Journal of the California Cannabis Research Medical
Notes re: Patterns of Use
By Tom O'Connell, MD
Since the Fall of 2001 I have conducted interviews of patients seeking a 'medical'
designation in the San Francisco Bay Area.
Over the first seven months the interviews became more focused and I developed
a standardized set of questions that was asked of all candidates. Recently
I began analyzing data provided by 625 patients, who were all seen between
July 1 and Dec. 31, 2002.
¥ 80% were men (average age 33); 20% women (average age 39).
¥ 70% (of all) were Caucasian; 15% were African-American; 7.5% Hispanic and
the rest split between Asian and "Other."
My patients typically made appointments to be seen at cannabis clubs. While
they range in age from 18 to 91, there were very few over the age of 56 -perhaps
reflecting that most people who will ever use cannabis try it before the age
of 21. Many did not have health insurance. Others (generally members of Kaiser
Permanente) reported that their doctors would not discuss cannabis with them.
While most cited 'somatic' symptoms/conditions- especially chronic pain- as
their reason for using cannabis, the intensity (and validity) were quite variable.
A careful chronology almost invariably reveals that cannabis use was chronic
before the painful condition existed.
More than 90%, when asked directly, acknowledged "stress," "anxiety," "insomnia" "agorophobia," " anorexia," and
other indications of emotional distress.
An inescapable conclusion is that much initial use is motivated by psychic
rather than -or as well as- physical pain.
Patterns of use
¥ 95% were using five or six days per week and had been for years -or decades.
¥ The average amount used varied from 1/16 to more than an ounce per week,
but the great majority admit to between 1/8 and 1/4 oz per week.
¥ Marijuana is smoked or otherwise ingested in multiple small doses with
an emphasis on avoiding becoming "stoned."
¥ Some always smoke in the morning. Others never smoke in the morning; Many
will smoke in the morning- but only on days off. In other words, work schedule
-and fear of exposure- play a big role in usage. There also seems to be an avoidance
of daytime use for other reasons.
¥ Although all age groups are represented, the great
majority -92.9%- were under the age of 56.
¥ The vast majority -84%- had first sampled ("initiated") cannabis
in either high school or junior high.
¥ The average age of initiation has been declining steadily -from older than
16 in the late 1960s to under 15 in the late '90s.
¥ Essentially all had initiated alcohol and most (93%) had also tried tobacco
at average ages remaining more or less constant at about 15.
¥ The rate of addiction to tobacco was extraordinarily high; 70 % became "every
day smokers." All had quit or were trying to quit, but only about half had
succeeded by the time of the interview. The rest remain unwilling "inveterate" smokers.
¥ Aggressive drinking -manifested by binge drinking
in high school or college, black-outs, and DUI citations- had also
been exceptionally high. Those who became daily cannabis smokers moderated
their drinking spontaneously, whether they thought about it or not.
The "substitution" effect of cannabis for alcohol is dramatically
demonstrated in this population. One almost never sees simultaneous
problem drinking in this group of daily pot smokers- even though two-thirds
of them had been problem drinkers in their youth.
¥ Lifetime initiation rates for other drugs were
MDMA (ecstasy) 49%
Looking for environmental factors that might explain
such high rates of illicit drug use, I began taking increasingly detailed
family histories. It soon emerged that there was a common pattern:
the biologic father had not played a positive, supportive role in their
lives between pre-school and the sixth grade -roughly ages four through
The most common reasons were:
-an unknown father
-early (before 7) death or divorce
-an alcoholic/workaholic father
-a stern, punitive father.
There are other, less common scenarios involving an invalid or an elderly father,
or a recent immigrant who cannot communicate in English.
¥ Many of my patients reported early self-esteem
problems which were made worse by the following:
-any learning or reading disability
-being in a racial minority
- being teased ( for any reason)
-frequent moves and attendant school changes.
Quite a few of the younger ones were evaluated for/identified with ADD; many
of the older ones would probably have qualified.
The bottom line is that most of the people who use cannabis
regularly and were forced to come to buyers' clubs for their "recommendations" -either
because they don't have a doctor, or their own doctor wouldn't discuss
it with them- were/are using seeking to control an emotional "disorder'
rooted in low self-esteem."
Cannabis was clearly only one of several agents they'd tried- along with alcohol
and tobacco. Any of these agents may be able to control the underlying emotional
disorder for a while, but pot is -for them, at least- the safest and least
harmful, especially over the long haul.
" Initiating" heroin seems an unquestionable indicator that the underlying
emotional disturbance is severe. Those who tried heroin also tried cocaine and
mushrooms at rates over 90%, and had the highest rates of problem drinking...
There's some preliminary data that access to cannabis predisposes against addiction
It appears that most adolescent drug use may be motivated by the same basic
causative factor: low self-esteem in its many guises.