Journal of the California Cannabis Research Medical
Notes on Learning What to Look For
By Tom O’Connell, MD
Because California, unlike other states with medical marijuana laws, has no
central registry, no one knows exactly— or even roughly— how many patients
have asked a physician to endorse their use of cannabis since Prop 215 was
passed in 1996.
Similarly, we don’t know how many recommendations have actually been signed.
This lack of information is troubling, but must be considered against recent
(and pending) federal prosecutions of patients and growers in which jurors
were deliberately kept from hearing that the alleged “crimes” are legal under
Any state requirement for a central registry might have had an even more chilling
effect than the early threats made against physicians’ federal narcotics permits.
Despite being stayed on First Amendment grounds, the threat alone has effectively
dissuaded most California physicians from even discussing use of cannabis with
The closest thing to a registry is a confidential list of patients issued ID
cards by the Oakland Cannabis Buyers’ Club (OCBC). Of the almost 20,000 issued
to date, approximately 1/3 were signed by specialists in AIDS, cancer, or pain
management. The presumption is that those specialists accede fairly readily
to patient requests.
Another third were signed by roughly 1,100 practitioners who have signed only
a few (five or fewer) but have renewed them faithfully each year. They are
probably accomodating favored patients in their practices and don’t fully support
the concept of medical use.
Finally, there is a small number (15 to 20) who support medical use and specialize
in cannabis evaluations. They account for the final 1/3 of the OCBC list. Some
work mainly in buyers’ clubs or ad hoc clinics arranged by activists, others
in private offices. Those working in clubs generally don’t advertise; those
located in private offices often do. The vast majority of the state’s physicians
(including those employed by Kaiser) will not sign recommendations or even
discuss cannabis with patients. Doctors willing to do so are kept busy.
Use Begins in Adolescence
My earliest interviews quickly disclosed that essentially everyone seen had
first tried cannabis during adolescence —especially those coming of age since
1970. The initiation age seems to have declined significantly since since cannabis
was discovered by white American youth in the mid-to-late 1960s.
Although Proposition 215 gave physicians responsibility for determining if
a given patient’s use was “medical,” there were no standards defining such
use; thus, a learning curve was inevitable.
Since cannabis had been illegal since 1937, there was no contemporary clinical
experience to draw on.
The federal government’s contention that cannabis is both dangerous and ‘habit
forming’ is, in reality, also completely lacking in clinical documentation.
To the contrary, there have been no deaths directly attributed to cannabis
and significant clinical toxicity seems very rare.
With AIDS and cancer patients presumably getting approvals to use cannabis
from their own doctors, most of the patients requesting my approval to use
it have presented with chronic pain— a notoriously difficult condition to quantify
in clinical practice.
Some claims of chronic pain seen early on were obviously justified; others
were not very impressive. What was impressive, however, were the candidates’ own
estimates of how important cannabis was to their daily functioning. When asked
to rate it on a scale of 1-10 with 10 comparable to food or water, they rarely
suggested a number lower than 8.5 and many gave an obviously heartfelt 9 or
10. Also impressive was that those with questionable pain were just as adamant
as those whose pain seemed more real. That suggested that cannabis is really
used as a psychotropic agent, perhaps without many patients even realizing
it. The details of everyone’s use were then asked. As mentioned, nearly all
had begun in adolescence and had been daily users for years or decades when
first seen. In many cases, the pain producing condition or injury had clearly
been superimposed on an established pattern of daily cannabis use.
Because patients’ responses also suggested that their use of cannabis had been
linked temporally to their use of alcohol, tobacco and other drugs, the range
of questioning was expanded. Since June 2002, a conscious attempt has been
made to ask everyone certain specific questions and record the answers. Forms
were developed to facilitate the gathering and recording of such data while
still preserving the conditions required for a very personal interview.
Since the last quarter of 2002, patient information has been entered into a
database. Based on early findings, forms and techniques have been refined to
facilitate data collection.
The patients tabulated below were seen between July 1 and Sept. 30, 2002. (Results
of several hundred interviews conducted since then seem to agree strongly.)
Some 293 patients are in the initial database (316 are eligible), but the amount
of data in different fields is variable; I will try to report that number (N)
for each field.
Age distribution (N=286)
Over 60: 8 (1-8)
50-59: 39 (9-47)
40-49: 46 (48-94)
30-39: 77 (95-172)
20-29: 96 (173-269)
18-19 14 (270-283)
Gender (N= 280)
Male 215, Female 65 (23%)
Previously tried cannabis (N=290)
Age at initiation (N=241)
Over 30: 5 (2.0%)
20-29 23 (9.5%)
15-19: 126 (52.3%)
10-14 79 (33.0%)
Under 10 5 (2.0%)
Also tried alcohol (N=240)
Both alcohol and cannabis were initiated in a ritualistic fashion
by nearly all: consumption to the point of intoxication, often with
older friends or siblings in attendance.
Age at alcohol initiation (N=236)
Over 20: 15 (6.5%)
15-19: 153 (55.2%)
10-15: 109 (46.2%)
Under 10 4 (1.8%)
Subsequent alcohol history:
Became blackout drinkers: 58 (25.6%) Most blackout drinking occurred in high
school or at college age.
Never developed a significant alcohol problem: 53 (24.4%)
Since January 1, 2003, everyone has been asked the time in their lives
they did the most drinking; how they rate that level of consumption,
and how it compares to their present consumption. For most it was either
high school or young adulthood (college age) and was aggressive; so
far, most claim their current drinking is 10% or less of what they
had consumed during their earlier peak.
The antagonism between chronic use of pot and heavy drinking —in a
population of former heavy drinkers— seems one of the most salient
findings, along with the proclivity of this group to experiment with
ALL drugs. (Despite that experimentation, relatively few developed
addictions, except to tobacco).
Tobacco Use (N=239):
Tried cigarettes: 218 (88.0%)
Those who report never having smoked one cigarette all stated it was
because parents had smoked so heavily that it completely turned them
Age at tobacco initiation (N=218)
20-29: 23 (8.55%)
15-19 102 (38.8%)
12-14 91 (32.6%)
under12: 20 (9.1%)
History with tobacco (N=226)
Never became daily smokers: 67 (33.3%)
Became daily smokers, then quit: 70 (36.4%)
Still smoking: 69 (30.2%)
Happy to still be smoking: 0/69
Other drugs tried (N=232)
psilocybin: 185 (80%}
LSD: 152 (65%)
peyote or mescaline: 97 (41.9%)
cocaine 148 (77.0%)
heroin 49 (21.1%)
Although this data is very preliminary, information from more recent
interviews— more focussed, but not yet tabulated— strongly supports
A finding that nearly all these patients have experienced either absent or
dysfunctional parenting from their biologic fathers calls for further investigation.
Are Patients “Scoring?”
In response to a colleague who questions whether some ADHD patients are in
fact addicted to cannabis:
First of all, the use pattern is never progressive like alcohol or heroin use
tends to be; it’s stable. Many if not most of my ADHD patients quit for a period
of time every year, and have no trouble doing so.
There’s mild craving but no withdrawal. If you had an effective medication
that was controlling really troublesome symptoms, and you were forced to go
off it for a period of time, you wouldn’t enjoy that.
Cannabis is a stabilizing agent for people who have demonstrated a real weakness
for both alcohol and tobacco and a tendency to explore other drugs. It’s the
most benign form of self-medication available, and demonstrably helpful. —Tom