Alexander DeLuca, M.D.
Cannabis as a Substitute for Alcohol
Tod Mikuriya, MD;
Journal of the California Cannabis Research Medical Group; Summer 2003. Posted
“Harm reduction” is a treatment approach that seeks to minimize the occurrence of drug/alcohol addiction and its impacts on the addict/alcoholic and society at large. A harm-reduction approach to alcoholism adopted by 92 of my patients in Northern California involved the substitution of cannabis —with its relatively benign side-effect profile— as their intoxicant of choice.
No clinical trials of the efficacy of cannabis as a subtitute for alcohol are reported in the literature, and there are no papers directly on point prior to my own account (Mikuriya 1970) of a patient who used cannabis consciously and successfully to reduce her problematic drinking.
There are ample references, however, to the use of cannabis as a substitute for opiates (Birch 1889) and as a treatment for delirium tremens (Clendinning 1843, Moreau 1845), which were among the first uses to which it was put by European physicians. Birch described a patient weaned off alcohol by use of opiates, who then became addicted and was weaned off opiates by use of cannabis. “Ability to take food returned. He began to sleep well; his pulse exhibited some volume; and after three weeks he was able to take a turn on the verandah with the aid of a stick. After six weeks he spoke of returning to his post, and I never saw him again.”
Birch feared that cannabis itself might be
addictive, and recommended against revealing to patients the effective
ingredient in their elixir. “Upon one point I would insist —the necessity of
concealing the name of the remedial drug from the patient, lest in his endeavor
to escape from one form of vice he should fall into another, which can be
indulged with facility in any Indian bazaar.” This stern warning may have
undercut interest in the apparently successful two-stage treatment he was
Since delirium tremens signifies advanced alcoholism, we can adduce that patients who were prescribed cannabis and used it on a longterm basis were making a successful substitution.
By 1941, due to prohibition, cannabis was no longer a treatment option, but attempts to identify and synthesize its active ingredients continued (Loewe 1950). A synthetic THC called pyrahexyl was made available to clinical researchers, and one paper from the postwar period reports its successful use in easing the withdrawal symptoms of 59 out of 70 alcoholics. (Thompson and Proctor 1953).
In 1970 the author reported (op cit) on
Mrs. A., a 49-year-old female patient whose drinking had become problematic. The
patient had observed that when she smoked marijuana socially, on week-ends, she
decreased her alcoholic intake. She was instructed to substitute cannabis any
time she felt the urge to drink. This regimen helped her to reduce her alcohol
intake to zero. The paper concluded, “It would appear that for selected
alcoholics the substitution of smoked cannabis for alcohol may be of marked
rehabilitative value. Certainly cannabis is not a panacea, but it warrants
further clinical trial in selected cases of alcoholism.”
Although the increasing use of marijuana
starting in the late ‘60s had renewed interest its medical properties —including
possible use as an alternative to alcohol (Scher 1971)— meaningful research was
blocked until the 1990s, when the establishment of “buyers clubs” in California
created a potential database of patients who were using cannabis to treat a wide
range of conditions. The medical marijuana initiative passed by voters in 1996
mandated that prospective patients get a doctor’s approval in order to treat a
given condition with cannabis —resulting in an estimated 30,000 physician
approvals as of May 2002. (Gieringer 2002) As this goes to press a year later,
the estimate stands at abut 50,000.
A majority of the patients identified themselves as blue-collar workers: carpenter (5), construction (3), laborer (3), waitress (3), truck driver (3), fisherman (3), heavy equipment operator (3), painter (2), contractor (2) cook (2), welder (2), logger (2), timber faller, seaman, hardwood floor installer, bartender, building supplies, house caretaker, ranch hand, concrete pump operator, cable installer, silversmith, stone mason, boatwright, auto detailer, tree service handyman cashier, nurseryman, glazier, gold miner, carpet layer, carpenter’s apprentice, landscaper, river guide, screenprinter, glassblower.
Eleven were unemployed or didn’t list an occupation; four were disabled, two retired, and two patients defined themselves as mothers. Others were in sales (5), musicians (5), clerical workers (3), paralegal, teacher, actor, actress, artist, sound engineer, computer technician.
Eighty-two of the patients were men.
Patients’ ages ranged from 20 to 69. Twenty-nine were in their twenties; 16 in their thirties; 24 in their forties; 20 in their fifties; three in their sixties.
Exactly half —46 patients— had taken some college courses, but only four had college degrees. Five did not complete high school.
Thirteen were veterans, all branches of the Armed Forces being represented.
All but six—five native-Americans, one African-American— were Caucasian.
Slightly more than half (49) reported being raised by at least one addict/alcoholic parent.
Thirty-one patients identified themselves as alcohol abusers, but reported other problems as primary: Pain (12), Depression (8), Headache (4), Bipolar Disorder (2) Anxiety (2), Arthrtitis (2), Asthma (2) Spinal Cord Injury/Disease (2), Paraplegia, PTSD, Crushed skull, Aneurysms aggravated by stress, ADHD, Multiple broken bones.
Eighteen patients reported having been injured while or after drinking heavily.
Fourteen had incurred legal problems or
been ordered into rehab programs.
Three reported first using at age 9 or younger; 61 between ages 10 and 19; nine began using in their 20s; three in their 30s; six in their 40s; two at age 50; and one at age 65.
Twenty-four patients reported realizing immediately upon using cannabis that it exerted a beneficial medical effect. Some of their responses still seem to reflect their relief at the time.
• “In 1980 I had quit drinking for a month. My
niece asked me if I ever tried marijuana to calm me down. So I tried it and it
worked like a miracle.”
Thirty-five patients answered ambiguously with respect to time —“When realized preferred to alcohol,” for example, or, “when I smoked when suffering.”
Seven reported becoming aware of medical effect within a year of using cannabis. Ten became aware within one to five years.
Three became aware of medical effect 12-15 years after first using. Ten became aware between 20 and 30 years after first using. All but one of these patients had resumed using cannabis after years of abstinence.
Efficacy was inferred from other responses on seven questionnaires. Two patients did not make follow-up visits.
Nine patients reported that they practiced total abstinence from alcohol and attributed their success to cannabis. Their years in sobriety: 19, 18, 16, 10, 7, 6, 4 (2), and 2.
Twenty-nine patients reported a return of symptoms when cannabis was discontinued. Typical comments:
• “I quit using cannabis while I was in the army and my drinking doubled. I was also involved in several violent incidents due to alcohol.”
All were strongly advised that smoking involves an assault on the lungs, and that vaporization is a safer method of inhaling cannabinoids.
Twelve patients reported using a pipe, and three owned vaporizers. All were strongly advised that smoking involves an assault on the lungs, and that vaporization is a safer method of inhaling cannabinoids.
Fights and accidents — vehicular, sports- and job-related— also create chronic pain patients, many of whom self-medicate with alcohol.
Eighteen patients reported having been injured while or after drinking heavily. This comment by Jamie R., a 26-year-old truck driver, describes a typical chain-reaction of alcohol-induced trouble: “Injured in a fight after consuming alcohol, resulted in staph infection of right knuckle, minor surgery and four days in hospital.” Injuries suffered while drunk add to pain and the need for relief by alcohol …or a less destructive alternative.
A total of 26 patients reported using cannabis for both pain relief and as an alternative to alcohol. Mike G., a 47-year old landscaper who was run over by a vehicle at age 5, requiring multiple surgeries and leaving him with pins in his right ankle, first used cannabis at age 16 and appreciated its benign side-effect profile: “Given pain pills for my right ankle, I got too drowsy. Smoked herb to relieve pain.” And when he had to discontinue cannabis use, “was unable to ease pain in ankle without herb, and drink when unable to have cannabis to smoke.”
for Mood Disorders
• Wendy S., a 44-year-old paralegal, suffering
from depression, alcoholism, and PMS noted simply, “Alcohol causes more
depression.” When she does not have access to cannabis, “Alcohol consumpion
increases and so does depression.” At her initial visit she reported consuming
5-10 drinks/day. At a follow-up (16 months) she had reduced her consumption to
• Carol G. presented initially at age 35 as homeless and unemployed, suffering “severe depression. Anxiety. Pain.” Her problem with alcohol was inferred from her response concerning non-medical-psychoactive drug use: “I drink and smoke too much —started when I couldn’t get marijuana.”
Carol had shyly requested a recommendation for cannabis from a Humboldt County physician but, as she recounted, “I’m paranoid and local Drs are scared, too. They gave me paxil & stop smoking pamphlet.”
At a follow-up visit (14 months) Carol reported a change in circumstance: “Now have a room. But am on G.R. and am paying too much.” She was still using alcohol “a little. I’m doing good dealing with not drinking. Being able to medicate with cannabis has helped a lot.” Eighteen months later the pattern hadn’t changed: “Alcohol several times/week. Depends on if I have cannabis, stress still triggers.”
• Lance B. presented as a 41-year-old alcoholic also suffering from arthritis, pain from knee- and ankle surgeries, and depression, for which he had been prescribed Librium, Valium, Buspar, Welbutrin, Effexor, Zoloft, and Depakote over the years; “No help!,” he wrote bluntly. On his return visit (one year) he reported “few relapses” and that he was able to take some classes.
• The dulling effects of Vicodin and other opiates were mentioned by seven patients. As Harvey B. put it, “When I can get Vicodin it helps the pain but I don’t like being that dopey.” Clarence S., whose skull was badly damaged in an accident, also appreciated the pain relief provided by opiates, but asserted that opiates “make me paranoid and mean.”
• Alex A., who was diagnosed with ADHD in ninth grade, touches on some recurring themes in describing the treatment of his primary illness: “I was prescribed Ritalin and Zoloft. The Ritalin helped me concentrate slightly but caused me to be up all night. The Zoloft made me sick to my stomach and never relieved my stress or depression. I have never been prescribed anything for my insomnia but I usually have to drink some liquor to get to sleep. I think that is a bad thing as I have now begun to drink excessive amounts of whisky, which has really started to affect my stomach.” Alex first used cannabis at age 19 and became aware of benefits immediately. “I found myself running to the refrigerator and then sleeping better than I had for years.” At age 21 he fears permanent damage. “From drinking (I believe) my stomach has been altered, along with my appetite… I cannot really eat that much and feel malnourished and weaker than a 21-year-old should. My joints ache constantly and I am not as strong as I used to be. I also fear that I will become or am an alcoholic and I do not want to see myself turn into my dad.”
At his follow-up visit (12 months) Alex reported cannabis to be “very effective.” He was employed, “not partying,” doing well socially, and trying to give up cigarettes.
As cannabis comes into wider use in California and elsewhere, it is important that its interactions with other medications be studied and publicized.
As cannabis comes into wider use in California and elsewhere, it is important that its interactions with other medications be studied and publicized. Cannabis may also have an amplifying effect on alcohol, enabling some patients to achieve a desired level of inhibition-reduction or euphoria while drinking significantly less.
As noted, all of the patients in this study were seeking physician’s approval to use cannabis medicinally —a built-in bias that explains the very high level of efficacy reported. However, the majority were using cannabis for other conditions as well, and would have qualified for an approval letter whether or not they reported efficacy with respect to alcoholism. Although medicinal use of cannabis by alcoholics can be dismissed as “just one drug replacing another,” lives mediated by cannabis and alcohol tend to run very different courses. Even if use is daily, cannabis replacing alcohol (or other addictive, toxic drugs) reduces harm because of its relatively benign side-effect profile. Cannabis is not associated with car crashes; it does not damage the liver, the esophagus, the spleen, the digestive tract. The chronic alcohol-inebriation-withdrawal cycle ceases with successful cannabis substitution. Sleep and appetite are restored, ability to focus and concentrate is enhanced, energy and activity levels are improved, pain and muscle spasms are relieved. Family and social relationships can be sustained as pursuit of long-term goals ends the cycle of crisis and apology.
Carl S., a 42 year old journeyman carpenter, is a success story from a harm-reduction perspective. At his initial visit he defined his problem as “intermittent explosive disorder,” for which he had been prescribed Lithium. Although drinking eight beers/day, he reported “Cannabis has allowed me to just drink beer when I used to blackout drink vodka and tequila.” By the time of a follow-up visit (12 months), Carl had been sober for four months. He also reported “anger outbreaks less severe, able to complete projects,” and, poignantly, “paranoia is now mostly realism.” He plans to put his technical skill to use in designing a vaporizer.
Treating alcoholism by cannabis substitution creates a different doctor-patient relationship. Patients seek out the physician to confer legitimacy on what they are doing or are about to do. My most important service is to end their criminal status —Aeschalapian protection from the criminal justice system— which often brings an expression of relief. An alliance is created that promotes candor and trust. The physician is permitted to act as a coach —an enabler in a positive sense.
As enumerated by patients, the benefits can be profound: self-respect is enhanced; family and community relationships improve; a sense of social alienation diminishes. A recurrent theme at follow-up visits is the developing sense of freedom as cannabis use replaces the intoxication-withdrawal-recovery cycle —freedom to look into the future and plan instead of being mired in a dysfunctional past and present; freedom from crisis and distraction, making possible pursuit of long-term goals that include family and community.
At AA meetings, cannabis use is considered a violation of sobriety. This puts cannabis-only users in a bind. Those who attend meetings can’t practice the “rigorous honesty” that AA considers essential to recovery; and those who avoid meetings are denied support and encouragement that might help them to stay off alcohol. Support-group meetings at which cannabis-using alcoholics are welcome would be a positive development.
• Frank R., first seen at age 29, was diagnosed as an alcoholic in 1987 and began attending AA meetings, which he found helpful although he could not achieve sustained sobriety. In 1998, after realizing that cannabis reduced his cravings for alcohol, he received approval to use it. At a follow-up in November ’99 he reported, “Have stopped drinking for the first time in many years. I have not taken a drink of alcohol in 14 months. I attribute some credit for this to daily use of cannabis. My life has improved with this treatment.”
Frank R. was seen again in April ’01 and reported, “I continue to maintain sobriety regarding alcohol. Have not had a drink for 2 1/2 years. I drank alcohol heavy for about 10 years, and had difficulty stopping drinking and staying stopped until I began this treatment. Pain symptoms from back spasms/scoliosis also better.”
in Drug of Choice
“By virtue of their role as warriors, the Rajputs were accorded certain privileged relaxations of the orthodox Hindu rules,” writes Carstairs, “in particular, those prohibiting the use of force, the taking of life, the eating of meat and drinking of wine.” The Rajputs viewed the daru-inspired release of emotions —notably sexual and aggressive impulses— as admirable. Rajput lore, as shared with Carstairs, glorified sexual and military conquests.
The priestly Brahmins, on the other hand, “were quite unanimous in reviling daru and all those who indulged in it. They described it as foul, polluting, carnal and destructive to that spark of Godhead which every man carries within him.” Bhang, a Brahmin told Carstairs, “gives good bhakti.” He defined bhakti as “emptying the mind of all worldly distractions and thinking only of God.”The Brahmin emphasis on self-denial includes “the avoidance of anger and or any other unseemly expression of personal feelings; abstinence from meat and alcohol is a prime essential.” Carstairs’s stated goal was to understand how the Brahmins could rationalize intoxicant use. He concluded:
“There are alternative ways of dealing with sexual and aggressive impulses besides repressing them and then ‘blowing them off’ in abreactive drinking bouts in which the superego is temporary dissolved in alcohol. The way which the Brahmins have selected consists in a playing down of all interpersonal relationships in obedience to a common, impersonal set of rules of Right Behavior. Not only feelings but also appetites are played down, as impediments to the one supreme end of union with God... Whereas the Rajput in his drinking bout knows that he is taking a holiday from his sober concerns, the Brahmin thinks of his intoxication with bhang as a flight not from but toward a more profound contact with reality.”
Two aspects of Carstair’s report resonate strongly with my own observations:
• The disinhibition achieved via alcohol is the
Rajput kind —a flight from reality, becoming “blotto”— whereas the disinhibition
achieved via cannabis is the result of focused or amplified contemplation.
Prohibition of marijuana, the intense advertising of alcohol, and its widespread availability encourage the adoption of alcohol as a drug of choice among U.S. adolescents.
It is likely that legal access to cannabis would result in fewer young adults adopting alcohol as their drug of choice, with positive consequences for the public health and countless individuals.
Ring Lardner, Jr., on Cannabis as a Substitute for Alcohol
Screenwriter Ring Lardner, Jr. won an Oscar
in 1938 for “Woman of the Year” and another in 1970 for “M*A*S*H.” His memoir
“I’d Hate Myself in the Morning” (which takes its title from his line to the
House Un-American Activities Committee) includes this description of his
colleagues Ian Hunter and Waldo Salt.
“Some years earlier, when the film community was still disproportionately Jewish, my good friend Paul Jarrico announced a discovery. He had been wondering why a small grup of his fellow screenwriters —Ian, Dalton Trumbo, Hugo Butler, Michael Wilson, and I— were such a close, cozy group. What bound us together, Paul reported, was the fact that we were all gentiles. ‘Nonsense,’ Ian declared, ‘It’s that we’re all drunks.’ Instantly, I knew he was right. It was by far the stronger bond.”