3 Physical and Psychological Effects

Medical Opinions

It should be easy to describe the effects of cannabis. After all it has been used for centuries and many doctors have tried to describe the results of using it. If that is not enough, I could, in theory, find a , hundred or more cannabis smokers in order to observe and question them while they smoke.

In practice it is more difficult. Descriptions of the effects of the drug show a large number of discrepancies which may be attrirbuted to the varying concentrations of the drug in different preparations. The potency varies widely depending on climate, cultivation and the way it is used. It has been noted that there are , three grades prepared in India; ganja is two or three times as 'potent as bhang, and charas is the strongest of all. McGlothlin
968) estimated that the marihuana available in the United States is one fifth to one eighth as intoxicating as the charas resin used in .1ndia. Usually cannabis is smoked, but at other times it is drunk or .mixed with other ingredients to make fudge, cake or sweetmeats.

Another complication is the fact that it is often taken in conjunction with other drugs. Porot (1942) reports that most users in orth Africa are also alcoholics. In the Middle East cannabis is often adulterated with cantharides (Spanish fly, an alleged aphrodisiac) or with datura and other poisonous substances. In India and the Far East it is sometimes mixed with opium which is used as a remedy for diarrhoea caused by tropical disease and impure food (Chopra, 1965).

If we decide to limit the description to the kind of cannabis smoked in this country, the reports are still conflicting. It would be sensible, and not too difficult, to verify these reports by setting up our own experiment. But if I arranged to study a group of people smoking cannabis, I would be committing a crime. Not only would I be aiding and abetting, but it is also an offence to 'permit' premises to be used for smoking cannabis.

It may be best to start the description of the effects with a few items of information which are not controversial. There is not much argument about the pharmacology of cannabis. The constituents of cannabis resin include cannabidiol and several tetrahydrocannabinols referred to collectively as T H C. These are the active principles and their potency depends on the conditions in which the plant is grown as well as the way the cannabis is prepared for use. The rate and degree of absorption, and hence the effect, depend upon the way the drug is taken; the effects start earlier when it is smoked than when it is taken by mouth. There is little precise knowledge about the way THC acts in the human body, but the experienced smoker is quite knowledgeable about the different kinds of pot; he chooses carefully before he buys and has learnt the art of smoking so as to get the maximum effect. An average-sized cigarette will start to take effect within a few minutes and the effect will last from three to five hours.

It is now possible to manufacture a form of synthetic cannabis, known as delta9-tetrahydrocannabinol (synthetic T HC). At present there is no large-scale manufacture of this substance, but it will not be long before the necessary technical processes are evolved. Some trials with synthetic THC have suggested that it is more potent and less poisonous than substances produced from the natural plant.

It is also agreed among all observers that tolerance does not develop. With most of the other recreational drugs the regular user finds that he has to increase the dose to obtain the same effect. In alcohol this is known as 'learning to hold your liquor'. But many smokers have used cannabis for years without needing to increase the amount they take. Indeed there are reports (Zinberg, 1969) that indicate that many smokers find that as they become more experienced they reduce the amount they take - a kind of reverse tolerance. Because the effects of the drug are felt soon after it is smoked, it is not difficult to adjust the dosage to achieve the effect the user seeks.

It is also agreed that even when cannabis is continually smoked over a long period, there are no signs of physical dependence. There are no withdrawal symptoms when the use of this drug is discontinued, so cannabis does not cause addiction in the proper sense of the word.

In 1964 the World Health Organization recommended the new terminology of' drug dependence' in place of the terms 'addiction' and 'habituation'. The characteristics of drug dependence will - vary with the drug used, thus it becomes necessary to designate the particular type of drug dependence in each case: for example, drug dependence of the morphine type, of the barbiturate type, etc. The WHO describes the characteristics of cannabis dependence as:

(a) Little tendency to increase the dose and no evidence of tolerance.
(b) Absence of physical dependence, so that there is no characteristic abstinence syndrome when the drug is discontinued.
(c) Moderate to strong psychic dependence on account of the desired subjective effects.

The mention of psychic dependence (more accurately described as psychological dependence) immediately takes us out of the area of general agreement. It is quite difficult to know what people mean when they talk about psychological dependence. Hundreds of Englishmen demand bacon and eggs for breakfast and feel they have not started the day properly without it. Is this psychological dependence? Usually the term is used in the sense that people are , upset if they are deprived of something they like very much. Thus people could be described as psychologically dependent on chocolate, on sexual intercourse, on anything that gives pleasure. Clearly this is far too general to be a useful definition, but it is difficult to limit it in a meaningful way.

Most cannabis users can stop smoking pot without any difficulty (Watt, 1965), and the question that interests the user is unlikely to be, 'Can I stop?', but, 'Why should I stop?'. One is tempted to dismiss the whole concept of psychological dependence as just another way of saying that some people will go to a great deal of trouble to obtain what they want. But there is a bit more to it than that.

A few people are obsessed with the idea of getting a supply of cannabis when they run short, and everyone who uses it has to break the law. It is unlikely that anyone would break the law to get a bar of chocolate, but very many people would do so if sexual intercourse were illegal. The term psychological (or psychic) dependence is misleading unless it is defined more precisely. All that can be usefully said about cannabis is that a few users will do dangerous and silly things in order to get the cannabis they want, the majority will go to some trouble to get their supply, and a fairly large minority will merely take pot when the opportunity arises and will feel no distress without it. This makes it clear that the extent of psychological dependence depends in the main upon the personality of the user and much less on the intrinsic effects of the drug.

It is probably true that anyone who smokes pot every day over many years has developed a psychological dependence on the drug. The same might be said of those who take tea or coffee every day.1 But in fact most users do not take cannabis regularly on a daily basis, but are more likely to have it at week-ends and on other occasions when they have time to spare without the smoke interfering with work or study. So they are much less likely to form a habit than those who smoke cigarettes or drink alcohol every day. Moreover it is well known that many young people take cannabis - for a period and then give it up when they marry, or when they take on a new commitment, or when their circumstances change in ;Other ways. Many of the students who take pot while at college stop smoking it when they come home. This suggests that if cannabis is habit-forming, it is a habit that can be broken without much difficulty.

We are still in a very controversial area when we attempt to describe what a person feels and how he will behave after he has taken pot. There are still books being published which describe the first signs of intoxication as nausea and vomiting, while I have met people who claim to have smoked pot on several occasions without it having any effect on them at all. If either of these statements were true for the majority, there would be no cannabis problem, for hardly anyone would bother to take it.

Sir Aubrey Lewis, Emeritus Professor of Psychiatry at the University of London, has made an extensive review of the international literature on cannabis, a total of 1,750 books and articles beset with contradictory observations and opinions. Among the physical effects reported are raised pulse rate and blood pressure, tremor of tongue and mouth, cold extremities, rapid shallow breathing, dyspepsia, pain in the abdomen, insomnia, palpitations and headaches. The descriptions of the psychological effects cover many pages of the review and include fixed ideas, emotional upheaval, hallucinations, depression, noisy laughter accompanied by sadness, intense depersonalization and, inevitably, erotic desires. The descriptions of 'cannabis psychosis' include schizophrenia, paranoid states, manic excitement, depression and anxiety, dementia, and practically every known variety of mental disorder. In fact it is difficult to make sense of these confused descriptions because few of the reports are specific about the dose and type of cannabis. It is a bit like assuming beer and methylated spirits are - equally damaging. As cannabis is illegal in many countries and home-produced in the others, there is no standardization in quality and therefore no control over potency. Furthermore it is well known that cannabis has a wide variety of effects depending on the social setting in which it is taken and the mood of the user at the time that he takes it.

Nearly all these reports quoted by Sir Aubrey Lewis come from countries which are under-developed scientifically as well as economically, and thus the standard of research and social investigation is less exact than we expect in this country. Consequently
it would be unwise to accept these results uncritically, especially as regards the vague criteria for diagnosis, the likelihood of other predisposing factors, the possible adulteration of the cannabis, and a social situation not comparable to Western society.

The Opinions of Users

I have quoted only a few lines from the many pages of adverse effects collected by Sir Aubrey Lewis, but enough to show that they are so vague and contradictory that it is impossible to make sense of them. It is interesting to note that these authorities hardly mention any pleasant effects of the drug. Perhaps this is because they are difficult to describe, although some people have tried. The most famous attempt to describe the euphoric effect of cannabis came from Théophile Gautier, a member of the Club des Hachichins established in 1844 in Paris. The speciality of this club was a sweetmeat (Dawamesc) which contained hashish. Gautier describes the effect of eating this delicacy as follows:

After the somewhat convulsive gaiety of the beginning, an indefinable feeling of well-being, a boundless calm, took over.
I was in that blessed state induced by hashish which the Orientals call al-kief. I could no longer feel my body; the bonds of matter and spirit were severed; I moved by sheer willpower in an unresisting medium.
Thus I imagine the movement of souls in the world of fragrances to which we shall go after death. A bluish haze, an Elysian light, the reflections of an azure grotto, formed an atmosphere in the room through which I vaguely saw the tremblings of hesitant outlines; an atmosphere at once cool and warm, moist and perfumed, enveloping me like bath water in a sort of enervating sweetness. When I tried to move away, the caressing air made a thousand voluptuous waves about me; a delightful languor gripped my senses and threw me back upon the sofa, where I hung, limp as a discarded garment.
Then I understood the pleasure experienced by the spirits and angels according to their degree of perfection, when they traverse the ethers and the skies, and how eternity might occupy one in Paradise.

Another graphic description of hashish was written by the poet Charles Baudelaire who was a founder member of the Club des Hachichins:

Here then, is happiness, with all its intoxications, follies and puerilities. You can swallow it without fear — one does not die of it. Your physical organs will be in no way affected... . The simplest words, the most trivial ideas, assume a new and strange guise; you are actually astonished at having hitherto found them so simple. Incongruous and unforeseeable resemblances and comparisons, interminable bouts of punning on words, rough sketches for farces, continually spout from your brain. .. . From time to time you laugh at yourself, at your own silliness and folly; and your companions, if you have such, laugh alike at your condition and at their own. But, since they laugh at you without malice, you laugh back at them without rancour.

Contemporary writers agree in essence with the sensations reported by Gautier and Baudelaire. Here is a quotation from a memorandum reported at a symposia organized by the Ciba Pharmaceutical Company in 1946:

Throughout the experiment I experienced a peculiar double consciousness. I was perfectly aware that my laughter, etc., was the result of having taken the drug, yet I was powerless to stop it, nor did I care to do so, for I enjoyed it as thoroughly as if it had arisen from natural causes. . . . I awoke next morning after seven hours' sleep, with a ravenous appetite, which I think was probably as much due to the great expenditure of energy in laughing as to any direct effect of the drug itself. . . . I should say that the immediate after-effect, the reaction from the stimulation of hashish, is not much greater, except for the drowsiness, than that following the common or beer garden variety of intoxication. My memory of what I said and did while under the hashish was complete and accurate.

Dr Sheldon Cholst2 is a trained psychiatrist. The following quotation is a short extract from an essay written in 1965 while he was under the influence of pot.

This hashish, this drug, this chemical, this resin from female Cannabis sativa flowers, these leaves of marihuana, this poisoner of frustrating reality, this antidote for restlessness that is frustrated, this instant joy and relaxation, this chemical age-regression that allows us to be young and old at the same moment of time. Like being in two places at the same time when one crosses the international date line in the Pacific on the same day and experiences the unreal 'way out' sensation of being - in two places at the same time — it is just such an unreal feeling that comes up in the hashish smoker. This smoke like from Aladdin's lamp that contains the genie that brings all things to the wisher, this smoke when inhaled does the same as Aladdin's lamp and brings out the ' genius in the inhaler for he becomes fresh and comes fresh to thoughts and ideas and he joys with laughter at his childhood pleasure. And if he is with congenial friends he finds himself happy with them too.

More than one user has told me that the best description they have seen comes from an anonymous pot smoker writing in the Guardian (3 December 1969).

How strange — I remember thinking — it is exactly as people tell you it will be, and yet until it has happened to you, you cannot have the faintest idea what they mean. Just as in making love or giving birth for the first time, you enter a new world of experience which, no matter how many times you may have heard it described, still comes as a revelation to you personally.

I felt utterly relaxed — rather sleepy in fact — and quite serene and composed. I could feel the texture and weight of the settee with startling clarity; could measure the precise curve of the cushion under my elbows, and the exact depth to which they sank into it. The radiator behind and to one side of me felt hotter to my left shoulder than to my right: a measurable difference in temperature, though I had never noticed it before. The texture of corduroy was microscopically detailed, each ridge of the material distinct and separate.

Time crawled. The music went on and on. I tried to smoke an ordinary cigarette but it tasted dry and boring and I soon stubbed it out. The cat jumped on to my lap and I stroked her, enjoying the sleek, glossy softness of her fur and the subtle curves and hollows of her body. Obviously I was stroking beautifully, for she purred like mad.

The room was full of delicate vibrations of light, which shimmered through the air. My mind too seemed twanging with these vibrations, and my skin. They were palpable, rhythmic waves. . . . I had taken my shoes off by now and the dense, opulent pile of the carpet felt even better to the soles of my feet than had the corduroy of the settee to my elbows — though still not as luxuriant as the cat. My senses were alight with more complexity and beauty of feeling than I had ever assimilated before. It was totally new and unimaginable. No words could have prepared me to expect this.

After a couple of hours (or so my watch recorded: it felt infinitely more) I went to bed and slept deeply and refreshingly, without dreaming. Next morning I woke with ease, earlier than usual, but full of energy and very clear-headed.

My description cannot convey the sensations I had when high; the word 'high' itself comes nearest, though I never felt disembodied or as though I were literally floating. I have simply set down with total , honesty and as much clarity as I can bring to such a non-verbal experience, what happened and how it felt.

Dr Anthony Storr3 described the effects of cannabis in a way most smokers in this country would accept `It is generally smoked in the company of others and its chief effect seems to be an enhanced appreciation of music and colour together with a feeling of relaxation and peace. A mystical experience of being at one with `. the universe is common, which is why the drug has been highly , valued in Eastern religions.'

These accounts may help people to understand why so many enjoy taking cannabis although some find it hard to believe the 'pore poetic descriptions. The truth is that the psychological 'effects are very variable, depending on the individual and the Circumstances at the time the drug is taken. It is also true that one has to learn how to get the desired effects from taking cannabis and experienced user has some control over the nature and course of the intoxication because he knows what to look for as the drug to work. But the man smoking pot for the first time does not appreciate the full effects and would probably give a misleading secount if he were asked to describe them. It is well known that experienced users teach novices to notice the subtle effects of the drug (Becker, 1967).

Nevertheless it is odd that the medical and scientific accounts so rarely mention the pleasurable aspects of pot, for it would seem obvious to me that they are the most important effects of all. There is the feeling among doctors that as cannabis now has no medical use, it is therefore not worth risking any possible harm it may do, as one might in the case of morphine which is both harmful and medically beneficial (like most other drugs in varying degrees). But the same argument could be used against hair dyes, sweets or swimming. The fact that all of these things give pleasure is a major argument in their favour. It would be possible to sholv that all of them in one way or another can be harmful, but it would be quite wrong to prohibit any of them, because the pleasure they give far outweighs the possibility of harm. Cannabis may, or may not, be in a similar category. The point I want to make here is that the possibility of injury is not of itself sufficient reason to prohibit a particular activity. But for some people, including some doctors, a substance that happens to bring happiness is suspect and a substance made solely for the purpose of giving pleasure is quite certainly unwelcome.

Four Types of Effects

The best way to avoid confusion and misunderstanding is to think of the effects of cannabis in four separate categories:

(1) Short-term effects after moderate use.
(2) Short-term effects after excessive use.
(3) Long-term effects after moderate use.
(4) Long-term effects after excessive use.

It is surprising how obscure most accounts have been about both time and quantity. So often when writers are describing the effects, it is unclear whether they are writing about physical and psychological effects while under the influence of the drug, or the effects hours and days later, or perhaps years later after continuous use. Much of the disagreement about the consequences of taking cannabis are caused by the lack of true knowledge of the amounts which have been consumed by the various groups of patients being studied and described. It will be necessary to carry out detailed studies in order to work out some standard of measurement so that it is possible to state the size of the dose and the potency of the various preparations of cannabis. Only then will it be possible to relate dose with response and so decide whether this is a drug which is dangerous (like many other drugs) when taken in overdosage and harmless in small doses.

Those conducting experiments in the US, in which cannabis is given to subjects under laboratory conditions, appear to be administrating doses far in excess of the amount of marihuana a smoker normally uses. The reports most often quoted to show that cannabis can cause psychotic reactions (Isbell, 1967; Hollister, 1968) are based on the administration of doses three times larger than would be taken by a man smoking pot to get relaxed and happy.

Short-term effects after moderate use. This is really a description of the high4 obtained by the experienced smoker of cannabis who has learnt to use the drug effectively. He is likely to experience a relaxed feeling of well-being, deeper awareness, heightened sensitivity, sociability, and contentment which usually ends in a pleasant drowsiness. The physical effects are various, but trivial and unimportant. Even the dilatation of the pupils, the most commonly reported symptom and the one which policemen invariably look out for, is disputed by Zinberg (1969).5

It is reasonable to ask what is meant by 'moderate use' in this context. The best definition of moderate use is the amount required to produce the desired high. This is not difficult for the experienced pot smoker because the effect is almost immediate (unlike alcohol) and it is possible to limit the intake to the amount required.

Short-term effects after excessive use. Acute intoxication is rare because the feelings are unpleasant and a user is only likely to take more than he needs for euphoria if he is seeking temporary oblivion. Excessive use will produce a series of varying experiences which come in waves. From among the many reports on acute intoxication the most usual hallucinations reported are perceiving parts of the body as distorted, depersonalization, spatial and temporal distortion. Although the descriptions of acute intoxication sound frightening to the non-user, it seems that these hallucinations are rarely horrible enough to put off a man from taking thetlrug again. Indeed they are not really hallucinations in the strict sense of the word, because the user is aware that the strange things he sees are the effects of the drug and he is not frightened by them as we all are sometimes by nightmares. Cannabis is not strong enough for those who wish to escape to a hallucinatory world for a time; they would turn to L SD.

The physical effects seem to be negligible and it is possible that there is a kind of self-protection caused by the quick reaction to the drug; the effects are so rapid that the user tempted to take large amounts of the drug feels drowsy and lazy before he can take enough to do physical damage. In any case cannabis does not seem to be very poisonous as the fatal dose in humans is unknown and there have been no deaths directly attributable to cannabis reported in this country.

Long-term effects after moderate use. This is the area where there is much heated controversy and many conflicting opinions. There are reports from India (Chopra, 1957) and Nigeria (Tella, 1967) on possible long-term effects, but these are not well documented. On the other hand Haneveld (1959) reports that easy availability of the drug in the Lebanon does not lead to mass dependence, nor do users increase their consumption if offered unlimited supplies. It is difficult to interpret the findings of studies made in the Middle East because cannabis is often adulterated with other substances, some of them poisonous. In fact it is difficult to understand why the controversy still rages as there have now been three authoritatiye reports, following detailed and careful sifting of the available evidence, and all three reports have come to the conclusion that no definite long-term ill-effects have been scientifically established.

The Indian Hemp Drugs Commission spent two years interviewing over 800 witnesses and in 1894 produced a report of over 3,000 pages. Among their conclusions were the following: 'There is no evidence of any weight regarding mental and moral injury from moderate use of the drugs.' (Ch. x para. 498.) 'The evidence shows the moderate use of ganja or charas not to be appreciably harmful, while in the case of moderate bhang-drinking the evidence shows the habit to be quite harmless.' (Ch. xi para. 510.)

In 1938 the Mayor of New York asked the Academy of Medicine to make a scientific study of the use of marihuana. A special team of thirty-one eminent physicians, psychiatrists, clinical psychologists, pharmacologists and sociologists reported in 1944. Their conclusions include the following: 'The evidence available justifies the conclusion that neither true addiction nor tolerance is found in marihuana users' (page 146). 'Furthermore those who have been smoking marihuana for a period of years showed no mental or physical deterioration which may be attributed to the drug' (page 218).

The Government Advisory Committee Report on Cannabis (often known as the Wootton report)6 was appointed to review the available evidence on the pharmacological, social and legal aspects of cannabis. In 1969 they reported: Having reviewed all the material available to us we find ourselves in agreement with the conclusion reached by the Indian Hemp Drugs Commission appointed by the Government of India (1893-1894) and the New York Mayor's Committee on Marihuana (1944), that the longterm consumption of cannabis in moderate doses has no harmful effects' (para. 29).

Long-term effects after excessive use. There have been several reports, particularly from the Middle and Far East, which suggest that the chronic use of cannabis can cause mental and physical deterioration. Of course it is true that too much of almost anything will produce ill-effects and it is likely that there are certain personality-types who will be tempted to take large doses of cannabis over a long period. In some countries and in some situations this is not really surprising and it is noticeable that these reports suggest that this over-indulgence is among the very poor slum dwellers. When one considers the utter misery and squalor in which the poor live in these Eastern countries, it is understandable that some of them choose to escape from the conditions by smoking cannabisln large quantities for most of the day.

Most of these reports come from countries where alcohol is against the local religion and is in any case too expensive for the poor who live in these crippling conditions. But the picture drawn by Bouquet (1951) in Tunisia, Benabud (1956) in Morocco and other more impressionistic observers is similar to the plight:of the chronic alcoholics and meths drinkers to be found in skid rows in London and in most other large urban communities in Western countries.

When cannabis is taken to excess in such conditions, it is hard to distinguish between the basic personality difficulties of the individual who finds himself in this situation, the environmental effects of prolonged deprivation and malnutrition, and the effects of the drug.

It seems probable that people living in these unhygienic conditions will suffer from inertia, lethargy and self-neglect, punctuated on occasions with outbursts of violent behaviour and 'feelings of increased capability with consequent failure' (Eddy, 1965). Reports of psychoses are also to be expected from studies in these deprived areas, but again it is difficult to see if the cause is the chronic use of the drug, as Benabud (1956) suggests, or the wretched food and the appalling housing. It is remarkable that the rates of total psychoses from areas where the drug is widely used are not much different from the rates of psychoses in other areas and this suggests that if cannabis does produce a specific psychosis it must be very rare.

Most of these observers of the Eastern scene also cite individual psycho-pathological factors as prominent causes of excessive indulgence. You are a kif addict long before you smoke your first pipe' is a Moroccan saying which indicates that it is the personality of the user and not the drug itself which leads to chronic misuse.

But these same investigators show no concern about the moderate user of cannabis in Eastern countries just as we are not worried about the moderate user of alcohol in this country. The few cases of excessive use found in Europe and the United States appear to be individuals with very severe personality problems and cannabis seems to be a symptom, not a cause. There is no evidence that in Western society serious physical or mental ill-effects are directly attributable to the smoking of cannabis. Although pot has been smoked for many years in this country, we have not found any deleterious long-term effects and as Bewley (1965) writes: 'People who use it (cannabis) do not normally come to the attention of a doctor unless they have some other illness.'

1. Regular users of tea or coffee are not usually deprived of their drug for a long period, so the withdrawal effects are rarely observed. But it has been shown that regular tea or coffee drinkers do feel distressed if they are unable to get their supply.

2. The quotations from Théophile Gautier (translated by Ralph J. Gladstone), Sheldon Cholst, and the anonymous subject reported by Victor Robinson at the Ciba Symposia are all taken from the American edition of The Marihuana Papers, edited by David Solomon and published by BobbsMerrill and in Britain by Panther Books. The quotation from Charles Baudelaire is from The Drug Experience, edited by David Ebin and published gy the Orion Press in 1961.

3. In the Sunday Times, 5 February 1967.

4. I use the vernacular 'high' instead of the scientific word 'intoxication* which gives the wrong impression. A cannabis smoker is high when he is in a euphoric state; this is quite different from the man intoxicated by alcohol which usually means drunk and incapable. The pot smoker's word for this is 'stoned'.

5-. Sirte observers usually find cannabis smokers in dim surroundings, it is not surprising that their pupils are large.

6. The results of the Wootton report are discussed in greater detail in chapter 7.