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Cannabis Substitution:
An Adjunctive Therapeutic Tool
in the Treatment of Alcoholism
BY TOD H. MIKURIYA, M.D.
The physical and psychosocial effects of alcoholism are varied in kind and amount, depending on each individual of pharmacologic effect of alcohol with the psychosocialaspects of the user. Tamarin and Mendelssohn vividly depict the destructive effects of prolonged alcohol intoxication : The anxiety-reduction model often utilized to explain initiation and perpetuation of episodic drinking wasfound inadequate to explain motivation for alcohol useby 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, how-ever, were poorly recalled by the alcoholics following The degree of inebriation appeared to be more closely related to patterns of alcohol ingestion than to the totalvolume of alcohol consumed. Compulsive and con-stricted behavior patterns, which were present duringsobriety, changed markedly during intoxication, withincreased verbalization, varied expression of feelings,increased interaction, and frequent behavioral regres-sion. During inebriation, psychic defenses appearedweakened with significant reduction of repression andreaction formation.* Such chronic abrasive difficulties have been noted by a patient of mine, a forty-nine-year-old lady (Mrs. A.) with a * John S. Tamert, M.D., Jack H. Mendelssohn: The Psychodynamics of Chronic Inebriation: Observation of Alcoholics during the Process of
Drinking in an Experimental Group Setting. American
f r o mMedical Times, vol. 98, no. 4 , April 1970, p p . 187-19 1.
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history of alcoholism dating back from her teens, unsuccess- fully treated by varied group and individual psychologicaltreatments for many years. When she was referred to me, shehad using illicitly obtained crude marijuana intermit- tently with a frequency of perhaps every weekend or so. Itwas noted that when she smoked marijuana she decreased her alcoholic intake. I instructed her to substitute cannabis daily -any time she felt the urge to partake in alcohol.
Just in case she should impulsively think of slipping back loading and stablizing doses was administered to afford her additional buttressing for her ego strength. As related to with providing a “stick, as well as a carrot for the donkey.” She offers me her observation in an interview after she
began to substitute cannabis daily for alcohol.
A: I’ve been on grass every day this week. I’ve also been on
Antabuse. I haven’t had a drink since I saw you. I’m prettyproud of that. It was . . . an effort to take it, because I amdepressed, and I thought, well, you know, I’ve got to do something now or never. So I smoked grass every day thisweek. And the first couple of days I was . . . I couldn’t setmyself a task to do anything. All I did was lay around thehouse and listen to music. I didn’t go out of the house, Ididn’t do anything. But then I found that if I don’t take asmuch, you know, just a couple of puffs is all I need, and Ifeel good and I can do what I have to do.
M: Such as. . .
A: Oh, well, this week I really did things. I finally
vacuumed my apartment. I haven’t unpacked all my suitcasesyet, but . . I cleaned the refrigerator, washed my hair, had company for dinner, my son and his girlfriend . . . uh . . I was really high, though. But I got through it. They ate. I Did you notice any decrement in your performance when you made up your mind you were going to do it? A: Yeah. But . . . I didn’t smoke as much. I’d take a couple
of puffs, and then maybe an hour later, take a couple of
other puffs. I had a little pipe in my kitchen.
Treatment of Alcoholism
How many puffs would you usually take? A: Well, I have a little water pipe. The barrel is about that big, and I fill it up maybe three-quarters of the way, and if Ismoked half of that I would be really stoned.
M: About how many puffs would you say that is? M: But taking just one or two gives you the desirable A: In alcoholic terms, you’d call it a glow.
A: No. So I find that if I limit myself, you know, if I’m careful . . . and you know how this happened? Uh . . . I got some grass that doesn’t burn, it’s wet, so I can only take oneor two and then I have to . . it goes out, and then relight it, so it was easier to do it than normally, because normally I would want to . . . just get way up there real fast.
M: What do you suppose would have happened if you had set about to do the same thing with alcohol? A: Well, I’ve tried that with alcohol, too. I guess you might call it playing a game, I don’t know, but I’ve limited myselfto, uh . . . well, Dr. S. said that if I could limit myself to one alcohol, and I would be okay, I wouldn’t get drunk orintoxicated. Uh . . . sometimes I could do that, but I foundthat after a week or two and the more stress I had, the less able I was to wait that hour. And then I found that I justdidn’t give a damn, and . . . like the day before 1 came in here 1 drank almost a fifth of alcohol, which for me is a lot. I tend M: And from what 1 understand, grass doesn’t have the same effect. It doesn’t seem to call for another toke? 172
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A: Right. There’s another big difference, and that’s . . .
your appetite. With alcohol, you want to . . . just want to get out of it, like put yourself to sleep, and with grass, uh . . .
Her first lesson was to learn her proper dose in order to
perform routine tasks. She also discovered that she was able
to function as a hostess and cook while taking a small
amount of cannabis. Her description of the phenomenon of
tolerance to alcohol contrasts graphically with the lack of
tendency to increase the dose of cannabis.
Alcohol euphoria appears to cause irritability, belligerence,
and loss of control behaviorally. Cannabis euphoria in this
woman causes, anything, a mild lethargy and mild temporal
distortion.
M: You said you noticed that it (alcohol) somehow de-
A: Yeah. Sure. Well, for instance, I would go to a party,
expecting to have a good time, being able to mix with people,
dance, saying whatever . . . was going on I would be able to
participate in it, and after every party I’d wake up the next
morning, feeling, OH, GOD, did I ever make an ass of myself,
because it would get away from me.
M: How would it get away from you?
A: Well, like half the time, before the party was over, I
didn’t know what I said or what I did. . . . Uh, like going up to somebody else’s husband . . . it was in groups where thissort of thing just, you know . . . wasn’t part of the scheme ofthings, you just didn’t do this. . . . And another thing that alcohol did, it gave me the courage to walk into a bar if I was You would pick up men in bars?
A: Yes. I was. . . . I suppose it started a long time . . . a
long time ago, but, uh, the year before I came to the Center,
was really getting into messes. Really. Trying to . . . just
dives. And getting drunk, and having blackouts, and waking
up not knowing where I was.
Treatment of Alcoholism
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M: Does grass give you this oblivion?A: Uh uh. No, there’s a big difference. Uh . . . a real big difference. It’s just not the same as drinking. With grass I . . (laugh) I just wouldn’t go into a bar . . . and pick up a man. . . it’s . . it’s for one thing, I wouldn’t meet the kind of M: So these different intoxicants change your personality A: Yes. Well, I have changed a great deal in the past year.
My behavior has changed, I’ve changed, my attitudes have changed. With alcohol, uh . . . well, there were three times inmy life when I made a half-assed attempt at suicide. And . . .
all three times alcohol was involved.
M: How have you changed since getting stoned on grass?A: I just feel good, relaxed, I don’t feel depressed, and I M: And in the way you feel toward others? A: Others? Very gentle. Uh . . . I told you Sunday that my son came over. He wanted to go swimming that afternoon,
and he wanted to know if he could bring a girl friend. I said,
sure. And when he came over, uh, 1 asked them if they
wanted to stay for dinner. And I had already started . . .
smoking grass that day, before they came over, that was . . .
Saturday. Uh . . . everything just went along fine. At least
thought so. I wasn’t concerned about whether my table was
set right, or whether I served right, or, uh . . . I mean, I just
put the food on the table, and they could eat, I . . just
wasn’t bothered about things that would normally bother
me.
M: If you’d been drinking, would it have been different? A: Uh . . . I think they would’ve waited until about ten o’clock at night to eat for one thing. And they probablywouldn’t have waited, they would have like gone out to eat.
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M: If you had been drinking?
A: Right. I probably would have gotten into a fight with
Bill, said some nasty things to him, whereas I ignored him.
So it seems grass gives you control, and at the same
A: Yeah, except that at the dinner table, I had the feeling
that . . . Bill certainly didn’t know what 1 was talking about.
And Chris didn’t know what I was talking about. Leonardwas laughing so he seemed to know, communicate with me . . . Uh . . . and I wasn’t concerned with it, I wasn’t bothered by . . . wasn’t bothered by little things that are unimpor-
tant, which when you are drinking are greatly magnified.
M: Such as?
A: Like my husband not smiling at the table. Or is eating
too much, or too little, or . . . anything. Or not talking.
M: So you become irritable?
A: Belligerent. Hostile. . . . Nasty.
M: Makes you wonder why you’d drink at all?
A: Yeah. This week I . . . I really . . . once 1 took the
Antabuse, it hadn’t been too much of a struggle. And the only thing that I’m concerned about with marijuana is that . . . it’s difficult to get, and it’s uh . . . it’s illegal.
M: Do you find it cheaper or more expensive than alcohol?
A: Oh, it’s cheaper. Even though it’s . . . gone up in price,
it’s still cheaper. A lot cheaper.
At about five months after the cannabis substitution thera- py began, the patient shows an increase in insightfulness and she “revisits” the different social situations where she woulddrink to excess and play her compulsive games. She smokes hemp drug instead and notes that she relinquishes very little in the way of self control. At the same time, her physical
health has improved, and she finds her disposition much less
irritable and herself able to think and concentrate more read-
ily.
Treatment of Alcoholism
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The major difference she describes between the effects of hemp drugs as compared with alcohol is that “it made mehigh like alcohol, but it didn’t give me that feeling in the pit She finds herself confronted with different dilemmas now, since she is afforded a new awareness and control over her life, instead of being continually sick and intoxicated and acting out in a maladaptive fashion. She finds that many of the friends that she seemed to have such warm relationships with have little in common with her anymore. She also dis- covers she is able to express anger more directly and in acontrolled and appropriate manner as compared with her un-controlled expression of anger under the influence of alcohol with its destructive disinhibiting characteristics.
Over two years of abstinence has afforded the opportunity in psychotherapy of working through the intricate problemsof personality growth arrest facilitated by a thirty-five year history of alcoholism. I can in no way claim a total cure. At least, she has become free from repetitious cyclic rage-guilt amplified by alcohol. It is, however, quite difficultfor her to give up these habits of 70 percent of her life. I amless concerned about her physical well-being for substitutionof cannabis for alcohol has allowed her liver and generalphysical health to return to normal. Her appearance, com-plexion, posture and energy level have gradually improved.
While all these gains make me optimistic, I realize the possi-bility of relapse-an unfortunate characteristic of certain It would appear that for selected alcoholics the substitu- Discussion.
tion of smoked cannabis for alcohol may be of marked reha-bilitative value. The drug effect of cannabis, as comparedwith alcohol, while having a sense of euphoria and detach- ment in common, lacks any other similarity except the intent for which it is taken. Excessive alcohol use produces a pre-dictable weakening and dissolution of various superego and ego functions, whereas cannabis does not seem to have thisattribute, providing, if anything, any increase in ego strength.
Because cannabis does not facilitate ego alien behavior asseen with alcoholic excess, a great burden of guilt is removed, 1 7 6
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thus freeing the individual for more constructive pursuits.
The fact that cannabis did not produce symptoms of irrita- bility upon withdrawal, nor effects on the gastrointestinaltract, as compared with alcohol, also assists in the rehabilita-tion of the individual. Since he is not physically sick any- more, he is thus free to begin resocialization and to perceive the subtleties of the world beyond his needs for immediategratification or succor. Certainly cannabis is not a panacea, but it warrants further clinical trial in selected cases of al-coholism.

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