A Review of the International Clinical
Literature by Sir Aubrey Lewis,
Emeritus Professor of Psychiatry,
University of London
The physical effects of cannabis intoxication
are raised pulse rate and blood pressure, dilated sluggish pupils,
injected conjunctival vessels, tremor of tongue and mouth, cold
extremities, rapid shallow breathing, ataxia and active deep reflexes.
The severity of the symptoms depends not only on the dose and
preparation but on the individual. A young English-woman on one
occasion smoked two-thirds of a home-made hashish cigarette which
had not upset her husband; she promptly developed gross inco-ordination
of the hands, astasia, rapid pulse, and dyspnoea. In soldiers
who took cannabis a temporary loss of consciousness has been reported
with slow irregular pulse and low blood pressure. Others have
described vertigo and vomiting, and death is said to have occurred
from cardiac failure or intestinal distention after gross overeating.
But severe physical disturbance is rare. A common initial effect
of smoking the drug is intense cough or burning feeling in the
throat and chest.
The psychological effects of acute intoxication
were first described in detail by Moreau de Tours:- euphoria; excitement;
disturbed associations; changes in the appreciation of time and
space; raised auditory sensitivity with elaboration of simple
phrases or tunes; fixed ideas; emotional upheaval; and illusions
Suggestibility is much increased (the assassination
of General Kleber is supposed to have been carried out by a fanatic
whose heightened suggestibility under cannabis made him a pliant
There are no aphrodisiac effects, in spite of
widespread popular belief. Erotic fantasies may be well to the
fore, but they do not lead to action.
There is much individual variation in the psychological
effects. Perhaps because of ethnic and social differences and
the effects of different preparations of the drug, widely divergent
accounts are to be found in published papers. Lord Todd put it
succinctly: "To give an accurate picture of the effects of
hashish is extremely difficult, partly because they are more subjective
than objective and because individual variation in response is
probably* greater with this than with any other drug. . . . . Among
the commonest recorded effects are the feeling of well-being alternating
with depression, distortion of time and space, and double consciousness.
Objectively there is a period of excitation and exaltation, followed
often by sleep or coma".
Some subjects feel acute anxiety as soon as the
drug takes effect; others are pleased, amused, elated, although
they may be aware that their thought processes are somewhat disordered,
their memory impaired and their self-control diminished. The phases
of abnormality might come in waves, heralded by sudden violent
headaches. The emotional state is not in keeping with the subject's
situation, and as the intoxication grows less, subjects mostly
feel apathetic and depressed. During the acute stage of intoxication,
they may have become suspicious and afraid that they will be permanently
insane, or that their friends are trying to find grounds for shutting
them up in a mental hospital. Characteristic visual phenomena
are almost invariably reported; they are not true hallucinations
but illusionary falsification, greatly elaborated by some subjects.
Perception of one's own body is commonly interfered with, and
outright depersonalization may occur. With small doses of cannabis
the effect may be wholly subjective, mild and gratifying.
The first signs of intoxication, appearing about
three hours after consuming the drug by mouth may be nausea or
vomiting, with gross movements and loquacity. Disorders of thinking
may be overt, or detectable by close examination. Intoxicated
persons may be unable to retain more than a single sentence, so
that conversation is disjointed and may be unintelligible; a communication
that has been heard and understood may be lost in a few seconds;
in the middle of a lively conversation, speech may stop abruptly
and the intended remark is gone beyond recovery. The disturbance
of memory may be severe in one person and negligible in another.
The time schedule varies according to the mode of consumption.
After smoking hashish resin, acute anxiety and restlessness may
come on within about half-an-hour; then calm and pleasant sensations
supervene with visual imagery; and in one to two hours the subject
becomes sleepy; when he wakes from the ensuing sleep he may be
able to recall details of the intoxication. If, however, he has
taken the cannabis in powder form, it may take three to six hours
for sleepiness to come on.
In Europeans, though the order of events may
vary a great deal, a typical sequence is euphoria with restlessness;
then confusion, disturbed visual and auditory perception; then
a dreamy state; and finally depression and sleep. On waking after
this sleep, there may be numbness, dysarthria and some amnesia.
Many Moroccans, when under the influence of the drug, become gay
or relaxed, though it is not rare for anger to be expressed in
some act of violence. According to one observer, they value cannabis
because it frees them temporarily from moral and cultural restraints
on conduct. In contrast to the torpor described in some subjects,
the Moroccans may feel that they can do difficult things easily,
and they may jump and dance. Hesnard, a psychiatrist who has observed
Turkish and Syrian hemp addicts, described them as incoherent
in speech but self-observant; talkative, exuberant, gesticulating
and running hither and thither, but incapable of mental work,
and agitated. Noisy laughter may be incongruously accompanied
by sadness. Intense depersonalization sometimes occurs.
They have erotic desires which they do not translate
into erotic behaviour. In Brazil, according to Wolff and other
Brazilian psychiatrists, the picture is different from that described
elsewhere; sexual orgies are alleged to take place.
The discrepancies in published accounts of acute
intoxication may be, in part, accounted for not only by individual
constitution and the effect of adulterants, but also by differences
in dosage. Practised hashish consumers have usually learned how
to regulate the dose of whatever preparation they use so that
the disagreeable effects are minimal.
Among the symptoms of acute intoxication,
gross mental disturbances are described which can properly be
called psychotic. They are usually the outcome of taking a fairly
large dose of the drug; and the clinical picture is that of a
severe exogenous psychosis-delirium with confusion, disorientation,
terror or anger, and subsequent amnesia about what happened during
the period of intoxication. Although most often described in countries
where cannabis is widely resorted to, striking instances are reported
also in Europeans.
Within this acute setting, the most frequent
psychotic features are: paranoid delusions of being pursued or
controlled; delusions of preternatural abilities; strong inclinations
to suicide which are not carried into action unless associated
with panic; and irritability. Waxy flexibility and other catatonic
features have been observed, though infrequently.
The impulse to suicide may be very strong; a
doctor who took forty drops of tincture of cannabis indica developed
at first great anxiety and fear of death, then "I was possessed
with an almost irresistible desire to commit suicide by rushing
to the adjoining canal or cutting my throat with the knives on
the table close by, though no attempt was made at doing so. Shortly
upon this, I was seized with fits of alternate laughter and crying,
without any apparent cause. When the symptoms were subsiding my
appetite became ravenous accompanied by great thirst. . . . .
I experienced no pleasurable intoxication or feeling of happiness,
but the very reverse".
There is a sharp contrast between the ecstatic
and relaxed state described in many reports and the restless activity
occasionally observed (along with exaltation, irritability, emotional
excess, noisiness and even reckless violence) in some subjects,
especially in the Punjab or in Brazil. Evidently, large doses
produce anomalous effects, seldom seen in mentally stable persons
or in those who have learned to regulate their intake so that
it should be pleasurable. An example of how excess can affect
the individual is provided by a French youth aged 20 who smoked
five hashish cigarettes straight off. He became very agitated
and restless, rushed around Paris and eventually, fourteen hours
after he had taken the drug, he went into a police station to
give himself up for having murdered his step father (an entirely
baseless delusion). The duration of the psychotic intoxication
was longer in his case than is usual; as a rule, the condition
clears up in three to six hours.
Exact psychological studies
of the effects of cannabis have suffered from the limitation that
they were carried out either on highly selected subjects - prisoners
and drug addicts - or on very small samples, sometimes only two
or three persons. The main findings have been that simple functions
like tapping speed and reaction time were very little affected
by moderate doses of cannabis, but that steadiness of hand movements
and complex reaction time were adversely affected, the maximum
change occurring about four hours after ingestion.
In intellectual tasks speed and accuracy were
impaired, the degree depending on the dose. Surprisingly, the
ability to estimate short periods of time was not reduced in an
American study, but the subjects were chronic addicts; whereas
in an experiment carried out by two psychiatrists on each other,
under laboratory conditions, time intervals were overestimated.
Two German psychiatrists examined thirty normal subjects, and
found three types of intellectual disorder - incapacity to fuse
details into a whole; reduced memory storage; and blocking; these
observations were made, however, after the drug had been administered
in the form of cannabinol 0.1 g.
Effect on Persons already Psychotic
In the 1930's, experiments were carried out on
schizophrenic and depressed patients in mental hospitals to see
what cannabis would do to them and how far the drugs, alleged
to be psychotomimetic, would intensify psychotic symptoms. The
findings were not uniform. Affectivity was altered but in different
ways and degrees; some schizophrenics became euphoric and hyperactive,
others became catatonic; surprisingly, only two-thirds of the
schizophrenics developed hallucinations. Some of the depressed
subjects became euphoric, others passed into a depressive stupor.
Autism was intensified in some schizophrenics and symptoms that
had previously cleared up were revived. The schizophrenic patients
showed less change in time and space perception than normal subjects
while under the influence of the drug. Impulsive acts were more
prone to occur in schizophrenic subjects than in normal cannabis
Initiation: Social Setting
Most of those who take cannabis in any society
have been introduced to the habit by an acquaintance. The amount
of pressure varies from country to country - the commoner the
habit, the more ready the compliance - and from group to group.
In Egypt (where penalties are severe and include capital punishment
for trafficking), the habit is nevertheless very widespread; and,
as was shown by a recent investigation on 253 men who had used
hashish at least once a month during the previous year, conformity
to the ways of the group emerges as a powerful factor, especially
among those who have been led to expect a blissful experience
and sexual stimulation from it. Taking it is a convivial affair;
four to six friends meet in the evening, smoke and engage in light
conversation. Similarly, an American report confirmed the view
that marihuana is a socially utilized intoxicant, seldom taken
in solitude. Those who have studied American college students
who smoke marihuana conclude that they do so because they are
alienated from the values of adult society, which exposes them
to conflicting demands; through this habit they can mortify their
parents and flout authorities. This is a speculative interpretation
of their motives.
The fullest available description of the social
conditions which foster the marihuana habit comes from Oakland,
California. It counterbalances, and perhaps corrects, the picturesque
and alarming observations made on more degraded, psychopathic,
criminal, or poverty-stricken and under-nourished groups. The
investigators obtained the confidence of the youngsters, mostly
Negroes and Mexicans, through providing them with club amenities,
without strings. They were firm in their conviction, based on
their own experience, that the use of such drugs as marihuana
results in harmless pleasure and increased conviviality, does
not lead to violence or madness, can be regulated, does not lead
to addiction, and is less harmful than alcohol. They were not
interested in being helped to abstain from marihuana, and they
cited case after case of individuals known to them who had not
suffered deterioration in health, school achievement, athletics
or career as a result of their habit of smoking marihuana. Boys
who take the drug in excess were considered by the rest to have
a weak personality.
There are several patterns of use and users among
these youths. They themselves recognize four types, for which
they have cant names. The "rowdy dude" wants to impress
and frighten others and has difficulty in getting marihuana from
other youths because he is reckless and irresponsible and they
fear he will get them into trouble with the police; he is subject
to pressures which direct him towards becoming a criminal or an
opiate addict. The "rowdy dude" may settle down, when
he stops taking alcohol or sniffing glue, and starts to take marihuana
instead. In that case he becomes a "pot head" who limits
himself to marihuana smoking, or a "mellow dude" who
uses amphetamines or barbiturates or methedrine as well as marihuana.
Both the "pot heads" and the "mellow dudes"
value sang-froid. They believe themselves to be intelligent,
daring, cool-headed, worthy of respect, and they do not resort
to violence; they remain at school or at work and engage in athletics.
They will smoke marihuana three or four times a day, especially
if they are going to a party; they believe it breaks through their
shyness in approaching girls and increases the pleasure of sexual
intercourse. The fourth type is the "player", an older
youth who sells drugs and becomes a violent criminal or a pimp
or fence; he may take to heroin but will mostly be on his guard
against any drug that may reduce his alertness.
Initiation into marihuana-smoking in this group
is usually effected through the desire to emulate older boys.
The Oakland investigators reject firmly the usual assumption that
those who take to the habit are mainly influenced by emotional
disturbances and social stresses. Their observations do not support
the explanation which regards marihuana use as an effort to escape
from reality or to vent underlying hatred of organized society.
They conclude that "induction into drug use is a developing
experience that depends on access to drugs, acceptance by drug-using
associates and kinds of image that youngsters have of drugs".
So far from retreating from reality, marihuana-users are held
to be making a positive effort to be in the mainstream. The investigators
likewise reject the notion of a steady progression from marihuana
to crime and opiate addiction. It may occur, as the four types
indicate, but most users steer away from these courses. Many of
the Oakland youths had experimented with heroin, but only four
had become addicts.
The summary conclusion by the Oakland observers
is unequivocal: "Youthful drug use in Oakland is an appreciably
extensive and deeply rooted practice, lodged primarily in the
lower strata but currently expanding into middle and upper class
strata. It is woven into a round of adolescent life as a collective
practice . . . . . and is buttressed by a body of justifying beliefs
and convictions, involves a repertoire of practical knowledge
and incorporates a body of precautions and protections against
apprehension or arrest. Drug use constitutes for the users a natural
way of life and does not represent a pathological phenomena".
The age at which use of the drug began, according
to practically all the studies reported, was in adolescence, though
children have sometimes begun before puberty. In a group of American
negro soldiers who had been admitted to hospital because of their
cannabis-taking and its ill effects, 13% said they had started
doing so before adolescence and two-thirds had started before
they were seventeen.
The majority of users, apart from university
students, belonged to the urban proletariat. In Nigeria, where
the habit has only recently been developing on a large scale,
the people mostly affected had drifted to the city and live on
the fringe of organised society. Others who take it are long distance
lorry drivers who believe that it increases staying power and
courage, enabling them to take daredevil risks: among twenty-six
cannabis-using patients admitted to Aro Hospital in Abeokuta,
eight were lorry or taxi drivers. In North Africa, the rural population
is also affected but much less so than the industrial workers
and the unemployed who are often under-nourished. During Ramadan
there is a rise in the number of cannabis-takers that has to be
admitted to the mental hospital. Among cannabis users from Upper
Egypt, who are predominantly* rural, there is a larger proportion
of people with average or above average incomes than in those
from Cairo. In several Asiatic countries the well-to-do smoke
or otherwise consume their cannabis in private and in moderation;
they do not get into the statistics or serve to tone down the
published description of the coarse effects of cannabis.
In Morocco and Nigeria and some other African
countries, cannabis-taking is not exclusively a masculine preserve,
though women who do so are far fewer than men. In South Africa,
10,044 male Africans and 632 females were convicted of possessing
cannabis; for Europeans, the corresponding figures were respectively
181 male and 4 female.
There is no convincing evidence that, other things
being equal, the nationals of any particular country are more
prone to take cannabis than, say, Englishmen or Burmese. In American
reports, especially those based on military experience, Negroes
and Puerto Ricans are to the fore but this is adequately accounted
for in terms of the psychological, economic and civic background
of their lives.
It is impossible at present to disentangle the
psychological, climatic, social and religious factors which may
determine the range and style of cannabis-taking. Confident statements
about one or other such influence rest on impressions and conjecture.
There are sweeping generalizations (such as that Moslems use cannabis
because they are forbidden alcohol, whereas Hindus prefer opium)
and detailed accounts of the extraordinarily diverse ways in which
the drug is prepared and taken in different countries. Ethnic
factors are loosely invoked, but never with adequate evidence.
It has been asserted, for example, by a psychiatrist who had had
extensive experience in Algeria, that hashish is suited to the
dreamy and contemplative temperament of the Moslem, alcohol to
the hyperactive Westerner. Another authority, well acquainted
with the Moroccan situation, says that the people of that country
are imaginative and emotional and that they gain relief through
the drug when they are in distress. A German psychiatrist who
had spent two years in Morocco reported this year, that impulsive
behaviour under hashish can be attributed to "the Moroccan
mentality", which is also "prone to trance states".
Another, with long Egyptian experience, attributes the growth
of the practice there to foreign domination, the prohibition of
alcohol, and the special tribunals for foreigners which made illicit
traffic easy and safe. A Brazilian doctor maintains that dwellers
in the lowlands need cannabis while those who live and work in
the high plateaux of the Andes need the coca leaf to sustain them
amid the extreme rigours of their lives.
Apart from the Brazilians and adherents of the
Ras Tafari cult in Jamaica, a direct association with contemporary
religions has not been reported; the continuing role of cannabis
in Ayurvedic and Unani medicine cannot be regarded as of a religious
The attitude of the general public towards cannabis
is not constant, nor evenly spread through the different sections
of society. In India, and particularly in Bengal, taking the drug
is not regarded with disapproval, according to most observers.
Sixty or seventy years ago, however, most of the population looked
down on the drug-takers, largely because of the degraded class
they came from; but consumption of the drug by sadhus who were,
in many cases, deeply committed to the habit, was viewed tolerantly.
The public attitude in Mexico has also been reported to be tolerant.
Satisfactory information about the attitude of various sections
of Western society does not exist; inference from newspapers tends
to be inconsistent.
Whether or how far particular features of personality
conduce to the establishment of the cannabis habit is a highly
contentious question, as much so as in the case of alcohol. At
one extreme are those (like P. O. Wolff reporting on the peasants
of Brazil) who deny that there is any predisposition, and at the
other extreme those who regard defects of personality as prepotent
- not only in bringing about habituation but also in determining
the form of psychological disturbance produced. Since the estimates
of personality are made in almost all cases retrospectively on
persons known to be cannabis-users, there is much uncertainty
as to whether the traits described were consequences of the habit
or had preceded it and favoured its development. The temperamental
qualities most often cited as predisposing are anxiety and impulsiveness,
shyness combined with a longing for social contacts, immaturity
and emotional instability, and various neurotic and psychopathic
features. They are clearly unspecific.
Two American psychiatrists who studied a hospital
group of cannabis-takers concluded that "the personality
pattern of these men is one of strong libidinous desires resulting
from early home conflict, a weak ego which identifies with an
undesirable father image, and a super ego created by the moral
mother. . . . . Use of marihuana removes the super ego which,
in turn, strengthens the ego and enables it to satisfy the libidinous
desires at various levels of infantile behaviour". Another
writer, less psychoanalytically recondite, has found that homosexual
tendencies are at work among the men who take cannabis to excess.
A respectable body of opinion is to the effect that, though there
is no doubt that faults of character may be found in those chronic
users who reach hospital or prison, the majority of moderate users
are within the normal range of personality. This is in sharp contrast
to reports like that on the United States marihuana-smoking soldiers
in the Panama Canal Zone, which found that 85% of the men were
mentally abnormal - 62 % were classified as constitutional psychopaths
and 23% as morons.
There are notoriously great differences between
countries in the prevalence of cannabis use, but reliable estimates
do not exist. Surmises are based on the quantities of the drug
seized by the police, the number of convictions, and the proportion
of people in mental hospitals who admit to having taken it. The
figures thus arrived at are very high for some countries. Thus
the most recent assessment for Egypt is that 27,000 kilograms
of hashish were smuggled into the country, to be used by about
80,000 habitués (out of a total young male population of
some three million persons). Gross figures are calculated for
Morocco (50% of the population - "a million habitués"),
and for some other countries. It is difficult to regard these
as more than guesses.
The same uncertainty holds good of current estimates
in North America and in Europe. A recent cautious statement, based
on United Kingdom convictions for possessing or using cannabis,
arrived at a figure of 30 regular users per 100,000 of population,
and as many more who have tried it a few times.
Interest has centred on university students.
In a sample of London students, 4% have been said to be steady
users and 10% occasional users; because of penalties, fluctuations
of opinion and other obstacles in the way of a trustworthy survey,
such a finding cannot be generalized. It has been reasonably stated
that the amount of addiction to a drug in any given population
is a composite of availability, price, legal codes, suggestion,
cultural attitudes, psychological needs and socio-economic factors;
the product of such mixed influences could hardly be unchanging.
In a questionnaire to which 1,245 students replied at Brooklyn
College, New York, it emerged that progression to other drugs
very seldom occurred though three-quarters of the students had,
at one time or another, experimented with marihuana. One-third
had done so on only one occasion.
ADVERSE EFFECTS OF ABUSE
Social Effects apart from Crime and Psychosis
Observers with long experience concur in the
opinion that continued excessive use of cannabis over a period
of years leads to moral and social decay; countries from which
such reports come are South Africa, Morocco, Algeria, Tunisia,
Syria, Turkey, Astrakhan and India. In a few reports, such conclusions
are extended to cover chronic use of the drug in only moderate
doses but the majority of observers distinguish between heavy
dosage and restrained use; restrained use is widely regarded as
harmless in its effects, provided the consumer had, from the outset,
a healthy mental constitution. In defining healthy mental constitution,
circular reasoning is apt to creep in.
The Mayor of New York's Committee on Marihuana
found that people who had been smoking marihuana daily for years
showed no abnormal psychological functioning which would differentiate
them from non-users. The population selected for study, however,
was composed mainly of men in prison who had volunteered for the
study; they were hardly a representative sample of users and non-users.
The Indian Hemp Commission of 1894 reported, after an elaborate
enquiry, that moderate use produces no injurious effects except
in persons with neurotic diathesis but that excessive use may
intensify mental instability and moral weakness, and lead to loss
of self respect.
The degradation that most writers report in the
excessive chronic cannabis user is apparent in several ways. He
is irritable and impulsive, or inert and dreamy; he neglects himself
grossly and is incapable of sustained effort; he may become a
beggar or a vagrant, taking no responsibility for his family;
he may practise homosexual or other sexual abnormalities or become
impotent; he may be hypochondriacal or apathetic. His unkempt
and prematurely aged appearance, inflamed eyes, tremor, and malnutrition
are said to make up a fairly characteristic picture.
Effect on Occupational Capacity
Because of his impaired judgment, especially
of space relations, and his irresponsibility, the chronic user
- as well as the person acutely intoxicated - is dangerous when
driving a car or lorry; this has been reported particularly from
African countries. But the general occupational record of chronic
users is not invariably bad, and no one has succeeded in determining
how many continuous users become incapable of regular work. Bouquet
and others have pointed out that there are some men who have been
smoking hemp for thirty or more years and continue to follow their
occupations satisfactorily: "A few daily pipes of kif are
merely an agreeable weakness, enough to produce the condition
of well-being they desire. They rest content with that".
In contrast, a pronouncement in the United Nations Commission
on Narcotic Drugs, E/CN/7/L.91, stated that "the study points
up unequivocally the danger of cannabis from every point of view,
whether physical, mental, social or criminological".
Published statements regarding the association
between crime and cannabis illustrate the confused and contradictory
standpoint taken up by experts, and the loose reasoning evident
when a causal nexus is being considered.
Taking the views first of those who believe that
cannabis can bring about criminal behaviour, some uncompromising
conclusions are put forward, e.g. "literature surveys and
personal contacts have clearly demonstrated the association between
the use of marihuana and the commission of various crimes".
Several describe outbursts by chronic users, in which they are
wildly agitated and, seizing some handy weapon, attack a nearby
person, often without the faintest motive for hostility: "murders
are frequent and motiveless". A Greek investigator inquired
into the subsequent history of 170 people who were arrested for
possessing* cannabis between 1919 and 1950 but had not previously
been before a court for any offence; he found that 117 of these
were subsequently sentenced for crimes of violence, blackmail
and similar serious offences. P. O. Wolff wrote in 1949 that the
drug had given rise to "a most appalling percentage of the
tragedies and crimes in Cuban society", and he described
similar consequences in Brazil. One of the outstanding French
authorities on cannabis recounts the sequence of events he has
often observed in victims of chronic intoxication: they pass into
a state of torpor in some secluded spot; then abruptly they become
agitated and the slightest opposition now moves them to violence
and perhaps to sexual crimes (especially if they combine other
drugs with their cannabis). A Moroccan investigator also emphasizes
the lack of adequate motive or premeditation in the outburst of
persistent, often murderous, violence; arson is fairly common;
the impulsive attacks may be in several respects like those of
an epileptic, occurring in a state of disturbed consciousness.
Lesser crimes, such as theft and procuring, are common but do
not seem to have evoked in observers the strong feeling indicated
by such epithets as "heinous", "savage", which
are applied to the outbursts of violence. Running amuck is considered
by some to be a manifestation of chronic cannabism.
Opposite these supporters of the view that cannabis
causes crime, are the almost equally numerous and authoritative
writers who deny any direct causal connection, though they do
not dispute the frequent concomitance of cannabis and crime. The
most influential and, in some respects, the most thorough enquiries
were made by the Indian Hemp Commission of 1894 and the Mayor
of New York's Committee in 1944. The former concluded that "the
connection between hemp drugs and ordinary crime is very slight
indeed" but that excessive use does, in some very rare cases,
make the consumer violent; six hundred witnesses were asked by
the Commission whether they knew of cases of homicidal frenzy,
and very few had. A considerable majority of the witnesses did
not consider that the drugs produced unpremeditated crimes of
violence and some said (as other writers have since) that there
is a negative relation because cannabis makes men quiet as a rule.
The Mayor's Committee reported to a similar effect; many criminals
might use the drug but it was not the determining factor in the
commission of major crimes.
Eight observers in Brazil reported in 1962 that
an exhaustive inquiry which they had made in the jails and hospitals
had not produced any evidence that cannabis is an important cause
of crime. This finding runs sharply counter to Pablo Wolff's observations
in the same country.
Similar negative conclusions about the causation
of crime in cannabis-takers come from Vancouver; the American
Armed Forces abroad; New York and California and Nigeria. The
Nigerian psychiatrist (Asuni), who examined a series of cannabis-takers,
found no major crime among them except in one man who was schizophrenic,
and another imprisoned for reckless driving. His general findings
are in keeping with the moderate contemporary view, viz. that
there is an antecedent predisposition towards psychopathic or
criminal behaviour in those cannabis-users who do commit crimes,
the cannabis often merely revealing or intensifying abnormal tendencies;
and that circumstances arising from cannabis-taking may have fomented
criminal conduct; "The people involved in cannabis-smoking
. . . . . tend to be driven underground. In this situation their
sense of isolation from the main body of society gets intensified.
Their sense of value also changes to that of their new subculture,
and this new sense of values may be generally asocial or anti-social".
The Medical Director of the Lexington Narcotic Center in 1947
described the same downward progression: "It would be difficult
for a normal personality to undergo such experiences without harm;
for the type of personality that seems to be the background for
addiction, they may cause irreversible distortions". Unfortunately,
the type of personality that predisposes to cannabis-taking has
not so far been described or identified convincingly.
Probable reasons why there should be flat contradiction
between the findings of different observers are: criminals in
some countries base their defence on alleged cannabis intoxication
which provoked behaviour that they cannot remember and for which
they cannot be held fully responsible (just as epilepsy is often
entered as the defence in our courts for crimes of violence);
many who use cannabis in various countries combine it with opium,
heroin, amphetamine, barbiturate or alcohol, and it is impossible
to tell which, if any, of these is to blame for the criminal behaviour
observed in a given individual; the samples of persons investigated
have mostly been small and the history of drug-taking, its duration
and degree in each individual has been provided by the man himself
who often believes it to be to his interest to lie about it. When
criminal behaviour occurs in people who take cannabis steadily,
it is by some confidently assumed, and by others confidently denied,
that the crime was caused by the cannabis, though the available
data are insufficient to permit a judgment either way. Only rarely
in published reports on criminals and cannabis has a satisfactory
effort been made to distinguish between chronic cannabis-use and
infrequent or casual experimentation, or between criminals who
have recognizable mental disorders and those who are mentally
normal, apart from the criminal episode.
The one delinquency which receives general reprobation
is driving while under the influence of cannabis whether on an
isolated occasion or when bemused by chronic excess.
The old story that cannabis was taken to nerve
men to go into battle and to commit murders to order, has little
or no foundation except perhaps that the mercenaries employed
to put down riots and revolts in India were, according to the
Indian Hemp Commission, habitual consumers of cannabis who acquired
"Dutch courage" thereby. As mentioned earlier, advantage
may be taken of the heightened suggestibility of the cannabis-user.
The most likely relation that emerges from the
welter of conflicting statements is that chronic or excessive
indulgence in cannabis may, in some people - a small minority
of the male public at risk - lead to attacks of disturbed consciousness,
excitement, agitation, or panic, and reduce self control. The
extent to which the affected person may commit a crime in this
state of mind depends more on his personality than on the dose
or preparation of cannabis which he has been taking.
"Cannabis psychoses" have been frequently
described and the accounts include practically every known variety
of mental disorder. The predominant and most frequently put forward
are schizophrenia - and especially catatonia; paranoid states;
manic excitement; depression and anxiety; and dementia. A writer
on the subject whose report (1903) has been often quoted or borrowed,
was Warnock, the Medical Superintendent of the mental hospital
in Cairo. He had recognized as hashish psychoses an acute hallucinosis
with restlessness and incoherence, and a manic condition; but
he added that "besides these types, there are numbers of
cases of chronic mania, mania of persecution and chronic dementia,
alleged to be produced by hasheesh, but I have no means of verifying
these allegations". He also wrote: "I doubt very much
if hasheesh insanity can be at present diagnosed by its clinical
characters alone". This is a cautious view; other observers
who have seen many patients to whom they gave this diagnosis,
dwell on dementia as a fairly common outcome of chronic use of
the drug, or assert that there is a typical and striking uniformity
of symptoms in the cannabis psychosis. An Indian psychiatrist,
Dhunjibhoy, defines it: "A patient admitted to an Indian
mental hospital with intense excitement, grandiose ideas, tendency
to wilful violence, a peculiar eye condition (marked conjunctival
congestion), total amnesia of all events, attacks of short duration,
followed by complete recovery, with a history of the drug habit
and without a psychopathic or neuropathic heredity, is a typical
case of "hemp insanity"." Some observers describe
severe mental deterioration as a familiar outcome while others
with much experience say this does not occur at all.
The term "Cannabis psychoses" begs
the question of the existence of such a syndrome. On the one hand,
there is a cloud of witnesses qualified to speak by lifelong contact
with the problem in mental hospitals of countries in which cannabism
is very common: they are convinced that the condition is correctly
identified. "The effects of the drug are detailed in all
the well known text-books and that its abuse is a direct source
of serious mental disorder is indisputable", wrote a senior
doctor of the I.M.S. in 1923. A high proportion of the patients
admitted to mental hospitals in India and Egypt and elsewhere
were diagnosed as falling in this category.
On the other hand, there were equally informed
doubts as to the legitimacy of the diagnosis in many cases. These
doubts were cogently expressed by the Indian Hemp Commission in
1894. Out of 1,344 admissions to the asylums of India during 1892,
there were only 98 patients in whom the use of hemp drugs could
reasonably be regarded as a factor in causing the insanity, and
in 37 of these there was a clear history of some other cause which
might have co-operated with the hemp drugs. The Commissioners
concluded, after an enquiry of still unequalled scope, that "the
usual mode of differentiating between hemp drug insanity and ordinary
mania was in the highest degree uncertain and therefore fallacious. . . . . The excessive use of hemp drugs may, especially in cases
where there is any weakness or hereditary predisposition, induce
insanity. It has been shown that the effect of hemp drugs in this
respect has hitherto been greatly exaggerated, but that they do
sometimes produce insanity seems beyond question". Nevertheless,
it has been questioned. Even so guarded a statement implies that
there are some sure criteria for establishing the causal role
of the cannabis, either when it has been established that a man
exhibiting a so-called "functional psychosis" had previously
been for years smoking or eating cannabis; or when such a history
precedes the onset of an "exogenous psychosis" exhibiting
the cognitive and other defects attributable to physical or chemical
damage to the brain. As a rule the writers on the subject do not
give enough detail to warrant any attempt at retrospective diagnosis;
but in those who do, there are instances of persistent confusional
syndromes shading off with the passage of time into chronic dementia,
in which the cannabis seems to have been the major cause.
The reasons for the discrepancy in opinion expressed
by equally experienced observers seem to be:
The notion* of a single cause for mental
disorder, widely held in the last century, is no longer
regarded as tenable. Consequently, the last two decades
have seen few assertions about cannabis being the
cause of insanity, but many espousing the view that it has
been either a necessary or a contributory cause, especially
where evidence of predisposition to psychosis is forthcoming
from a patient's previous personality and health record.
The clinical picture of what has been
regarded as cannabis psychosis has not had any characteristic
features (such as delirium tremens has, for example). It
has often been indistinguishable from schizophrenia.
The reasons put forward earlier (page
48) for the discrepant opinion about crime and hashish,
In many of the published reports it
is made clear that the hashish was combined with other substances
- datura, alcohol, heroin or amphetamine - which could be
responsible for the psychosis which developed. The cannabis
might have had nothing to do with it.
The history of the patient's previous
mental state has been only cursorily enquired into, often
for lack of dependable informants. Many of these patients
may have had established or incipient mental illness, quite
independently of cannabis, before the incident - a crime
or a catastrophe - which brought them into a mental hospital.
The diagnostic methods employed in
many studies were, by any reasonable standard, woefully
inadequate. In one large area, the diagnoses might be made
by a policeman. The long-standing belief that cannabis causes
insanity could strengthen this diagnosis in a doubtful case.
Ingrained beliefs and habits are known to be powerful enemies
of unbiased diagnosis.
There is no unequivocal evidence that cannabis
can be the major or sufficient cause of any form of psychosis.
Neither is there clear evidence that moderate euphoriant or tranquillizing
doses, even if taken over a long period, do mental harm in the
majority of people of average mental stability, though rare isolated
cases are on record in which persons apparently in good mental
health have reacted with a pronounced mental disturbance to moderate
doses. In large doses, cannabis can result in severe psychosis
which may not clear up; it can be of the schizophrenic paranoid
form, anxiety, or excitement. It is usually assumed that persons
constitutionally predisposed to psychosis will be those most vulnerable
to cannabis; but although this is in keeping with current psychiatric
theory, it lacks experimental or statistical confirmation. In
many cases it could be argued that the patient would have fallen
ill with schizophrenia or other psychosis even if he had not had
any cannabis. This would be a weak contention if it were not so
often stated by clinicians that the "hashish psychosis"
may be indistinguishable from schizophrenia.
BENEFITS AND THERAPEUTIC USE
Benefits have been claimed from cannabis, but
trustworthy reports have been few and vague. It is said to promote
relaxation and calm after the trials of daily life, and to assist
shy people to enter into warm social relations; it lessens awareness
of pain and misery; it helps to allay neurotic anxiety; and it
is an aid to religious fervour. A prominent American psychiatrist
recently wrote, apropos of eleven university students who had
had severe adverse reactions from cannabis: "The evaluation
of harm a drug does requires some consideration of its benefits.
Users of marihuana state that it is a source of positive pleasure,
that it enhances creativity, that it provides insight, and that
it enriches their lives. These are hardly minor claims. All but
two of the eleven individuals reporting adverse reactions considered
the benefits to far outweigh the unfortunate aspects and they
planned to continue use of the drug".
From ancient times, cannabis has been credited
with therapeutic powers, especially in India. Its introduction
into Europe in the mid-nineteenth century led to the familiar
burst of enthusiasm for a new remedy. This dwindled as time passed
but died slowly: "During the period 1840 to 1900, there were
something over one hundred articles published which recommended
cannabis for one disorder or another". Its vogue preceded
the advent of synthetic hypnotics and analgesics, and it was lauded
for its effect in alleviating pain, migraine, insomnia, dysmenorrhea,
difficult parturition and cramps. In 1890, Russell Reynolds wrote
that "when pure and administered carefully it is one of the
most valuable medicines we possess".
It was also said to be good for mental disturbances
though its proponents rather shamefacedly acknowledged that this
line of treatment had a homeopathic flavour. As late as 1928,
an article appeared reporting that cannabis was valuable for severe
melancholia. There are still a few who assert the therapeutic
value of the drug; because it heightens suggestibility and weakens
inhibitions, they find it a useful adjuvant in eliciting submerged
memories and feelings which the patient cannot otherwise communicate.
Its antibiotic powers have also been explored in Central Europe.
TOLERANCE AND DEPENDENCE
Even on such straight-forward matters as tolerance
and the development of physiological dependence, there are contradictory
statements. Practically all informed opinion is satisfied that
neither of these develops; yet there are statements to the contrary.
"Quite serious disorders are observed in those addicted to
the drug over a long period when their poison is removed. Attacks
of physical prostration and intellectual apathy, especially, are
noted". (Bouquet). A Turkish and an Egyptian observer separately
describe how the patients increase the quantity of cannabis they
take in order to maximize the pleasurable effects. In Russia,
Skliar has observed severe symptoms after withdrawal of "anascha";
among them were anxiety, pains in the limbs, vomiting, diarrhoea,
sweating, yawning and depression, all of which would clear up
quickly if some of the drug was administered. (There seems, however,
doubt as to whether opium and cocaine may have been mixed with
the cannabis in "anascha".) Frazer in 1949 observed
states of extreme violence and confusion developing in Indian
soldiers whose supply of cannabis had been abruptly stopped. To
round off the picture with a paradox, Meunier and Richet found
that the human organism becomes more sensitive to hashish the
more it is taken, with the result that the dose could be gradually
lessened to half without diminishing the effects.
Although it is said that many of those who take
to cannabis prefer it because they know they can stop it without
any disagreeable withdrawal symptoms, several observers agree
that the psychological symptoms which develop on withdrawal can
be very disagreeable, the main ones being loss of appetite, dyspepsia,
pain in the abdomen, fatigue, insomnia, agitation, palpitations
COMBINATION AND PROGRESSION
In some countries, notably India and North Africa,
it was not uncommon for cannabis to be combined with datura or
with opium, alcohol or heroin. Immigrants into Israel from North
Africa, the Near East or the Middle East were "prone to take any
narcotic drug they could lay their hands on".
Progression from cannabis to heroin, morphia
or cocaine is the subject of discordant conclusions, often based
on concordant data. From many countries, including the United
States, come reports that a very high proportion of all heroin
addicts have previously taken cannabis, and that once they have
progressed to this stage, they seldom return to cannabis. What
determines the progression is contested. The majority of observers
attribute it to association with friends or acquaintances who
have themselves become heroin or cocaine addicts; others suppose
that it arises from dissatisfaction with the relief or pleasure
to be obtained from cannabis; and a minority postulate a predisposition
to marihuana which is also a predisposition to heroin. No one
suggests that there is a truly pharmacological reason why such
"escalation" should occur. Some hold that in a large
proportion of cannabis-users, especially adolescents, there is
some obscure but powerful factor (which could be psychological
or social) greatly increasing the risk that they will take to
opiates sooner or later; other authorities maintain that the transition
from the marihuana stage to the heroin stage occurs only in a
small minority of marihuana-users and that there is no more justification
for indicting marihuana as a preliminary to dependence on narcotics
than for indicting coffee or tobacco.
Into this darkness some light is cast by a recent
study of 2,213 addicts admitted to Lexington and Fort Worth hospitals
during 1965. The patients were classified according to the state
they came from, the opiate they had been taking and whether they
had been marihuana-users or not. In each of sixteen states, more
than 50% of the subjects had used marihuana as well as opiates.
In each of twelve other states, most of the opiate addicts had
never used marihuana. The dominant sequence of events had been
marihuana-smoking, arrest, and then opiate use; the respective
mean ages for these three events were, first, marihuana-use at
17, arrest at 19, and then onset of heroin use at 20. When the
marihuana-users were compared with the non-users of this drug,
it was found that the former were twice as likely to be heroin
addicts and to secure their drugs from underworld pushers as the
addicts who said they had never used marihuana. They also had
an earlier age of arrest and of onset of opiate use. Ball and
his colleagues who made this study conclude: "As to the issue
of association, marihuana-smoking is seen as a predisposing influence
in the aetiology of opiate addiction in the United States. Among
metropolitan residents of the high addiction Eastern and Western
states, opiate use is commonly preceded by the smoking of marihuana
cigarettes and arrest. Thus, both marihuana-use and delinquency
are predisposing factors within the metropolitan host environment. . . . . Enough is now known about the association of marihuana
and opiate use to delineate the dominant relationship of these
two events. The incipient addict is predisposed to opiate addiction
by his use of marihuana, for the following reasons: marihuana
is taken for its euphoric effects, it produces a "high";
both marihuana and heroin are only available from underworld
sources of supply; both are initially taken within a peer group
recreational setting; both are illegal; the neighbourhood friends
with whom marihuana-use begins are often the same friends who
initiate the incipient addict to the use of opiates. . . . . Data
of the present study support the conclusion that marihuana-use
is closely associated with opiate addiction in the high drug use
metropolitan areas of the East and West, but not associated with
opiate addiction in twelve Southern states".
This detailed and temperate study lends support
to the view that marihuana users are more likely than non-users
to progress to opiate addiction.
PROHIBITION AND PREVENTION
In many countries laws have been passed which
make possession and use of cannabis an offence; in some, the penalties
are very severe, and may include capital punishment for trafficking
in the drug. The extent to which the laws are enforced varies
greatly. Penalties and sentences are often equated with those
considered appropriate for heroin and morphine addicts: the Medical
Director of the Federal Bureau of Prisons in Washington, D.C.
said in 1962: "In our Federal prisons we have about 160 marihuana
offenders; the average sentence of the group is nearly six years,
which is approximately what the average sentence for (all) drug
There are diverse opinions about the effectiveness
of penal legislation. A few believe that it has a deterrent effect;
thus a Greek observer is sure that if the sale of hashish were
legal in his country, the power of advertising is so great that
very large numbers of people would take to the drug. Others review
the fluctuations of state policy in their own country, veering
from rigorous application of severe laws to lax administration
and tolerance, and conclude that the laws have not achieved their
purpose. It seems, reading the contrasting statements on this
matter, that most persons with relevant experience would like
to have legislation applicable to the excessive user and the trafficker,
but they object to blanket legislation which permits, and even
encourages, the imposition of long terms of imprisonment or other
stringent punitive measures. It is generally acknowledged that
it is not so much the law as the way it is acted on by the police,
customs officers and magistrates that determines its efficacy
(which is, in any case, limited). Lindesmith, advocating that
legislation should be on the same lines as for alcoholism, gives
an example, that persons driving a car while under the influence
of marihuana might be fined and deprived of their licences for
a period of time: "Laws such as this, with penalties of a
reasonable nature would probably be more effective than those
now in effect because they would be more enforceable and more
in accord with the nature of the problem being dealt with. They
would have the effect of reducing the discrepancy that now exists
between the laws as written and the laws as they are actually
Total prohibition of all indulgence in cannabis
was firmly rejected by the Indian Hemp Commission in 1894: "The
Commission now unhesitatingly give their verdict against such
a violent measure as total prohibition in respect of any of the
hemp drugs". Their chief reasons were that cannabis is, in
moderation, harmless; that its withdrawal would excite much resentment
among the population, especially the poorest sections; and that
if it were forbidden, the people would take to more dangerous
drugs. But they went on to say: "While opposed to this amount
of interference, the Commission feels strongly that a regulating
influence is necessary and should, in future, be exercised by
the Government of India over the various systems of administration
of the excise on hemp drugs".
The fear that the prohibition of hashish would
result in recourse to worse drugs such as heroin, datura or alcohol,
has been expressed by several workers, especially those with Tunisian
experience. An outstanding authority (Bouquet) wrote in 1951 that
if cannabis had been absolutely prohibited thirty or thirty-five
years ago in North Africa, the problem would now be manageable
but the point has been reached at which suppression would result
in an increase in heroin addiction. There is, however, some inconsistency
in this matter. Writers who fear that total prohibition would
lead to worse dependence on other drugs, at the same time advocate
determined police action to cut off all clandestine supplies of
cannabis - a measure which would surely have the same effect,
if successful, as total prohibition. A variant of this fear is
voiced by the W.H.O. Expert Committee on Mental Health (1967)
who say that "condemnation by society may arouse guilt feelings
in the user, drive him to even greater dependence on drugs, and
prevent him from seeking treatment".
Another observer, chiefly concerned with comparing
United States with English methods of dealing with narcotic addiction,
emphasized in 1962 that in America people were driven by social,
legal and economic pressures to band together to establish their
own group way of life, or subculture: "Addiction as such
may not be as antisocial as the kinds of behaviour forced on the
addict by the punitive approach to addiction". The more cannabis-taking
is driven underground, or the more it is punished by imprisonment,
the greater, according to some writers, is the likelihood of cannabis-smokers
being corrupted and turned permanently towards antisocial behaviour
of other kinds.
Partial prohibition or indirect measures of control
have been tried in many countries. The commonest methods are by
taxation and setting up a government monopoly. Neither, from the
statements of those who have had experience of the effects, has
proved effective in limiting the spread or reducing the prevalence
of the habit. A few observers have urged that the risks can be
reduced by suppressing the resin or other concentrated form while
tolerating the powder; or by harrying and supervising adolescent
marihuana-users, on the assumption that if they could consume
as much as they wished whenever they wished there would be a much
larger number of serious chronic victims - "wretched ragamuffins
who are a danger and a burden to society". But these assumptions
and assurances are made on the strength of the particular writer's
experience; they lack statistical or other firm support.
It is generally agreed that taxing the drug does
not deter the inquisitive or venturesome experimenter, the adolescent
who emulates his slightly older associates, or the psychologically
dependent man who craves the drug. They find the money somehow
to pay for it, as people do for alcohol.
Control by blocking the sources of illicit supply
is evidently the ideal. The measures taken have been described
in official reports. They bypass the small fry - the pedlars and
carriers - and aim at catching the wholesale trafficker; they
also try to destroy the hemp crops: thus the United States Bureau
of Customs and the corresponding Mexican authorities collaborate
in detecting the hemp fields and rooting them out.
A minority of those who discuss prohibition and
its problems are concerned with what moral justification the state
has for interfering with a citizen's right to do as he pleases
as long as he does not infringe the rights of others or harm society.
Some stress the alleged detriment caused by cannabis to the user's
character and his occupational capacity, reducing his social usefulness;
or they point to injuries caused by his behaviour in driving lorries
or cars under the influence of the drug. On the other hand, some
urge that if alcohol and tobacco can be tolerated and taxed, there
is no logical ground for abstaining from doing likewise with cannabis
(onto which, they suggest, an unwarranted moralistic stigma has
been pinned); they believe that if a drug, such as alcohol or
cannabis, is generally and readily obtainable in a given society,
most people learn to use it in moderation, while the psychopathic
minority who use it to excess would do so with some available
alternative drug anyway. The significant débâcle
of alcohol prohibition in the United States has a bearing on the
argument for treating cannabis like alcohol. A well established,
socially permissible drug is evidently ineradicable by total prohibition,
whereas a comparative newcomer like cannabis in Western countries,
is a weakling which might be kept in check by firm action, some
At the present time, it is widely accepted that
dependence on a drug is a medical condition calling for medical
treatment. This contention is easily justified in the case of
drugs to which a physical dependence may develop. In the case
of cannabis, however, where the dependence is purely psychological,
the issue has been contested. The majority of writers are in favour
of psychiatric treatment (provided that the user wants to be treated),
combined with social measures of rehabilitation and appropriate
social investigation. Broadly, of course, a medical approach is
concerned with the welfare of the individual, a social approach
is directed more at the protection of society: they complement
each other. An antithesis between medical research and social
research in this field or between medical and social treatment
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entries up to 1965 - and disorderly. Because almost every theme
is beset with contradictory observations and opinions, the digest
has to be inconclusive on many of the problems raised.
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