Tod H. Mikuriya, M.D.

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Cannabis Substitution: Harm Reduction Treatment for Alcoholism and Drug Dependence
By Tod H. Mikuriya, M.D. and Jerry Mandel, PhD. October 2001

Since 1992, the senior author's medical practice has transitioned from medical psychiatric in-patient consultation to seeing patients who need a physician's recommendation in order to become a member of a cannabis club which sells them marijuana, or to grow marijuana for their own personal use. These clubs and personal marijuana gardens have been legal since the California Compassionate Use Act of 1996, voter initiative Proposition 215, was approved by 55% of the voters. By law, voter initiatives cannot be overturned by legislation

The senior author has seen over 6,500 patients the past nine years, since the first cannabis center opened in San Francisco in 1992. These patients are a great research resource in the study of medical marijuana. Patients can be classified by disease classification, and seldom analyzed conditions studied. Does cannabis influence a certain condition? In what ways? Listen to the patients. Most are delighted to have a sympathetic ear listen to the details. A substantial number of patients 104 at first review - used marijuana frequently, over many years, in a successful effort to end their debilitating drug use. For most, marijuana replaced alcohol; not just at crisis moments, such as detoxification or delirium tremens, but as a serious adjunct to a different way of life. Alcoholism, which had proved disastrous, was replaced with a regimen of marijuana smoking, which is relatively speaking a godsend to the patients.
The research method of this study is unique, because it is being conducted in a state of prohibition, surrounding large regions offering sanctuary. Those studied were not randomly selected but chose to consult the senior author, and getting a non-smoking control group comparable to them would be a career. However, each individual patient was a de facto experimental and control group. Alcoholic vs. Medical Marijuana User, Before and After.

There appears to be a pattern among our 104 patients - alcohol had long been a problem drug, and the resultant problems, even the wounds, were visible. Pain, depression, insomnia, are frequently mentioned; so, too, serious physical injuries, often committed under the influence. Serious health problems emerged at an early age. In this group of 104, cannabis replaced alcohol as the central drug focus, and life improved dramatically, healthwise to say the least. Like day for night. 1. PATIENT BACKGROUND

Age of Patients Cover A Wide Range:

The 104 "drug replacement" patients are fairly evenly dispersed throughout the adult age range, with a median age of about 40..

AGE OF "CANNABIS AS DRUG THERAPY" PATIENTS Under 35 Number of Patients (% Across) 39 38% 35-49 37 36% 50 + Over 28 27% (TOTAL) (104) (100%)

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Tod H. Mikuriya, M.D.

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Marijuana in the U.S. is no longer just a young person's drug. The young generation which, en masse, had discovered marijuana in the 1960's, are themselves about to enter their sixties. The broad age distribution of patients enabled the viewing of cannabis substitution over the course of a life-time. Drug Problems Start Early: Many patients traced the cause of their own alcoholism back to their childhood. The senior author was long ago impressed by these histories, and routinely asks patients if their parents were alcoholics. Most of the "cannabis substitution" cases were raised by at least one alcoholic parent: Over half those in the study group had one or two alcoholic parents; a few others had a markedly mentally disturbed parent though not an alcoholic one.

ALCOHOLISM AMONG PARENTS OF 104 "DRUG THERAPY" PATIENTS

1 or Both Parents Alcohol Abusers No Alcoholic or Abusive Parent 37 Mentally Disturbed Not Alcoholic 7 (TOTAL)1 (98)

No. of Patients
(% Across)

54

55%

38%

7%

(100%)

1. Parental alcohol history not recorded for six patients.

Treating pain - physical and psychological - with drugs, including marijuana, starts early: A considerable number of problems emerge when these not-yet-alcoholic children of alcoholics are very young. Often patients volunteer these early histories as they connect directly with their current use of marijuana, and the problems which cannabis alleviates. I've suffered from migraines my entire life. A few years ago I got in a car accident. I have been on Prozac, Paxil and Zoloft. Marijuana is the best treatment I have found for my disorders. The prescribed drugs all had many adverse effects on me, physically and mentally.

In the ninth grade (about age 14 in the U.S.) I was prescribed Ritalin and Zoloft. Ritalin caused me to be up all night; Zoloft made me sick to the stomach. I usually have to drink some liquor to get to sleep. This is a bad thing as I have now begun to drink excessive amounts of whisky. I feel malnourished and weaker than a man in his twenties should be. . . not as strong as I used to be. I also fear that I will, or am, an alcoholic and I do not want to see myself turn into my dad.

At a young age I was under mental evaluation with no luck. At 13, it (marijuana) relieved feelings of anxiety and depression,

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Tod H. Mikuriya, M.D.

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At a young age I was under mental evaluation with no luck. At 13, it (marijuana) relieved feelings of anxiety and depression, subdued rage and anger, calmed and relaxed, and controlled emotional pits.

Chronic depression has run in my family for generations, and cannabis is the only thing I've found that keeps my spirits high. If I have a constant supply of cannabis, alcohol is not consumed

Major, lasting pain, can also come from other sources, like an accident. One patient's alcoholism can be traced to a major accident he had at age 5, a result of which is that he still has, and expects to forever have, pins in an ankle. He found two drugs which eased the pain and enabled him to function: first alcohol and, at age 16, marijuana. Now, many years later: I use cannabis to prevent the abuse of alcohol. I'm unable to ease pain in the ankle without herb, and drink when unable to have cannabis to smoke.

The general condition we see is of a generational transmission of psychic pain. Many have spoken of a lineage of great warriors or hunters; why not a lineage of the vanquished? The condition for which marijuana seems to work so well is deep-seated, existential, and, in many cases, transmitted as if by genes. It is, though, a lineage that, for whatever cause, can also be joined. Others can enter this secret order if, perchance, a core of pain enters a life . . . like when a 5-year old's ankle gets permanently smashed in an auto accident. A ruthless God as well as an abusive parent can grant admission to this eternal society. Adult Children of Alcoholics (ACAs) have two strikes: direct emotional abuse and or abandonment by parent(s); and lack of role models for coping with uncomfortable feelings other than by inebriation. Cannabis provides control and relief without toxicity.

2. DRUG-RELATED PROBLEMS RELIEVED BY CANNABIS

Of those 104 cases, what are the drug problems which we claim have been reduced or alleviated by cannabis? Naturally, every patient is unique. A very few of them have failed to benefit from cannabis, or the benefits proved only short-term. Nonetheless, common features stand out, though elaborating many key details requires special research which we will pursue in the near future. Alcoholism is the most common drug problem which cannabis replaces: The drug which caused the lion's share of problems among the 104 "drug replacement" patients is alcohol. Over 90% were alcoholics, though a few, at times, were addicts to heroin, cocaine, amphetamines, or some other drug. These bouts with non-alcoholic drugs were viewed by older patients as youthful flings in a lifetime which, until cannabis replaced alcohol, was increasingly dominated by alcohol problems. In many patients there seemed to be a hard core of pain, marked by isolation, a sense of being rejected, of not being in a place where people smile and pleasures come easily and pain falls away. "Being," itself, is not a secure calm resting place. One is

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Tod H. Mikuriya, M.D.

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out-of-synch with the universe, from the inside out and vice-versa. Tamert and Mendelssohn summarize the psychophysiologic process: The anxiety reduction model often utilized to explain initiation and perpetuation of episodic drinking was found inadequate to explain motivation for alcohol use by the alcoholic. Euphoria and elation were manifest only during the initial phases of intoxication. Prolonged drinking was characterized by progressive depression, guilt, and psychic pain. These unpleasant affects, however, were poorly recalled by the alcoholics following cessation of drinking.

Compulsive and constricted behavior patterns, which were present during sobriety, changed markedly during intoxication, with increased verbalization, varied expression of feelings, increased interaction, and frequent behavioral regression. During inebriation, psychic defenses appeared weakened with significant reduction of repression and reaction formation. (Tamert and Mendelsohn 1969)
Injuries when using alcohol, add to pain and the need for relief by drugs: It still amazes the authors that so many of the ACA patients take cannabis for the relief of continuous pain from damage incurred due to behavior while intoxicated on alcohol. One patient who began the medicinal use of marijuana very soon after he was, in his word, "T-Boned" in an auto accident, still had "numbness in arms, fingers, (and) neck pain. I use pot to relax my muscles and to not drink." Many patients report that some of their pain is from injuries incurred when drunk - a mugging, a barroom brawl, a night never recalled except for the pain. Even winning can be losing, as physician notes record: Injured in a fight after consuming alcohol, resulted in staph infection of right knuckle, minor surgery and 4 days in hospital. However they were sustained, an inordinately high number of injuries, often severe, reported by the 104 patients studied, occurred while under the influence of alcohol. Nearly 50% incurred serious damage from one or more drunken episodes. The combination of frequent injury with major lasting damage attracts the physician's interest. . . especially when relief is readily at hand.
INJURY TO SELF UNDER ALCOHOL

YES Number of Patients (% Across) 40 45%

NO
44 49%

Maybe/Unclear 5 6%

(TOTAL)1 (89) (100%)

1. For 17 patients, this question was not asked, or there was no answer. 3. A CANNABIS-INFLUENCED LIFE-STYLE REPLACES ALCOHOLISM
At a certain point in the lives of many of the 104 patients studied, self-medication with alcohol failed to relieve the physical and psychic pain, and obviously and increasingly had negative consequences. (van der Spuy 1972) Some, with previous experience with marijuana, turn to it with a new determination, or desperation, to substitute it for alcohol. Several patients had a sense marijuana could substitute for alcohol shortly after they started using marijuana as teenagers or young adults, but the illegal context of cannabis use led them to continue to rely heavily on alcohol. Being able to obtain consistently high quality marijuana in an open, safe, legal manner - a

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Tod H. Mikuriya, M.D.

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situation created, in California, with the passage of Proposition 215 - made the substitution feasible. Others, with little past experience with marijuana, heeded the suggestion of friends and relatives, and unexpectedly found their alternative to alcoholism. Prescribed medications often don't work, and have negative side effects: Some patients, recognizing that alcohol fails to relieve their pains, sleeplessness, depression and other symptoms, go to their doctor, even if, as one of the 104 cases put it: I don't like going to doctors; afraid I'll be diagnosed with something and put on prescription drugs. I have trouble sleeping so use alcohol to allow me to finally go to sleep. I otherwise lay awake and go crazy with fears, anger, sadness. Cannabis helps me stay off harder drugs. Cigarettes, too. The pills prescribed by their physicians often did not work. The oldest among the 104 patients - a 71 year old who did 150 pushups and 50 curls in the morning - described how he came to marijuana: A psychiatrist told me my alcohol was killing me. He prescribed every kind of tranquilizer possible and nothing worked. My niece (suggested) marijuana to calm me down, and it worked like a miracle. Cannabis was the only thing that worked. A lot of times those prescribed pills had terrible side effects. And, so too, the ones prescribed after that. One patient, who had an accident which injured his skull, said the medications prescribed for him "made me paranoid and mean." Another, with chronic back pain, commented: I hurt a lot more without cannabis, and can't function as well. It seems to relax me so the medicines work better and faster. Additionally, cannabis is natural, and all these other drugs - Vicodin, Soma, Aleve, Librium, Baclofen - have lots of side effects. Keenly drug sensitive and with histories of problem drinking, many patients returned to alcohol if no prescribed drug would control underlying problems,. Maybe they used a little pot, here and there, but essentially they turned to alcohol. For the selected 104 patients, alcohol controlled something powerful and unwanted, but as a way of life it was not sustainable. There was so much alcohol, so many fights, so many scrapes and bruises, mental and physical, that the alcohol and the scars built up, and if, God willing, they lived long enough, new physical problems developed - with the liver, stomach, spine, esophagus. A cannabis regimen replaces alcoholism: At some point, many patients come to marijuana and find that they fit into two life-styles; their central medical problems can be addressed in two very different ways - an alcohol and a cannabis mediated style. A few statements in the patient records show the contrast between the worlds. (Effects of cannabis?) Stopped drinking. . . anger? Intermittent outbreaks, less severe; paranoia is now mostly realism. Restarted walking my dogs, weight-lifting, exercise, dance. I'm able to complete projects now.

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Tod H. Mikuriya, M.D.

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Major depression my whole life. Years ago, I smoked marijuana and I could stay off alcohol and could come out of my depression from it. I quit all the pills (for depression) because they didn't work for me. Cannabis has helped me with my depression better than I'd hoped. It sparked my creativity, released the internal pressure caused by the anxiety of having no purpose. I don't fight with my wife and I find it easier to handle my children. Cannabis has reduced my alcohol consumption by about 85%, and when this phase is over I would like to reduce my cannabis consumption as well. I'm also interested in other treatments for depression and anxiety. What does life look like after cannabis becomes part of the Daily Regimen? The average amount smoked by the senior author's patients is 2 joints a day (assuming 7 joints per eighth of an ounce of high quality marijuana). Almost half the 104 cases smoke more than that. Many of these patients are self-medicated as a rule, from not that late in the morning to not that early at night. And they do it for years. Most smoke continually with no apologies, no intention of quitting or even cutting back. Several recall what happened when they quit, voluntarily or otherwise. I quit using cannabis while I was in the army, and my drinking doubled. I was involved in several violent incidents due to alcohol and I was arrested. None of the problems (with violence and alcohol) occur while using cannabis. Not only does cannabis prevent my violent tendencies, it also keeps me from drinking. Marijuana eased, if not voided, my depression. I stopped drinking abruptly on receiving my first marijuana, but resumed when my (cannabis club) card expired. This treatment works for me. Only gains; no losses. Marijuana simultaneously removes the craving for, & relieves the symptoms masked by, alcohol: It will be interesting, as we gather more research information, to see how many of the 104 patients, primarily ex-alcoholics, smoke marijuana only to relieve pain, or induce and assist sleep, or calm the jitters, or break out of and stay out of depression, as well as replace alcohol. . . and how many smoke marijuana to do several of those things, as well as replace alcohol. Hardly another drug touches so many aspects of disease concurrently as marijuana. Cannabis has allowed me to significantly lower my stress levels, which has directly reduced my back problems and enabled me to make positive lifestyle changes as well. I am focused more than before and have dropped excessive commitments and projects from my agenda, reducing stress even more. A magical herb; the best herbal therapy I've ever used. Cannabis greatly improved the pain in my back and consequently my sleeplessness, which has been directly related to my desire to drink alcohol. I have not been using alcohol to combat discomfort, physical or otherwise. As a result, I have kept my motivational level up and have applied myself to school and my life in general more than in past years.

4. HISTORICAL CASES: CANNABIS FOR ADDICTION IS LIKE DAY FOR NIGHT. . . AND MISREAD FOR A CENTURY
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Tod H. Mikuriya, M.D.

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CENTURY
The substitution of marijuana for alcohol, the replacement of a life dominated by one drug vs. the other, is conventionally and simplistically described as just "one drug replacing another." Lives mediated by cannabis or alcohol tend to run very different courses. The earliest description of cannabis as therapy for addiction to other drugs in an English-language medical journal, to our knowledge, captured the contrast between habitual alcohol, opium and chloral use and subsequent long-term cannabis use. (Birch 1889) The first patient: . . . could not live without chloral and he was utterly miserable. His depression of spirits he described as being terrible; he had frequently contemplated suicide; insomnia was almost complete. He agreed voluntarily to place himself under circumstances which admitted of surveillance and restraint. His chloral was peremptorily stopped, and he was prescribed a pill containing half a grain of ext. cannabis ind. to be taken three times a day. The craving for the chloral had almost vanished in twenty-four hours, natural sleep returned after a few days. Eventually he returned to his home and work, a happy man; but much disappointed because the name of the drug used was not communicated to him. The second case, a most miserable object, intensely anaemic, and extremely emaciated - an "exhumed corpse", suffering acute agony in every limb. His liver and spleen were both materially enlarged. His history was shortly this. . . . he became a confirmed and very excessive spirit drinker till, fearing the consequences, he resolved to conquer the habit, and did so most thoroughly, but with opium, Laudanum. His friends who had only just rescued him from his isolated position, were quite hopeless of the possibility of recovery. There was insomnia, anorexia, disordered bowels, conscious delusions. Again cannabis - a quarter of a grain of the extract, gradually increasing to half a grain, one grain, and one grain and a half three times a day, with the happiest result. Ability to take food returned; an appetite appeared; he began to sleep well; his pulse exhibited some volume; and after three weeks he was able to take a turn on the verandah with the aid of a stick. After six weeks he spoke of returning to his post, and I never saw him again. Unfortunately, after describing two extraordinary cases of cannabis, not just painlessly detoxifying two hope-to-die drug habitus, but enabling and generating happy, economically productive results, Birch threw away whatever impact he might have had on the therapeutic use of cannabis1 by giving equal weight to prevailing horrific myths about cannabis in contrast to his own eye-witness experiences.

Upon one point I would insist - the necessity of concealing the name of the remedial drug from the patient, lest in his endeavor to escape from one form of vice he should fall into another, which can be indulged with facility in any Indian bazaar. Hence the prescription should be made as complex as possible, and at the earliest moment the dose of the extract should be diminished gradually till eventually it is withdrawn altogether. 5. LATE 1960s CASE: CANNABIS FOR ALCOHOLISM IS LIKE DAY FOR NIGHT
Although many authors recommended cannabis to relieve delirium tremens or the immediate symptoms of drug detoxification prior to marijuana prohibition in the 1930s, nothing in the medical literature until the end of the 1960s built upon the two cases of long-term substitution reported by Birch. In 1970, Medical Times published the senior author's notes of a patient who "when she smoked

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Tod H. Mikuriya, M.D.

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long-term substitution reported by Birch. In 1970, Medical Times published the senior author's notes of a patient who "when she smoked marijuana she decreased her alcoholic intake." (Mikuriya 1970) The "Discussion" (the final two paragraphs) opened: "It would appear that for selected alcoholics the substitution of smoked cannabis for alcohol may be of marked rehabilitative value. And ended: Certainly cannabis is not a panacea, but it warrants further clinical trial in selected cases of alcoholism.

Since 1970, the medical literature on cannabis sometimes noted that marijuana replaced alcohol abuse but, to our knowledge, there were few descriptions of the long term replacement of alcoholism by marijuana smoking. It has been a long time since federal funds were granted research on the positive effects of smoked marijuana, if ever. Medical journals, it seems to us, have had very few articles, ever, about smoked marijuana as a substitute for alcoholism. The major National Commissions, governmental and otherwise, and medical panels or collections of articles on marijuana, havent been the forum for describing those alcoholics who find it in their interests to replace alcohol with marijuana as their dominant mind altering drug. 6. THE IMPLICATIONS OF THERAPEUTIC CANNABIS
Though the moralist sees abstinence as the only wise course in cases of debilitating drug use, abstinence seems impossible for most of the 104 patients in our study. Given the underlying problems of most of them, offering nothing - abstinence - would be a violation of the Hippocratic Oath. When pain salvers are around, "Do No Harm" means prescribing drugs. Freedom from toxicity afforded by cannabis compared with alcohol is the simple physiologic reality. The problematic biphasic chronic alcohol inebriation-withdrawal cycle ceases with cannabis substitution. Sleep and appetite are restored, ability to focus and concentrate is helped, energy and activity levels are improved, pain and muscle spasms are relieved. Family and workplace relationships are restored as long term goals replace crises and apologies. Sobriety through cannabis substitution for some is not unrealistic. In providing a substitute for alcoholism and other drug habits, cannabis restores normal physiologic functioning of CNS, GI, hepatic, orthopedic, and endocrine systems.

The removal of the criminal stigma from self perception is a factor in the healing and reversing the alienation that is part of the alcoholic role. Most of the 104 patients in our current study came to a physician to legally get access to high quality medicine at a decent price in a clean well lighted place, without their lives being made any more stressed and chaotic by having to use the black market. The physician is enabled to form a therapeutic alliance with the agreed upon goal of sobriety. And dreams instead of nightmares and crises. Plans and long term goals become possible.
Cannabis has long been described as creating a unique dual consciousness, its users simultaneously in and outside the "real world." Contrast this to the world surrounding users of large amounts of alcohol. For many of the patients in this study, the shift from alcohol to cannabis opened a new option on what had been an intractable and worsening problem. In using cannabis as a substitute for alcohol, the cumulated problems of a hard alcoholic life did not disappear; but they could be seen and act upon from a distance, and soberly. At minimum, more effective coping and control resulted from cannabis substitution. Hope is restored with relief from chronic poisoning, and a life line back to functionality and dreams replaces injuries and nightmares. For the senior author, as a physician, another duality regarding cannabis has often become more important, urgent, and

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Tod H. Mikuriya, M.D.

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For the senior author, as a physician, another duality regarding cannabis has often become more important, urgent, and threatening than any caused by smoking cannabis per se. That duality is imposed by federal prohibitory laws. For physicians to alleviate the problems that patients with long-standing alcoholism bring to them, is to risk being defined and treated as a criminal. The commission of acts of civil obedience under California law constitutes federal civil disobedience. If the experiences of alcoholics, described above, are not unique to the geographic range of the author's medical practice, then there are tens of thousands of persons in the U.S., alone, who could benefit from cannabis substitution for alcoholism. Many patients remark that other physicians will not hear of the curative value of cannabis for debilitating drug problems, or will not recommend cannabis because of fears of legal repercussions. (Medicinal marijuana is legal in California and seven other states in the U.S., but it is illegal under federal law.) So, along with advocating drug treatment instead of arrest, we urge the restoration of cannabis to our arsenal of drug treatments. (Cannabis products were available from the middle 1840s through 1940.) To do otherwise is to concede victory to the dogmatic moralists dictation of medical standards against the best interests of physicians and their patients.

REFERENCES
Amer J Psychiat. 1971. Special Section Marijuana. 128(2):189-219 Birch, E.A.. 1889. The Use of Indian Hemp in the Treatment of Chronic Chloral and Chronic Opium Poisoning. Lancet i:625. (Reprtd in T. Mikuriya, ed. 1973. Marijuana: Medical Papers 1839-1972, Oakland, CA: Medi-Comp Press.) Mikuriya, T. 1970. Cannabis Substitution: An Adjunctive Therapeutic Tool in the Treatment of Alcoholism. Med Times 98(4):187-191. (Reprtd in T. Mikuriya, ed. 1973. Marijuana: Medical Papers 1839-1972, Oakland, CA: Medi-Comp Press.) Mikuriya, T. 2002. Cannabis an Easement; a Proposed Unique Drug Category (in press) J. Cannabis Therapeutics Tamert, J.S., Mendelssohn, J.H. 1969. The Psychodynamics of Chronic Inebriation: Observation of Alcoholics During the Process of Drinking in an Experimental Group Setting. Am J. Psychiat. 125:7. Van Der Spuy, H.I.J. 1972. Influence of Alcohol on the Mood of the Alcoholic. Br J Addict 67:255-265.

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