an SSRI antidepressant.

Pre Prohibition

O’Shaughnessyⁱ in 1839 visited cannabis buyers centers in India and mingled with the “dissolute and depraved” to learn about the preparations of this social drug for clinical medical trials finding it to be useful in the treatment of tetanus and seizures.

Cannabis substitution for more harmful medicines

In 1843 Clendinningⁱⁱ utilized cannabis substitution for the treatment of alcoholism and opium addiction. Potter recommended full dose Squibb cannabis extract for withdrawal from opium addictionⁱⁱⁱ.

The Indian Hemp Drugs Commission Report in 1894 recognized the comparative safety of cannabis in its unsurpassed ethnographic studies within different cultures with a concern that if prohibited would cause the use of more dangerous drugs.^iv

Cannabis combination with other medicines: decrease of dose, suppression of side effects

Mc Meens citing Fronmueller in 1860^v described the use of cannabis either alternating or combined with opiates reduced harm from increased dose, tolerance, dependence, and side effects. Cannabis was confirmed as useful in the treatment of delirium tremens and alternative to opium for analgesia^vi. Dutt independently described the comparative safety in Materia Medica of the Hindus^vii. Yeo warned about addiction to morphine in the treatment of neuralgia and cannabis suggested as an alternative.^viii

Cannabis and mood disorders

The connection between dependency on drugs and mood disorders may represent unsuccessful attempts to self medicate uncomfortable feelings with the “cure” causing more harm and aggravation of the underlying condition.

Moreau described cannabis as being useful in the treatment of depression in 1845.^ix

The drug is listed in medical texts and pharmaceutical catalogs for treatment of melancholia or mania.^{x xi xii xiii}

Patients report that cannabis facilitate both anti mania and antidepressant medications. Cannabis used in combination with antidepressants appears to decrease the side effects of nervousness, muscle tension, and nausea for SSRI type antidepressants. Other patients report that cannabis is complementary. A typical report is that the SSRI elevates mood overall and cannabis improves affectual responsivity. Cannabis can either diminish the dosage needs for sufferers of bipolar disorders or substitute altogether for antimania medications. With symptoms of mania or agitation cannabis appears to decrease affectual lability.

Cannabis substitution for more harmful non-medical drugs

Notwithstanding some polysubstance abusers who maladaptively combine cannabis with other psychoactives, there appears to be a significant number of persons who have learned that cannabis can totally substituted.

Following the therapeutic paths of Clendinning, throughout the 19th and early 20th century, cannabis was found useful in the treatment of opiate and sedative abuse. Brunton describes use of cannabis for the treatment of opiate dependence or as a substitute when opiates were not tolerated.^xiv Shoemaker finds in some instances cannabis to be used for the cure of opium or chloral habit.^xv Birch ^xviadvocated for the use of Indian Hemp in the treatment of chronic chloral and opium poisoning. Mattison, an early addiction specialist, reccommended cannabis in as a substitute of morphine and cautioned his fellow physicians about hypodermic use of the drug. ^xvii

Alcohol abuse, stimulant, sedative, and opiod abuse and dependence are conditions potentially treatable with cannabis substitution. All of these conditions involve management of mood and emotional reactivity. While there have been numerous synthetic homologs developed, short acting psychotropic continue to have high potential for dependency and abuse. The quality of immediacy for mood management would appear to be inseparable from abuse potential but cannabis appears to be the exception because of lesser or milder withdrawal symptoms.

Pharmacologic mechanisms

This may be accounted for by the lipophillic water insolubility of the tetrahydrocannabinols that appears to act through the prostaglandins as eicosanoids, precursors whose structures are similar.^xviii While largely unknown in specific details, appears to modulate the behavior of the CNS either directly, or through the adrenopituitary axis. Additionally, eicosanoid peripheral physical activity in specific organ systems like lung tissue has been demonstrated in animals.

California cannabis center members and patients in my private practice^xix independently rediscovered and confirmed that cannabis as a safer substitute for prescribed and non medical psychoactive drugs in the control of depression, anger, and anxiety. Cannabis substitution may be a gateway drug back to sobriety and dealing with the underlying psychopathologic etiologies.

Gieringer summarized 2479 California cannabis users interviewed by the author^xx noted 5.5% (136) described that the use of cannabis to be less harmful than alcohol, opiate, and other for drug dependencies as primary presenting illness. This group of self medicators cannabis has found far fewer adverse effects than opioids, sedatives, and stimulants. This small percentage is for dependencies as primary grossly underreports dependencies in chronic pain conditions.

Antabuse® (disulfiram) and alcoholism

I have personally successfully treated two patients suffering severe alcoholism with a combination of disulfiram and cannabis substitution. This “carrot and stick” approach appears to address the needs of pharmacologic management of mood and avoids relapse with emotionally stressful events.^xxi

Posttraumatic Stress Disorders: A specialized category of dependencies

Adult children of alcoholic families are doubly harmed by abuse and functional ignorance. Abuse by violence, sexual abuse or emotional absence by one or both parents is compounded by failure to provide coping skills to deal with normal feelings and pathologic role models. Alcoholism and polysubstance dependence is significant with destructive and symbiotic family involvements.

Vietnam veterans and other survivors of horrific experiences of adulthood suffer from living nightmares and flashbacks triggered by certain specific stimuli that cause overwhelming fight-flight reactions. Chronic depression with insomnia and fearfulness frequently incapacitate and isolate.

Both groups have come to realize that cannabis is less toxic or harmful than alcohol, opiods, and other psychotropics in their continuing struggles with indelible memories and their physiologic concomitants. Cannabis is used to relieve depression, decrease emotional overreactivity, and sleep deficit.

The alternative medical movement represents a populist rebellion against conventional medicine for treating chronic relapsing illness that include alcohol and other drug dependencies. Cannabis self medication has been discovered to be a viable alternative to treat these conditions that may enhance or substitute for conventional pharmacotherapy.  —THM Berkeley, CA 10/6/99