The Report of the National Commission on Marihuana and Drug Abuse
Marihuana: A Signal of MisunderstandingCommissioned by President Richard M. Nixon, March, 1972
The National Commission on Marihuana and Drug Abuse
Marihuana: A Signal of Misunderstanding
Table of Contents
I. Marihuana and the Problem of Marihuana
Origins of the Marihuana Problem
The Need for Perspective
The Search for Meaning
The Limits of Rationality
Formulating Marihuana Policy
II. Marihuana Use and Its Effects
The Marihuana User
Patterns of Use
Profiles of Users
Moderate and Heavy Users
Very Heavy Users
Becoming a Marihuana User
Situational Factors and Behavioral Correlates
Social Group Factors
The Dynamics of Persistent Use
Becoming a Multidrug User
Profiles and Dynamics
Effects of Marihuana on the User
Botany and Chemistry
Factors Influencing Drug Effect
Method of Use
Set and Setting
Duration of Use
Patterns of Use
Definition of Dependence
Effects Related to Pattern Use
Immediate Drug Effects
The Intoxicated State
Long Term Effects
Very Long Term Effects
Tolerance and Dependence
General Body Function
Motivation and Behavioral Change
III. Social Impact of Marihuana Use
Marihuana and Public Safety
Marihuana and Crime
The Issue of Cause and Effect
Marihuana and Violent Crime
Marihuana and Non Violent Crime
A Sociocultural Explanation
Marihuana and Driving
Marihuana, Public Health and Welfare
A Public Health Approach
The Population at Risk
Confusion and Fact
Assessment of Perceived Risks
Potential for Genetic Damage
Effects of LongTerm, Heavy Use
Progression to Other Drugs
Preventive Public Health Concerns
Marihuana and the Dominant Social Order
The Adult Marihuana User
The Young Marihuana User
The World of Youth
Why Society Feels Threatened
Youth and Radical Politics
Youth and the Work Ethic
The Changing Social Scene
IV. Social Response to Marihuana Use
The Initial Social Response
The Current Response
The Criminal Justice System
Law Enforcement Behavior
Law Enforcement Opinion
The Non Legal Institutions
The Medical Community
The Public Response
V. Marihuana and Social Policy
Drugs in a Free Society
Drugs and Social Responsibility
A Social Control Policy for Marihuana
Approval of Use
Elimination of Use
Discouragement or Neutrality
Implementing the Discouragement Policy
The Role of Law in Effective Social Control
Recommendations for Federal Law
Recommendations for State Law
Discussion of Federal Recommendations
Discussion of State Recommendations
Discussion of Potential Objections
A Final Comment
Part One -- Biological Aspects
II. Biological Effects of Marihuana
Botanical and Chemical Considerations
Factors Influencing Psychopharmacological Effect
Route of Administration
Quantification of Dose Delivered
Effect of Pyrolysis on the Cannabinoids
Set and Setting
Pattern of Use
Amount of Drug Consumed
Duration of Use
Interaction With Other Drugs
Acute Effects of Marihuana (Delta 9 THC)
Effects on Mentation and Psychomotor Performance
The Intoxicated Mental State
Unpleasant Reactions - Too Stoned and Novice Anxiety
Persistent Effects After Acute Dose
Effects of Marijuana on Concomitant Behavior
Effects of Short-Term or Subacute Use
Effects of Long-Term Cannabis Use
Dependence And Tolerance
Genetics and Birth Defects
Organic Brain Damage
I -- marihuana and the problem of marihuana"There are no whole truths; all truths are half -truths. It is trying to treat them as whole truths that plays the devil."
Alfred North Whitehead (1953)
We are a nation of problem-solvers. We are restless and impatient with perceived gaps between the way things are and the way we think ought to be. Understandably, such an impulse toward self-correction never leaves us wanting for social problems to solve. Although it is a prerequisite to social progress, this problem-solving orientation misdirects our attention. In order to maximize public awareness we are apt to characterize situations as being far worse than they really are. Because any activity is commonly regarded as a move toward a solution, rhetoric and stopgap legislation sometimes substitute for rational reflection. We become so impressed with social engineering that we overlook inherent human limitations.
Since the mid-sixties, American society has been increasingly agitated by what has been defined as a marihuana problem. The typical sequences of "a national problem" have resulted: exaggeration, polarization and the inevitable demand for a. solution. The appointment of this Commission and the publication of this Report reflect the escalation of marihuana use into the realm of social problem. Since the beginning of our official life, we have grappled with the threshold question: Why has the use of marihuana reached problem status in the public mind?
Origins of the Marihuana Problem
Marihuana has been used as an intoxicant in various parts of the world for centuries and in this country for 75 years. Yet use of the drug has been regarded as a problem of major proportions for less than a decade. We will not find the reasons for contemporary social concern in pharmacology texts or previous governmental reports, for we are dealing with two separate realities: a drug with certain pharmacologic properties and determinable, although variable, effects on man; and a pattern of human behavior, individual and group, which has, as a behavior, created fear, anger, confusion, and uncertainty among a large segment of the contemporary American public. The marihuana behavior pattern is the source of the marihuana controversy.
The most apparent feature of the behavior is that it is against the law. But inconsistency between behavior and the legal norm is not sufficient, in itself, to create a social problem. Marihuana, has been an illegal substance for several decades; and the widespread violation of laws against gambling and adultery have not excited the public to the same extent as has marihuana-smoking in recent years.
At the same time, we suspect that illegality may play an important role in problem definition where drugs are concerned. Alcohol is of proven danger to individual and societal health and the public is well aware of its dangers, yet use of this drug has not been accorded the same problem status. Marihuana's illegality may have been a necessary condition for the marihuana problem, but the increased violation of the legal proscription does not by itself explain the phenomenon.
The Commission believes that three interrelated factors have fostered the definition of marihuana as a major national problem. First, the illegal behavior is highly visible to all segments of our society. Second, use of the drug is perceived to threaten the health and morality not only of the individual but of the society itself. Third, and most important, the drug has evolved in the late sixties and early seventies, as a symbol of wider social conflicts and public issues.
More than anything else, the visibility of marihuana use by a segment of our population previously unfamiliar with the drug is what stirred public anxiety and thrust marihuana into the problem area. Marihuana usage in the United States has been with us for a very long period of time, dating back to the beginning of the century. For decades its use was mainly confined to the underprivileged socioeconomic groups in our cities and to certain insulated social groups, such as jazz musicians and artists. As long as use remained confined to these groups and had a negligible impact on the dominant social order, the vast majority of Americans remained unconcerned. From the other side, the insulated marihuana user was in no position to demand careful public or legislative scrutiny.
However, all this changed markedly in the mid-1960's. For various reasons, marihuana use became a common form of recreation for many middle and upper class college youth. The trend spread across the country, into the colleges and high schools and into the affluent suburbs as well. Use by American servicemen in Vietnam was frequent. In recent years, use of the drug has spanned every social class and geographic region.
The Commission-sponsored National Survey, "A Nationwide Study of Beliefs, Information and Experiences," indicated that some 24 million Americans have tried marihuana at least once and that at least 8.3 million are current users.
Other surveys uniformly indicate that more than 40% of the U.S. college population have tried marihuana, and in some universities the figure is much higher. Also, use of the drug has become almost as common among young adults out of college, and among older teenagers in high school. The National Survey indicates that 39%, of young adults between 18 and 25 years of age have tried marihuana. The stereotype of the marihuana user as a marginal citizen has given way to a composite picture of large segments of American youth, children of the dominant majority and very much a part of the mainstream of American life.
Public confusion, anger, and fear over this development became increasingly apparent during the mid and late 1960's. Such mass deviance was a problem and the scope of the problem was augmented by frequent publicity. The topic of the usage of marihuana by the young received considerable attention from newspapermen and television reporters. The drug's youthful users abetted the media in this regard by flaunting their disregard of the law, Few of us have not seen or heard of marihuana being used en masse at rock concerts, political demonstrations and gatherings of campus activists.
In addition, new scientific and medical interest in marihuana and its use was stimulated by the sudden public interest. For the first time in the American experience, the drug became the subject of intensive scrutiny in the laboratories and clinics. Unfortunately, this research was conducted in the spotlight of public controversy. Isolated findings and incomplete information have automatically been presented to the public, with little attempt made to place such findings in a larger perspective or to analyze their meanings.
Any new marihuana research has had ready access to the news spotlight and often has been quickly assimilated into the rhetoric of the marihuana, debate. Science has become a weapon in a propaganda battle. Because neither the reporters nor the public have the expertise to evaluate this information, the result has been an array of conflicting anecdotal reports, clinical studies on limited populations, and surveys of restricted utility.
Visibility, intense public interest, and fishbowl research are all important components of the marihuana problem.
The symbolic aspects of marihuana are the, most intangible of the items to which the Commission must address itself, and yet they may be at the heart of the marihuana problem. Use of marihuana was, and still is, age-specific. It was youth-related at a time in American history when the adult society was alarmed by the implications of the youth " movement": defiance of the established order, the adoption of new life styles, the emergence of "street people," campus unrest, drug use, communal living, protest politics, and even political radicalism. In an age characterized by the so-called generation gap, marihuana symbolizes the cultural divide.
For youth, marihuana became a convenient symbol of disaffection with traditional society, an allure which supplemented its recreational attraction. Smoking marihuana may have appealed to large numbers of youth who opposed certain policies or trends, but who maintained faith in the American system as a whole. In ;a time when symbolic speech is often preferred to the literal form, marihuana was a convenient instrument of mini-protest. It was also an agent of group solidarity, as the widely-publicized rock concerts so well illustrate.
For the adult society, the decade of the sixties was a distressing time. The net effect of racial unrest, campus disruption, political assassination, economic woes and an unpopular war was widespread uneasiness. Attending a general fear that the nation was witnessing its own disintegration was a desire to shore up our institutions and hold the line. That line was easy to define where drugs, particularly marihuana, were concerned.
Use of drugs, including marihuana, is against the law. For many, marihuana symbolized disorder in a society frustrated by increasing lawlessness. Insistence on application of the law tended also to harden views, thereby escalating still further the use of marihuana as a symbolic issue.
The social conflicts underlying the drug's symbolic status have dissipated somewhat in the past few years; and in some ways, the Commission has similarly noted a partial deflation of the marihuana problem and of the emotionalism surrounding it. We are hopeful that our attempt to clarify the scientific and normative dimensions of marihuana use will further deemphasize, the problem orientation and facilitate rational decision-making.
The Need for PerspectiveThis Commission has the task of exploring the marihuana controversy from as many vantage points as possible in its attempt to make sound, realistic and workable policy recommendations. Because we are dealing essentially with a complex social concern rather than a simple pharmacologic phenomenon, any social policy decision must discuss the realities of marihuana as a drug, marihuana use as a form of behavior, and marihuana as a symbol.
Particularly important is the determination of the longevity of the behavior. Are we dealing with a behavior that is becoming rooted in our culture or are we experiencing an aberration, a fad that will in time, of its own accord, pass away?
The vortex of the marihuana controversy is the present, but the prudent policy planner must not be blinded by the deluge of recent statistics. It is important that we scan the past for clues about the meaning of certain behavior and the promise offered by various social policy responses. We are convinced that a wider historical understanding will also go a long way toward deflating marihuana as a problem.
HISTORICAL PERSPECTIVEWhen viewed in the context of American society's ambivalent response to the non-medical use of drugs, the marihuana problem is not unique. Both the existing social policy toward the drug and its contemporary challenge have historical antecedents and explanations. Somewhat surprisingly, until the last half of the 19th century, the only drugs used to any significant extent for non-medical purposes in this country were alcohol and tobacco.
American opinion has always included some opposition to the nonmedical use of any drug, including alcohol and tobacco. From colonial times through the Civil War, abstentionist outcries against alcohol and tobacco sporadically provoked prohibitory legislation. One 18th century pamphleteer advised against the use of any drink "which is liable to steal away a man's senses and render him foolish, irascible, uncontrollable and dangerous." Similarly, one 19th century observer attributed delirium tremens, perverted sexuality, impotency, insanity and cancer to the smoking and chewing of tobacco.
Despite such warnings, alcohol and tobacco use took deep root in American society. De Tocqueville noted what hard drinkers the Americans were, and Dickens was compelled to report that "in all the public places of America, this filthy custom [tobacco chewing] is recognized." Nonetheless, the strain in our culture opposed to all non-medical drug use persisted and in the late 19th century gained ardent adherents among larger segments of the population.
Beginning in earnest around 1870, abstentionists focused the public opinion process on alcohol. As science and politics were called to the task, public attention was drawn to the liquor problem. "Liquor is responsible for 19% of the divorces, 25% of the poverty, 25% of the insanity, 37% of the pauperism, 45% of child desertion and 50% of the crime in this country," declared the Anti-Saloon League. "And this," it was noted, "is a very conservative estimate."
The Temperance advocates achieved political victory during the second decade of the 20th century. By 1913, nine states were under statewide prohibition, and in 31 other states local option laws operated, with the ultimate effect that more than 50% of the nation's population lived under prohibition. Four years later, Congress approved the 18th Amendment and on January 16, 1919, Nebraska became the 36th state to ratify the Amendment, thus inscribing national Prohibition in the Constitution.
Although on a somewhat smaller scale and with lesser results, public attention was simultaneously attracted to a growing tobacco problem. Stemming partly from the immediate popularity of cigarette-smoking, a practice introduced after the Civil War, and partly from riding the coattails of abstentionist sentiment, anti-tobacconists achieved a measure of success which had previously eluded them. The New York Time editorialized in 1885 that:
The decadence of Spain began when the Spaniards adopted cigarettes and if this pernicious habit obtains among adult Americans, the ruin of the Republic is close at hand. . . .Between 1895 and 1921, 14 states banned the sale of cigarettes.
Although though there has been some posthumous debate about the efficacy of alcohol Prohibition as a means of reducing excessive or injurious use, the experiment failed to achieve its declared purpose: elimination of the practice of alcohol consumption. The habit was too ingrained in the society to be excised simply by cutting off legitimate supply.
In addition, the 18th Amendment never commanded a. popular consensus; in fact, the Wickersham Commission, appointed by President Hoover in 1929 to study Prohibition, attributed the Amendment's enactment primarily to public antipathy toward the saloon, the large liquor dealers and intemperance rather than to public opposition to use of the drug.
Subsequent observers have agreed that Prohibition was motivated primarily by a desire to root out the institutional evils associated with the drug's distribution and excessive use; only a minority of its supporters opposed all use. And in this respect, Prohibition succeeded. Upon repeal, 13 years after ratification, liquor was back, but the pre-Prohibition saloon and unrestrained distribution had been eliminated from the American scene.
Both the scope of the alcohol habit and the ambivalence of supporting opinion are manifested in the internal logic of Prohibition legislation. The legal scheme was designed to cut off supply, not to punish the consumer. Demand could be eliminated effectively, if at all, only through educational efforts. Only five states prohibited possession of alcohol for personal use in the home. Otherwise, under both federal and state law, the individual remained legally free to consume alcohol.
The anti-tobacco movement was not propelled by the institutions outrage or the cultural symbolism surrounding the alcohol problem It never succeeded on a national scale. Local successes were attributable to the temporary strength of the abstentionist impulse, together with the notion that tobacco-smoking was a stepping-stone to alcohol use Lacking the consensus necessary to reverse a spreading habit, tobacco "prohibition" never extended to possession. Insofar as the anti-tobacco movement was really a coattail consequence of alcohol Prohibition, is not surprising that all 14 states which had prohibited sale repealed their proscriptions by 1927.
By the early 1930's, the abstentionist thrust against alcohol and tobacco had diminished. State and federal governments contented themselves with regulating distribution and extracting revenue. When the decade ended, the general public no longer perceived alcohol and tobacco use as social problems. The two drugs had achieved social legitimacy.
A comparison between the national flirtation with alcohol and tobacco prohibition and the prohibition of the non-medical use of other drugs is helpful in analyzing the marihuana issue. In 1900, only a handful of states regulated traffic in "narcotic" drugs--opium, morphine, heroin and cocaine even though, proportionately, more persons probably were addicted to those drugs at that time than at any time since. Estimates from contemporary surveys are questionable, but a conservative estimate is a quarter of a million people, comprising at least 1% of the population. This large user population in 1900 included more females than males, more whites than blacks, was not confined to a particular geographic region or to the cities, and was predominantly middle class.
This 19th century addiction was generally accidental and well hidden. It stemmed in part from over-medication, careless prescription practices, repeated refills and hidden distribution of narcotic drugs in patent medicines. Society responded to this largely invisible medical addiction in indirect, informal ways. Self -regulation by the medical profession and pharmaceutical industry, stricter prescription practices by the state governments and regulation of labeling by the Federal Government in 1906 all combined in the early years of the new century to reduce the possibility of this accidental drug addiction.
About this same time, during the late 19th and early 20th centuries, attention within the law enforcement and medical communities was drawn to another use of narcotics----the "pleasure" or "street" use of these drugs by ethnic minorities in the nation's cities. Society reacted to this narcotics problem by enacting criminal legislation, prohibiting the non-medical production, distribution or consumption of these drugs. Within a very few years, every state had passed anti-narcotics legislation, and in 1914 the Federal Government passed the Harrison Narcotics Act.
The major differences between the temperance and anti-narcotics movements must be, emphasized. The temperance, movement was a matter of vigorous public debate; the anti-narcotics movement was not. Temperance legislation was the product of a highly organized nation-wide lobby; narcotics legislation was largely ad hoc. Temperance legislation was designed to eradicate known problems resulting from alcohol abuse; narcotic--, legislation was largely anticipatory. Temperance legislation rarely restricted private activity; narcotics legislation prohibited all drug-related behavior, including possession and use.
These divergent policy patterns reflect the clear-cut separation in the public and professional minds between alcohol and tobacco on the one hand, and "narcotics" on the other. Use of alcohol and tobacco were indigenous American practices. The intoxicant use of narcotics was not native, however, and the users of these drugs were either alien, like the Chinese opium smokers, or perceived to be marginal members of society.
As to the undesirability and immorality of nonmedical use of narcotics, there was absolutely no debate. By causing its users to be physically dependent, the narcotic drug was considered a severe impediment to individual participation in the economic and political systems. Use, it was thought, automatically escalated to dependence and excess, which led to pauperism, crime and insanity. From a sociological perspective, narcotics use was thought to be prevalent among the slothful and immoral populations, gamblers, prostitutes, and others who were already "undesirables." Most important was the threat that narcotics posed to the vitality of the nation's youth.
In short, the narcotics question was answered in unison: the nonmedical use of narcotics was a cancer which had to be removed entirely from the social organism.
Marihuana smoking first became prominent on the American scene in the decade following the Harrison Act. Mexican immigrants and West Indian sailors introduced the practice in the border and Gulf states. As the Mexicans spread throughout the West and immigrated to the major cities, some of them carried the marihuana habit with them. The practice also became common among the same urban populations with whom opiate use was identified.
Under such circumstances, an immediate policy response toward marihuana quite naturally followed the narcotics pattern rather than the alcohol or tobacco pattern. In fact, marihuana was incorrectly classified as a "narcotic" drug in scientific literature and statutory provisions. By 1931, all but two states west of the Mississippi and several more in the East had enacted prohibitory legislation making it a criminal offense to possess or use the drug.
In 1932, the National Conference of Commissioners on Uniform State Laws included an optional marihuana, provision in the Uniform Narcotic Drug Act, and by 1937 every state, either by adoption of the Uniform Act or by separate legislation, had prohibited marihuana use. In late 1937, the Congress adopted the Marihuana Tax Act, superimposing a, federal prohibitory scheme on the state scheme.
Not once during this entire period was any comprehensive scientific study undertaken in this country of marihuana, or its effects. The drug was assumed to be a 'narcotic' to render the user psychologically dependent, to provoke violent crime, and to cause insanity. Although media attention was attracted to marihuana use around 1935, public awareness was low and public debate non-existent. As long as use remained confined to insulated minorities throughout the next quarter century, the situation remained stable. When penalties for narcotics violations escalated in the 1950's, marihuana penalties went right along with them, until a first-offense possessor was a felon subject to lengthy incarceration.
With this historical overview in mind, it is not surprising that the contemporary marihuana experience has been characterized by fear and confusion on one side and outrage and protest on the other. As scientific and medical opinion has become better known, marihuana has lost its direct link with the narcotics in the public mind and in the statute books.
But extensive ambivalence remains about the policies for various drugs. Marihuana's advocates contend that it is no more or less harmful than alcohol and tobacco and should therefore be treated in similar fashion. The drug's adversaries contend that it is a stepping-stone to the narcotics and should remain prohibited. At the present time public opinion tends to consider marihuana less harmful than the opiates and cocaine and more harmful than alcohol and tobacco.
Interestingly, while marihuana. is perceived as less harmful than before, alcohol and tobacco are regarded as more harmful than before. In some ways, the duality which previously characterized American drug policy has now been supplanted by an enlightened skepticism as to the variety of approaches to the non-medical use of various drugs.
Despite this shift in attitudes, however, the use of alcohol and tobacco is not considered a major social problem by many Americans, while marihuana use is still so perceived.
This remains true despite the fact that alcoholism afflicts nine million Americans. According to the National Institute on Alcohol Addiction and Alcoholism of the National Institute of Mental Health: alcohol is a factor in half (30,000) of the highway fatalities occurring each year; an economic cost to the nation of $15 billion occurs as a result of acoholism and alcohol abuse; one-half of the five million yearly arrests in the United States are related to the misuse of alcohol (1.5 million offenses for public drunkenness alone) ; and one-half of all homicides and one-fourth of all suicides are alcohol related, accounting for a total of 11,700 deaths annually.
Similarly, tobacco smoking is not considered a major public concern despite its link to lung cancer and heart disease. According to the Surgeon General in The Health Consequences of Smoking, 1972:
cigarette smoking is the, major "cause" of lung cancer in men and a significant "cause" of lung cancer in women; the risk of developing lung cancer in both men and women is directly related to an individual's exposure as measured by the number of cigarettes smoked, duration of smoking, earlier initiation, depth of inhalation, and the amount of "tar" produced by the cigarette; and data from numerous prospective and retrospective studies indicate that cigarette smoking is a significant risk factor contributing to the development of coronary heart disease (CHD) including fatal CHD and its most severe expression, sudden and unexpected death.
CULTURAL PERSPECTIVERealizing the importance of social change in understanding the issues surrounding the use of marihuana and other drugs, the Commission decided early that an objective appraisal of cultural trends was vital for the, development of policy recommendations. Since neither the increase in marihuana use nor its attendant controversy is an isolated phenomenon, we sought a wider cultural perspective. To this end, the Commission sponsored a wide-ranging seminar on "Central Influences on American Life." With the cooperation of the Council for Biology in Human Affairs of the Salk Institute, we elicited a three-day conversation among 13 exceptionally thoughtful and perceptive observers of American life.*
*The participants included Jacques Barzun, as moderator, Mary Bingham, Claude T. Bissell, Kenneth Boulding, Robert R. Bowie, Theodore Caplow, Jay W. Forrester, T. George Harris. Rollo May, Jay Saunders Redding, Jonas Salk, Ernest van den Haag, and Leroy S. Wehrle.
It is well beyond both our mandate and our competence to attempt a definitive presentation of the status of the American ethical system However, we shall try to suggest some of the more salient influence in our changing society, recognizing that only against the backdrop of society's fears, aspirations and values can a rational response to marihuana be formulated. Although we are not prepared to identify specific causal connections between these social trends and marihuana use, we do believe that some of the major points raised in the discussion of cultural change provide essential background in understanding the marihuana problem.
The Search for MeaningOne overriding influence in contemporary America is the declining capacity of our institutions to help the individual find his place in society. As one of the participants at the Seminar observed:
A society is stable, peaceful, happy, not when it has rid itself of the tensions-because you never get rid of the tensions, because people's drives will be satisfied in ways that clash and so on-but when a very high proportion of the people feel fulfillment of some sort within the context which the society normally provides. The long-term problem now, for many many people, not just young people, is that this condition is not met.Another noted:
What is wrong with our social system, it seems to me, is that it no longer inspires in people a feeling of purpose, meaningfulness and so on.A number of institutional trends have joined to deprive the individual of a sense of communal inspiration. Perhaps most important is the economic element. Whereas the individual's economic achievement formerly gave his life broad social meaning and inspired his existence, automation and technological advance have tended to depersonalize the individual's role in the economy. Instead of the economic system being dependent on individual productivity, the individual is increasingly dependent on the system. As his work dwindles in significance to the total society, it diminishes in meaning for him. Moreover, as more and more of our people share the nation's affluence, Horatio Alger's example is no longer needed to climb the economic ladder.
A particularly emphatic manifestation of the declining economic demand on the individual is the institutionalization of leisure time. Whereas the economy used to require long hours of work, now it barely requires more than a five-day week. Expanding vacation time and reduced work-weeks tend to diminish the strength of the work ethic. The implications of enforced leisure time are only now becoming apparent, and the concept of "idle hands are the devil's plaything" has to be reexamined in terms of acceptable forms of non-work behavior. This new time component, allowing for the assertion of individuality, has produced both privileges and problems.
In the last decade we have seen the beginnings of the institutionalization of this leisure ethic. A leisure-time industry has sprung up to organize this time period for the individual. Many Americans, due to the nature of their jobs in an automated economic system, find little personal satisfaction in their work, and many are now searching for individual fulfillment through the use of free time. Where meaning is not found in either work or recreational pursuits, the outcome is likely to be boredom and restlessness. Whether generated by a search for individual fulfillment, group recreation or sheer boredom, the increased use of drugs, including marihuana, should come as no surprise.
Another social development which has chipped away at individual identity is the loss of a vision of the future. In an age where change is so rapid, the individual has no concept of the future. If man could progress from land transportation to the moon in 60 years, what, lies ahead? Paralleling the loss of the technological horizon is the loss of a vision of what the future, in terms of individual and social goals, ought to look like. Are times moving too fast for man to be able to plan or -to adjust to new ways and new styles? This sense of the collapsing time frame was best summed up by one of the Seminar participants:
.... there are great forces that have developed over the last several decades that cause one to lose sight of the distant future. Let me contrast a rural farm family of several decades ago which settled a farm. They expected their children to live there, they can imagine their grandchildren living there-there is an image of the future. There is really no one who [now] has any image of where his great grandchildren will he or what they will do. This comes about because of the nature of industrial society; it comes about because we have retirement plans instead of looking after one's own old age. There area whole set of these [factors].
Now the morality, the ethics get tied into it because ethics are really a long-time horizon concept. It's something you engage in because it's contrary to immediate reward and immediate gratification and so you look to some distant future. But as one loses sight of any future then I think the ethics and morality creep up to the very near term also . . . We have no one who has got an image of this country two hundred years from now, who is trying to create a structure that be believes will exist that long. So a number of these things . . . tie together in terms of the long-term goals and how they have shifted. In any of our systems there tend to be a conflict between the short-term and the long-term goals. If the long-term goals are lost sight of then the short-term expediencies seem to be the things that well up.To the extent that planning for the future no longer gives the individual his inspiration, he must look to the present. Such a climate is conducive to pleasure-seeking, instant gratification and an entire life-perspective which our society has always previously disclaimed A third force depriving the individual of a presumed place in society is the loss of a sense of community, a sense of belonging. Mobility, mass living and rapid travel all conspire to destroy the smaller community. The family moves from place to place and then separates with each child going his own way. This global thinking leaves little time for home-town concern.
The dissipation of geographic roots parallels a social uprooting. As one of our Seminar participants noted:
When you grow up with a, small number of people with whom you have to live for a while, it does something which isn't done now. It forces you to face yourself. It forces you to ask what kind of pet-son you are, because you can't get away with it with a group you're going to have to live with. They know what you really are. The mobility has the effect of making it possible for people to live playing parts for years. It seems to me we see it among the youngsters: role playing as distinguished from being somebody. . . .All of these social trends have their most potent impact on young people who are just beginning to develop their values, beliefs and commitments. The adult society has found it easier to adjust to the emergence of the leisure value. Having experienced it as a gradual process, they see it as a reward for previous toil. For many of our young, however, a substantial segment of leisure time may be considered an essential part of living; they have known no other experience. Similarly, an adult society, increasingly influenced toward the present, at least has developed an historical perspective. Also, adult values were internalized at a time when a future vision was possible. For many of the young, however, the present weighs more, heavily. This notion is best reflected in the vociferous youth response to the Vietnam conflict, the embodiment of a war fought for the future,
Finally, all of these cultural changes have occurred, especially for the young, in an environment of affluence. The successful economic system has maximized individual freedom. But the individual has been given unlimited choices at exactly the time when a, value system within which to make such choices is in doubt. Because he has no sense of direction, the result is restlessness, boredom and an increase in the likelihood of present-oriented choices. Self-destructive drug-taking is one form such behavior may take. One of our Seminar participants observed in this connection:
It seems to me that you've got this affluence. So that while most of us grew up with the feeling that the channels within which we were going to have to move and make choices were very narrow, channels for these youngsters look absolutely open. It's an absolutely a, la carte menu-it's the biggest a la, carte menu you can imagine. [This occurs] in a situation in which this sense of radical change is going on so fast that you can't master it, together with a feeling that the society is being operated by very large organizations which you can't get a grip on, giving one a sense of helplessness, of not knowing where to take hold. All these things inherently are disorienting to youngsters and don't give them a, feeling of challenge, [but rather] a doubt as to the meaning of their own lives, of the significance of their being here, [a sense of] being atoms. So then they do act like children in the sense of behaving violently to call attention to themselves. They do a whole lot of other things which, it seems to me, are the sort of things you often see when people feel their lives have no meaning.
Another major influence in contemporary American life with substantial relevance to the marihuana problem is the uneasy relationship between the individual and society's institutions, particularly the state. For 50 years, there has been a continuing upward flow of power to large institutional units, whether they be corporate conglomerates, labor unions, universities or the Government. We have created a society which "requires the individual to lean on society," observed one of our Seminar participants, "in ways that formerly he did not have to do. He used to lean on the clan, on the family, on the village. We have used bureaucracy to deal with these problems." For many, the Federal Government epitomizes this development, bureaucratizing a social response to the most human of needs.
We suspect that the implications of this trend for the individual, although inevitable, became more visibly apparent in the 1960's. Mass institutions must deal through rules; the individual becomes a number. "Intuitively, [the individual] feels that bureaucracies must make man into an object in order to deal with him." So we have a depersonalization at exactly the time that many individuals are casting about for identity and fulfillment.
Simultaneously, technological advance poses the awesome prospect of 1984: the intrusion of the omnipresent state into the private affairs of the individual. Computerized data-banks and electronic surveillance are perceived as restrictions on individuality at a time when the desire for personal privacy is ascendant.
Another cultural feature of governmental bureaucracy during the sixties has been failure to match expectations. Government promises the elimination of poverty, the dissipation of racial discrimination, the excision of drug abuse, and creates rising expectations. But government is often ill-equipped or unable to perform such monumental tasks. As individual helplessness increases, as the "responsibility" of the bureaucracy enlarges, those in need often feel that the gap between public declaration and performance must be the result of a conspiracy to fail. And for the rest of us, there is the credibility gap. The net result is a loss of confidence in society's institutions. Viewed from this perspective, youthful dissent, cynicism and disobedience of the 1960's were not such surprising consequences.
Still another significant feature of institutional life in contemporary America is the lag between purpose and implementation. That is, some of our social institutions have not yet begun to deal with the consequences of the social and economic changes which have occurred over the last several decades. The best example, and the one most germane to the youth, is the educational system. Two generations ago, the labor force could assimilate the large majority of the nation's youth. Neither a high school nor a college education was prerequisite to occupational choice or achievement. Increased educational attainment was presumed to be limited to either the privileged or the able and would be rewarded by certain careers.
Today, however, the labor force grows more quickly than the system is able to assimilate it, and the educational system now serves as custodian as well as teacher. Although we sincerely wish to achieve the democratic ideal of a highly educated populace, we also keep our children in school as long as possible because we have nothing else for them to do. The trend is strikingly apparent even in the last 20 years.
I think one of the problems is that there is no longer a penalty for failure. We-the educators-have had to lower standards in order to accommodate these people who need no longer fear failure. Of course this has been a cyclical thing, a wheel within a wheel. [If ] there is no longer a penalty for failure, then there is no longer the need to acquire.The changing function of education has been felt in both the secondary schools and in our institutions of higher learning. Numerous high school graduates cannot read. Colleges and junior colleges have sprung up overnight to accommodate the population, but many provide classrooms with little specific purpose. Only slowly is the educational system beginning to come to grips with its role in a changed society. At the university level, many educators have been appalled at sacrifices which have ensued from the custodial feature; rote learning, they contend, has supplanted citizen and character education.
The Limits of Rationality
The social response to the individual's search for meaning has fostered an ambivalence, an unwillingness to act, a paralysis. In large measure, according to one Seminar member, this default of authority reveals the intensity of the search:
In the same way we are getting universities that can't teach, families that can't socialize and police forces that can't catch criminals. In every case, the same issue is involved: the subject of authority questions the legitimacy of authority and the exerciser of it is unable to find-very often doesn't even try to find-a defense, because he feels in himself a sympathy, as do so many parents, with the challenge.To a significant extent, society is waiting, hoping that the impulse for change will settle around certain fundamental attributes of the American ethic. At the present time, however, no consensus about the nature of these fundamentals exists. We are all looking for values that have deep roots, as we attempt to sort out the durable from the ephemeral.
All of the participants at our Central Influences Seminar agreed that the unique feature of this search was its a rational quality. As one observer put it:
We have been discussing the question of how we change a society. I don't think it's changed by rational intention. As I understand societies, historically and our own, what really is required to change it is something on a deeper level that involves myth, ritual, sacrament-a number of these functions that have always been related to societies. On these you can't just suddenly make up your mind and then prescribe.
Regarding our problem of authority, you cannot really ask the question: why can't these people hang onto their authority? They can't hang onto it because what gave them authority is something not of themselves, but part of the society, part of a ritual, a sacrament: a way of behaving in the group which gave them authority, [whether] professorial, parental or policy authority. In each one of these cases, what we see is not the diminishing of these men so much but rather the developing emptiness, the lack of the particular ethic that gave them authority to start with. This is why we are in a terrible dilemma.
What is essentially lacking is a system of ethics, morality or religion that gives birth -to the myths, the rituals, the sacraments that are its expression. These touch human beings on the unconscious level. These are the ways we see the world. They are not our conscious thought, but the ways we form ourselves, form each other, love each other or hate each other-in terms not so much of rational intention as a deeper unconscious-conscious and unconscious-which is my definition of a myth; much more of a feeling level, a living level. That is what is not present now.
What we need, below and above all of our deliberations, is the growth and development of an ethical system. We just do not have this now.As we move into the 1970's, our society is collectively engaged in the task -of determining what America means, and how each individual should find fulfillment in `a changing age. From this wider perspective of flux emerges an uncertainty about what the increased prevalence of marihuana use means for the individual and the total society.
Formulating Marihuana PolicyPresent symbolism, past implications, and future apprehensions all combine to give marihuana many meanings. These diverse notions of what marihuana means constitute the marihuana problem. In this atmosphere, the policy-maker's position is precarious insofar as no assumption is beyond dispute. Accordingly, the Commission has taken particular care to define the process by which a social policy decision should be reached.
In studying the arguments of past and present observers to justify a particular kind of marihuana policy, we conclude that a major impediment to rational decision-making in this area is oversimplification. As suggested earlier, many ingredients are included in the marihuana mix-medical, legal, social, philosophical, and moral. Many observers have tended to isolate one element, highlight it and then extrapolate social policy from that one premise. In an area where law, science and morality are so intertwined, we must beware of the tendency toward such selectivity.
It is wrong to assume, as many have done, that a particular statement of marihuana's effects compels a given social policy or legal implementation. An accurate statement of the effects of the drug is obviously an important consideration, but it is conclusive only if the effects are extreme one way or the other. For example, if the use of a particular drug immediately causes the user to murder anyone in his presence, we have no doubt that a vigorous effort to eliminate use of that drug would be in order. On the other hand, if the effects of the drug are purely benign, presenting no danger whatsoever to the user or society, no reason would exist to suppress it.
We know of no psychoactive substance, including marihuana, which falls at either of these extremes. Thus, it begs the issue to contend, as some have done, that because we don't know enough about the effects of heavy, chronic use, we should maintain the status quo. We know a lot about the adverse effects of alcoholism and heavy cigarette smoking, and yet no responsible observer suggests that we should adopt total prohibition for these drugs. Similarly, previous estimates of marihuana's role in causing crime and insanity were based quite erroneous information; but to infer from this that marihuana should be considered totally benign and hence made freely available is also not logical. Both approaches are simplistic; both approaches fail to take into account the social context in which the drug is used and the dynamic factors affecting the role that marihuana use may or may not play in the future.
A similar manifestation of scientific oversimplification is the focus on causality. Many opponents of marihuana use feel compelled to establish a causal connection between marihuana use and crime, psychosis, and the use of other drugs, while, their adversaries focus the dispute on negating such relationships. The Commission believes that this tendency misses the mark.
The policy-maker's task is concerned primarily with the effects of marihuana on human behavior. For both philosophical and practical reasons, proof of causal relationships is next to impossible. At the same time, however, the extent to which marihuana use is associated with certain behaviors and whether any significant relationships exist can offer important clues.
We must be cautious when dealing with such data. Yet we cannot afford to paralyze the decision-making process simply because absolute "proof " is lacking. Spokesmen on both sides of the marihuana debate should focus not on causation but instead on the relevance of the association between various behavioral effects and marihuana use.
Some partisans stoutly maintain that the state has no right to interfere with essentially private conduct or that the state has no right to protect the individual from his own folly. Some of the greatest minds of the Western world have struggled over such philosophical issue always with the same outcome: a recognition of the need to draw a line between the individual and his social surroundings. That is, everything an individual does, in private or not, potentially may affect others. The issue is really to determine when the undesirable effect upon others is likely enough or direct enough for society to take cognizance of it and to deal with it. Coupled with this is the further question of whether the nature of the behavior and its possible effect is such that society should employ coercive measures.
Advocates of liberalization of the marihuana laws commonly contend either that the decision to use marihuana is a private moral decision or that any harm flowing from use of the drug accrues only to the user. Defenders of the, present restrictions insist that society not only has the right but is obligated to protect the existing social order and to compel an individual to abstain from a behavior which may impair his productivity. Unfortunately, the issue is not so simple and the line often drawn between the private conduct and behavior affecting the public health and welfare, is not conclusive or absolutely definable.
For example, a, decision to possess a firearm, while private is considered by many to be of public magnitude, requiring governmental control. A decision to engage in adulterous conduct, although generally implemented in private, may have public consequences if society believes strongly in the desirability of the existing family structure. Similarly, excessive alcohol consumption, in addition to its adverse effects on individual health, may impair familial stability and economic productivity, matters with which the total society is concerned.
So, while we agree with the basic philosophical precept that society may interfere with individual conduct only in the public interest, using coercive measures only when less restrictive measures would not suffice this principle merely initiates inquiry into a rational social policy but does not identify it. We must take a careful look at this complicated question of the social impact of private behavior. And we must recognize at the outset the inherent difficulty in predicting effects on public health and welfare, and the strong conflicting notions of what constitutes the public interest.
Again and again during the course of our hearings, we have been startled by the divergence of opinion within different segments of our population. Sometimes the disagreement is quite vehement, and relates to the underlying social concerns of particular groups. For example, we were told repeatedly by leaders of the urban black communities that they wanted to purge all drug use from their midst, marihuana included, and that the "legalization" of marihuana would be viewed as part of a design to keep the black man enslaved.
On the other hand, we were informed repeatedly by the activist student element that the pre-sent social policy regarding marihuana was merely a tool for suppression of political dissent, and until the law was changed, there could be no hope of integrating the dissident population into the mainstream of American society.
Such statements reemphasize the degree to which marihuana is regarded as a symbol of a larger social concern.
The conflicting notions of the public interest by different segments of the population reinforced in the Commission's deliberations the realization that we have been called upon to recommend public policy for all segments of the population, for all of the American people. The public good cannot be defined by one segment of the population, the old or the young, users or non-users of marihuana, ethnic minorities or white majority. At the same time, the fears of each of these groups must be taken into consideration in arriving at the basic social objectives of the Commission's public policy recommendation. Where such fears are real, they must be confronted directly; where they are imagined, however, they must be put in perspective and, hopefully, laid to rest.
Public debate and decision-making in our society suffer from the glorification of statistical data. After a particular social phenomenon, such as marihuana use, has been defined as a problem, armies of social scientific researchers set out to analyze and describe the problem. A sophisticated computer technology instantly translates millions of bits of data into correlations, probabilities and trends. The most striking findings are then fed to a data-hungry public. The result is data overload.
Descriptive information about the nature and scope of marihuana use as a behavior is an essential component of the policy-maker's knowledge-base. However, such information does not in itself have social policy implications. The policy-maker must define goals and evaluate means; only after he asks the right questions will statistical data suggest useful answers. Unfortunately, a tendency exists in the marihuana debate to assign prescriptive meanings to descriptive data without testing the underlying assumptions. Further, the data have often been accumulating in a fragmented way. No overall plan was devised beforehand; the result has been an ad hoc use of available data triggered by individual research interests rather than by long-term policy needs.
What does it mean that 24 million people have tried marihuana? Some have suggested that it means marihuana ought to be legalized. But does it mean the same thing if 15 million tried the drug once and have decided not to use it again? And does it mean the same thing if popular interest in the drug turns out to be a passing fancy, which wanes as suddenly as it waxed?
On the other side of the controversy, what does it mean that a substantial percentage of the public would favor increased penalties for marihuana use? The prescriptive implications of a democratic impulse may be offset by a preference for individual freedom of choice. Also, this segment of public opinion may have been influenced by incorrect information, such as unwarranted belief in marihuana's lethality or addiction potential. So, although the policy-maker must be aware of political realities, he must not allow his function to be supplanted by public opinion polls. This is an area which requires both awareness of public attitudes and willingness to assert leadership based on the best information available.
Perhaps the major impediment to rational decision-making is the tendency to think only in terms of the legal system in general and of the criminal justice system in particular. This thinking is certainly understandable, given the history of marihuana's involvement with the criminal law. Nonetheless, the law does not exist in a social vacuum, and legal alternatives can be evaluated only with reference to the values and policies which they are designed to implement and the social context in which they are designed to operate.
Legal fallacies are apparent on both sides of the marihuana controversy. Many of the persons opposed to marihuana use look exclusively to the law for social control. This reliance on the law is stronger today because many of our fellow citizens are uneasy about the diminishing effectiveness of our other institutions, particularly when the non-legal institutions have been relatively lax in controlling drug related behavior. Increasing reliance is placed upon the legal system to act not only as policeman, but as father confessor, disciplinarian, educator, rehabilitator and standard-bearer of our moral code. Little or no thought is given to what impact this over-reliance on the law has on the viability of other social institutions, not to mention it's effect on the legal process.
A society opposed to marihuana use need not implement that policy through the criminal law. Non-legal institutions, such as the church, the school and the family, have great potential for molding individual behavior. Accordingly, the policy-maker must delicately assess the capacity of the legal system to accomplish its task and must consider the mutual impact of legal and non-legal institutions in achieving social objectives.
We recognize the short-sightedness of an absolute assumption that the criminal law is the necessary tool for implementing a social policy opposed to marihuana use. But equally short-sighted is the opposing contention which attempts to analyze the law separately from its underlying social policy objective. This argument assumes that if the law isn't working, or if the costs of enforcing the law outweigh its benefits, the law should, therefore, be repealed.
If society feels strongly enough about the impropriety of a certain behavior, it may choose to utilize the criminal law even though the behavior is largely invisible and will be minimized only through effective operation of other agencies of social control. Laws against incest and child-beating are good examples. In weighing the costs and benefits of a particular law, one must provide a scale and a system of weights. The scale is the normative classification of behavior, and the system of weights is the largely subjective evaluation of the importance of the values breached by the behavior. This weighing process is what is open to dispute.
In sum, no law works alone. Where an unquestioned consensus exists about the undesirability of a particular behavior and all social institutions are allied in the effort to prevent it, as is the case with murder and theft, the law can be said to "work" even though some murders and thefts may still be committed. Where society is ambivalent about its attitude toward the behavior and other institutions are not committed to its discouragement, the law cannot be said to be working, even though many people may not engage in the behavior because it is against the law.
The question is whether the social policy, which the law is designed to, implement, is being achieved to a satisfactory extent. To determine the role of law regarding marihuana, we must first look to society's values and aspirations, and then define the social policy objective. If we seek to discourage certain marihuana-related behavior, we must carefully assess the role of the legal system in achieving that objective.
The ReportIn this Chapter, we have tried to put the marihuana problem in perspective. In the remainder of this Report, we explore several aspects of the phenomenon of marihuana use, its effects, its social impact and its social meaning, assessing their relative importance in the formulation of social policy.
In Chapter II, we consider the effects of the drug on the individual user, with particular attention to the size of the user population for whom various effects are relevant. The Commission emphasizes that this material is related only indirectly to its policy-making function. The social policy planner is concerned not about the effects on the individual per se, but about the impact of any adverse effect on his behavior and on the larger society and about the meaning of this behavior in the larger social perspective. The material in Chapter II serves primarily to educate and inform.
In Chapter III, the Commission evaluates the various threats which marihuana use is perceived to present to the public safety, public health, and dominant social order. This Chapter is designed to assess the social impact of marihuana use, the initial step in the policy making process.
In Chapter IV, we consider what role marihuana use plays and will play in the life of American society. This is the dynamic element of marihuana use and is the most intangible of the marihuana realities, but is particularly important from a policy-planning perspective. This consideration is the one most overlooked by contemporary observers and participants in the marihuana debate.
Because social meaning is not a directly measurable entity, we must examine the ways in which society responds to the behavior and whether such responses, both formal and informal, are fluid or. static. After analyzing public opinion, law enforcement behavior and the reactions of medical, educational, and other segments of the population, we then discuss what marihuana use has come to mean and is likely to mean in the future. Particularly important in this highly speculative endeavor is the wider cultural perspective which we described earlier in this Chapter.
In Chapter V, we bring this information to bear on a policy-making process. After establishing the philosophical framework, we explore the spectrum of social policy options, choosing the one we judge most suitable to the present time. Then we consider the range of legal alternatives for implementing this chosen policy, and select the one we believe to be most appropriate for achieving it.
In an addendum to the Report, we present some ancillary recommendations. Some of these recommendations flow from our basic premise, others are a result of independent evaluation by the Commission of other areas of concern.
We ask the reader to set his preconceptions aside as we have tried to do, and discriminate with us between marihuana, the drug, and marihuana, the problem. We hope that our conclusions will be acceptable to the entire public, but barring that, we hope at the least that the areas of disagreement and their implications will be brought into sharper focus.
marihuana use and its effects
"Facts are stubborn things; and whatever may be our wishes, our inclinations, or the dictates of our passions, they cannot alter the state of facts and evidence." John Adams (1770)
The ultimate objective of the Commission is to evaluate the total impact of actual and potential marihuana use on contemporary American society. This endeavor involves three phases: first, an evaluation of the nature and scope of contemporary American marihuana use; second, a careful reevaluation of the pharmacological effects of the drug on the human body with special emphasis on the drug's capacity to alter or modify behavior; and third, an evaluation of the impact of marihuana use on society. This chapter deals with the first and second phases, and Chapter Three deals with the third.
The Marihuana UserCannabis has been used widely for many centuries in nonindustrialized countries of Asia and Africa. Today, as in earlier years, use of drug is concentrated primarily among lower socioeconomic groups. in these countries, the practice is estimated to be confined to a tenth of the lower socioeconomic, male population. Although such use of the drug is well-established, it offers little direct comparison with the American experience.
Although the commercial, industrial and therapeutic value of the hemp plant was widely recognized and exploited in the United States from the earliest days of its history, knowledge and use of its intoxicating and psychoactive properties remained largely unknown until about 1900.
At that time, the custom of smoking marihuana was generally limited to groups of Mexican itinerant workers in the border states of the Southwest. By 1910, marihuana use began to emerge in other southern states and cities, particularly New Orleans, and in the port cities along the Mississippi River. In time, these cities became distribution centers for enterprising sailors. From there, marihuana use spread cross-country to other urban centers, mining camps, railroad construction sites, farm labor camps, "bohemian" communities of artists and jazz musicians, and various other groups outside the mainstream of American society.
Recently, of course, use of the drug has spread to young, white, middle class groups and especially to high school and college populations.
DEMOGRAPHIC CHARACTERISTICSOn the basis of the Commission-sponsored National Survey, we have concluded that contemporary marihuana use is pervasive, involving all segments of the U.S. population. The Survey estimated that about 24 million Americans over the age of 11 years (15% of the adults 18 and over, and 14% of the 12-17 year olds) have used marihuana at least once, referred to in this Report as ever-users. Until recently twice as many males as females had used it; the most up-to-date studies of high school students, college-age individuals, and young adults carried out by the Commission indicate that this sex differential appears to be diminishing. In many youthful populations use is almost equally distributed between males and females.
Marihuana use does not appear to vary significantly by race. With respect to the religious affiliation of the users, Jews and Catholics appear to be slightly overrepresented as compared to Protestants.
Usage is highest in cities, towns, and suburbs but not uncommon in rural areas. States in the Northeast and West have considerably higher rates of use than have the North Central states, which in turn have significantly higher rates than those in the South.
Use is found in all socioeconomic groups and occupations, though slightly more predominant among persons with above-average incomes. A New York survey of the state's general population indicated that ever-use as well as regular use is almost equally prevalent among sales workers, clerical workers, skilled, semiskilled and unskilled workers, managers, owners, professionals and technical workers.
At the same time, the incidence of use seems to vary according to educational attainment. Among all adults not now in school, 5% of those with an eighth grade education or less have used the drug, contrasted with 11% of those who completed some high school, 14% of those who graduated from high school, 25% of those who completed some college and 21 % of those who graduated from college.
Age is presently one of the most significant correlates of marihuana use. Among the total population, those who have tried or used marihuana at least once, termed ever-users, are heavily concentrated in the 16-25 age bracket. Of all the ever-users, about half are in this group. At the same time, however, we should emphasize that use is by no means confined to teenagers and young adults.
The proportion of individuals in different age groups who have used marihuana is indicated in Figure 1.
The incidence of use is greatest among young people: 27% of the 16-17 year olds, 40% of the 18-21 year olds, and 38% of the 22-25 year olds have tried marihuana; at the low extremes, 6% of the 12-13 year olds and 6% of the over-50 generation have used the drug.
Among those now in school, incidence also seems to rise with increasing school level: Ever-users represent 44% of those persons now in college or graduate school; 30% of high school juniors and seniors; 17% of freshmen and sophomores; and 8% of students in junior high school.
At the same time, the use of the drug among adults is by no means confined to college students. Even among the 18-25 year olds, 75% of the ever-users are not now in school.
The initial patterns of contemporary marihuana use appear to be shifting; there is a trend toward increased use among college students as well as non-college students. Non-student users now span social class, income level and occupational classification. In addition, the proportion -of users increases during the teens, peaks during the young adult years and then falls off rapidly (Figure 1).
Having described the incidence of any use of marihuana ever, and demographic characteristics of the 24 million Americans who have tried the drug, we recognize the need to place this information into perspective. The policymaker must also be concerned with the patterns of use: frequency, amount consumed at each smoking, and duration of use.
PATTERNS OF USE
The most striking of the use patterns revealed in the National Survey is that 41 % of the adults and 45 % of the youth who have ever used marihuana reported that they no longer use the drug. Twenty-nine percent of the adults and 43% of the youth reported that they are still using marihuana (see Table 1). When asked why they bad terminated use, the overwhelming majority of adults (61%) specified, among other reasons, that they had simply lost interest in the drug.
Table I.-EXPERIENCE WITH MARIHUANA
Percent of ever-users
Frequency Adults Youth Designation
(18 and (12-17)
Have used marihuana but no longer 41 45
u se. lExperimenters.
Once a month or less 9 15
2-3 times pet month 8 10 Intermittent users.
Once per week 4 9 @
Several times per week 5 4 Moderate users.
Once daily 1 1 1
More than once daily 2 4 Heavy users.
No answer 30 12
These data indicate that at least 41% of the adults and 45% of the youth have used marihuana but have -discontinued use; 9% of the adults and 15% of the youth use the drug sporadically, once a, month or less. These persons can be characterized as experimental marihuana users.*
To ensure an understanding of this section of the Report, some definitions are required at this juncture. In this report, the Commission employs the following designations:
Frequency of UseExperimental-At least one trial to once a month or less.
Intermittent-Two to 10 times monthly.
Moderate-11 times monthly to once, daily.
Heavy-Several times daily.
Very Heavy-Almost constant intoxication with potent preparations; brain rarely drug free.
Duration of UseShort Term-Less than two years.
Long Term-Two to 10 years.
Very Long Term-Over 10 years.
Twelve percent of the adults and 19% of the youth who have ever used marihuana can be designated intermittent users; they continue to use the drug more than once a month, but less than several times a week, probably on weekends. Six percent of the adults and five percent of the youth are moderate users who continue to use marihuana several times a week to once daily.
Finally, 2% of the adults and 4% of the youth who have ever used marihuana are heavy users: they use the drug several times daily. A very small fraction of these heavy users may be very heavy users, who are intoxicated most of their waking hours and probably use very potent preparations of the drug.
In addition to frequency, duration of use is an important variable in discussing use patterns and especially when considering drug effects. Most users in this country have smoked the drug over a short term, that is, less than two years. Others have used the drug over a long term, two to 10 years. Very few Americans can be considered very long term users, that is, over 10 years.
Another important element of use is the amount of marihuana used on each occasion. Most intermittent and moderate users average about one-half to one cigarette per occasion, usually at night. Most heavy users smoke at least one to two cigarettes an occasion, with a few using as many as five consecutively.
As this brief description of use patterns suggests, marihuana use and the marihuana user do not fall into simple, distinct classifications. Although it is possible to sketch profiles of various marihuana-using populations, no valid stereotype of a marihuana user or non-user can be drawn. The spectrum of individuals who use or have used marihuana varies according to frequency, intensity and duration of use. It is meaningless to talk of "the marihuana user" or "marihuana use" without first clarifying descriptive data.
*All respondents for the National Survey were asked to complete a self administered questionnaire. This instrument covered many sensitive areas, including a series of items on personal experience with marihuana and other drugs. Given the nature of the questions, the contractor took every precaution to insure that the interviewee responded honestly and that his responses were kept strictly confidential. Even the interviewer who orally administered the rest of the Survey was not permitted to view the written instrument.
One of the inevitable costs of such confidentiality is the risk that a certain percentage of respondents would not complete one or more of the questions. Where a significant number of questions remained unanswered, the questionnaire was not tabulated at all. However, in 30%, of the otherwise complete questionnaires, the adult respondents who had ever used the drug did not answer the question, "On the average, about how often do you use marihuana at the present time?"
Concerned about the meaning of this non-response rate, the, Commission directed the contractor to conduct a detailed analysis comparing the non-respondents with all respondents and with those individuals who had never used marihuana at all. On the basis of this analysis, we are confident that the overwhelming majority, if not all, of the non-respondents are experimenters.
In the flrst place, the demographic characteristics of the non-respondents coincide closely with those of the non-users and less frequent users. Very few of the young adults, where more frequent use is concentrated, failed to respond.
Secondly, the non-respondents are disproportionately located in the geographic regions where use was least prevalent and least frequent. For example, 50% of the ever-users in the North Central region failed to respond, compared to 71% in the West. Yet only 5% of the ever-users in the North Central region continue to use the drug more than once a week, compared to 21% in the West; and less than .5% of the ever-users in the North Central region use the drug more than once a day, as compared to 4% in the West.
PROFILES OF USERSSeveral studies by the Commission and many other recent college and high school surveys have elucidated a variety of personality types or categories of marihuana users. These profiles relate primarily to the patterns depicted above and to the meaning of marihuana use for various individuals. Essentially we will describe a continuum with much overlapping among the categories. The reader should understand that group identification is at best a hazardous occupation; the traits described are not exclusive to marihuana users. A much larger number of individuals who have not used the drug can be similarly described.
The first and by far the largest group has been designated as "experimenters" because of their extremely infrequent or non-persistent marihuana usage. Experimentation with the drug is motivated primarily by curiosity and a desire to share a social experience. These experimenters are characteristically quite conventional and practically indistinguishable from the non-user in terms of life style, activities, social integration, and vocational or academic performance.
Disciplined, optimistic, and self-confident, experimenters appear to be as conventional, responsible, goal-oriented and orderly as non-users.
The intermittent users are motivated to use marihuana for reasons similar to those of the experimenters. They use the drug irregularly and infrequently but generally continue to do so because of its socializing and recreational aspects. For the intermittent user, marihuana often contributes to the establishment and solidification of close social relations among users similarly inclined. The individual has a sense of belonging to an intimate group.
Investigations of behavioral aspects of marihuana smoking clearly demonstrate that marihuana smoking is a social activity, believed by intermittent users to enhance the enjoyment of shared activities, especially music, art, films and food.
In a Commission-sponsored study to determine the effects of repeat doses of marihuana, under free access conditions, the subjects smoked almost exclusively in groups. A certain number of these individuals tended to share much of their leisure time in common activities, and marihuana, smoking was the focal activity around which other types of social interactions revolved, such as conversation, watching TV, listening to music and playing games. The intermittent users studied exhibited an increased sense of well-being, relaxation, and friendliness during these activities. They were more inclined to seek and emphasize the social rather than personal effects of the drug.
Intermittent marihuana users, like the experimenters, are generally conventional in most respects. They are more liberal politically and socially and they tend to stress education for personal improvement rather than for recognition or high grades. Like many non-users, these individuals are likely to be self-expressive, intellectually and culturally oriented, creative, and flexible. Placing a high value on experimentation and responsible, independent decision-making, they often manifest a desire to search for new experiences, resulting in some behaviors which depart from the norms of the larger society. Often accompanying their search is a sense of uncertainty about the future.
Moderate and Heavy Users
The final groups of marihuana users are the moderate and heavy users. This range is wide and includes individuals who use marihuana more than 10 times a month to several times a day. Practically all of the American research effort to date has focused on the large majority of individuals who use less often, that is, the experimental and intermittent users. Consequently, not enough is known about characteristics and behavior of the moderate and the heavy users, so it is difficult to distinguish accurately between the two groups. We suspect however that the moderate users share traits with both the intermittent and the heavy users. Having already discussed the intermittent group, we will now turn to the characteristics of the heavy group.
Heavy users seem to need the drug experience more often. Their initial and continued marihuana use is motivated not only by curiosity and an urge to share a social experience but also by a desire for "kicks," "expansion of awareness and understanding," and relief of anxiety or boredom.
Generally, the heavy marihuana user's life style, activities, values and attitudes are unconventional and at variance with those of the, larger society. These individuals are more pessimistic, insecure, irresponsible, and nonconforming. They find routine especially distasteful. Their behavior and mood are restless and uneven.
Heavy users place particularly strong emphasis on impulsive response in the interest of pleasure-seeking, immediate gratification, and individual expression. They tend to evidence social and emotional immaturity, are especially indifferent to rules and conventions, and are often resistant to authority. However, several surveys have also revealed that they tend to be curious, socially perceptive, skillful and sensitive to the needs of others, and possess broadly based, although unconventional, interests.
The Boston free-access study permitted the Commission to observe a group of individuals whose life styles, activities, values and attitudes are representative of a segment of the unconventional youthful subculture. The month-long period of controlled study during the fall prevented the participation of individuals who were married, steadily employed, or enrolled in school.
Individuals who smoked marihuana once a week or less were sought by the researchers but were exceedingly unusual among the population available for the study. Consequently, the group studies contrasted with the student and full-time working populations in which weekly marihuana use is more common. For this reason, the intermittent users studied appeared to be similar to, rather than different from, the moderate and heavy users studied. Both groups had used marihuana for an average of five years.
Under the study's confined conditions, participants tended to smoke more marihuana than they did "on the outside." The intermittent users, who by our definition averaged eight times a month under outside conditions, averaged three cigarettes a day during the study. The range was from one-half to six cigarettes daily.
The moderate and heavy users, who "on the outside" averaged 33 times a month, now averaged six-and-a-half cigarettes a day. The range was three-and-a-half to eight cigarettes. In discussing the Boston study, we will call this group "daily" users.
Smoking usually occurred at night, sometimes during the afternoon and only occasionally upon awakening. The intermittent and heavy users usually smoked one cigarette a session. The daily users were more likely to smoke more than one a session. A few individuals in the daily group could have been considered constantly intoxicated on a few occasions during the 21 -day period.
The mean age of the subjects studied was 23. Based on IQ testing, they were superior intellectually, although they had completed, on the average, only two-and-a-half years of college. Their job histories were rather erratic, characteristic of a pattern of itinerant living. The intermittent users -were from a middle or upper class background, while the daily users generally shared a lower socioeconomic status. Broken homes and instances of alcohol or drug abuse were more common in the family backgrounds of the daily users.
Alcohol was rarely used by the subjects. Use of hallucinogens and amphetamines was significantly more widespread and had begun earlier in the daily user group. In contrast to the intermittent group, the daily users almost uniformly reported that marihuana smoking produced relaxation, noting also increased alteration in perception or psychedelic-like effects. Similarly, they reported an increased sense of well-being, friendliness, carefreeness and decreased hostility. Additionally, the daily users appeared to demonstrate a moderate psychological dependence on the marihuana experience while the intermittent users demonstrated little or no psychological dependence.
Analysis of social-behavioral aspects of daily users' marihuana smoking clearly demonstrated that it is a pivotal social activity around which conversation, other personal interactions, and much of the users' lives revolve. Smoking almost exclusively occurred in groups and was the focal activity around which these groups formed. The daily users exhibited a readiness to take part in but not to initiate a smoking session.
In contrast to the intermittent users, all the daily users in a group smoked when marihuana was made available. Marihuana smoking appeared to be a primary means of reinforcing group solidarity. Yet these users were more inclined to seek the personal effects of the drug rather than the socializing effects sought by the intermittent users.
The social adjustment of the daily users, when judged from a traditional psychiatric standpoint, was impaired. Individuals tended to be more withdrawn and to interact less with each other than the intermittent users, regardless of the type of activity or state of intoxication. However, the daily users did appear to accommodate themselves better than the intermittent users to the effects of the intoxication on social interaction.
Despite a relatively high level of scholastic attainment and superior intelligence, many of the subjects were performing well below their intellectual capability, usually working at menial, mechanical or artisan tasks. They were not oriented toward achieving the traditional goals of the larger society.
Nonetheless, during the period of the Boston study, the subjects could not be characterized as displaying a general lassitude and indifference, carelessness in personal hygiene or lack of productive activity, all supposed to be characteristic of very heavy use. Even during the periods of heaviest marihuana smoking, they maintained a high level of interest and participation in a variety of personal activities, such as writing, reading, keeping up on current world events, and participating in athletic and aesthetic endeavors.
Additionally, all of the subjects maintained a desire to complete all aspects of the research study. Although they could be labeled 'underachievers" in terms of the traditional standards of the larger society, these individuals were motivated to pursue actively the interests and activities of their own subculture.
Generally, most studies which have been undertaken indicate that individuals who are heavy marihuana users cannot find a place for themselves in conventional society. Their heavy marihuana use may reflect and perhaps perpetuate their unconventionality while providing social acceptance in one of the non-conventional subcultures.
Very Heavy Users
The Commission's analysis of frequency, quantity and duration of marihuana use suggest that the United States is at the present time in a fortunate position. All of the studies available to the Commission have indicated that only a minute number of Americans can be designated as very heavy marihuana users. These studies uniformly indicate that chronic, constant intoxication with very potent cannabis preparations is exceedingly rare in this country.
The Commission believes that important distinctions must be made between the daily (moderate and heavy) American marihuana user and the very heavy hashish or charas user in other parts of the world where cannabis is widely cultivated and its use deeply ingrained. Many of the North African and Asian users do not employ the drug only as an intoxicant in the western sense. Instead, it is frequently used in "folk medical practice," in religious rites and as a work adjunct particularly in those occupations which are physically demanding, monotonous, unintellectual, and offer little possibility of advancement.
In these countries, very heavy use is typically associated with young males from a lower socioeconomic background. Nonetheless, use is more widespread among all ages and elderly chronic users are not uncommon.
Generally, these very heavy users consume high amounts of very potent preparations continually throughout the day so that they are rarely drug-free. These individuals evidence strong psychological dependence on the drug, requiring compulsive drug-taking. Clear-cut behavioral changes occur in these extreme cases. The very heavy User tends to lose interest in all activities other than drug use. A common element of the behavioral pattern is lethargy and social deterioration. Not surprisingly, these users have been held in low esteem and very heavy use has been subject to societal disapproval in almost all countries.
BECOMING A MARIHUANA USEROur attempt to classify marihuana users is primarily for descriptive purposes. It does not imply that all individuals who resemble any of the categories are necessarily marihuana users. Nor is it implied that all marihuana users fit neatly or precisely into these slots. There is no "typical" marihuana user, just as their is no typical American. The most notable statement that can be made about the vast majority of marihuana users-experimenters and intermittent users-is that they are essentially indistinguishable from their non-marihuana using peers by any fundamental criterion other than their marihuana use.
But if most users and non-users of marihuana essentially are indistinguishable, why have some people chosen to use the drug and others not, and why have some people continued to use it and others not? An important part of the explanation is that use of marihuana, like all human behavior, occurs within specific social and cultural settings. The individual's biological characteristics and personality probably play an important role in determining the pattern his use will take. However, the cultural and social setting play a larger role in determining whether be will use it at all.
Numerous studies have demonstrated that the young person who chooses to use marihuana differs in some important sociological respects from his peer who does not choose to do so. These differences relate to his willingness to experiment with a drug, especially a forbidden one. in short, the process of becoming a marihuana user is not a " seduction of the, innocent" as is often portrayed. Based on interrelated familial, social and cultural factors, persons, especially young persons, who may choose to use marihuana can be predicted statistically.
The decision to use marihuana is related to parental life style.
Parents provide the most important example of acceptable drug-taking behavior for their children. That marihuana users frequently have medicine-taking, cigarette-smoking, or liquor-drinking parents has been demonstrated. In a series of Canadian studies, grade and high school students who said their mothers took tranquilizers daily were three times more likely to try marihuana than the students who did not so report.
Beyond the influence of a drug-taking example, parents have the primary influence on their childrens' acquisition of skills, values and attitudes necessary to be mature and responsible adults. Many parents have oriented their children toward becoming independent, competent, educated, and adaptive adults.
Simultaneously, many young people observe in their parents' lives the trend toward shorter work periods, earlier retirement and increased emphasis on leisure time activities. It appears that the incidence of adolescent marihuana use is strongly correlated with this trend toward increased leisure time.
Situational Factors and Behavioral Correlates
All studies of the ever user, including the Commission-sponsored National Survey, have established that marihuana smoking is significantly correlated with a number of demographic variables. Males, college students, and residents of metropolitan areas, especially in the Northeast and West, are generally overrepresented in proportion to their percentage of the total population.
Among the behaviors statistically correlated with marihuana, use are radical politics, visits to psychiatrists, sexual freedom, and separate residences from parents. The most significant behavior seems to be use of legal drugs, especially alcohol and tobacco. Young people who choose to experiment with marihuana are fundamentally the same people, socially and psychologically, as those who use alcohol and tobacco. For example, in a study of high school youngsters, only 3% of all the nonsmokers in the sample had ever tried marihuana, compared with 50% of all the current cigarette smokers. Similarly, for alcohol drinking outside the family setting, only 2% of all the nondrinkers had tried marihuana, as compared to 27% of the drinkers. The National Survey tends to confirm the close association between marihuana use and cigarette smoking and alcohol use. Among all the adults sampled in the Survey, 71% had smoked cigarettes and 39% are current smokers. Similarly, of adult non-marihuana users, 70% have smoked cigarettes and 38% are current smokers. These percentages increase somewhat for marihuana users: 87 have smoked cigarettes and 54% are current cigarette smokers.
In regard to alcohol consumption, 40% of all the adults sampled indicated that they had not consumed beer or bard liquor in the 30 days prior to the survey. Marihuana users tended to have consumed alcohol more often than non-marihuana users (Table, 2).
Table 2.-LIQUOR CONSUMPTION DURING 30-DAY PERIOD
1-4 5-10 11 or No
0 days days days more answer
Percent of nonmarihuana users. . 45 19 6 7 21
Percent of marihuana users...... 26 30 12 8 24
Social Group Factors
One of the most influential factors in determining behavior in contemporary America among adolescents and young adults is peer group influence. Knowing other people who use marihuana predisposes the individual to use marihuana, and having marihuana-using friends provides the social opportunity for the curious. Ile individual who is already part of a, social group which uses marihuana indicates by this choice that his attitudes and values are already to some degree compatible with illicit drug use.
Social peer groups are especially influential upon individuals who have not yet become "successful" adults, such as adolescents, college students and young adults, who spend a great deal of time and effort competing for status in situations where status opportunities are minimal. The social peer group provides an opportunity for achieving status among equals by demonstrating competence and autonomy. Outstanding performance in athletics, organizations or academics demonstrates competence but not autonomy because these activities are adult-oriented and controlled. Additionally, only a relative few are able to excel.
Opportunity to prove oneself is more readily available in the peer group. Often, adolescents participate in forms of delinquent behavior, termed symbolic infractions, in order to demonstrate autonomy and competence to their peers. These include joy-riding, vandalism, sexual promiscuity, underage drinking, violation of rules of decorum and dress, and purposeless confrontation with authority.
Marihuana use has recently been added to the list of infractions and offers several advantages for adolescents and young adults. Most important, it provides a shared group experience which offers the, shy, lonely, socially awkward neophyte a means of entrance to the group, complete with its own ceremonial initiation. Repetition of the behavior serves to increase closeness and commitment to the group. Usually the experience is pleasurable and the individual is able to control his level of intoxication. This delinquency is viewed as relatively harmless to oneself and others, although its symbolic impact on parents and authority is often greater than that of other common infractions.
Therefore, a, subtle process of acquiring attitudes favorable to drug use, of having friends and acquaintances who define the marihuana experience in acceptable and pleasurable terms, and of having a social belief system which prepares one to accept the conversion process to begin with, are all powerful complementary factors which direct a young person toward marihuana use. At this point, the use of marihuana provides further opportunities for acquiring new marihuana using friends and entering the social milieu of marihuana, users.
The Dynamics of Persistent Use
The cultural and social factors sketched above, in combination with the individual's somatic and psychic characteristics, determine the pattern of his drug behavior once he has chosen to experiment with it. The majority of individuals who reach this point progress no further and often discontinue marihuana use. The most common explanation for discontinuing use is loss of interest; the effect lost its novelty and became boring. Other less common reasons are fear of legal hazards, social pressure, and concerns over physical and mental drug effects. Among the infrequently noted reasons are: interference with other activities; replacement by alcohol; unavailability; cost; unpleasant experiences; fear of moral transgression; or progression to other forms of non-drug interests such as yoga, transcendental meditation, agrarian communes, esoteric religion and restrictive diets.
For those who continue use, psychosocial factors are important determinants of the use patterns. Many marihuana users are strongly committed to traditional society in which they desire to rise socially. They have chosen to participate fully in the traditional adult-oriented activities and the formal achievement-reward system. Their peer groups consist primarily of similarly oriented individuals. The infrequent use of marihuana by these persons is a social activity for fun and satisfies curiosity.
Those individuals who continue to use marihuana more frequently appear to be different types of people and oriented toward a different part of the social system. Most of them maintain stable career orientations and continue to function within the broader society. But they feel more burdened by the traditional system of social controls and more removed from contemporary society's institutions. These individuals tend to turn away from more traditional adult-oriented reward systems and intensify their peer-group orientation. Their interests and activities emphasize an informal "in-crowd," out-of-school or work orientation. The meaning of marihuana use by this peer group emphasizes the ideological character of usage. In contrast to the infrequent type of user, these individuals seem to build their self-identity around the marihuana-using peer group.
BECOMING A MULTIDRUG USERThe more one smokes marihuana, the more involved his interpersonal relationships are likely to become with his peers who share the experience with him. As he spends more time with this group, he begins to sever his contacts with conventional individuals and conventional routines. He may eventually view himself as a drug user and be willing to experiment with other drugs which are approved by his peer group. Only ;a small portion of the marihuana users who reach this stage are likely to become persistent, frequent users of these other drugs. The majority appear to experiment only.
The Commission's studies have confirmed the association between marihuana usage and the consumption of other drugs for curiosity and pleasure. This association holds for all drugs, including over-thecounter and prescription pain relievers, tension relievers, sleeping pills, and stimulants as well as hashish, methamphetamines, cocaine, LSD and mescaline, and heroin. The National Survey showed that current marihuana users are about twice as likely to have used any illicit drugs than are those who have ceased using marihuana (Table 3).
Table 3.-ILLICIT DRUG USE BY ADULTSHave used Currently
but no using
Substance Never used marihuana longer use marihuana
Hashish Less than 0.5 percent 28 63
LSD or mescaline Less than 0.5 percent 11 28
Methamphetamine Less than 0.5 percent 10 23
Cocaine Less than 0.5 percent 4 10
Heroin Less than 0.5 percent 1 4
The Commission additionally has contracted a study of 105 selected, middle class, young, working adults from California, who are marihuana smokers. Of this sample, 11% were daily marihuana users and 47% used it several times a week; 33% used it several times a month; 6% used it once to several times a year; and 3% had used it but were not currently using marihuana. The study indicates that while most of the subjects were frequent marihuana users, the incidence of other drug use was relatively low (Table 4).
Table 4.-FREQUENCY OF OTHER DRUG USE BY MARIHUANA USERS
Percent who use marihuana
Substance who Once to Several Several
never several times times Daily
used times a month a week
marihuana a year
Among high school students, marihuana, is normally the, first illicit drug used, although several recent studies have suggested that a significant number of students initiate illicit use, with other drugs. Of the marihuana users, a majority have used no other illicit drug, and they tend to be experimental or intermittent users of marihuana.
The more frequently the adolescent uses marihuana, the more likely he is to experiment with other drugs. For example, in one recent study of San Diego high school students of predominantly white middle socioeconomic background, 80% of the students who used marihuana weekly or more often had used other drugs, and 50% of this group had used LSD. In contrast, 33% of the less than weekly users bad used other drugs.
Profiles and Dynamics
The personality profile of the heavy marihuana user discussed earlier includes elements propelling him toward heavy involvement in the multiple-drug-using-subculture. Heavy drug use by these individuals may reflect and aggravate a total alienation and disaffiliation from American society and its institutions. This group hopes to find in drug use more than simple, fun or relief from boredom. The heavy use of drugs represents a shift into the drug subculture and an adoption of a totally new life style. Some observers feel that this shift provides a new identity which allows the individual to counteract his apathy and search for meaning in a society he views as unloving, lonely, and meaningless. He seeks to become involved with what he describes as the exciting, relevant, "real" experience of life. Additionally, he believes drug use provides new feelings and awareness needed to overcome barriers between himself, others, and the natural world.
The drug culture as a community also helps to meet the needs of the individual. It provides a ready supply of drugs, unites common experiences and secrets that enhance the drug experience, and protects the individual against undesired experiences and against "the outside world." Most important, the culture instills self-confidence by reassuring the individual that he has been wise in choosing this new identity.
Frequently, these are individuals who express feelings of loneliness, isolation and over-protection from their home and family. One frequent pattern involves an intimate, dominating mother and a distant, unemotional father. In some cases, the drug-use ritual and the, sense of community closeness offered by the drug subculture appear to satisfy certain personal needs. Additionally, joining the subculture provides a release from sheltered life, a test of competence, an opportunity to participate, and a chance to express anger. When the anger is turned inward instead of directed at society and family, drug use becomes a form of passive, self-destructiveness.
After the individual views himself as a drug user and has become immersed in the drug-using subculture, the drugs he chooses to experiment with and his pattern of use are determined primarily by non-drug factors well beyond the simple properties of the psychoactive chemical. These factors are predominantly socioeconomic and sociocultural, although psychic and somatic factors also play a role in determining who will continue and how intensively.
The availability of a distribution system which stocks the other drugs is essential. Most often, contact with this distribution system is increased by having friends or acquaintances who use or sell other drugs. However, much of the marihuana selling takes place, at the customer level between friends, and involves little profit and relatively small quantities of the drug. The marihuana user who only buys has little contact with the professional multidrug dealing system. However, the user-buyer-seller of marihuana is more involved with the multidrug system, uses more himself and has more friends who use and sell other drugs. This factor of being a seller rather than only a buyer-user is influential in determining the degree of an individual's involvement with and commitment to the use of other drugs.
Marihuana use does not itself determine which drugs the heavily involved user will choose to use. Generally, the selection of other drugs is influenced by the social group. For example, blacks and whites have roughly equal rates of trying and using marihuana, but their choice of other drugs and the styles of drug use are quite different and distinctive, due to their frequently different sociocultural backgrounds. Additionally, one recent study of white high school and college students revealed different patterns of further drug use among males and females. Men and women used marihuana in equal numbers, but the men who used other drugs tended to use hallucinogens while the women tended to use amphetamines.
An extensive survey of drug use among 3,500 liberal arts undergraduates attending 14 campuses in the New York area demonstrated the racial character of drug use among this population (Table 5).
Table 5.-RACIAL CHARACTER OF DRUG USE
Meth- Amphet- Hallu-
Percentage tried drugs Heroin Cocaine amphet- amine cinogens
Blacks................ 9 16 5 9 13
Whites................ 4 7 11 19 21
According to recent studies, heroin usage is not common among white marihuana users. Heroin is most strongly linked to marihuana use in black and Spanish-speaking ghettos where many feel they have little chance of personal advancement and self-fulfillment. In such communities, a segment of the population constructs new illegitimate but accessible avenues for social coping. For some this involves the hustle (non-violent stealing) and the excitement of obtaining and using heroin and cocaine. They regard marihuana as a "cool" drug and use it for its social and calming effects.
In contrast, studies have demonstrated that the psychedelics are more often used by the white, middle to upper middle class, college educated populations. The typical use of these drugs in high school college and working populations is episodic and experimental, and is usually discontinued rather rapidly in contrast with marihuana use, which for many persons is of long duration. In many instances, psychedelic drug use begins almost simultaneously with marihuana.
For a few, drug use becomes an ideologic focus, reflecting disillusionment with society and rejection of the "establishment." These and other motives, including mere pleasure-seeking, lead to continued use of LSD and other hallucinogens. Marihuana is viewed as a dilute LSD and is often used to enhance or prolong the effects of that drug. Sometimes it is encountered after first LSD use.
Methamphetamine, or "speed," use is more characteristic of those lower socioeconomic white, youth who are not school or work oriented. Living for the moment is the characteristic attitude of the speed scene. The speed user views marihuana as he does alcohol and uses it for fun or for its calming effects.
For these three groups of illicit drug users, marihuana use has different meanings and is secondary in importance to the use of the other drugs. Whether or not marihuana leads to other drug use depends on the individual, on the social and cultural setting in which the drug use takes places, and on the nature of the drug market. Its use, however, is neither inevitable nor necessary.
The Effects of Marihuana on the UserThe previous section has attempted to paint a broad picture of the marihuana user. This section will deal with the, drug and its effects on these individuals.
The meaning of drug often varies with the context in which it is used. The physician would define a drug as any substance used as a medicine in the treatment of physical or mental disease. Today, due to the influence of many factors, the layman may focus on the negative connotations of drugs, such as the stupefying, poisoning, habit-forming misuse of the opiate drugs. The considerably wider and more scientific definition of a drug which will be used in this section is: any chemical substance which has an action on living tissues.
A psychoactive drug is any substance capable of modifying mental performance and individual behavior by inducing functional or pathological changes in the central nervous system.
As defined, psychoactive drugs exert their major effect on the state of the mind including emotions, feelings, sensibility, consciousness and thinking. The definition implies neither positive nor negative meanings. Chemical substances are not inherently good or bad. All substances, including medicines and foods, which man has chosen to consume have certain desired effects (whether therapeutically beneficial or pleasurable) and undesired effects (whether detrimental or unpleasant). For example, eating food is certainly a necessary and pleasurable activity. However, obesity plays an important role in many diseases, including diabetes, high blood pressure and heart attacks, and tends to limit physical activities.
The classification of any drug effect as either beneficial or harmful often greatly depends on the values the classifier places on the expected effects. This is especially relevant with respect to the psychoactive drugs such as tranquilizers, stimulants, coffee, cigarettes, alcohol, marihuana and other licit or illicit drugs. For all of these drugs, the weights of benefit and harm are difficult to determine when viewed merely in terms of their stated effects.
BOTANY AND CHEMISTRYMarihuana refers to a preparation derived from a plant, cannabis sativa L. The preparation contains varying quantities of the flowers and their resinous secretions, leaves, small stems and seeds. These plant parts contain many chemical substances. The chemical substance which produces the major drug effects is tetrahydrocannabinol (THC). According to current information, the amount of THC present determines the potency of the preparation. Hereinafter, any reference to drug content or drug effect of marihuana will, for all practical purposes, mean that of tetrahydrocannabinol.
The drug content of the plant parts is variable, generally decreasing in the following sequence: resin, flowers, leaves. Practically no drug is found in the stems, roots or seeds. The potency and resulting drug effect of marihuana fluctuates, depending on the relative proportions of these plant parts in the marihuana mixture.
Most marihuana available in this country comes from Mexico and has a THC content of less than 1%. Marihuana of American origin often contains less than two-tenths of 1% THC. Marihuana originating in Jamaica and Southeast Asia often has a 2% to 4% THC content.
Marihuana is the least potent preparation of the plant. Jamaican ganja, containing primarily the flower tops and the small leaves or bracts, has a THC content of about 4% to 8% depending on the mixture. Indian ganja is less potent. The most potent preparation is hashish (charas) which is composed of only the drug-rich resinous secretions of the flowers. Generally, the THC content of hashish is 5 % to 12 %.
FACTORS INFLUENCING DRUG EFFECT
A number of variable factors exert an important influence on the psychopharmacologic effects of marihuana in man, as is true for all drugs. Failure to take these factors into consideration probably accounts for a large part of the inconsistency and controversy surrounding the description of the drug effect.
The dosage or quantity of the drug (tetrahydrocannabinol) consumed is the most important variable. As with most drugs, the larger the dose taken, the greater the physical and mental effect will be and the longer the effect will last. The effect of a high dose of marihuana on an individual would be quite different from the effect of a low, usual "social" dose.
Method of Use
The method of use has a bearing upon the drug effect. The method is directly related to both dosage and time lapse before the drug effect is felt. Injection directly into a vein delivers the total dose immediately, producing a rapid, maximal response of minimal duration. Smoking and inhalation cause rapid but less efficient delivery of the dose; variable quantity of the drug is destroyed during burning or escapes into the air and does not reach the lungs. Oral ingestion produces different effects, according to the system in which the drug is dispersed. Generally, oral ingestion diminishes the drug effect, but prolongs it.
Another factor which influences the effect of the drug is metabolism. During the metabolic process, the body cells, principally in the liver and lungs, chemically alter drug substances, changing their activity and providing for their elimination from the body. Increasing evidence indicates that marihuana is first changed by the body in a way that activates or enhances the drug effect and is subsequently altered in a way that inactivates the drug prior to its removal from the body.
The rate and direction of these metabolic steps can significantly influence the effect of marihuana. For instance, individuals with extensive exposure to marihuana or other drugs metabolize more rapidly, and perhaps differently, from those individuals with no drug exposure.
Set and Setting
An important variable in discussing the effect of marihuana on the user is the social and emotional environment; that is, the individual's "set" and "setting."
"Set" refers to a combination of factors that create the "internal environment" of the individual, including personality, life style, and philosophy, past drug experiences, personal expectations of drug effect, and mood at the time of the drug experience.
"Setting" refers to the external environment and social context in which the individual takes the drug. These factors are most influential when drugs are taken at low dosages and, like marihuana, produce minimal physical and subtle subjective mental effects. The effect of marihuana generally will be quite different for an intermittent social adult smoker from that of a youth deeply involved in the youthful drug subculture. These factors partially account for the belief of a marihuana user that he is experiencing a "high" in certain experiments even when he is given a non-marihuana substance (placebo) but is told it is marihuana.
Another important factor that determines the immediate effect of any drug is tolerance. Tolerance has two different connotations. The first, initial tolerance, is a measure of the amount of a drug which a subject must receive on first exposure to produce a designated degree of effect. A variety of innate and environmental factors contributes to initial tolerance among individuals. Different individuals require varying amounts of the drug to attain the same physical and mental effect.
The second connotation, which shall be referred to when we use the word tolerance, is that of an acquired change in tolerance. That is, within the same individual, as a result of repeated exposure to the drug, the same dose of the drug may produce a diminishing effect so that an increased amount of the drug is required to produce the same specified degree of effect.
Tolerance develops at differential rates to given effects of the same drug. If tolerance has developed to one specific effect, it has not necessarily developed to other specific effects.
By definition, the development of tolerance is neither beneficial nor detrimental. If tolerance develops rapidly to the desired mental effect of a "high" but slowly to the behavioral or physical effects, rapid increase in dose would be necessary in order to have the desired effect, and progressive behavioral and physical disruption would be seen. This is the pattern for amphetamines.
However, if tolerance develops slowly or not at all to the desired mental effects but more rapidly to the behaviorally or physically disruptive effects, no dosage increase or only a slight one would be necessary and the unpleasant and undesired effects would progressively diminish.
With regard to marihuana, present indications are that tolerance does develop to the behaviorally and physically disruptive effects, in both animals and man, especially at high frequent doses for prolonged time periods. Studies in foreign countries indicate that very heavy prolonged use of very large quantities of hashish leads to the development of tolerance to the mental effects, requiring an increase in intake to reach the original level of satisfaction. However, for the intermittent use pattern and even the moderate use pattern, little evidence exists to indicate the development of tolerance to the desired "high," although the high may persist for a shorter time period. During the Boston free-access study, no change was apparent in the level of the high produced by a relatively large dose of the drug over a 21-day period of moderate to heavy smoking.
The fact that some individuals smoke more of the drug than others may merely reflect a desire for a different level of "high." There is a tendency to develop a tolerance to the physical effects and behaviorally disruptive effects, especially the depressant effects, in heavy daily users. The development of such behavioral tolerance of this nature may explain the fact that experienced marihuana smokers describe a lower occurrence rate of undesirable drug effects. The development of tolerance may also explain why these smokers exhibit normal behavior and competent performance of ordinary tasks, while not appearing intoxicated to others even though they are at their usual level of intoxication.
Repeated exposure to marihuana has been said to cause an individual to need lesser amounts of the drug to achieve the same degree of intoxication. This "reverse tolerance" may be related to one's learning to get high or to the recognition of the subtle intoxication at low doses. Or perhaps, such tolerance reflects an increase in the body's ability to change the drug to an active chemical. To date, the existence of "reverse tolerance" has not been substantiated in an experimental setting.
Duration of Use
Tolerance development is only one of a variety of occurrences which possibly are related to repetitive use of marihuana. Any discussion of drug effect must also take into account the time period over which the drug use occurs. Immediate effects of a single drug experience must be contrasted with effects of short-term use and the effects of longterm use in order to detect any cumulative effects or more subtle, gradually occurring changes.
This issue of an individual's change over a period of years is quite complex; a multitude of factors other than marihuana use may affect his life. As previously defined, short-term refers to periods of less than two years, long-term to periods of two to 10 years, and very long-term to periods greater than 10 years. Most of the American experience involves short-term and long-term use, with low doses of weak preparations of the drug.
Patterns of Use
The drug effect of marihuana can be realistically discussed only within the context of who the user is, how long he has used marihuana, how much and how frequently he uses it, and the, social setting of his use.
In general, for virtually any drug, the heavier the pattern of use, the greater the risk of either direct or indirect damage. For purposes of this discussion, the patterns of use developed in the first section of this chapter will be utilized. Because frequency of use is presently the, primary determinant of use patterns in this country, we employ similar designations:
(1) The experimenter who uses marihuana, at most a few times over a short term and then generally ceases to use it, or uses once a month or less;
(2) The intermittent user who uses marihuana, infrequently, that is more than once monthly but less than several times a week;
(3) The moderate user who uses it from several times a week to once daily, generally over a long term;
(4) The heavy user who uses it several times a day over a long term and;
(5) The very heavy user who is constantly intoxicated with high tetrahydrocannabinol content preparations, usually hashish, over a very long term.
Again, these classifications are not intended to be rigid but are designed to facilitate a discussion of the many usage patterns.
Definition of Dependence
Before describing the effect of marihuana, on the user, two additional definitions are required. They concern the concept of dependence which has so clouded public and professional consideration of psychoactive drugs. Throughout the remainder of this report, we refer Separately to psychological and physical dependence, defined as follows:
Psychological dependence is the repeated use of psychoactive drugs leading to a conditioned pattern of drug-seeking behavior. The intensity of dependence varies with the nature of the drug, the method, frequency, and duration of administration, the mental and physical attributes of the individual, and the characteristics of the physical and social environment. Its intensity is at its peak when drug-seeking becomes a compulsive and undeviating pattern of behavior.
Physical dependence is the state of latent hyper-excitability which develops in the central nervous system of higher mammals following frequent and prolonged administration of the morphine-like analgesics, alcohol, barbiturates, and other depressants. Such dependence is not manifest subjectively or objectively during drug administration. Specific symptoms and signs, the abstinence syndrome, occur upon abrupt termination of drug administration; or with morphinelike agonists by administering the specific antagonists.
EFFECTS RELATED TO PATTERN USESet out below is a brief summary of effects of marihuana, related to frequency and duration of use. The remainder of the Chapter discusses the effects of immediate, short-term, long-term and very long-term use of the drug.
intermittent users ------ Little or no psychological dependence.
Influence on behavior related largely to
conditioning to drug use and its social
value to the user.
No organ injury demonstrable.
Moderate users ------------ Moderate psychological dependence in-
creasing with duration of use.
Behavioral effects minimal in stable per-
sonalities, greater in those with emo-
Probably little if any organ injury.
Duration of use increases probability of
escalation of all effects including shift
from moderate to heavy use.
Heavy users -------------- American "pot head."
Strong psychological dependence.
Detectable behavior changes.
Possible organ injury (chronic diminution of pulmonary function).
Effects more easily demonstrable with long-term use.
Very heavy users ---------- Users in countries where the use of cannabis has been indigenous for centuries.
Very strong psychological dependence to point of compulsive drug seeking and use.
Clear-cut behavioral changes.
Greater incidence of associated organ injury.
IMMEDIATE DRUG EFFECTSThe immediate effects are those which occur during the drug intoxication or shortly following it. The user is aware of some of these effects, for they often cause him to use the drug. At the same time, many changes may occur in his body which can be measured by others but are not obvious to him.
A description of an individual's feelings and state of consciousness as affected by low doses of marihuana is difficult; the condition is not similar to usual waking states and is the result of a highly individual experience. Perhaps the closest analogies are the experience of day dreaming or the moments just prior to falling asleep. The effect is not constant and a cyclical waxing and waning of the intensity of the intoxication occurs periodically.
At low, usual "social" doses, the intoxicated individual may experience an increased sense of well-being; initial restlessness and hilarity followed by a dreamy, carefree state of relaxation; alteration of sensory perceptions including expansion of space and time; and a more vivid sense of touch, sight, smell, taste, and sound; a feeling of hunger, especially a craving for sweets; and subtle changes in thought formation and expression. To an unknowing observer, an individual in this state of consciousness would not appear noticeably different from his normal state.
At higher, moderate doses, these same reactions are intensified but the changes in the individual would still be scarcely noticeable to an observer. The individual may experience rapidly changing emotions, changing sensory imagery, dulling of attention, more altered thought formation and expression such as fragmented thought, flight of ideas, impaired immediate memory, disturbed associations, altered sense of self-identity and, to some, a perceived feeling of enhanced insight.
At very high doses, psychotomimetic phenomena may be experienced. These, include distortions of body image, loss of personal identity, sensory and mental illusions, fantasies and hallucinations.
Nearly all persons who continue to use marihuana describe these usual effects in largely pleasurable terms. However, others might call some of these same effects unpleasant or undesirable.
As discussed earlier, a wide range of extra-drug factors also influences marihuana's effects. The more the individual uses marihuana and the longer he has been using it, the more likely the experiences will be predominantly pleasurable, and the less likely the effects will be unpleasant. An increasing sensitization to those effects viewed as pleasant occurs as the user has more experience with the drug.
Persons subject to unpleasant reactions may eliminate themselves from the using group although the occasional experience of an unpleasant effect does not always discourage use.
A large amount of research has been performed in man and animals regarding the immediate effect of marihuana on bodily processes. No conclusive evidence exists of any physical damage, disturbances of bodily processes or proven human fatalities attributable solely to even very high doses of marihuana. Recently, animal studies demonstrated a relatively large margin of safety between the psychoactive dose and the physical and behavioral toxic and lethal dose. Such studies seemed to indicate that safe human study could be undertaken over a wide dose range.
Low to moderate doses of the drug produce minimal measurable transient changes in body functions. Generally, pulse rate increases, recumbent blood pressure increases slightly, and upright blood pressure decreases. The eyes redden, tear secretion is decreased, the pupils become slightly smaller, the fluid pressure within the eye lessens and one study reports that the eyeball rapidly oscillates (nystagmus).
A minimal decrement in maximum muscle strength, the presence of a fine hand tremor, and a decrease in hand and body steadiness have also been noted. Decreased sensitivity to pain and overestimation of elapsed time may occur.
The effects of marihuana on brain waves are still unclear and inconsistent. Generally, the intoxication produces minimal, transient changes of rapid onset and short duration. Sleep time appears to increase, as does dreaming.
Investigation of the effects of marihuana on a wide variety of other bodily function indices has revealed few consistently observed changes.
These few consistently observed transient effects on bodily function seem to suggest that marihuana is a rather unexciting compound of negligible immediate toxicity at the doses usually consumed in this country. The substance is predominantly a psychoactive drug. The feelings and state of consciousness described by the intoxicated seem to be far more interesting than the objective state noted by an observer.
Marihuana, like other psychoactive substances, predominantly affects mental processes and responses (cognitive tasks) and thus the motor responses directed by mental processes (psychomotor tasks). Generally, the degree of impairment of cognitive and psychomotor performance is dose-related, with minimal effect at low doses. The impairment varies during the period of intoxication, with the maximal effect at the peak intoxication. Performance of simple or familiar tasks is at most minimally impaired, while poor performance is demonstrated on complex, unfamiliar tasks. Experienced marihuana users commonly demonstrate significantly less decrement in performance than drug-naive, individuals.
The greater his past marihuana experience, the better the intoxicated individual is able to compensate for drug effect on ordinary performance at usual doses. Furthermore, marked individual variation in performance is noted when all else is held constant. The effect of marihuana on cognitive and psychomotor performance is therefore highly individualized and not easily predictable. Effects on emotional reactions and on volition are equally variable and are difficult to measure under laboratory conditions, but can be significant.
The Intoxicated State
Studies of intoxicated persons have suggested possible explanations for the subtle effects on mental processes produced by marihuana, Generally, a temporary episodic impairment of short-term memory occurs. These memory voids may be filled with thoughts and perceptions extraneous to organized -mental processes. Past and future may become obscured -as the individual focuses on filling the present momentary memory lapse. His sense of self -identity may seem altered if he cannot place himself in his usual time frame.
This altered state of mind may be regarded by the individual as pleasant or unpleasant. The important factors of dosage and set and setting play a most important role in this determination. When the nature of the drug-taking situation and the characteristics of the individual are optimal. the user is apt to describe his experience as one of relaxation, sensitivity, friendliness, carefreeness, thoughtfulness, happiness, peacefulness, and fun. For most marihuana users who continue to use the drug, the experience is overwhelmingly pleasurable.
However, when these circumstances are not optimal, the experience may be unpleasant and an undesirable reaction to the marihuana intoxication occurs. In these instances, anxiety, depression, fatigue or cognitive loss are experienced as a generalized feeling of ill-being and discomfort. A heavy sluggish feeling, mentally and physically, is common in inexperienced marihuana smokers who overshoot the desired high or in persons who might orally ingest too large a dose. Dizziness, nausea, incoordination, and palpitations often accompany the "too stoned" feeling.
"Novice anxiety reactions" or feelings of panic account for a majority of unpleasant reactions to marihuana. When the distortion of self image and time is recognized by the individual as drug-induced and temporary, the experience is viewed as pleasurable. Anxiety -and panic result when these changes cause the individual to fear that the loss of his identity and self-control may not end, and that he is dying or "losing his mind." These anxiety and panic reactions are transient and usually disappear over a few hours as the drug's effects wear off, or more quickly with gentle friendly reassurance.
The large majority of these, anxiety reactions occur in individuals who are experimenting with marihuana. Most often these individuals have an intense underlying anxiety surrounding marihuana use, such as fears of arrest, disruption of family and occupational relations, and possible bodily or mental harm. Often they are older and have relatively rigid personalities with less desire for new and different experiences.
The incidence of these anxiety reactions may have decreased as marihuana use has become acceptable to wider populations, as the fears of its effects have lessened and as users have developed experience in management of these reactions.
Rare cases of full-blown psychotic episodes have been precipitated by marihuana. Generally, the individuals had previous mental disorders or had poorly developed personalities and were marginally adjusted to their life situation. Often the episode occurred at times of excessive stress. These episodes are characteristically temporary. Psychotherapy and sometimes medications are useful in prompt control and treatment of this psychological reaction. In addition, rare nonspecific toxic psychoses have occurred after extremely high doses. This state of nonspecific drug intoxication or acute brain syndrome is self-limited and clears spontaneously as the drug is eliminated from the body.
In summary, the immediate effect of marihuana on normal mental processes is a subtle alteration in state of consciousness probably related to a change in short-term memory, mood, emotion and volition. This effect on the mind produces a varying influence on cognitive and psychomotor task performance which is highly individualized, as well as related to dosage, time, complexity of the task and experience of the user. The effect on personal, social and vocational functions is difficult to predict. In most instances, the marihuana intoxication is pleasurable. In rare cases, the experience may lead to unpleasant anxiety and panic, and in a predisposed few, to psychosis.
The monkeys experienced severe central nervous system depression and one group showed mild hyperactivity, but all rapidly returned to normal behavior after the development of tolerance to these effects. Minimal dose-related toxic effects on bodily organs were noted at autopsy at the conclusion of the experiment. These non-specific findings of unknown meaning included bypocellularity of the bone marrow and spleen and hypertrophy of the adrenal cortex.
A 28-day study employing intravenous administration of from one to ten thousand times the minimal effective human dose to monkeys produced -similar findings clinically. In the high dose groups delayed deaths from acute hemorrhagic pneumonia were possibly caused by accumulation of clumps of THC in the lung producing irritation similar to that seen at the injection sites. No other organ pathology was noted. These animal studies illustrated that the margin of safety between active dose and toxic dose was enormous.
A few studies have recently been carried out to observe the effect of a few weeks of daily marihuana smoking in man. The amount smoked was a relatively large American dose. Frequency of use was once to several times daily.
During the 21-day Boston free-access study, no harmful effects were observed on general bodily functions, motor functions, mental functions, personal or social behavior or work performance. Total sleep time and periods of sleep were increased. Weight gain was uniformly noted.
No evidence of physical dependence or signs of withdrawal were noted. In the heaviest smokers, -moderate psychological dependence was suggested by an increased negative mood after cessation of smoking.
Tolerance appeared to develop to the immediate effects of the drug on general bodily functions (pulse rate) and psychomotor-cognitive performance (time estimation, short-term memory, and shootinggallery skill) but not to the "high." Marihuana intoxication did not significantly inhibit the ability of the subjects to improve with practice through time on these psychological-motor tasks.
Neither immediate nor short-term (21 day) high-dose marihuana intoxication decreased motivation to engage in a variety of social and goal-directed behaviors. No consistent alteration that could be related to marihuana smoking over this period of time was observed in work performance of a simple task, participation in aspects of the research study, or interest and participation in a variety of personal activities, such as writing, reading, interest and knowledge of current world events, or participation in athletic or aesthetic activities.
Marihuana smoking appeared to affect patterns of social interactions. Although use of the drug was found to be a group social activity around which conversation and other types of social behavior were centered, it was not uncommon for some or all of the smokers to withdraw from the social interaction and concentrate on the subjective drug experience.
During the first part of the smoking period, both intermittent and daily users demonstrated a marked decrement in total interaction. Total interaction continued to diminish among intermittent users but increased above presmoking levels among the daily users during the later parts of the smoking period. The quality of the interaction was more convivial and less task-oriented when marihuana was available to the group.
Additionally, an assessment of the effect of marihuana on risktaking behavior revealed that daily users tended to become more conservative when engaging in decision-making under conditions of risk.
Our knowledge about marihuana is incomplete, but certain behavior characteristics appear to be emerging in regard to long term American marihuana use which, for the most part, is significantly less than 10 years. These impressions were confirmed in the Boston free-access study. The group of American young adults studied averaged five years (range 2-17 years) of intermittent or daily use, of marihuana.
No significant physical, biochemical, or mental abnormalities could be attributed solely to their marihuana smoking. Some abnormality of pulmonary function was demonstrated in many of the subjects which could not be correlated-with quantity, frequency or duration of smoking marihuana and/or tobacco cigarettes. (One other investigation recently completed uncovered no abnormalities in lung or heart functioning of a group of non-cigarette smoking heavy marihuana users). Many of the subjects were in fair to poor physical condition, as judged by exercise tolerance.
The performance of one-fifth of the subjects on a battery of tests sensitive to brain function was poorer on at least one, index than would have been predicted on the basis of their IQ scores and education. But a definite relationship between the poor test scores and prior marihuana or hallucinogen use could not be proven.
In the past few years, observers have noted various social, psychological and behavioral changes among young high school and college age Americans including many who have used marihuana heavily for a number of years. These changes are reflected by a loss of volitional goal direction. These individuals drop out and relinquish traditional adult roles and values. They become present rather than future oriented, appear alienated from broadly accepted social and occupational activity, and experience reduced concern for personal hygiene and nutrition.
Several psychiatrists believe they have detected clinically that some heavy marihuana-using individuals appear to undergo subtle changes in personality and modes of thinking, with a resulting change in life style. In adopting this new life style, a troubled youth may turn toward a subculture where drug use and untraditional behavior are acceptable.
This youthful population resembles in many respects the marihuana smoker described in the Boston study. No evidence exists to date to demonstrate that marihuana use alone caused these behavioral changes either directly or indirectly. Many individuals reach the same point without prior marihuana use or only intermittent or moderate use; and many more individuals use marihuana as heavily but do not evidence these changes. For some of these young people, the drop out state is only a temporary phase, preceding a personal reorganization and return to a more conventional life style.
If heavy, long-term marihuana use is linked to the formation of this complex of social, psychological and behavioral changes in young people, then it is only one of many contributing factors.
VERY LONG-TERM EFFECTS OF HEAVY AND VERY HEAVY USE
Knowledge of the effects of very heavy, very long-term use of marihuana by man is still incomplete. The Commission has extensively reviewed the world literature as well as ongoing studies in Jamaica and Greece, and carefully observed very heavy, very long-term using populations in countries in other parts of the world, such as Afghanistan and India. These populations smoke and often drink much stronger drug preparations, hashish and ganja, than are commonly used in America. From these investigations, some observable consequences are becoming much clearer.
Tolerance and Dependence
Some tolerance does occur with prolonged heavy usage; large drug doses are necessary for the desired effects. Abrupt withdrawal does not lead to a specific or reproducible abstinence syndrome and physical dependence has not been demonstrated in man or in animals. The very heavy users studied did evidence strong psychological dependence, but were able to cease use for short periods of time. In these users,
withdrawal does induce, symptoms characteristic of psychological dependence. The anxiety, restlessness, insomnia, and other non-specific symptoms of withdrawal are very similar in kind and intensity to those experienced by compulsive cigarette smokers.
Although the distress of withdrawal exerts a very strong psychogenic drive to continue use, fear of withdrawal is, in most cases, not adequate to inspire immediate criminal acts to obtain the drug.
General Body Function
In the Jamaican study, no significant physical or mental abnormalities could be attributed to marihuana use, according to an evaluation of medical history, complete physical examination, chest x-ray, electrocardiogram, blood cell and chemistry tests, lung, liver or kidney function tests, selected hormone evaluation, brain waves, psychiatric evaluation, and psychological testing. There was no evidence to indicate that the drug as commonly used was responsible for producing birth defects in offspring of users. This aspect is also being studied further.
Heavy smoking, no matter if the substance was tobacco or ganja, was shown to contribute to pulmonary functions lower than those found among persons who smoked neither substance. All the ganja smokers studied also smoked tobacco. In Jamaica, ganja is always smoked in a mixture with tobacco; and many of the subjects were heavy cigarette smokers, as well.
In a study of a Greek hashish-using population preliminary findings revealed poor dentition, enlarged livers, and chronic bronchitis. Further study is required to clarify the relationship of these to hashish use, alcohol or tobacco use, or general life style of this user population.
Similarly, the Jamaican and Greek subjects did not evidence any deterioration of mental or social functioning which could be attributed solely to heavy very long-term cannabis use.
These individuals appear to have used the drug without noticeable behavioral or mental deviation from their lower socioeconomic group norms, as detected by observation in their communities and by extensive sociological interviews, psychological tests and psychiatric examination.
Overall life style was not different from non-users in their lower socioeconomic community. They were alert and realistic, with average intelligence based on their education. Most functioned normally in their communities with stable families, homes, jobs, and friends. These individuals seem to have survived heavy long-term cannabis use without major physical or behavioral defects.
The incidence of psychiatric hospitalizations for acute psychoses and of use of drugs other than alcohol is not significantly higher than among the non-using population. The existence of a specific longlasting, cannabis-related psychosis is poorly defined. If heavy cannabis use produces a, specific psychosis, it must be quite rare or else exceedingly difficult to distinguish from other acute or chronic psychoses.
Recent studies suggest that the occurrence of any form of psychosis in heavy cannabis users is no higher than in the general population. Although such use is often quite, prevalent in hospitalized mental patients, the drug could only be considered a. causal factor in a, few cases. Most of these were, short-term reactions or toxic overdoses. In addition, a concurrent use of alcohol often played a role in the, episode causing hospitalization.
These findings are somewhat surprising in view of the widespread belief that cannabis attracts the mentally unstable, vulnerable individual. Experience in the United States has not involved a level of heavy marihuana, use comparable to these foreign countries. Consequently, such long-lasting psychic disturbances possibly caused by heavy cannabis use have not been observed in this country.
Motivation and Behavioral Change
Another controversial form of social-mental deterioration allegedly related to very long-term very heavy cannabis use is the "amotivational syndrome." It supposedly affects the very heavy using population and is described world-wide as a, loss of interest in virtually all activities other than cannabis use, with resultant lethargy, amorality, instability and social and personal deterioration. The reasons for the occurrence of this syndrome are varied and hypothetical; drug use is only one of many components in the socioeconomic and psychocultural backgrounds of the individuals.
Intensive studies of the Greek and Jamaican populations of heavy long-term cannabis users appear to dispute the sole causality of cannabis in this syndrome. The heavy ganja and hashish using individuals were from lower socioeconomic groups, and possessed average intelligence but had little education and small chance of vocational advancement. Most were married and maintained families and households. They were all employed, most often as laborers or small businessmen, at a level which corresponded with their education and opportunity.
In general, their life styles were dictated by socioeconomic factors and did not appear to deteriorate as a result of cannabis use. The Jamaicans were working strenuously and regularly at generally uninteresting jobs. In their culture, cannabis serves as a work adjunct. The users believe the drug provides energy for laborious work and helps them to endure their routine tasks.
In contrast, others have described Asian and African populations where heavy to very heavy hashish or charas smoking for a very long time is associated with clear-cut behavioral changes. In these societies, the smokers are mostly jobless, illiterate persons of the lowest socioeconomic backgrounds. They generally begin to use the drug in their early teens and continue its use up to their 60's.
The users prefer to smoke in groups of two to 20, generally in a quiet place out of the reach of non-smokers. Weakness, malnutrition and sexual difficulties, usually impotence, a-re common. Some of them report sleep disturbances.
Most users who have used the drug for 20 to 30 years are lazy and less practical in most of their daily acts and reluctant to make decisions. However, their ability to perform non-complicated tasks is as good as non-smokers.
Although the smokers think they become faster in their daily work, a general slowness in all their activities is noticed by others. This user population is typically uncreative. They make little if any significant contribution to the social, medical or economic improvement of their community.
Once existing marihuana, policy was cast into the realm of public debate, partisans on both sides of the issue over-simplified the question of the effects of use of the, drug on the individual. Proponents of the prohibitory legal system contended that marihuana, was a, dangerous drug, while opponents insisted that it was a harmless drug or was less harmful than alcohol or tobacco.
Any psychoactive drug is potentially harmful to the individual, depending on the intensity, frequency and duration of use. Marihuana is no exception. Because the particular hazards of use differ for different drugs, it makes no sense, to compare the harmfulness of different drugs. One may compare, insofar as the individual is concerned, only the harmfulness of specific effects. Is heroin less harmful than alcohol because, unlike alcohol, it directly causes no physical in-jury? Or is heroin more harmful than alcohol because at normal doses its use is more incapacitating in a behavioral sense?
Assessment of the relative dangers of particular drugs is meaningful only in a wider context which weighs the possible benefits of the drugs, the comparative scope of their use, and their relative impact on society at large. We consider these questions in the next Chapter, particularly in connection with the impact on public health.
Looking only at the effects on the individual, there, is little proven danger of physical or psychological harm from the experimental or intermittent use of the natural preparations of cannabis, including the resinous mixtures commonly used in this country. The risk of harm lies instead in the heavy, long-term use of the drug, particularly of the most potent preparations.
The experimenter and the intermittent users develop little or no psychological dependence on the drug. No organ injury is demonstrable.
Some moderate users evidence a degree of psychological dependence which increases in intensity with prolonged duration of use. Behavioral effects are lesser in stable personalities but greater in those with emotional instability. Prolonged duration of use does increase the probability of some behavioral and organic consequences including the possible shift to a heavy use pattern.
The heavy user shows strong psychological dependence on marihuana and often hashish. Organ injury, especially diminuation of pulmonary function, is possible. Specific behavioral changes are detectable. All of these effects are more apparent with long-term and very long-term heavy use than with short-term heavy use.
The very heavy users, found in countries where the use of cannabis has been indigenous for centuries, have a compulsive psychological dependence on the drug, most commonly used in the form of hashish. Clear-cut behavioral changes and a greater incidence of associated biological injury occur as duration of use increases. At present, the Commission is unaware of any similar pattern in this country.
Social Impact of marihuana use
social response to marihuana use
Botanical and Chemical Considerations
Factors Influencing Psychopharmacological Effect
A renewed interest in marihuana studies has been prompted by the recent clarification of the complexities of its chemistry, new techniques to quantity the amounts of active drug in natural materials, and the availability of purified tetrahydrocannabinols. These advances allow more precise scientific research on psychiopharmacological effect.
A major advance has been a quantification of dose of THC in relation to clinically observable phenomena. This has been extensively studied over a wide dose range for marihuana (Rodin and Domino, 1970; Melges et al., 1970; Tinklenberg et al., 197O; Weil et al., 1968; Meyer et al., 1971; Clark and Nakashima, 1968; Clark et al., 1970; Jones and Stone, 1970; Mayor's Committee, 1944; Manno et al., 1970) and Delta 9 tetrahydrocannabinol (Isbell et al., 1967; Waskow et al., 1970; Hollister et al., 1968; Perez-Reyes and Lipton, 1971; Lemberger et -al., 1971; Dornbush and Freedman, 1971).
Investigations by Isbell et al. (1967), Kiplinger et al. (1971) and Renault et al. (1971) have clearly demonstrated that when reliable quantities of smoked marihuana or THC are delivered to the subject, a reproducible linear dose-dependent effect occurs on indices of physiologic, psychomotor, and mental performance as well as on mood and subjective experiences over a dose range of 12.50 to 200 micrograms of Delta 9 THC per kilogram of body weight.
In a 154 pound man this is comparable to consuming 0.88 to 17.5 milligrams of Delta 9 THC or 88 to 150 milligrams of marihuana containing one percent Delta 9 THC. It is generally assumed that good quality marihuana available in the United States contains 1% Delta 9 THC and an average marihuana cigarette consists of 500 milligrams of marihuana; thus, 5 milligrams of Delta 9 THC (Hollister, 1971).
As with most drugs, the larger the dose taken, the greater the psychopharmacologic effect. Isbell et al. (1967) noted that clinical syndromes vary from a mild euphoric feeling of relaxation at low doses (25 micrograms per kilogram) to an intensive hallucinogenic-like experience at high doses (250 micrograms per kilogram).
Similar time-action curves have been demonstrated for smoked Delta 9 THC and equivalent quantities of smoked marihuana (Hollister et al.,1968; Isbell et al., 1967 Renault et ai., 1971 Kiplinger et al., 1971). Symptoms began almost immediately after smoking (2-3 minutes). At lower doses, the peak effect is seen at 10 to 20 minutes and the duration of effect is 90 minutes to two hours. At higher doses, symptoms persist for three to four hours.
Therefore, as with most drugs, the larger the dose taken, the longer the action. The subjective symptoms experienced by the subject appear to parallel in time the subjective effects and some physiological indices such as pulse rate (Isbell et al., 1967; Hollister, 1968 - Renault and Schuster, 1971; Kiplinger et al., 1971; Galanter et al., 1972; Lemberger et al., 1971). Others such as reddening of the eyes have a delayed peak response and longer duration (Kiplinger et al., 1971).
ROUTE OF ADMINISTRATION
A second factor which influences the effect experienced by the user is the manner in which the substance is consumed. That is, whether it is smoked, swallowed or injected.
Isbell et al. (1967) demonstrated that smoked material is two and a half to three times as effective as orally consumed marihuana in the form of a 95% ethanolic solution in producing equivalent physiologic and subjective effects.
In addition, the oral time-action curve is extended with onset of symptoms one-half to one hour after administration. A peak effect is reached in two to three hours and the effect persists for three to five hours at low doses and six to eight hours at larger doses (Hollister et al., 1968; Isbell, et -al., 1967; Lemberger et al., 1971; Perez-Reyes, and Lipton, 1971).
In general, the effects produced by ingested THC or ingested marihuana extract are comparable to those produced by nearly one-third the amount of smoked and inhaled THC or marihuana (Hollister, 1971).
Recent work has been reported which clarifies these findings. Lemberger et a]. (1971) studied absorption into the blood utilizing radioactive labeled THC by three routes of administration: smoked, ingested in 95% ethanolic solution in cherry syrup, and intravenously injected. The first appearance of the drug into the, blood was immediate intravenously; almost immediate, by inhalation; and delayed for 15 to 30 minutes when ingested.
Perez-Reyes and Lipton (1971) using labeled AO THC demonstrated that rate of absorption by the gastrointestinal tract, and the duration of action is greatly influenced by the vehicle used to ingest the drug. Speed and completeness of absorption varied when the THC was dissolved in 100% ethanol or sesame oil or emulsified with a bile salt (sodium glycocholate), and administered to a subject who had fasted 12 hours. With the bile salt vehicle, the physiologic and subjective effects were noted between 15 to 30 minutes after ingestion and lasted two to three hours. In contrast, the effects, with ethanol or sesame oil, appeared after one ,hour and lasted four to six hours.
Hollister and Gillespie (1970) hypothesized that this delayed gastrointestinal absorption of THC might be accounted for by the nonpolar vehicle required to dissolve TUC or marihuana extracts.
Furthermore, Perez-Reyes and Lipton (1971) found that the peak levels and duration of radioactivity in the plasma paralleled the physiologic and subjective effects, although the plasma levels remained high for a longer period of time than the effect. Subjects receiving the drug emulsified in sodium glycocholate or dissolved in sesame oil had three times higher plasma levels of radioactivity with much less excreted in the feces than those receiving the drug dissolved in ethanol.
These results indicate that the THC was poorly absorbed from the gastrointestinal tract when given in all alcoholic solution. The sesame oil solution and the glycocholic acid preparation allowed more complete absorption and the latter preparation was much faster. It is of interest that the degree of subjective high after ingestion of 37 milligrams Delta 9 THC also parallels the plasma radioactivity.
Thus, the subjects reported their experience, as intense and unpleasant both with the bile salt and the sesame oil, and as moderate and entirely pleasant with ethanol. (Perez-Reyes and Lipton, 1971) This correlates well with earlier findings of Hollister et a]. (1968).
QUANTIFICATION OF DOSE DELIVERED
The problem in quantifying the THC dose delivered by different routes of administration has been clarified by several studies using radioactive compounds. However, until a method for determining the THC blood concentration is developed, only estimates oil amount delivered are possible.
Radioautographic studies clearly demonstrate that intravenous injection gives the, most complete and consistent delivery (Lemberger et a]., 1971; Me Isaac et M., 1971; Ho et a]., 1971; Kennedy and Waddell, 1971; Idanpaan-Heikkila, 1971). These investigators have demonstrated that THC is poorly absorbed from the injection site after intraperitoneal or subcutaneous injection.
As discussed earlier, the completeness of absorption ocurring after oral administration of THC appears to depend upon the vehicle. Judged by radioactivity levels, almost complete absorption of the THC occurs with an oil or bile acid vehicle, but absorption is incomplete with an alcohol vehicle. (Perez-Reyes et al., 1971)
Recent animal studies performed for NIMH indicated that the oral dose necessary to produce comparable gross behavioral changes in lab animals is about three times higher than the intravenous dose (Marihuana and Health. 1971: 171). Ferraro (1971) demonstrated the comparability of effective oral doses of THC in chimpanzees and humans. Furthermore, preliminary work performed in the laboratories of M. Isaac (1971) and Harris (1971) and Mechoulam (1971) appear to indicate that the intravenously administered dose of Delta 9 THC necessary to produce detectable behavioral changes in monkeys (20 to 50 microgram/ kg) on conditioned learning tasks is comparable to that in man. (Kiplinger et a]., 1971; Lemberger et al., 1971).
The dose of THC absorbed from natural marihuana extracts ingested orally is uncertain. THC is present as an acid in variable quantities in natural marihuana. THC acid has not presently been proven to be active. Claussen and Korte (1968) reported that the THC carboxylic acid is converted to free THC during the smoking process. Whether these, acids are active themselves; are absorbed from the gastrointestinal tract or converted there into THC; or are decarboxylated in the, body is unknown presently.
Because inhalation is the most widely used route of administration of marihuana, several laboratories have investigated the effect of combustion and smoking oil marihuana. Because techniques and conditions varied between laboratories, precise quantification of the delivery to the smoker's lungs is uncertain.
Manno, et al. (1970) calculated that about 50% of the THC contained in a marihuana cigarette would be delivered to the smoker's lungs for absorption if the entire cigarette were smoked in 10 minutes and each inhalation was retained for 30 seconds with no sidestream loss. Truitt (1971) and co-workers (Foltz et al., 1971) found that 50%c of THC was pyrolyzed and 6% was lost in the side stream while noting that almost 21% of the THC remained in the butt when three-fourths of the cigarette is consumed.
Agurell and Leander (1971) studied the transfer of THC using actual smoking subjects where only the main stream smoke was collected. They found that 14-29%% of the THC was transferred in the mainstream smoke for a cigarette and 45% for a pipe. However, they stated that this amount transferred would be comparable if no butt was left.
Agurell and Leander found that the amount transferred was not effected by depth of inhalation but that smokers using deep inhalation retained 80% of the transferred THC while those using superficial inhalation tended to exhale more than 20% of the transferred THC. Mikes and Waser (1971) also found about 22% in the mainstream smoke.
These divergent data appear to be comparable when corrected for loss to sidestream and retention in the unsmoked portion. Thus, the efficiency of delivery of THC by smoking and inhalation using good techniques, and smoking the entire cigarette approximates 40-50% of the original THC contained. A small fraction is lost in the uninhaled sidestream smoke, about 50% is destroyed during pyrolysis and a variable amount is exhaled from the respiratory dead space.
In apparent confirmation, Lemberger et al. (1971, 1972), using radiolabeled THC added to a marihuana cigarette, found that the initial plasma level of radioactivity after smoking was about onehalf the level after intravenous injection. Oral administration of the same dose of THC in an alcohol vehicle produced about one-half the peak level as smoking. However, Galanter et al. (1972) noted marked variability in the amount of THC absorbed using a standardized routine of inhaling, breath-holding and finishing the cigarette within a set time period.
EFFECT OF PYROLYSIS ON THE CANNABINOIDS
Several investigators have studied the effect of pyrolysis on the cannabinoids. Most have concluded that only negligible changes occur in the original cannabinoid fraction of marihuana except for decarboxylation of the acids to the cannabinoids. No evidence was found for isomerization of Delta 9 THC or Delta 8 THC nor the formation of any new pyrolysis products (Manno et al., 1970; Coutselinis & Miras, 1970; Claussen and Korte, 1968; Foltz et al., 1971; Agurell and Leander, 1971). Mikes and Waser (1971) suggested that a small percentage of cannabidiol was converted to Delta 9 THC, but this observation was not confirmed by the other groups.
Coutselinis and Miras (1970) noted that less THC was destroyed during smoking when Delta 9 THC was the only cannabinoid present rather than when a resin or a mixture of cannabinoids were present. This was believed to be at least partially accounted for by the distribution of THC in the cigarette. More destruction occurred when the THC was evenly distributed in the cigarette than when it was present in a well-defined lump.
SET AND SETTING
A most important variable encountered when evaluating the effect of marihuana is the interaction of the drug with the non-drug factors, set and setting. Set refers to the drug-taker's biological make-up including personality, past drug experiences, personal expectations of drug effect, and mood at the time of the drug experience. Setting refers to the external surroundings and social context in which the individual takes the drug. Set and setting exert their largest effect on psychoactive drugs, like marihuana, with subtle subjective mental effect and minimal physiological effect. Set and setting exert a variable but often marked influence on the potential drug effects (Waskow et al., 1970; Wickler, 1970).
The results of a series of experiments by Jones (1971) suggests the subjective state produced by "a socially relevant dose of smoked marihuana.... 9mg THC" is determined more by set and setting than by the THC content of the marihuana.
In one experiment, a greater variety and more intense pleasurable symptoms occurred in a fourman group allowing unstructured interpersonal interaction than in unstructured solitary test situations. Contrasting behavioral patterns were observed by the investigator and reported subjectively by the individuals. Subjects tested individually demonstrated a relaxed, slightly drowsy, undramatic state as they read, listened to the radio, or sit doing nothing. In the group setting there was elation, euphoria, uncontrolled laughter, a marked lack of sedation and much conversation. (Jones, 1971)
This strongly emphasizes the importance of setting in the marihuana experience. The reason is apparent why marihuana is usually used with other people. However, most investigators studying its effects evaluate their subjects alone, in well-controlled, sterile, scientific laboratories.
The importance of the placebo effect (the subject experiences a drug effect from an inert material) to the "social high" obtained from marihuana was studied in another experiment (Jones and stone, 1970; Jones, 1971). Misjudgments of the pharmacologic potency of both the smoked placebo (marihuana without THC) and active marihuana were commonly made by the subjects although physiologic and performance indices routinely matched the distinction correctly. The smoking of a material that smells and tastes like marihuana by individuals with marihuana experience appeared to produce a mental state that is interpreted as being high if combined with the expectation of becoming high.
The importance of learning to get high was demonstrated when individuals who smoked marihuana less than twice a month were compared with those who used marihuana at least seven times a week. Although both groups rated the active marihuana equally potent, the frequent users rated the placebo equally to the active drug, while the infrequent users experienced significantly less high from the placebo.
The infrequent users' experiences appears to reflect mainly pharmacologic factors with moderate set-setting influence. However, the frequent users' response to the placebo appears to reflect mainly learned set-setting influence and minimal pharmacologic factors. (Jones, 1971)
Smith and Mehl (1970) call learning to get high " reverse tolerance." During the early exposures to marihuana the individual learns to appreciate the subtle drug effect with repeated experience with the drug. Consequently, less drug may be required to experience the desired high in the early stages of marihuana use.
Further evidence for this is seen when the familiar smoking route and smell and taste cues are made ineffective by giving the active and inactive material by the oral route (Jones and Stone, 1970). Both groups of users can significantly distinguish the intoxication produced by 25mg of active material. But the frequent user rates this high significantly poorer than his smoking high while the infrequent user rates them correctly.
The development of tolerance is another important factor that may influence the psychophysiological effects of marihuana. Although tolerance occurs with many drugs and the process has been studied for over a century, the mechanism of this complex phenomenon is not completely known. Kalant et a]., (1971) have extensively discussed tolerance to the psychotropic drugs.
Tolerance has two different connotations. The first, termed "initial tolerance," is an expression of the dose of the drug which the subject must receive at his first exposure to produce a designated degree of effect. These authors state that a variety of congenital and environmental factors contribute to the wide range of differences in "initial tolerance" observed among different individuals, sexes, species, age groups and so on.
The second meaning of tolerance is that of an "acquired change in tolerance" within the same individual as a result of repeated drug exposures so that an increased drug dose is required to produce the same specified degree of effect, or the same dose produces less effect. In this chapter, tolerance will be used synonymously with "acquired increase in tolerance." -Tolerance can only be discussed for each specific drug action and not for all the actions of a given drug on the body. That is, tolerance occurs at different rates for some of the various effects of the same drug on the body and may not occur for other effects of the same drug. The relationship between "initial tolerance" and "acquired change in tolerance" has not been clearly established.
There are two classes of tolerance based on possible mechanisms. The first, dispositional tolerance refers to changes in absorption, distribution, excretion and metabolism which produce a reduction in the intensity and duration of contact between the drug and the target tissue on which it acts.
The second, functional tolerance includes changes in the properties and functions of the target tissue making it less sensitive to the same dose of the drug. Physiological tolerance implies a, change in the target organ while psychological or "learned tolerance" implies the acquisition of new skills or functions to replace those changed in the target tissue (Kalant et al., 1971).
Considerable evidence is accumulating which demonstrates that tolerance does develop in numerous animal species (pigeons, rats, dogs, monkeys, chimpanzees, mice) to the behavioral and physiological effects of marihuana and THC in doses many times larger (from 1 mg. to 500 mg./ kg/day) than the minimal active dose (Carlini, 1968; Silva et al., 1968; McMillan et al., 1970, 1971; Frankenheim et al., 1971; Carlini et al., 1970; Thompson et al., 1971; Pirch et al., 1972; Ferraro, 1971; Elsinore, 1970; Cole et al., 1971).
Lipparini et al. (1969) were not able to demonstrate tolerance in the rabbit.
Tolerance, appears to develop rapidly to high doses even when injections are spaced up to about a week apart. Tolerance to high doses appears to be long-lasting with little loss of tolerance even after a month. But at low doses in the behavioral range, tolerance appears to completely dissipate in a few days after a single dose. The magnitude of tolerance development can be large. After repeated exposure, a dose of over one hundred times the original produces little effect (McMillan et al., 1971).
The development of tolerance to THC in animals occurs for some effects but not for others (McMillan et al., 1971; Pirch et al., 1972; Thompson et al., 1971 ). This differential development of tolerance may explain why tolerance to certain effects studied has not been demonstrated (Masur and Khazan, 1970; McMillan et al., 1971; Barry and Kubena, 1971; Kubena et al., 1971).
Lomax (1971) and Thompson et al. (1971) have noted that the development of tolerance to one effect of the drug (hypothermia or sedation) may allow the expression of the opposite effect (hyperthermia or stimulation) to which tolerance does not develop.
Cross tolerance has been demonstrated between delta-9-THC, delta-8-THC and its synthetic analogues. Cross tolerance, has not been demonstrated between THC and lysergic acid diethylamide (LSD), mescaline or morphine (McMillan et al., 1970).
Preliminary work performed by McIsaac (1971) and Harris et al., (1972) demonstrated a reduction in the duration and quality of response on a conditioned learning task by monkeys on the seeond intravenously administered dose of THC. Tolerance developed extremely rapidly so that no effect on behavior was seen after five days. After a. two-week period without THC, the animals were retested and the same degree of tolerance had persisted. The researchers believe these observations might indicate a rapid behavioral adaption or "learned" functional tolerance.
However, evidence indicates that dispositional tolerance and/or physiological type of functional tolerance also plays a role at least at higher doses. Tolerance develops to the central nervous system depressant effects, hypotherma hypopnea (Thompson et al., 1971) and the EEG effects (Pirch et al., 1971) of the drug. McMillan et al., (1971) have demonstrated that tolerance to the effects of THC on behavior can be blocked by the hepatic microsomal enzyme inhibitor, SKF-525-A which has been shown to be a potent inhibitor of THC metabolism (Dingell et al., 1971). Methodological techniques must be, developed which will allow microdistribution studies to be performed in tolerant animals with low doses of THC before the mechanism of tolerance development can be clarified.
Evidence for the development of marked tolerance by man has been suggested by studies of heavy daily very long term users of hashish, charas or ganja in foreign countries. Reports from the, Eastern literature (Chopra and Chopra, 1939; Dhunjibhoy, 1930; Ewans, 1904) and more recently from Greece (Miras, 1965; Fink et al., 1971) and Afghanistan (Weiss, 1971) relate daily consumption of enormous quantities of potent cannabis preparation estimated to contain up to about one gram of THC per day.
Weiss (1971) has noted that daily charas smokers start with small doses and then in order to achieve the same effect gradually increase their daily dose about 5-6 times over a 20 to 30 year period. Generally, most reach their maximum dose by age 40 and then gradually decrease their daily dose by 50% usually ceasing use by their 60's. Some smokers have been noted to raise their original daily dose up to a maximum of 10 times within the first two years.
Others have noted that moderate use for many years does not necessitate increased doses (Sigg, 1963).
At least part of the increase in daily amount of drug used is accounted for by the finding that the duration -of the intoxication becomes shorter over the years so that the very heavy smoker must consume the drug more frequently to remain intoxicated. Additionally, smokers report that they have on occasion discontinued use for days or months after which they experienced similar effects at smaller doses (Weiss, 1971).
Fink et al. (1971) noted that as hashish users total daily dose was decreased by more than half over the years, the frequency of use per day declined correspondingly.
Rubin and Comitas (1972) noted that very long term Jamaican ganja smokers generally consumed an average of seven spliffs daily (a ganja cigarette several times the size of an American marihuana cigarette) with a maximum of 24.
Further evidence for the development of tolerance, at least to certain of the depressant effects, is that these very long term smokers apparently tolerate the extremely high doses well without dysphoria or decreased ability to perform their usual activities (Weiss, 1971; Fink et al., 1971; Rubin and Comitas, 1972).
Smith and Mehl (1970) noted the, accumulating American anecdotal evidence of mild tolerance development after heavy daily use for a number of years. Jones (1971) and Meyer et a]. (1971) have suggested diminished effect on physiologic and psyochomotor performance, that is, little or no impairment of function in daily users compared with infrequent, intermittent users of marihuana. Additionally, several investigators have noted that frequent users had little or no impairment on psychomotor performance tasks while marihuananaive individuals given the same dose had impaired function. (Clark et al., 1968, 1970; Jones and Stone, 1970; Mayor's Committee, 1944; Weil et al., 1968).
Subsequently (Mendelson et al., 1972) repetitive daily (free access) use over a 21-day period by groups of long-term intermittent (average 7.7 sessions per month) and moderate, marihuana users (daily average, 33 smoking sessions per month) was studied. The development, of tolerance was strongly suggested to the physiological pulse rate and general depressant effect on activity as well as psychological effects which impair recent memory, time estimation and psychomotor coordination.
No tolerance development occurred to the subjective effects of marihuana for experienced users over the 21-day period (global "highness", somatic, perceptual, awareness, feeling, control, friendliness, ambivalence and altered thinking). Furthermore, with the exception of a higher ambivalence rating for the daily riser group, there were no differences in the subjective reports of the daily users or intermittent users. (Mendelson et al., 1972). The ambivalence score is believed (Katz et al., 1968) to be the best measure of "psychedelic ef fects" of hallucinogenic drugs.
In a prior study (Meyer et al., 1971) found that while the heavy smokers experienced more profound subjective effects soon after smoking, they were less intoxicated than the intermittent users one hour later.
These findings suggest to the investigators that the quality of the "high" may be different for heavy and intermittent users and may change with heavy use. Tolerance, to the subjective effects of marihuana may occur predominantly to the depressant effects so that the stimulatory effects (or hallucinatory-like) would be predominant in the heavy users. The intermittent users who smoked marihuana several times daily in the, current study showed no increase in the ambivalence, rating.
The increased daily frequency of marihuana use by both groups over time by shortening the interval between smoking sessions appears consistent with earlier observations (Meyer et al., 1971) that the duration of the desired "high" is shorter in heavy users than in intermittent users.
Fink et al. (1971) confirmed several of these findings in a study in which intermittent users smoked a fixed dose (14 mg. of THC) of marihuana. They noted a suggestion of development of tolerance to pulse rate, short-term memory, digit symbol substitution but not to the subjective high or EEG changes. However, the subjects did feel that the duration of the intoxication shortened progressively during the second half of the experiment.
Schuster and Renault (1971) administered twice daily fixed doses of marihuana (smoke from 430 mg. of marihuana with 1.5% THC content) to intermittent users over a 10-day period. A peak tachycardia, of 20 to 30 beats per minute and a usual social high were produced. Preliminary observations revealed the development of tolerance to time estimation in a few days, but no evidence for tolerance to the tachycardia, orthostatic blood pressure, or rating of the high.
Hollister (1971), in preliminary studies found no significant evidence of tolerance after five daily oral doses of 20 mg. of THC. Clinical responses measured were subjective judgment of the high, mood, pulse rate, reading comprehension or excretion of urinary metabolites.
Smith and Mehl's (1970) clinical observations of many marihuana smokers suggest a J-shaped time curve of tolerance to marihuana. A novice marihuana smoker often reports feeling no high or requiring considerably more drug to get high on his first few trials with the drug than after he obtains more experience with the drug. This phenomenon has been called "reverse tolerance." These clinicians believed this represented "learning to get high" or acquiring the ability to appreciate or become sensitive to the subtle aspects of the intoxication.
Goode (1971) found that more frequent and term marihuana smokers tend to require fewer "joints" to get high but differences were not statistically significant.
Weil et al. (1968) reported that experienced users of marihuana achieved a "high" after being given the same dose as naive (non-users) persons who did not experience a high but did demonstrate objective physiologic and psychomotor drug effects.
Meyer et al. (1971) found that heavy marihuana, users (daily for three years) were most sensitive to the "high" and required less marihuana to achieve a social high than infrequent intermittent users (use one to four times per month for less than two years).
Phillips et al. (1971) reported an increase in severity of symptoms after repeated administration of THC to rats. This "sensitization" may be a correlate of reverse tolerance.
Lemberger et al. (1971) supplied additional evidence for reverse tolerance based on the intravenous administration of 0.5 mg of THC to experimental subjects. Naive subjects experienced no effect from this small dose. However, daily marihuana users, who were told they were receiving a non-pharmacologically active dose of THC, reported a "marihuana high," which lasted up to 90 minutes.
Lemberger et al. (1971, 1972) and Mechoulam (1970) suggested the possibility that enzymes necessary to convert THC to a more active compound require prior use of marihuana.
Reverse tolerance appears to be a complex phenomenon. Jones (1971) presented evidence which stressed the importance of expectation, setting and prior drug experience on learning to get "high." As the user gains more experience with marihuana, the more the individual's mind is able to respond to the expectation of the "high" by actually becoming high when given an inert material which smells and looks like marihuana.
Weil (1971) believes that the capacity to get "high" is an inherent characteristic of each individual's mind. He, believes that marihuana facilitates the user's abilitv to achieve this altered state of consciousness, that is, learn how to get high.
Mendelson et al. (1972) did not find evidence for reverse tolerance. In fact, the daily users were more likely than the intermittent users to smoke two cigarettes per occasion. Both groups had had an average of five years of marihuana use. Several other investigators did not obtain any evidence of reverse tolerance after repetitive daily use in experienced subjects (Hollister, 1971; Schuster and Renault, 1971; Fink et al., 1971).
Metabolism of the drug by the body exerts an important influence on the psychopharmacologic effect of marihuana. Many laboratories in many countries have been examining the metabolism, of the cannabinoids using in vitro liver microsomal enzyme preparations.
With the recent availability of radiolabeled Delta 9 and Delta l THC, cannabinol and cannabidiol much activity has occurred in vivo in animals. A comprehensive review of these areas including studies of absorption, disposition, excretion, metabolism and stimulation-inhibition of metabolism is beyond the scope of this report. Readers interested in further details in this area are referred to an excellent comprehensive review by Lemberger (1972).
From animal and in vitro studies it appears that the liver rapidly changes Delta 9 and Delta 11 THC in a similar manner by hydroxylation to 11-OH THC. This compound appears to be as potent or possibly more potent pharmacologically than the parent compounds This metabolite appears to be, rapidly hydroxylated to 8-11 dihydroxy Delta 9 THC (7-11 dihydroxy All THC) which is inactive. The 8-OH Delta THC appears to be a minor active metabolite (Christensen et al., 1971; Burstein et 1970; Ben-Zvi et al., 1970; Foltz et al., 1970; Wall et al., 1970,71; Nilsson et al., 1970).
These metabolites are excreted primarily into the bile and then to the feces. Some evidence exists for an enterohepatic circulation returning the drug to the blood. (Miras and Coutselinis, 1970; Klausner and Dingell, 1971)
Another metabolic pathway appears to be present resulting in a series of acidic metabolites excreted primarily in the urine (Agurell et al, I., 1970). Recently, Burstein and Rosenfeld (1971) isolated and identified a majo r rabbit urinary metabolite, 11-carboxy-2'-hydroxy-Delta 9 THC. They postulate that other acidic metabolites might be esters or amides of this compound (Figure 7).
Recently, Nakazawa and Costa (1971) demonstrated that A' THC was metabolized by lung microsomes forming two unidentified products not found in liver homogenates.
Lemberger et al. (1970, 1971, 1972) and Galanter et al. (1972) have performed metabolic studies in mail using intravenous, oral and smoked Delta 9 THC. These studies indicate that the THC disappears from the plasma in two phases.
The initial rapid phase has two components and represents metabolism by the liver and redistribution from the blood to the tissues. The slower second phase represents tissue retention and slow release and subsequent metabolism.
The plasma 1/2 life of THC was significantly shorter in daily users than nonusers at both the first component of phase one (10 minutes versus 13 minutes) and phase two (27 hours versus 56 hours). Tissue distribution was similar in daily and nonuser (1/2 life 2 hours).
Therefore, immediate metabolism of THC and subsequent metabolism is more rapid for daily user than the non-user implying specific enzyme induction. THC persists in the plasma for a considerable period of time, at least three days, with a half life of 57 hours for nonusers and 28 hours for daily users.
The presence of 11-hydroxy THC and more polar metabolites in the plasma of both users and nonusers within 10 minutes indicates that the metabolite probably accounts for the pharmacological activity of marihuana, not THC.
Further metabolism of the 11-hydroxy THC to more polar inactive 8-11 dihydroxy A' THC metabolite occurs more rapidly in users than nonusers. During the first few hours after injection, unchanged THC, its polar metabolites and nonpolar metabolites in the plasma, decline rapidly and then level off as they are distributed to the tissues. THC persists in the plasma, for at least three days, and both users and non-users excrete metabolites in the urine and feces for more than a week.
Delta-9-THC is extensively metabolized to more polar compounds which were excreted in the urine and feces. Urinary excretion and biliary excretion (reflected a day later in the feces) was greatest during the initial 24 hours, then gradually tapered off. All THC is metabolized since no unchanged THC was excreted in the feces or urine. No difference in total cumulative excretion was observed but a significantly larger percentage of the metabolites were excreted in the urine of users than nonusers. About 40-45% of the metabolites were collected in the feces in both groups in one week. Urinary excretion in this period accounted for 30% in daily users and 22% in nonusers. (Lemberger et al., 1970, 1971, 1972)
Perez-Reyes et al. (1971) found a similar pattern of excretion of metabolites after oral administration.
Urine contained no Delta 9 THC, only a small quantity (3%) of 11-hydroxy THC and 90% more polar acidic compounds as yet unidentified. (Lemberger, 1971). Preliminary studies by Burstein and Rosenfeld ('1971) suggest that these human acidic urinary metabolites are identical to the 11-carboxy-2' hydroxy THC found in rabbits.
In man, Lemberger et al. (1971, 1972) found that 11-OH THC and 8-11-OH THC were primarily excreted in the feces. Twenty-two percent of the metabolites in the feces were unchanged 11-hydroxy THC and slightly less were 8-11-dihyd-roxy THC. The remainder were unidentified more polar compounds, perhaps conjugates of these metabolites.
All user subjects (Lemberger et al., 1970, 1971, 1972) but no non-user noted a high after intravenous injection of the 0.5 mg dose of Delta 9 THC. This would be a dose range of 5 to 7 micrograms/kg. Highs have been noted by Kiplinger et al. (1971) with smoking THC to deliver a dose of 6.25 micrograms/kg. The high for some lasted up to 90 minutes. Thus, the plasma levels of Delta 9 THC and its metabolites seen after intravenous injection suggest that psychopharmacologic effects are seen in the first component of the rapid phase and terminated by redistribution and metabolism after the initial phase. The 11-hydroxy Delta 9 THC would be present at this early phase and is probably responsible for the activity of Delta 9 THC in marihuana.
Further evidence that the 11-OH Delta 9 THC is responsible for marihuana's effect was seen in oral and inhalation studies. By the oral route, blood levels of unchanged THC were relatively low compared to the radioactivity levels of the metabolic products at the time of peak subjective effect. While the blood level of unchanged THC at the peak oral effect was identical to that after intravenous injection of the 0.5 mg. dose, the psychologic, effect was much more pronounced after oral administration of the larger 20 mg. dose of THC. Again after inhalation, the plasma levels of the metabolites correlate temporally with the subjective effects but the plasma levels of unchanged Delta 9 THC do not. (Lemberger, 1970, 1971, 1972; Galanter, 1972)
PATTERN OF USE
The drug effect of marihuana can only be realistically discussed within the context of who the user is, how long he has used, how much and how frequently he uses and what is the social context of the use. In general, for virtually any drug the heavier the use pattern, that is the longer the duration, the more frequently the use and the larger the quantity used on each occasion, the greater the risk for either direct or indirect damage.
Tolerance development is only one of a variety of occurrences which are related to the repetitive use of marihuana. Any discussion of drug effect must take into account the time period over which the drug is used (duration of use). This is necessary in order to detect cumulative effects or more subtle gradually-occurring changes. Of course, the issue of causality is quite complex because of the multitude of factors other than marihuana use that have a direct or indirect effect on the individual over a period of years.
For the purposes of this report, immediate or acute effects will refer to those drug effects which occur during the drug intoxication or shortly following it. Short-term or sub-acute will arbitrarily refer to periods of less than two years; long-term, from two to 10 years; and very long term (or chronic), greater than 10 years.
Frequency of use, will arbitrarily be designated in the following manner: experimental use refers to use of marihuana at least one time but not more than once a month; intermittent use refers to use more than once a month but not more than 10 times a month (several times a week) ; moderate use refers to use of the drug more than 10 times a month but not more than once a day; heavy use designates use more than once, daily and very heart use refers to use many times a day, usually with potent preparations (high THC content), producing almost continual intoxication so that the smoker's brain is rarely drug free.
AMOUNT OF DRUG CONSUMED
Relatively little actual data are available on the amount of marihuana, smoked per occasion or per day by current users in the United States. (McGlothlin, 1971, 1972). Estimates of the quantity of THC consumed are difficult because of the variability of potency as well as weight and size of the marihuana cigarette ("joint") and the degree of cleaning of stems and seeds from the dried leaves manicuring").
The analytic data available indicates most of the marihuana used in the United States is of Mexican origin and averages about I % THC per dry cleaned weight of marihuana (Lerner and Zeffert, 1968; Jones, 1971). Subjective ratings by experienced marihuana users appear to substantiate the data that marihuana containing 1% THC is of average quality (Jones and Stone, 1970; Weil et al., 1968).
Marihuana cigarettes are estimated (McGlothlin, 1971, 1972) to average about 0.5 g in weight and, therefore, contain about 5 mg of THC. Cigarettes used in the eastern states are generally smaller than those, rolled in the west (McGlothlin, 1971; New York Police Department, 1969, 1970)
Most data indicates that for the large majority of users one-half to one cigarette (2.5 to 5 mg THC) is sufficient to "get high" in intermittent moderate users, although often two or more cigarettes were smoked to achieve additional effect (Nisbet and Vakil, 1972; Shean and Fechtmann, 1971; McGlothlin et al., 1970- McGlothlin, 1972; Jones, 1971; Goode, 1970).
Current American daily users appear to consume one to two cigarettes per occasion (Jones, 1971) although some users estimate they smoke three to five cigarettes per occasion (McGlothlin et al., 1970). Goode (1971), however, found practically no relationship between amount required to get high and frequency of use (daily to less than monthly) or duration of use (less than two years to six or more years). In fact, the heavy and longer term users were less likely to require more "joints."
Thus, the estimated 15 mg THC for current daily users is about one-half that estimated for confirmed regular users 30 years ago in the United States (Mayor's Committee, 1944; Charen and Perelman, 1946) and one-third to one-fourth the median daily consumption of daily users in North Africa and India.
The maximum daily consumption of 10 cigarettes (50 mg THC) for current heavy U.S. marihuana smokers (Jones, 1971; McGlothlin, 1972) is about the same as the average amount consumed by daily chronic users in other countries, and about one-fourth or less of the maximum in these countries (Soueif, 1967; Sigg, 1963; Indian Hemp Drug Commission's Report, 1893-1894; Chopra, 1940; Chopra and Chopra, 1939).
Studies of American military in Vietnam (U.S. Congress, 1971; Colbach and Crowe, 1970; Forrest, 1970), and Germany (Tennant et al., 1971) described the daily use of quantities of hashish or potent marihuana comparable to amounts consumed by regular chronic users in other countries.
Experimental data appear to confirm these estimates of quantity of THC consumed. Isbell et al. (1967) and Jones (1971) found that most subjects reported a normal "high" after smoking 5-10 mg of THC. Meyer et al. (1971) found that a "very high" state was attained by ad libitum smoking of 3.12 mg THC by daily users and 3.78 mg THC by intermittent users.
In experiments by Johnson and Domino (1971), subjects were urged to smoke until they were as high as they had ever been on marihuana and felt they could not smoke any more. These subjects smoked from one to four cigarettes containing 8.7 mg of THC to reach this level of intoxication. The range was from 8.7 to 30 mg of THC with a mean of about 20 mg THC.
Intermittent and daily users were allowed to smoke marihuana on a free choice basis over a 21day period in studies by Mendelson et al. (1972). Each cigarette contained one gram of marihuana of approximately 2% THC content, or about 20 mg of THC.
Subjects were asked to rate their high on a 10 point scale with 10 corresponding to highest ever; five as moderately high and zero, no effect. Ratings for the daily user group ranged from zero to nine with an average of about six for all cigarettes rated. Individual means ranged f rom three to about seven. On almost all occasions, subjects in both groups smoked the entire cigarette.
Kiplinger et al. (1971) and Lemberger, et al. (1971) noted that daily long-term users were able to detect effects of the "high" at doses calculated to deliver as low as 5-7 micrograms/kg THC (equivalent to smoking about 100 mgs. of marihuana containing 1 % THC). Perhaps this explains the finding that many users are able to "get high" smoking US wild-growing marihuana containing front near zero to 0.5% THC (Lerner, 1969; Phillips et al., 1970; Fetterman et al., 1971).
Several ad libitum experiments were performed with marihuana of unknown composition (Williams et al., 1946; Siler et al., 1933) using "confirmed regular marihuana users" confined over a 39 and six-day period. The users, who generally consumed three cigarettes per day, under these rather artificial conditions of the, experiment consumed means of 17 (range nine to 26) and five (range one to 20) cigarettes per day respectively.
Miras and Coutsilinis (1970) reported recent experimental data on chronic Greek hashish users who routinely use, single smoked doses of hashish containing 100 mg of THC. Under ad libitum conditions, these users averaged 150-350 mg of THC per day over a 30-day period.
The subjects studied during a 21-day period of free choice Marihuana consumption by Mendelson et al. (1972) generally consumed all of one cigarette containing 20 mg of THC per smoking session. 'The subjects who were previously daily users were more likely during the experiment to consumer more, than one, cigarette per session than the, previously intermittent users.
Individual consumption by the intermittent users ranged from an average of about one-half to
six cigarettes per day (group mean three) while the daily users consumed an average of three-anda-half to nine cigarettes per day (group mean six-and-a-half). Reasons given by the subjects for the dramatic shift in the frequency of marihuana use included boredom, testing the limits of their endurance, demonstrating its harmlessness to the research staff, and subtle social pressure.
DURATION OF USE
Very little American data exists on the duration of marihuana use. Practically no data exists which demonstrates the extent that persons who initiated marihuana use some 20-40 years ago have continued its use. Robins and Murphy (1967) in a follow-up study of St. Louis black males noted that 20% of those who had tried marihuana by age 24 were still using it to some degree 15 years later. McGlothlin et a]. (1970, 1971) reported on a sample of predominantly white adults who began using, marihuana in adolescence and had continued infrequent use for more than 20 years.
In the case of Western and particularly middle class American use of marihuana, the rapid climb to prominence of the phenomenon since the midsixties raises the question of whether the entire drug movement is transient or permanent. Certainly, the majority of the youthful users and many of the adults have used the drug less than 10 years and probably less than five years.
One 1970 survey (Lipp, 1970) revealed that 77% of those students who initiated marihuana use four to five years earlier were still using it to some degree. A recent study (Walters et a]., 1972) indicates that students who first used marihuana before entering college in September 1965 and had continued use of marihuana in February 1969 ("old user") differed from the, vast majority of users who began their drug use in college ("new user").
The old user is more likely to experiment with a wide variety of drugs, to be extremely active in radical political organizations, to be alienated from American society, to be less definite about career plans, and to have more heterosexual activities.
The Commission-sponsored National Survey indicated that marihuana use by both youth (12-17 years of age) and adults (18 and over) is experimental in approximately 75% of those who have ever used marihuana. These individuals have, either stopped using it (66% of adults and 57% of youth) or are, using, it once, a month or less. In contrast, 13% of the ever used subsample (12% adults, 16% youth) use marihuana once a week or more.
In other non-Western countries, cannabis use frequently persists for long periods. Especially in the East, persons using it for 20-40 years or more are not uncommon. In other cultures, initiation is most common in adolescence. Once the habit is established it is likely to continue on a daily basis for many years and frequently continues as a lifetime practice (Weiss, 1971; Sigg, 1963; Soueif, 1967; Watt, 1936; Chopra and Chopra, 1939; Bouquet, 1951; VN, 1957).
Probably the duration of use will vary considerably depending on cultural acceptance or rejection (McGlothlin, 1972).
INTERACTION WITH OTHER DRUGS
Little experimental work has been done on the interaction between marihuana and other drugs used socially or medically although this will become an important area as usage increases.
Marihuana is often used with sweet wines to enhance its effect. Some evidence for an additive effect of marihuana and alcohol on motor and mental performance and subjective effect has been seen experimentally (Manno et al., 1971; Jones and Stone, 1970). Some degree of additive effects would be expected with barbiturates based on their similarity to alcohol. A more complex, mixed pattern of effect might be expected with amphetamines and hallucinogens. These latter combinations are rarely used socially (Hollister, 1971).
Acute Effects of Marihuana
Effects of Short-Term or Subacute Use