Investigations of Very Heavy, Very Long-Term Cannabis Users

In Marihuana: A Signal of Misunderstanding - Commissioned by President Richard M. Nixon, March, 1972.

Proving a causal relationship between the use of any substance and an associated illness or condition is extremely difficult. Ideally, prospective longitudinal studies on large populations of both substance users and nonusers matched for socioeconomic and psycho-cultural variables should be performed for many years in order to detect subtle or cumulative effects. Unfortunately, the enormous expenditures of research effort and finances that would be required for a large scale investigation of this nature are prohibitive.

Consequently, carefully designed and controlled, clinical and epidemiological studies of very heavy, very long-term cannabis users in foreign countries must be relied upon to provide important data on possible effects because these populations are not obtainable in the United States.

GREECE

Preliminary results (Freedman and Fink 1971, Fink and Dornbush 1971, Fink 1971) from an intensive medical, neurological, and psychiatric study of 31 male chronic hashish users in Greece, performed under contract to the National Institute of Mental Health, have revealed few abnormalities in these individuals. Non-users matched for socioeconomic, and psycho-cultural factors including life style, alcohol and tobacco consumption and nutrition and general health have not been studied.

In collaboration with Professors Miras and Stefanis in Athens, Fink and co-workers are studying a population of chronic hashish users that Professor Miras has known for many years. The population studied is composed of 31 male subjects ranging in age from 26 to 69 years with a mean of 46 years.

The subjects report starting hashish use at 13 to 35 years of age with a mean of 19. They have -used hashish from 10 to 49 years, with a median of 28 years. In the past they used an average of eight grams of hashish daily with a range of 2 to 24: grams daily. (The hashish it estimated to contain 4% THC on the average. Therefore, average daily use was 320 mg. of THC).

In the past, 27 of the subjects were daily -users and four used every other day. Frequently of hashish use per day was: once per day-2 subjects, twice per day-6 subjects, three times per day-14 subjects, four times per day-4 subjects, and five, or more times per day-5 subjects.

The men reported a reduction in drug use with time ascribed to increasing difficulty in obtaining adequate supplies due to increased enforcement of the drug regulations. At present they use an average of three grams of hashish daily (320 mg. of THC) with a range of one to 10 grams daily.

Twelve now use hashish daily, eight use, every other day and 11 use less frequently. Frequency of daily hashish use is: once per day-5 subjects, twice per day-12 subjects, three times per day-10 subjects, four times per day-2 subjects, and gve(sic) or more times per day-2 subjects.

The men are primarily hashish users. One has used opiates. Two are heavy users of alcohol and six report occasional to frequent use of alcohol at the present time. Tobacco is smoked by all subjects averaging 40 cigarettes per day.

Twenty-three of the subjects report periods of abstinence from hashish averaging ten months but up to three years. Hashish use is primarily social by 20 subjects, and 15 subjects smoke in solitude.

Pipes and cigarettes in which hashish is mixed with tobacco are used interchangeably. The usual time of smoking is after work (21 subjects) but 12 subjects smoke before work and five smoke anytime.

In this population, the median education is three-and-a-half years of school with a range of none to nine. Five of the men are illiterate. Twenty-one of the men are married, one is cohabiting, four are single and five are divorced or separated.

All of the married men are employed and support their families. The subjects report changing their jobs frequently and 11 had periods of unemployment from three to 120 months. Ten were classified as skilled workers and 21 as unskilled workers. Their jobs include selling scrap metals, general labor, cartage, messenger, maintenance assistants, etc.

Arrests are common and 19 report at least one non-hashish related arrest. Eighteen have been in regular military service, six were exempt because of hashish use and seven for other reasons.

Interestingly, 10 of the 15 wives interviewed prefer the behavior and attitudes of their husbands when they are using hashish compared to when they are drug-free.

In regard to family and personal background 20 had refugee parents, 13 had alcoholic or hashish using fathers, 26 had three or more siblings, 19 had dominant mothers. Fifteen of 21 had dominant wives. Seven reported broken homes under age 16.

Apparently, the subjects participation in society is consistent with their lower socioeconomic background. No gross behavioral deviation was detected I in this population.

Psychiatric status was evaluated by history and psychiatric interview. Nine have had psychiatric hospitalization of which three were in the military and related to hashish use. Two have, had psychiatric outpatient treatment. Eight had histories of neurotic traits during childhood. In their psychiatric evaluation, three men are considered to have psychiatric pathology. Two of these were considered sociopaths on the basis of homosexuality and criminal behavior. The third was diagnosed as a schizophrenic. No overt signs of any organic mental syndrome were detected. None of the three men were believed to require psychiatric intervention. The schizophrenic, although suspicious and withdrawal, is a successful business man and lives with his family on weekends.

Complete physical and neurological examination revealed three prominent findings. All had very poor dentition which the men ascribed to hashish smoking. Chronic bronchitis was detected in 14 of the men and emphysema in three others. This finding is not surprising because all subjects were tobacco cigarette smokers averaging 40 cigarettes per day, in addition to their very heavy hashish consumption. Enlarged livers were also found in nine of the 31 subjects.

Because no extensive psychological test battery has been developed or standardized in Greece, American tests were used. These tests are not culture-free, and it is possible that certain items or subtests were inappropriate for the subjects because they had not acquired the type of knowledge or skills required due to their poor level of education.

The Wechsler-Bellevue I.Q. tests were translated into Greek and administered. Because of these, factors, comparison of level of performance between these subjects and white middle class Americans is meaningless.

The mean I.Q. is 86 with a range of 69 to 109. The mean verbal is 90.3 and the mean performance was 83.6. The group of subjects performed lower than expected on digit symbol, digit span and similarities but higher than expected on comprehension, arithmetic, vocabulary and picture completion. The Ravens Progression Matrices showed a similar pattern and mean I.Q. The significance of these findings will depend on a comparison with a matched nonuser population.

Resting electroencephalograms were obtained in 30 subjects and evaluated independently by four experts. Twenty-five were within normal limits.

Testing was incomplete in one record. One record in a subject who had a head injury within the prior three months showed focal slowing.

Two of the four experts judged the remaining three, records as showing low degrees of average to low voltage theta activity indicative of cerebral dysfunction. The remaining two experts judged these records as within normal limits.

This medical and psychological data suggests some effects of very long term, very heavy hashish use. Without a matched comparison group, factors independent of hashish use, such as age, socioeconomic conditions, or environmental conditions, may account for the observed changes.

However, the researchers note that these men have survived chronic hashish use in high doses without gross behavioral deviation.

JAMAICA

Another foreign investigation (Ruben et al., 1972) conducted in Jamaica (under contract for the National Institute of Mental Health) studied chronic cannabis users and matched nonuser controls. Preliminary findings have shown little evidence of significant differences between the two groups in the extensive anthropological, medical, psychiatric and psychological investigations.

Ganja use is widespread and endemic in the Jamaican lowest socioeconomic strata, and in particular in a millenial-religious sect known as the Rastafarians. More than 50% of all male Jamaicans are estimated to use some form of cannabis, and probably about 20% are regular heavy users of ganja.

The drug was brought to Jamaica from India over 130 years ago by indentured East Indian laborers. However, presently the heaviest ganja users are Afro-Jamaicans who comprise 90% of the population.

The Rastafarian religious sect, founded by Marcus Garvey, preach a "Back to Africa" destiny and claim Haile Selassie to be God. The Rastafarians have always worn. long hair and beards and dressed eccentrically. They believe that "the herb" was given them by God to help them to understand his wisdom exemplified in their greeting, "Peace and Love."

The Rastas reject the values of the dominant society and regard the government as "the powers of Babylon". They have, chosen to opt out of conventional society and instead work and live in a communal existence in poverty. They emphasize the value of ganja in achieving a new level of meaning in this existence.

The Rastafarians add ganja to their infant first bath and start feeding the drug to their infants from the time of weaning in an infusion known as ganja tea. They continue to smoke and drink the drug throughout life.

They, like many other Jamaicans, believe in its medicinal properties especially for asthma and indigestion and promotion of healing; that it gives protection from evil spirits; that it cleanses the skin and purifies the blood; that it promotes sexual vigor; that it gives energy for work and relieves fatigue and provides relaxation after work.

Extensive in-depth studies have been carried out by a team of anthropologists from The Research Institute for the Study of Man in conjunction with The Departments of Psychiatry, Pathology, Physiology and Medicine, of the University of the West Indies. Anthropology field workers lived for extensive periods of time in five rural communities (including fishing, farming and cane cutting areas) and two urban districts.

Over 2,000 people were observed and studied in these communities. Overall life styles of the ganja users were not notably different from nonusing individuals in the Jamaican lowest socioeconomic strata. Users are working, maintaining stable families and homes, and actively participating in their society. No evidence was noted of crime or aggressive behavior or drug use other than alcohol related to ganja use. No evidence of physical dependence was demonstrated. Minimal psychological dependence was observed but no drug craving was expressed.

Thirty long-term ganja smokers and 30 nonusers matched demographically to control factors other than ganja use, were chosen as representative of this functioning lower socioeconomic population and selected for intensive hospital study in order to determine, differences between the two groups.

The mean age of the subjects was 33 with a range of 23 to 51. The primary occupation of one-third of the subjects was farming. The next most common occupations were, fishing, skilled and semiskilled laborers. Half practiced no formal religion, five were Rastafarians and the remainder practiced a wide variety of traditional religious. Almost three-fourths of the males had stable "marriages" and the remaining single subjects were predominantly the younger ones.

The subjects were divided into three groups. Twenty-three were nonganja smokers, 28 were regular daily ganja smokers and 9 were occasional ganja smokers using the drug several times a we or less. Three types of regular ganja smokers were delineated: light smokers using one to four spliffs daily moderate smokers using four to seven spliffs daily; and heavy smokers using eight or more spliffs per day.

Age of first use ranged from 8-36 years of age. Regular use of ganja occurred at a median age of 16 years with a range of 9-25 years. All ganja smokers had used the drug at least 7 years and some up to 37 years with a mean of 17.5 years.

The ganja users consumer on the average seven spliffs of ganja daily with a range of one to 24 per day. The typical ganja cigarette or cigar, termed a spliff is roughly a four-inch-long paper cone and contains about two to three grams of ganja with a delta 9 THC content of about 2.9% on the average (range of 0.7-10.3%) mixed with about half of a Tobacco cigarette. Also many smoke ganja in a Chillum pipe using very deep inhalation to fill their lungs with smoke. They consume 14 pipe fulls per week on the average, with a range of 1-25 per week.

No significant differences in neurological abnormalities, electroencephalographic abnormalities, hemochemical changes including liver function, urinalysis, chest X-ray abnormalities or chromosome damage in lymphocytes were found in the users or controls.

One user had a long history of bronchial asthma and another had a mild case of Jamaican neuropathy, but nothing suggests these disabilities were in any way related to ganja use. Minor electrocardiographic abnormalities were present in about one-third of both users and controls. This may be related to a syndrome of unknown etiology known as Jamaican cardiomiyopathy.

Thorough physical examination and hematological studies revealed only minimal significant differences between ganja smokers and non-ganja smoking controls. Comprehensive evaluation of red blood cell indices revealed that the ganja smokers had significantly higher hemoglobin levels and packed red cell volumes (hematocrit) than the non-ganja smokers.

These hematologic findings are compatible with those reported recently (Sangan and Balberzak, 1971) for heavy tobacco cigarette smokers. The authors noted that cigarette smoking causes a functional tissue hypoxia due to deficits in lung func tionwith resultant arterial oxygen unsaturation. Thus, an increased demand is placed on the bone marrow to provide more red blood cells to increase the oxygen carrying capacity of the blood.

In addition to the heavy smoking of ganja in spliffs and pipes, 27 of the 30 ganja smokers were tobacco smokers, and several have smoked tobacco cigarettes heavily. 19 of the 30 non-ganja smokers were tobacco cigarette smokers and tended to be light tobacco cigarette smokers.

Thus, the data appears to suggest that a combination of factors including number of years and quantity of cigarette smoking, ganja spliff smoking and ganja chilum pipe smoking is significantly correlated with the hematological changes indicative of functional hypoxia. However, pulmonary function studies did not demonstrate significant decrements correlated with ganja or tobacco smoking.

No significant differences were found between groups by a thorough psychiatric and psychological examination. All subjects were judged to be in normal mental health. Subjects were administered a battery of standardized reliable American psychological tests known to be sensitive to impairment in brain function. These tests were not culture free so that comparison of performance, between Jamaicans and Americans is meaningless Nineteen tests evaluating 47 variables were performed including one personality test, three tests of intelligence and verbal abilities, and 15 neuropsychological tests.

Two of 47 variables had statistically significant differences between ganja smokers and non-smokers. The smokers scored higher on the digit span subtest of the Wechsler Adult Intelligence Scale and bad a more centralized personality organization on the Lowenfeld Mosaic Test.

Non-smokers had the best performance on the number of edge contacts with the non-dominant hand on the Holes Test. These few significant differences were considered chance findings by the investigators.

In general no consistent differences were found on these psychological tests between ganja smokers and non-smokers. The data clearly indicate that the long-term ganja use by these men did not produce demonstrable intellectual or ability deficits when they were without the drug for three days. No evidence in these results suggest permanent brain damage.

The alleged role of ganja in producing personality change in the direction of a loss of competitive striving and an unwillingness to work, termed the amotivational syndrome was also investigated.

Based on clinical impressions gained from careful sociological and psychological techniques, the investigators noted that the chronic ganja smoker differed little in work habits or record from his matched control. No evidence of an amotivational syndrome was found. In fact, the subjects believe ganja has a functional value as a work adjunct. It provides energy for work and helps them do arduous boring jobs.

In the Jamaican culture, ganja may produce a "motivational syndrome". In an objective videotape evaluation of work energy output and ganja smoking, ganja use did not lower productivity on simple repetitive tasks, such as woodcutting which requires compulsive concentrated effort.

A study of cultivators points up the relationship of population, land, and economic pressures to ganja use. In the area studied land resources are scarce, farms small and cultivation difficult on the hilly slopes. Market conditions determine income from cash crops and restrictions on migration maintain population pressures on limited resources.

For these farmers, the researchers suggest that ganja use, decreases total cultivated acreage and consolidates production while disruption of competition and social cohesiveness among the farmers is avoided.

These data may indicate that heavy ganja use during cultivation in farming situations with limited alternatives may serve to maintain the status quo. However, it is possible that the compulsive concentrated effort experienced by the cultivators with heavy ganja use may be productive in areas with good soil and climatic conditions where systematic weeding can increase crop yields.

As a result of the extensive anthropological study, the investigators believe that ganja use in Jamaica is a culturally determined phenomenon. A "ganja complex" exists which consists of closely related, learned patterns of behavior manifested by the members of the society.

The ganja complex appears to be functional for the working-class Jamaican. Various elements Of the complex including economic, social and personal are interrelated in ways that contribute to operation of the whole culture.

AFGHANISTAN

Dr. Salamuddin Weiss (1971) studied 1011 chronic hashish users in Kabul in order to obtain a general picture of the charas habit in Afghanistan.

Cannabis is cultivated in this tropical country. A concentrated product, charas, the resin obtained from the flowering tops of the female plant, is the preparation generally used. The most common method of smoking charas is in a clay water pipe called a Chelum. Next most commonly used is a pipe or needle and straw. Infrequently, charas is smoked in tobacco cigars or cigarettes. Chewing the leaves or drinking a charas mixture as a confection is quite rare.

Although charas smokers are found throughout society, they are predominantly found in certain groups. The ages of the subjects studied ranged from 13 to 70 years old. More than 75% were, married. Almost all were males.

Socioeconomic status was as follows: 70%, lower, 28% middle and 2% upper. 82% are illiterate, 27% had a primary school education and less than 1% had any higher education.

Most smoking occurs in groups of two to 20 friends in quiet out of the way places. Most users smoke several times a day. The longer one has smoked charas, the shorter the duration of the high and the more often the individual can smoke each day.

Weakness, sexual difficulties and physical impotence are commonly reported by smokers. Most report they have a good appetite and eat more than normal, but malnutrition is common.

One hundred chronic smokers were selected at random and examined medically: 93 were malnourished; no evidence of illness was found in 79 subjects; 13 showed signs of respiratory illness (bronchitis) ; 7 showed sleep disturbances and one had pulmonary tuberculosis. No deaths have been reported from charas overdose. One subject out of the 1,011 was known to be chronically psychotic.

A review of over 150,000 outpatient and inpatient psychiatric visits per year over the past 10 years revealed 20 short-term psychotic episodes yearly involving charas alone and 16, short-term psychotic episodes yearly involving both charas and other drugs. An absence of chronic mental illness related to charas use was noteworthy.

Most charas smokers commence use during their teens, gradually increasing their use about five or six times until they reach their highest dose between the ages of 20 to 40 years.

At the extreme, smokers have raised their daily dosage up to 10 times their starting dose within the first two years. They then gradually decrease their daily requirement by about 50% upon reaching their 60's. Generally, most smokers cease charas use after their 60's, but some. use extremely low doses for the rest of their lives.

I These patterns of use are consistent with the development of tolerance. Additionally, chronic smokers note they are able to use larger doses than they did when they began use without any significant signs of intoxication. Also after stopping charas use for a few days or months, the users report they restart use at smaller doses to achieve the desired effect.

No physical dependence was noted. Marked psychological dependence was present which makes it difficult to stop their habitual use. Discontinuation of charas use produced mild psychologic abstinence signs. These signs, generally include restlessness loss of appetite, sleeplessness, nervousness, headache, and gastrointestinal upset.

Most smokers after discontinuation of use are quite able to live with their families and perform their jobs without discomfort. Most chronic smokers return to charas use within days or months. Out of a group of 100 randomly selected ex-smokers who had used for eight to 22 years, 42 have not returned to charas use, 16 use occasionally and 42 have returned to daily use within one to 13 months.

Most common explanation given by the subjects for restarting use were to continue close relationships with charas using friends and lack of a busy job.

A group of 100 opium addicts were selected at random from the community; 51 of these started their drug use with charas and later substituted opium for charas.

Generally, charas smokers report that they become faster in their daily jobs, but observation reveals a slowness in these activities. The ability to perform a non-complicated job is comparable to non-charas smokers. They tend to be cooperative but lazy persons. They tend to be more theoretical than practical and avoid making decisions. They do not demonstrate creativity or contribute significantly to the improvement of their community.

Summary

Marihuana has been used by man in countries around the world for many centuries. Scientifically, more is known about marihuana's effects than many other botanical substances consumed by man.

Marihuana is one of several preparations from the plant, cannabis sativa. The plant contains many different chemicals, but tetrahydrocannabinol appears to be the major active psychopharmacologic ingredient. The potency of the preparation is determined by the THC content, which varies according to the origin of the seed, the conditions of cultivation, and the extent of manicuring.

Several important factors exert significant influences on the psychopharmacological effect. These include dose, method of use, set and setting, and pattern of use including frequency and duration of use.

The acute subjective experience is dose-dependent. At low doses commonly used in this country a mild intoxication occurs, but at higher doses psychotomimetic experiences can occur. Few consistent physiological effects are noted. No pathologic bodily changes have been conclusively demon, strafed from acute use. Subtle effects on recent memory, psychomotor function, and social behavior have been demonstrated.

The margins of safety between the effective dose and the toxic dose is quite large. No human fatalities have been noted in this country caused by marihuana. The most common adverse reactions are becoming too intoxicated, and the acute anxiety panic reaction. Both of these are transient and related to dose consumed as well as set and setting factors.

Acute psychotic, reactions are quite rare. They usually last a few days to weeks and occur in predisposed persons either with preexisting mental disorders or borderline personalities especially under stressful conditions. Transient acute brain syndrome or toxic psychosis is possible at extremely large doses.

Evidence has accumulated which indicates that differential tolerance does develop at least, in persons who smoke large amounts of marihuana several times a day. Development of tolerance to the depressant effects on behavior appears to precede development of tolerance to the intoxicant effect.

Physical dependence has not been demonstrated. Little, if any, psychological dependence is present in most intermittent marihuana users. Moderate psychological dependence occurs in moderate to heavy users and marked psychological dependence has been described in very heavy chronic users.

Some detrimental effects have been conclusively linked to short- and long-term marihuana use for very heavy users. The most frequently reported change in the heavy, long-term smokers of large quantities of potent preparations is chronic bronchitis comparable to that developed by a heavy, long-term tobacco cigarette smoker. A chronic cannabis psychosis probably occurs rarely in heavy chronic, hashish smokers in Eastern countries. Most psychotic episodes are the acute variety and clear in a few days to weeks. No objective evidence has been demonstrated that even very heavy, long-term hashish use causes organic brain damage.

Objective studies of chronic, heavy smokers of potent preparations have not causally linked this drug with the amotivational syndrome which has been described by many clinicians. Almost all chronic, heavy hashish smokers are indistinguishable from their peers in the lower socioeconomic strata of their respective societies in social behavior, work performance, mental status and overall life style.

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