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ABSTRACT. Ninety-two Northern Californians who use cannabis as an
alternative to alcohol obtained letters of approval from the author. Their
records were reviewed to determine characteristics of the cohort and ef-
ficacy of the treatment, which was defined as reduced harm to the pa-
tient. All patients reported benefit, indicating that for at least a subset of
alcoholics, cannabis use is associated with reduced drinking. The cost of
alcoholism to individual patients and society at large warrants testing of
the cannabis-substitution approach and study of the drug-of-choice phe-
nomenon. [Article copies available for a fee from The Haworth Document De-
livery Service: 1-800-HAWORTH. E-mail address: <docdelivery@haworthpress.
com> Website:  2004 by The Haworth Press,
Inc. All rights reserved.]
KEYWORDS. Addiction, alcohol, alcoholism, cannabis, depression,
drug-of-choice, harm reduction, marijuana, pain
INTRODUCTION
Physicians who treat alcoholics are familiar with the cycle from drunkenness and disinhibition to withdrawal, drying out, and apologyfor behavioral lapses, accompanied over time by illness and debility as Tod H. Mikuriya, MD, is Psychiatric Medical Consultant, Berkeley, CA, and Presi- dent, California Cannabis Research Medical Group.
Address correspondence to: Tod H. Mikuriya, MD, 1186 Sterling Avenue, Berke- ley, CA 94798-1757 (E-mail: [email protected]).
Journal of Cannabis Therapeutics, Vol. 4(1) 2004  2004 by The Haworth Press, Inc. All rights reserved.
Digital Object Identifier: 10.1300/J175v04n01_04 the patient careens from one crisis to another. “Harm reduction” is atreatment approach that seeks to minimize the occurrence of drug/alco-hol addiction and its impacts on the addict/alcoholic and society atlarge. A harm-reduction approach to alcoholism adopted by 92 of mypatients in Northern California utilizes the substitution of cannabis,with its relatively benign side-effect profile, as the intoxicant of choice.
No clinical trials of the efficacy of cannabis as a substitute for alcohol are reported in the literature, and there are no papers directly on pointprior to my own account (Mikuriya 1970) of a patient who used canna-bis consciously and successfully to discontinue her problematic drink-ing.
There are ample references, however, to the use of cannabis as a sub- stitute for opiates (Birch 1889) and as a treatment for delirium tremens(Clendinning 1843; Moreau 1845), which were among the first uses byEuropean physicians. The 1873 Indian Government Finance Depart-ment Resolution recommended against suppressing cannabis use forfear that people (p. 1395) “would in all probability have recourse tosome other stimulant such as alcohol.” The Indian Hemp Drugs Commission Report of (1893-1894) articu- lated the same concern (p. 359): “. . . driving the consumers to have re-course to other stimulants or narcotics which may be more deleterious.”Birch (1889) described a patient weaned off alcohol by use of opiateswho then became addicted and was weaned off opiates by use of canna-bis. He noted (p. 625), “Ability to take food returned. He began to sleepwell; his pulse exhibited some volume; and after three weeks he wasable to take a turn on the verandah with the aid of a stick. After sixweeks he spoke of returning to his post, and I never saw him again.” Birch feared that cannabis itself might be addictive, and recom- mended against revealing to patients the effective ingredient in theirelixir (p. 625), “Upon one point I would insist–the necessity of conceal-ing the name of the remedial drug from the patient, lest in his endeavorto escape from one form of vice he should fall into another, which canbe indulged with facility in any Indian bazaar.” This stern warning mayhave undercut interest in the apparently successful two-stage treatmenthe was describing.
At the turn of the 19th century in the United States, cannabis was listed as a treatment for delirium tremens in standard medical texts(Edes 1887; Potter 1895) and manuals (Lilly 1898; Merck 1899; ParkeDavis 1909). Since delirium tremens is associated with advanced alco-holism, we can adduce that patients who were prescribed cannabis andused it on a long term basis were making a successful substitution.
By 1941, due to its prohibition, cannabis was no longer a treatment option, but attempts to identify and synthesize its active ingredientscontinued (Loewe 1950). A synthetic THC called pyrahexyl was madeavailable to clinical researchers, and one paper from the postwar periodreports its successful use in easing the withdrawal symptoms of 59 outof 70 alcoholics (Thompson and Proctor 1953).
In 1970 the author reported (Mikuriya 1970) on Mrs. A., a 49-year- old female patient whose drinking had become problematic. The patienthad observed that when she smoked marijuana socially on weekendsshe decreased her alcoholic intake. She was instructed to substitute can-nabis any time she felt the urge to drink. This regimen helped her to re-duce her alcohol intake to zero. The paper concluded (p. 175), “It wouldappear that for selected alcoholics the substitution of smoked cannabisfor alcohol may be of marked rehabilitative value. Certainly cannabis isnot a panacea, but it warrants further clinical trial in selected cases of al-coholism.” The warranted research could not be carried out under conditions of prohibition in the USA, but in private practice and communicationswith colleagues I encountered more patients like Mrs. A. and general-ized that somewhere in the experience of certain alcoholics, cannabisuse is discovered to overcome pain and depression, target conditions forwhich alcohol is originally used, but without the disinhibited emotionsor the physiologic damage. By substituting cannabis for alcohol, pa-tients were able to reduce the harm their intoxication caused themselvesand others.
Although the increasing use of marijuana starting in the late ’60s had renewed interest in its medical properties, including possible use as analternative to alcohol (Scher 1971), meaningful research was preventeduntil the 1990s, when the establishment of “buyers clubs” in Californiacreated a potential database of patients who were using cannabis to treata wide range of conditions. The medical marijuana initiative passed byvoters in 1996 mandated that prospective patients obtain a doctor’s ap-proval in order to treat a given condition with cannabis, resulting in anestimated 30,000 physician approvals as of May 2002 (Gieringer2003).
In a review of my records in the spring of 2002, 92 patients were identified as using cannabis to treat alcohol abuse and related problems.
This paper describes characteristics of that cohort and the results oftheir efforts to substitute cannabis for alcohol.
METHODOLOGY
Identifying Alcoholism
The initial consultation (20 minutes) provided multiple opportunities to identify alcoholism as a problem for which treatment with cannabismight be appropriate. The intake form asked patients to state their rea-son for contacting the doctor, and enabled them to prioritize their pres-ent illnesses and describe the course of treatment to date. The form alsoasked patients to identify any non-prescribed psychoactive drugs theywere taking (including alcohol), and invited remarks. A specific ques-tion concerned injuries incurred “while or after consuming alcohol.”Examination of medical records provided an additional opportunity toidentify alcohol abuse, as did the taking of a verbal history.
Evaluating Efficacy
At follow-up visits (typically at 12-month intervals), patients were asked to list the conditions they had been treating with cannabis and toevaluate their status as “stable,” “improved,” or “worse.” Patients wereasked to evaluate the efficacy of cannabis (five choices from “very ef-fective to “ineffectual”) and to describe any adverse events. Patientswere also asked to describe any changes in their “living and employ-ment situation,” and if so, to elaborate. The question about use ofnon-prescribed psychoactive drugs, including alcohol, was repeated.
Comparison of responses in a given patient’s initial and follow-up ques-tionnaires enabled assessment of the utility of cannabis as an alternativeto alcohol.
Patient Background
Gieringer (2003) notes that (p. 55), “Many patients who find mari- juana helpful for otherwise intractable complaints report that their phy-sicians are fearful of recommending it, either because of ignoranceabout medical cannabis, or because they fear federal punishment orother sanctions. This is especially true in regions where the use of mari-juana is less familiar and accepted.” The patients whose records formthe basis for this study were all seen in ad hoc settings arranged by localcannabis clubs, 88 in rural counties of Northern California, four in theSan Francisco Bay Area. They form a special but not unique subset,having intentionally sought out a physician whose clinical use of canna- bis and confidence in its versatility and relative safety was extensiveand well known in their communities.
A majority of the patients identified themselves as blue-collar work- ers: carpenter (5), construction (3), laborer (3), waitress (3), truck driver(3), fisherman (3), heavy equipment operator (3), painter (2), contractor(2), cook (2), welder (2), logger (2), timber faller, seaman, hardwoodfloor installer, bartender, building supplies, house caretaker, ranchhand, concrete pump operator, cable installer, silversmith, stone mason,boatwright, auto detailer, tree service-handyman-cashier, nurseryman,glazier, gold miner, carpet layer, carpenter’s apprentice, landscaper,river guide, screenprinter, and glassblower.
Eleven were unemployed or did not list an occupation; four were dis- abled, two retired, and two patients defined themselves as mothers. Oth-ers were in sales (5), musicians (5), clerical workers (3), paralegal,teacher, actor, actress, artist, sound engineer, and computer technician.
Eighty-two of the patients were male. Patients’ ages ranged from 20 to69. Twenty-nine were in their twenties; 16 in their thirties; 24 in theirforties; 20 in their fifties; and three in their sixties. Exactly half (46 pa-tients) had taken some college courses, but only four had college de-grees. Five did not complete high school. Thirteen were veterans, allbranches of the Armed Forces being represented. All but six (five na-tive-Americans, one African-American) were Caucasian. Slightly morethan half (49) reported being raised by at least one addict/alcoholic par-ent.
Prioritizing Alcoholism
Fifty-nine of the patients identified alcoholism or cirrhosis of the liver as their primary medical problem. Secondary and tertiary prob-lems reported by this group were depression (19), pain (17), insomnia(15), arthritis (8), anxiety/stress (8), PTSD (3), cramps (4), hepatitis C(4), gastritis (2), ADHD (2), cramps/PMS (3), scoliosis, irritable bowelsyndrome, glaucoma, and anorexia.
Thirty-three patients identified themselves as alcohol abusers, but re- ported other problems as more significant: pain (12), depression (7),anxiety/stress (6), headache/migraines (5), insomnia (5), head injuries(3), bipolar disorder (3), arthritis (2), asthma (2), spinal cord injury/dis-ease (2), gastritis (2), paraplegia, ADHD, multiple broken bones, Par-kinson’s, and cramps.
Nineteen patients reported having been injured while or after drink- Fourteen had incurred legal problems or been ordered into rehab pro- Cannabis Use/Awareness of Medicinal Effect
Patients were asked when they started using cannabis and when they realized it exerted a medicinal effect. Three reported first using at age 9or younger; 61 between ages 10 and 19; nine began using in their 20s;three in their 30s; six in their 40s; two at age 50; and one at age 65.
Twenty-four patients reported realizing immediately upon using canna-bis that it exerted a beneficial medical effect. Some of their responsesstill seem to reflect their relief at the time: • “In 1980 I had quit drinking for a month. My niece asked me if I ever tried marijuana to calm me down. So I tried it and it workedlike a miracle.” • “Helped pain very much! Helped sleep–excellent.” Thirty-five patients answered ambiguously with respect to time: “When realized preferred to alcohol,” for example, or, “when I smokedwhen suffering.” Seven reported becoming aware of medical effect within a year of us- ing cannabis. Ten became aware within one to five years. Three becameaware of medical effect 12-15 years after first using. Ten became awarebetween 20 and 30 years after first using. All but one of these patientshad resumed using cannabis after years of abstinence.
Use of OTC and Prescription Drugs
Patients were asked to list other drugs (prescribed, over-the-counter, and herbal) that they were currently using or had used in the past to treattheir illnesses. Most common of the prescription drugs were SSRIs(31), opiates (23), NSAIDs (18), disulfuram (15), and Ritalin® (methyl-phenidate) (8).
Delivery Systems
Seventy-eight patients smoked joints, the average amount being one joint a day (assuming 3.5 joints per 1/8 ounce of high-quality mari- juana). Twelve patients reported using a pipe, and three owned vaporiz-ers. All were strongly advised that smoking involves an assault on thelungs, and that vaporization is a safer method of inhaling cannabinoids.
OBSERVATIONS
Alcoholic Parents
A slight majority of patients (51) reported being raised by at least one alcoholic parent. This is not surprising. The children of alcoholics enteradulthood with two strikes. They have endured direct emotional abuseand/or abandonment by parent(s), and they lack role models for copingwith uncomfortable feelings other than by inebriation. It is to be ex-pected that many, when encountering problems early in life, are treatedwith, or seek out, mind-altering drugs.
Reported Efficacy
As could be expected among patients seeking physician approval to treat alcoholism with cannabis, all reported that they’d found it “veryeffective” (45) or “effective” (38). Efficacy was inferred from other re-sponses on seven questionnaires. Two patients did not make follow-upvisits but had reported efficacy at the initial interview.
Nine patients reported that they had practiced total abstinence from alcohol for more than a year and attributed their success to cannabis.
Their years in sobriety: 19, 18, 16, 10, 7, 6, 4 (2), and 2.
Patients who reported a return of symptoms when cannabis was dis- continued (19), ranged from succinct to dramatic: • “I started drinking a lot more.”• “More anxiety, less happiness.”• “Use alcohol when cannabis isn’t available.”• “If I don’t have anything to smoke, I usually drink a lot more.”• “I quit using cannabis while I was in the army and my drinking doubled. I was also involved in several violent incidents due to al-cohol.
• “My caretaker got arrested and I lived too far from the city to pur- chase at a club, and I started doing heroin again and almost killedmyself and some of my friends.” • “Stress level becomes higher, become more uptight. Went back to drinking in the 1970s.”–A female patient with 19 years of sobriety.
Several patients specifically noted that cannabis use reduced the • “I crave alcohol when I can’t smoke marijuana.”• “Had to quit drinking at 48 yrs. old. Found cannabis helped stop the urge to drink.”–A 69-year-old commercial fisherman.
Three patients reported a sad irony: they had “fallen off the wagon” when they had to stop using cannabis in anticipation of drug tests. Pa-tient S., a 27-year-old cable installer, had six alcohol-related arrests byage 21, “. . . after not smoking herb (for probation drug test) and black-ing out on alcohol, I found my drinking getting out of hand and I begangetting into more trouble.” He later relapsed when denied use of canna-bis at a residential treatment facility.
Cannabis for Analgesia
The large number of patients using cannabis for pain relief (29) re- flects the high percentage of blue-collar workers who suffer musculo-skeletal injury during their careers. As expressed by a carpenter, “Nobodygets to age 40 in my business without a bad back.” Nurses who must liftgurneys, farm workers, desk-bound clerical workers, and many othersare also prone to chronic back and neck pain.
Fights and accidents (vehicular, sports- and job-related) also create chronic pain patients, many of whom self-medicate with alcohol.
Eighteen patients reported having been injured while or after drink- ing heavily. This comment by a 26-year-old truck driver describes atypical chain-reaction of alcohol-induced trouble: “Injured in a fight af-ter consuming alcohol, resulted in staph infection of right knuckle, mi-nor surgery and four days in hospital.” Injuries suffered while drunk addto pain and the need for relief by alcohol, or a less destructive alterna-tive.
A total of 29 patients reported using cannabis for both pain relief and as an alternative to alcohol. A 47-year-old landscaper was run over by avehicle at age 5, requiring multiple surgeries and leaving him with pinsin his right ankle: “Given pain pills for my right ankle, I got too drowsy.
Smoked herb to relieve pain.” After he had to discontinue cannabis use, he reported, “was unable to ease pain in ankle without herb, and drinkwhen unable to have cannabis to smoke.” Cannabis for Mood Disorders
Twenty-six patients reported using cannabis to treat depression (44 if the category is expanded to include anxiety, stress, and PTSD), andtheir comments frequently touched on the negative synergies betweenmood disorders and alcoholism. A 44-year-old paralegal, sufferingfrom depression, alcoholism, and PMS, noted simply, “Alcohol causesmore depression.” When she did not have access to cannabis, she noted,“Alcohol consumption increases and so does depression.” At her initialvisit she reported consuming 5-10 drinks/day. At a follow-up visit (after16 months) she had confined her consumption to weekend usage.
A 33-year-old river guide (and decorated Army vet) put it this way: “I have had a problem with violence and alcohol for a long time and Ihave a rap sheet to prove it. None of the problems occurred while usingcannabis. Not only does cannabis prevent my violent tendencies, but italso helps keep me from drinking.” On his follow-up visit (12 months)this patient reported improved communication with family membersand fewer problems relating to other people. His alcohol consumptionhad decreased from 36 drinks/week to zero (one month of sobriety).
Patient L.G. presented initially at age 35 as homeless and unem- ployed, suffering “severe depression. Anxiety. Pain.” Her problem withalcohol was inferred from her response concerning non-medical-psy-choactive drug use: “I drink and smoke too much–started when I couldn’tget marijuana.” L.G. had requested a recommendation for cannabisfrom a Humboldt County physician but, as she recounted, “I’m paranoidand local doctors are scared, too. They gave me Paxil® [paroxetine] andstop smoking pamphlet.” At a follow-up visit (14 months), L.G. re-ported a change in circumstance: “Now have a room. But am on G.R.
[General Relief] and am paying too much.” She was still using alcohol“a little. I’m doing good dealing with not drinking. Being able to medi-cate with cannabis has helped a lot.” Eighteen months later the patternhadn’t changed: “Alcohol several times/week. Depends on if I havecannabis, stress still triggers.” Fewer Adverse Side-Effects
Compared with NSAIDs, steroids, SSRIs, opioids, and benzodiaze- pines, cannabis has a benign side-effect profile. In acute conditions these other drugs may be tolerable, but taking them to treat chronic con-ditions may be worse than the illness. Patients’ comments on their pre-scribed analgesics and anti-depressants tended to be negative withrespect to efficacy (22), side-effects (26) and cost (15), not surprising,perhaps, in a cohort seeking an herbal alternative.
Patient R.B. presented as a 41-year-old alcoholic also suffering from ar- thritis, pain from knee and ankle surgeries, and depression, for which hehad been prescribed Librium® (chlordiazepoxide), Valium® (diazepam),Buspar® (buspirone), Welbutrin® (bupropion), Effexor® (venlafaxine),Zoloft® (sertraline), and Depakote® (valproate) over the years; “Nohelp!” he wrote bluntly. On his return visit (one year) he reported “fewrelapses” and was able to take some classes.
The dulling effects of Vicodin® (hydrocodone) and other opiates were mentioned by seven patients. As patient P.B. put it, “When I canget Vicodin it helps the pain but I don’t like being that dopey.” Patient S.F., whose skull was badly damaged in an accident, also ap- preciated the pain relief but asserted that opiates (obtained through theVeterans’ Administration) “made me paranoid and mean.” Patient C.A., who was diagnosed with attention-deficit hyperactivity disorder (ADHD) in ninth grade, touches on some recurring themes indescribing the treatment of his primary illness: “I was prescribed Ritalinand Zoloft. The Ritalin helped me concentrate slightly but caused me tobe up all night. The Zoloft made me sick to my stomach and never re-lieved my stress or depression. I have never been prescribed anythingfor my insomnia but I usually have to drink some liquor to get to sleep. Ithink that is a bad thing as I have now begun to drink excessive amountsof whisky, which has really started to affect my stomach.” C.A. first used cannabis at age 19 and became aware of benefits im- mediately. “I found myself running to the refrigerator and then sleepingbetter than I had for years.” At age 21 he fears permanent damage.
“From drinking (I believe) my stomach has been altered, along with myappetite . . . I cannot really eat that much and feel malnourished andweaker than a 21-year-old should. My joints ache constantly and I amnot as strong as I used to be. I also fear that I will become or am an alco-holic and I do not want to see myself turn into my dad.” At his follow-up visit (12 months), C.A. reported cannabis to be “very effective.” He was employed, “not partying,” doing well socially,and trying to give up cigarettes.
Interactions, Positive and/or Negative
Several patients (3) indicated that cannabis had a welcome amplify- ing effect on the efficacy of other medications. As cannabis comes intowider use in California and elsewhere, it is important that its interac-tions with other medications be studied and publicized.
DEFINING SUCCESS
The harm-reduction approach to alcoholism is based on the recogni- tion that for some patients, total abstinence has been an unattainablegoal. Success is not defined as the achievement of perpetual sobriety. Atreatment may be deemed helpful if it enables a patient to reduce the fre-quency and quantity of alcohol consumption; if drunken episodes and/or blackouts are reduced; and if success in the workplace can be achieved;if specific problems induced by alcohol (suspended driver’s license, forexample) can be resolved; and if ineffective or toxic drugs can be avoided.
As noted, all of the patients in this study were seeking physician’s ap- proval to use cannabis medicinally, a built-in bias that explains the veryhigh level of efficacy reported. However, the vast majority presentedwith comorbid conditions, and would have qualified for physician’s ap-proval to use cannabis whether or not they reported efficacy with re-spect to alcoholism.
Although medicinal use of cannabis by alcoholics can be dismissed as “just one drug replacing another,” lives mediated by cannabis and al-cohol tend to run very different courses. Even if use is daily, cannabisreplacing alcohol (or other addictive, toxic drugs) reduces harm be-cause of its relatively benign side-effect profile. Cannabis-only usage isnot associated with car crashes; it does not damage the liver, the esopha-gus, the spleen or the digestive tract.
The chronic alcohol-inebriation-withdrawal cycle ceases with suc- cessful cannabis substitution. Sleep and appetite are restored, ability tofocus and concentrate is enhanced, energy and activity levels are im-proved, and pain and muscle spasms are relieved. Family and social re-lationships can be sustained as pursuit of long-term goals ends the cycleof crisis and apology.
Patient M.S., a 42-year-old journeyman carpenter, is a success story from a harm-reduction perspective. At his initial visit he defined hisproblem as “intermittent explosive disorder,” for which he had beenprescribed Lithium. Although drinking eight beers a day, he reported “Cannabis has allowed me to just drink beer when I used to blackoutdrink vodka and tequila.” By the time of a follow-up visit (12 months),Mark had been sober for four months. He also reported, “anger out-breaks less severe, able to complete projects,” and, poignantly, “para-noia is now mostly realism.” He plans to put his technical skill to use indesigning a vaporizer.
THE DOCTOR-PATIENT RELATIONSHIP
As a certified addictionologist, I have supervised both inpatient and outpatient treatment for thousands of patients since 1969. In the tradi-tional alcoholism medical-treatment model, the physician is an author-ity figure to a patient whose life has spun out of control. The patiententers under coercive circumstances, frequently under court order, withphysiologies in toxic disarray. Transference dynamics cast the physi-cian into a parental role, producing the usual parent-child conflicts. Af-ter detoxification when cognition has returned from the confusionalstate of withdrawal, the patient leaves, usually with powers of denial in-tact. Follow-up outpatient treatment is oriented to Alcoholics Anony-mous (AA) and/or pharmacological substitutes.
Treating alcoholism by cannabis substitution creates a different doc- tor-patient relationship. Patients seek out the physician to confer legiti-macy on what they are doing or are about to do. My most importantservice is to end their criminal status, Aeschalapian protection from thecriminal justice system, which often brings an expression of relief. Analliance is created that promotes candor and trust. The physician is per-mitted to act as a coach or an enabler in a positive sense.
As enumerated by patients, the benefits can be profound: self-respect is enhanced; family and community relationships improve; a sense ofsocial alienation diminishes. A recurrent theme at follow-up visits is thedeveloping sense of freedom as cannabis use replaces the intoxica-tion-withdrawal-recovery cycle, freedom to look into the future andplan instead of being mired in a dysfunctional past and present; andfreedom from crisis and distraction, making possible pursuit of long-term goals that include family and community.
RE: ALCOHOLICS ANONYMOUS
Although nine patients made voluntary reference to attending AA meetings (three presently, six in the past), it is likely that many more ac- tually tried the 12-step program, but the question was not posed on theintake form. A future study should examine the relationship betweencannabis-only users and Alcoholics Anonymous. At AA meetings, can-nabis use is considered a violation of sobriety. This puts cannabis-onlyusers in a bind. Those who attend meetings can’t practice the “rigoroushonesty” that AA considers essential to recovery; and those who avoidmeetings are denied support and encouragement that might help them tostay sober. Support-group meetings at which cannabis-only users arewelcome would be a positive development.
Patient T.H., first seen at age 29, was diagnosed as an alcoholic in 1987 and began attending AA meetings, which he found helpful al-though he could not achieve sustained sobriety. In 1998, after realizingthat cannabis reduced his cravings for alcohol, he received approval touse it. At a follow-up in November ’99, he reported, “Have stoppeddrinking for the first time in many years. I have not taken a drink of al-cohol in 14 months. I attribute some credit for this to daily use of canna-bis. My life has improved with this treatment.” T.H. was seen again in April 2001 and reported, “I continue to main- tain sobriety regarding alcohol. Have not had a drink for 2 1/2 years. Idrank alcohol heavy for about 10 years, and had difficulty stoppingdrinking and staying stopped until I began this treatment. Pain symp-toms from back spasms/scoliosis also better.” FACTORS IN DRUG OF CHOICE
Experimentation with drugs and alcohol typically begins in adoles- cence and participants in the present study fit the well established pattern.
It is also in adolescence that most individuals select a drug-of-choice.
Factors in the process have not been thoroughly studied, but drug-of-choice is not simply a function of an individual’s brain chemistry;social group plays a key role (Carstairs 1951).
Carstairs spent a year in a large village in northern India where the two highest castes, Rajputs and Brahmins, consumed alcohol and can-nabis, respectively. The Rajputs were the warriors and governors; theyviewed the alcohol-inspired release of emotions, notably sexual and ag-gressive impulses, as admirable. The Brahmins were the religious lead-ers whose emphasis on self-denial included (p. 79.), “the avoidance ofanger and or any other unseemly expression of personal feelings; absti-nence from meat and alcohol is a prime essential.” Carstairs’goal was to understand how the Brahmins could rationalize There are alternative ways of dealing with sexual and aggressiveimpulses besides repressing them and then ‘blowing them off’ inabreactive drinking bouts in which the superego is temporarilydissolved in alcohol. The way which the Brahmins have selectedconsists in a playing down of all interpersonal relationships in obe-dience to a common, impersonal set of rules of Right Behavior . . .
Whereas the Rajput in his drinking bout knows that he is taking aholiday from his sober concerns, the Brahmin thinks of his intoxi-cation with bhang as a flight not from but toward a more profoundcontact with reality.
Two aspects of Carstairs’ report resonate strongly with my own ob- 1. The disinhibition achieved via alcohol is the Rajput kind, a flight from reality, becoming “blotto,” whereas the disinhibition achievedvia cannabis is the result of focused or amplified contemplation.
2. “Drug of choice” tends to be–perhaps invariably is–determined by social factors, and, once determined, becomes a defining ele-ment of individual self-image, i.e., possible but not easy to changein adulthood. Undoubtedly, alcohol’s status as a legal drug that iswidely advertised and can be purchased virtually anywhere influ-ences the number of college students and other young adults whomake it their initial drug of choice. Perhaps the firmer implemen-tation of California’s medical marijuana law will make it possibleto study whether young adults with a family history of alcoholism,given no legal obstacle to using cannabis as an alternative to alco-hol, would do so, with positive results.
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