Journal of the California Cannabis Research Medical
Cannabis Use in Adolescence:
Self-Medication for Anxiety
Data from the author's practice show
that many Californians use cannabis to treat emotional conditions.
Government studies obscure this reality and some reformers seem reluctant
to acknowledge it.
By Tom O’Connell, M.D.
In response to TV news footage of able-bodied young men buying cannabis in
Oakland, city officials voted in 2004 to limit the number of dispensaries.
The politicans were exploiting (and re-enforcing) a misconception that Californ-ia’s
medical marijuana law applies only to those with serious physical illnesses.
Many of my own patients are seemingly able-bodied young men. Their histories
reveal problems that are indeed serious (impaired functionality at school and/or
work, use of addictive drugs) and that are treated effectively with cannabis.
I began screening Californians seeking a physician’s approval to use cannabis
in November 2001. Although the reference in Proposition 215 to a doctor’s “recommendation” of
cannabis implied that some applicants would be seeking to use it medicinally
for the first time, the applicants I encountered, almost invariably, had been
using it in non-addictive, stable patterns.
Use of cannabis typically preceded —often by years— the onset of whatever physical
symptoms they were citing to justify their use.
These patients were among those identified as criminals and deviants for decades
by government propaganda. The idea that they were criminals who belonged in
jail or addicts requiring “treatment” simply didn’t make sense.
Never in history has such a large collection of admitted illegal drug users
been so willing to present themselves for unbiased examination.
Developing Research Tools
Although basic demographic data could be obtained by questionnaire, I developed
a detailed interview to examine pertinent areas of personal history. Systematic
exploration of prior drug use revealed that nearly all had tried alcohol
and tobacco aggressively about the same time they tried pot. Many had then
tried a variety of other drugs.
My patients’ drug-initiation patterns suggested they had been addressing similar
needs. Herein, I realized, might be a key to defining the “medical” use of
cannabis and perhaps to better understand its appeal as a “recreational” agent.
I adapted my interview accordingly, as I learned more.
The discovery that most were using cannabis to treat insomnia suggested self-medication
of anxiety or depression —so I expanded that portion of the interview dealing
with psychotropic symptoms. Upon learning that many of the younger males had
already been labeled with ADD, I sharpened my focus on school and family histories.
The finding that a large percentage had been raised by single mothers and that
many biological fathers of intact families were either heavy drinkers or preoccupied
with work suggested a common etiology for the symptoms exhibited in adolescence.
By June 2002 I had a standardized list of questions on a form that doubled
as a cue sheet and a place to record answers efficiently and inobtrusively.
A total of 3,815 patient encounters between mid-November 2001 and December
1, 2004 have been recorded. Of those, 2,799 were evaluated with the structured
interview. An earlier group of 1,016 had been screened with a more traditional
history and physical. Approximately two thirds (1,850) of the 2,799 structured
interviews were first-timers; the rest were ‘renewals’ of patients seen at
least once previously.
The applicants were seen at several different venues in the Bay Area and many
had traveled from other parts of the state— sometimes hundreds of miles Virtually
all of my original patients had been made aware of my availability through
word of mouth spread through the loose network of buyers’ clubs, which had —over
the first five years of Prop 215— become concentrated in the few Bay Area counties
where they were tolerated by local governments. Presumably they knew that I
was pro-cannabis, but not that I looked favorably on its use as a treatment
for depression and anxiety.
This article relies on detailed data from 790 patients and demographic data
from an additional 364 patients.
Only 3.6% (34/937) were older than 60 when first seen.
5.5% were born before 1946.
16.4% born 1946 - 1955
15.4% born 1956 - 1965
28.0% born 1966 - 1975
35.6% born 1976 - 1985
Those who initiated cannabis use in the 1960s are now in their fifties
and sixties. Most have been using cannabis on a regular basis for decades,
others have resumed after periods of abstinence. The sharp cut-off
in the upper age limit of this population is evidence that an illegal
mass market for “marijuana” really didn’t begin until large numbers
of vulnerable adolescents were exposed to it.
Of 1118 applicants, 236, or 21.1% were female, a 4:1 ratio which has obtained
throughout the three years of the study. The same 4:1 ratio of males to females
seems to apply to all racial groups.
Applicants were assigned to four rather arbitrary categories on the basis of
race. When there was doubt about which category was most appropriate, they
were asked their preference. The only observed areas of significant racial
differences were in drug initiation rates. Although the rates at which Black
cannabis smokers try illegal drugs other than cannabis are considerably higher
than the those reported in annual national surveys, they are considerably
lower than among White pot smokers— especially for psychedelics, methamphetamine
and heroin (see table at top left, next page).
Patterns of Use
Patients report that in terms of potency (although not variety), the cannabis
found “on the street” in Northern California is comparable to that available
Although the vast majority were experienced, chronic users, their knowledge
of cannabis lore varied widely and seemed mostly to reflect individual differences
in curiosity. Some were very knowledgeable about strains and delivery systems,
others extremely naive. Very few were using edibles on a regular basis— many
had either experienced or heard about the extended cognitive effects that can
follow ingestion of innocuous appearing baked goods, and —although not clear
on the reasons— preferred to avoid them.
Overwhelmingly, the mode of ingestion favored by applicants was smoking. Knowledge
of vaporizers is beginning to spread, thanks to the cannabis clubs that sell
them. Younger patients seem more inclined to use them on a regular basis. Some
older users express resistance —the best vaporizers are expensive and old habits
hard to change. Several complained that taste and aroma were lacking.
Late afternoon and evening are the favored times to use cannabis. Early morning
use is favored by those with ADD type symptoms and is discussed more fully
under that heading. Almost all patients have fairly consistent schedules for
their use of cannabis; it is generally solitary and private unless trusted
friends are around. Most people did not tempt fate by smoking at or near work.
Consumption, measured in ounces per week, varied from as little as 1/16 to
well over an ounce, with 70% reporting they use between 1/8 and1/4 ounce. People
smoking 1/2 ounce or more were more apt to either grow it themselvesor have
access to a friend who did.
My impression is that the extreme variations in amounts consumed are more a
reflection of different sensitivities to cannabis than to any greater desire
to get “stoned.” In fact, the impression one gets from discussing cognitive
effects in general is that almost all find excessive effects undesirable and
try hard to avoid them (which is the main reason inhalation is favored over
Alcohol & Tobacco Use
The most obvious relationship between alcohol, tobacco, and cannabis is that
nearly all those who try cannabis have either tried the others or will soon
do so. That linkage —first noted in the mid-1970s1— was amply confirmed by
the present study: 100% of applicants had tried cannabis by attempting to
get “high,” usually as adolescents (about 30% either failed on their first
attempt or weren’t sure). 99.3% had also tried alcohol by getting drunk (many
were also monumentally sick) and 93.7% had tried tobacco by inhaling at least
Few are teetotalers, but nearly all who still drink
do so moderately.
Repeat use of both alcohol and tobacco tended to be aggressive. More
than half had binged in high school or as young adults; 35% had experienced
alcohol black-outs; and 12.5% had received DUI citations. Yet essentially
all who have continued to use cannabis on a regular basis subsequently
moderated their alcohol consumption. Few are teetotalers, but nearly
all who still drink do so moderately. Most have reduced alcohol consumption
to 20% of their peak levels —or less.
Cannabis also has enabled patients to reduce tobacco use. Although 68.1% of
cannabis applicants became daily cigarette smokers for a while, over half (53%)
of the smokers have since been able to quit and almost all the rest are trying.
Even inveterate tobacco smokers (those unable to remain abstinent) uniformly
relate their cigarette consumption to both stress and access to cannabis: when
the former is high and the latter is low, they tend to smoke a lot more tobacco.
I can recall only two applicants who said they enjoyed smoking cigarettes and
had no intention of quitting.
Initiation of Other Drugs
An individual’s first use of a drug is important for the obvious reason that
drugs never tried never become problems. However, mere trial of an agent does
not signal that repeat use will follow or what its pattern might be if it does.
How chronic use of one agent might ultimately affect use of others is largely
ignored by conventional research.
While children as young as nine occasionally initiate drugs, the greatest incidence
is from 12 on.2 Since most people have tried all the drugs they will ever use
by age 25, adolescence and young adulthood are clearly important areas for
any drug policy to focus on. At first glance, the high initiation rates for
other drugs observed in this population (table at top of next page) would seem
to support the hypothesis that cannabis is a “gateway” to use of other drugs.
A more detailed evaluation discloses that relatively few episodes of problem
use or “addiction” ensued. Those whose use became problematic were generally
able to solve their problems without professional help. Discussing those issues
with applicants left a strong impression that continued use of cannabis had
played a significant role in helping them control not only alcohol and tobacco,
but illegal drugs as well.
Their aggressive trials of psyche-delics can be seen as a manifestation of
the same curiosity exhibited for other agents and presumably impelled by the
same symptoms which had led them to try alcohol, tobacco and cannabis in the
first place. The response of many to being questioned about peyote and mescaline
was that they would have tried them had they been able to find them.
The fact that white cannabis users tried psychedelics at more than double the
rate of blacks is startling and remains unexplained. Availability in their
respective communities is probably a factor.
In attempting to determine the origin of the symptoms motivating this population’s
aggressive adolescent drug sampling, the most obvious place to start was family
background. A common element was the absence of their biological fathers from
their early lives —either physically, through early death or divorce, or emotionally,
through a variety of other mechanisms listed below
Paternal Factors Associated With Adolescent Use of Cannabis
- Early Death (before age 6)
- Early Divorce
- Alcoholic Father
- Workaholic Father
- Elderly Father (over 40 when patient born)
- Invalid Father
The role played by insecurity and low self-esteem during applicants’ school
careers became increasingly transparent. One or more of the above situations
obtained in nearly all patients.
Pre-school day care, kindergarten and primary school are the first opportunities
for most children to socialize outside the family. Being different for any
reason — too short, too tall, unfashionable attire, unusual name, etc.— can
quickly become something one is teased about. Intrinsic shyness and sensitivity
to teasing can make the school setting difficult to bear.
Applicants are now asked to rate their experiences in primary, junior high
and high school as “happy,” “unhappy.” or “mixed.” After emotional tone is
registered, they are asked if they were ever “class clowns” or considered disruptive
by their teachers. They are also asked if descriptions of “Attention Deficit
Hyperactivity Disorder” apply to them.
ADHD and ADD are diagnostic labels increasingly applied to school children
exhibiting behaviors that irritate and frustrate their teachers. The concept
that the condition frequently persists throughout life (“Adult ADD”) has been
endorsed by the medical establishment, and increasing numbers of patients are
being treated with Adderall and other long-acting amphetamines.3
Although the behaviors had long been noted among educators and pediatricians,
a unifying diagnosis seems to have originated in the late ‘60s with Paul Wender,
a child psychiatrist at the University of Utah.4, 5 Treatment of affected children
with stimulants, primarily methylphenidate (Ritalin), began in the 1970s and
has become both increasingly common. The ADD/ADHD diagnoses are now codified
in the American Psychiatric Association’s Diagnostic and Statistical Manual
of Mental Disorders.
ADD has been associated from the beginning with dyslexia and several other
so-called “learning disorders.” Among my male patients, the diagnosis of ADD
was either made or suggested for some 10-15% while they were in school. Nearly
as many were diagnosed as adults, or the diagnosis was applied informally by
family members or close friends.
The ADD diagnosis is associated in conventional literature with both “substance
abuse” during adolescence and low self-esteem. The ratio of boys to girls diagnosed
with ADD has remained at about 4:1. As the diagnosis is made more frequently
in adults, it has been noted that fathers with ADD are more apt to have sons
with the condition (and vice-versa). This is a pattern one might expect in
a highly competitive, male dominated society.
The idea that “self-esteem” is both important to a child’s early success and
strongly influenced by the biologic father is certainly not new. Single mothers,
low self-esteem, and a proclivity to try multiple drugs in adolescence have
all been reported as common in children diagnosed with ADD.
There is universal agreement among applicants
who have been diagnosed with and/or treated for ADD that cannabis
helps them achieve and retain focus.
The term “attention deficit disorder” is clearly a misnomer. These individuals
are not inattentive; rather, their problem seems to be that they are so aware
of other stimuli around them that they have trouble remaining focused on the
chore/problem at hand. There is universal agreement among applicants who have
been diagnosed with and/or treated for ADD that cannabis helps them achieve
and retain focus. They also are the ones most likely to use cannabis early
in the day.
Cannabis as Palliative
ADD and other psychiatric conditions are defined by the DSM without reference
to the objective external standards which Anatomic and Clinical Pathology
readily provide for ‘somatic’ (physical) diseases.6
Upon closer analysis, modern “mood” and “behavioral” disorders represent various
combinations of symptoms either observed in— or reported by— those said to
be afflicted. The symptoms include chronic insomnia, dysphoria, depression,
anxiety, excessive anger, difficulty in focusing, agoraphobia, and morning
These symptoms abound in the chronic cannabis users I have interviewed. They
had usually been present since adolescence and predated whatever somatic symptoms
the patient could cite —with varying degrees of credibility— as their reason
for seeking an application.
Prop 215, the state initiative that legalized the medical use of marijuana,
refers to “seriously ill patients.” Why would applicants prefer to cite somatic
symptoms instead of emotional ones? Several explanations can be offered:
• Many male adolescents feel that a “macho” image allows for physical injury
and pain, but not for emotional impairment.
• Medical marijuana advocates, in seeking to maximize public support for their
cause, often invoke “the dying.”
• Law-enforcement opponents of medical marijuana, starting with former state
attorney general Dan Lungren, have sought to trivialize mood disorders and assert
that they are not properly treated by cannabis. Former Drug Czar Barry McCaffrey,
in his first public response to California’s new law, ridiculed the inclusion
of chronic insomnia on a list of conditions treatable by cannabis .
• There is general agreement by all but the most doctrinaire opponents of medical
use of cannabis that it effectively palliates a wide variety of symptoms produced
by an even wider variety of named diseases. The most common symptoms are chronic
pain both of neuritic and musculo-skeletal origin.
The effectiveness of cannabis in treating two “functional” disorders, migraine
and asthma — which are classically exacerbated by but not thought to be caused
by emotions— was well established before the Marijuana Tax Act of 1937. Cannabis
also helps control chronic diarrhea produced by Crohn’s Disease, Ulcerative
Colitis, or Irritable Bowel Syndrome. Its effectiveness in controlling the
tenesmus and cramping of the latter condition also suggests a spasmolytic mechanism
In a context where most of the somatic conditions were clearly additive in
that the applicants had aleady been using cannabis to manage emotional symptoms,
the expenditure of scarce assets to “confirm” what amounted to a somatic excuse
for their pot use did not seem reasonable; particularly when the underlying
psychotropic reasons for its use were deemed adequate and a detailed history
had shown they fit the “profile.” There is also a relatively small subset in
whom more sporadic and casual use of pot had become far more regular after
the patient developed a new somatic condtion.
The Gateway Hypothesis
Drugs are initiated in sequence. Prior to the late 1960s, alcohol and tobacco
were primary agents tried by adolescents. When researchers began studying
the phenomenon of youthful cannabis initiation they reported that nearly
all their subjects had already tried both alcohol and tobacco— and that many
had subsequently tried several other agents. Their assumption that cannabis
was a “gateway” from legal to illegal drugs became the prevailing explanation.7
The presumption that all drug use is both hedonistic and harmful added conviction
to that interpretation. Data showing that most heroin addicts had used cannabis
before heroin bolstered the gateway theory, and it seems to have gone unchallenged
for 30 years even though it never met a basic theoretical test of “causality.”
Evidence that cannabis is capable of benignly and effectively palliating the
psychotropic symptom complexes so often encountered in juveniles and young
adults was clearly beyond the scope of any research funded— or even permitted— by
NIDA. That such symptoms tend to persist into mid-life for many who suffer
from them is now endorsed in psychiatric literature and has spurred development
of a host of pharmaceuticals intended to treat them. Yet most of applicants
for whom these pharmaceuticals were prescribed report that cannabis provides
more effective and durable relief.
A little-noticed 2002 paper by Morral et al demonstrated that a theoretical “common
factor” could provide a better explanation than “gateway” for the initiation
patterns observed.8 My data suggest that the common factor is adolescent angst.
The previously unrecognized role of cannabis as effective self-medication for
symptoms experienced by adolescents also explains why so many adults have continued
to use it despite potential social and legal penalties.
Proposition 215 encouraged many individuals who had been considered “recreational” users
of cannabis to apply for “medical” status. Interviews placing their cannabis
use in broader context showed that it is frequently an alternative to the use
of alcohol, tobacco, and “harder” drugs.
The federal government, by imposing a Prohibition based on biased, inadequate
studies, is depriving the American people of a safe and effective medicine.
Beyond that concern, the increasing enthusiasm for drug testing and punishing
those who test positive for cannabis wth either criminal or social sanctions
is destructive to the large —but at this writing unknown —number of Americans
treating emotional symptoms with what may be, for them, the best agent available.
1. Kandel, DB, Editor. Examining the Gateway Hypothesis; Stages and Pathways
of Drug Involvement. Cambridge University Press 2002.
2. Guo, JieHill, Karl G.Hawkins, J. David Catalano, Richard F. Abbott, Robert
D. Journall of the American Academy of Child and Adolescent Psychiatry, July,
3. Pary R, Lewis S, Matuschka PR, Rudzinskiy P, Safi M, Lippmann S. Attention
deficit disorder in adults. Ann Clin Psychiatry. 2002 Jun;14(2):105-11
4. Wender, PH Minimal Brain Dysfunction in Children. Wiley New York1971.
5.Wender, PH ADHD; Attention-Deficit Disorder in Children and Adults Oxford,
2000 University Press.
6. Kirk, SA & Kutchins, H. The Selling of DSM; the rhetoric of science
in Psychiatry. Aldyne De Gruyter New York 1992
7. Kandel, DB, Logan, JA. Patterns of Drug Use from Adolescence to Young Adulthood:
I. Periods of Risk for Initiation, Continued Use, and Discontinuation AJPH
74 (7) 660
8. Morral AR, McCaffrey DF, Paddock SM. Reassessing the marijuana Gateway Effect
Addiction. 2002, 97 1499