Welcome to the world wide web page of Tod H. Mikuriya, M.D.
for Alcoholism and Drug Dependence
By Tod H. Mikuriya, M.D. and Jerry Mandel, PhD.
1992, the senior author's medical practice has transitioned from medical
psychiatric in-patient consultation to seeing patients who need a physician's
recommendation in order to become a member of a cannabis club which sells
them marijuana, or to grow marijuana for their own personal use. These clubs
and personal marijuana gardens have been legal since the California Compassionate
Use Act of 1996, voter initiative Proposition 215, was approved by 55% of
the voters. By law, voter initiatives cannot be overturned by legislation
The senior author has seen over 6,500 patients
the past nine years, since the first cannabis center opened in San Francisco
in 1992. These patients are a great research resource in the study of medical
marijuana. Patients can be classified by disease classification, and seldom
analyzed conditions studied. Does cannabis influence a certain condition? In
what ways? Listen to the patients. Most are delighted to have a sympathetic
ear listen to the details.
There appears to be a pattern among our 104 patients - alcohol had long been a problem drug, and the resultant problems, even the wounds, were visible. Pain, depression, insomnia, are frequently mentioned; so, too, serious physical injuries, often committed under the influence. Serious health problems emerged at an early age. In this group of 104, cannabis replaced alcohol as the central drug focus, and life improved dramatically, healthwise to say the least. Like day for night.
104 "drug replacement" patients are fairly evenly dispersed throughout
the adult age range, with a median age of about 40..
AGE OF "CANNABIS AS DRUG THERAPY" PATIENTS
Drug Problems Start Early:
patients traced the cause of their own alcoholism back to their childhood.
The senior author was long ago impressed by these histories, and routinely
asks patients if their parents were alcoholics.
of the "cannabis substitution" cases were raised by at least
one alcoholic parent: Over
half those in the study group had one or two alcoholic parents; a few others
had a markedly mentally disturbed parent though not an alcoholic one.
1 or Both Parents Alcohol Abusers
No Alcoholic or Abusive Parent
Mentally Disturbed Not Alcoholic
No. of Patients
alcohol history not recorded for six patients.
pain - physical and psychological - with drugs, including marijuana, starts
early: A considerable number of problems emerge when these not-yet-alcoholic
children of alcoholics are very young. Often patients volunteer these early
histories as they connect directly with their current use of marijuana,
and the problems which cannabis alleviates.
suffered from migraines my entire life. A few years ago I got in a car accident.
I have been on Prozac, Paxil and Zoloft. Marijuana is the best treatment
I have found for my disorders. The prescribed drugs all had many adverse
effects on me, physically and mentally.
the ninth grade (about age 14 in the U.S.) I was prescribed Ritalin and Zoloft.
Ritalin caused me to be up all night; Zoloft made me sick to the stomach.
I usually have to drink some liquor to get to sleep. This is a bad thing
as I have now begun to drink excessive amounts of whisky. I feel malnourished
and weaker than a man in his twenties should be. . . not as strong as I used
to be. I also fear that I will, or am, an alcoholic and I do not want to
see myself turn into my dad.
a young age I was under mental evaluation with no luck. At 13, it (marijuana)
relieved feelings of anxiety and depression, subdued rage and anger, calmed
and relaxed, and controlled emotional pits.
depression has run in my family for generations, and cannabis is the only
thing I've found that keeps my spirits high. If I have a constant supply
of cannabis, alcohol is not consumed
lasting pain, can also come from other sources, like an accident. One patient's
alcoholism can be traced to a major accident he had at age 5, a result of
which is that he still has, and expects to forever have, pins in an ankle.
He found two drugs which eased the pain and enabled him to function: first
alcohol and, at age 16, marijuana.
Now, many years later:
use cannabis to prevent the abuse of alcohol. I'm unable to ease pain in
the ankle without herb, and drink when unable to have cannabis to smoke.
general condition we see is of a generational transmission of psychic pain.
Many have spoken of a lineage of great warriors or hunters; why not a lineage
of the vanquished? The condition for which marijuana seems to work so well
is deep-seated, existential, and, in many cases, transmitted as if by genes.
It is, though, a lineage that, for whatever cause, can also be joined. Others
can enter this secret order if, perchance, a core of pain enters a life .
. . like when a 5-year old's ankle gets permanently smashed in an auto accident.
A ruthless God as well as an abusive parent can grant admission to this eternal
Children of Alcoholics (ACA’s) have two strikes: direct emotional abuse and
or abandonment by parent(s); and lack of role models for coping with uncomfortable
feelings other than by inebriation. Cannabis provides control and relief
2. DRUG-RELATED PROBLEMS RELIEVED BY CANNABIS
the most common drug problem which cannabis replaces:
The drug which
caused the lion's share of problems among the 104 "drug replacement" patients
is alcohol. Over 90% were alcoholics, though a few, at times, were addicts
to heroin, cocaine, amphetamines, or some other drug. These bouts with non-alcoholic
drugs were viewed by older patients as youthful flings in a lifetime which,
until cannabis replaced alcohol, was increasingly dominated by alcohol problems.
In many patients there seemed to be a hard core of pain, marked by isolation,
a sense of being rejected, of not being in a place where people smile and
pleasures come easily and pain falls away. "Being," itself, is
not a secure calm resting place. One is out-of-synch with the universe, from
the inside out and vice-versa. Tamert and Mendelssohn summarize the psychophysiologic
“The anxiety reduction
model often utilized to explain initiation and perpetuation of episodic drinking
was found inadequate to explain motivation for alcohol use by 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, however, were poorly recalled by
the alcoholics following cessation of drinking.
Compulsive and constricted behavior patterns, which
were present during sobriety, changed markedly during intoxication, with increased
verbalization, varied expression of feelings, increased interaction, and frequent
behavioral regression. During inebriation, psychic defenses appeared weakened
with significant reduction of repression and reaction formation.” (Tamert and
when using alcohol, add to pain and the need for relief by drugs:
It still amazes the authors that so many of the ACA patients
take cannabis for the relief of continuous pain from damage incurred due
to behavior while intoxicated on alcohol. One patient who began the medicinal
use of marijuana very soon after he was, in his word, "T-Boned" in
an auto accident, still had "numbness in arms, fingers, (and) neck pain.
I use pot to relax my muscles and to not drink." Many patients report
that some of their pain is from injuries incurred when drunk - a mugging,
a barroom brawl, a night never recalled except for the pain. Even winning
can be losing, as physician notes record:
in a fight after consuming alcohol, resulted in staph infection of right
knuckle, minor surgery and 4 days in hospital.
they were sustained, an inordinately high number of injuries, often severe,
reported by the 104 patients studied, occurred while under the influence
of alcohol. Nearly 50% incurred serious damage from one or more drunken episodes.
The combination of frequent injury with major lasting damage attracts the
physician's interest. . . especially when relief is readily at hand.
Number of Patients
1. For 17 patients, this question was not asked, or there was no answer.
3. A CANNABIS-INFLUENCED LIFE-STYLE REPLACES ALCOHOLISM
At a certain point
in the lives of many of the 104 patients studied, self-medication with alcohol
failed to relieve the physical and psychic pain, and obviously and increasingly
had negative consequences. (van der Spuy 1972) Some, with previous experience
with marijuana, turn to it with a new determination, or desperation, to substitute
it for alcohol. Several patients had a sense marijuana could substitute for
alcohol shortly after they started using marijuana as teenagers or young
adults, but the illegal context of cannabis use led them to continue to rely
heavily on alcohol. Being able to obtain consistently high quality marijuana
in an open, safe, legal manner - a situation created, in California, with
the passage of Proposition 215 - made the substitution feasible. Others,
with little past experience with marijuana, heeded the suggestion of friends
and relatives, and unexpectedly found their alternative to alcoholism.
Prescribed medications often don't work, and have negative side effects:
patients, recognizing that alcohol fails to relieve their pains, sleeplessness,
depression and other symptoms, go to their doctor, even if, as one of the
104 cases put it:
don't like going to doctors; afraid I'll be diagnosed with something and
put on prescription drugs. I have trouble sleeping so use alcohol to allow
me to finally go to sleep. I otherwise lay awake and go crazy with fears,
anger, sadness. Cannabis helps me stay off harder drugs. Cigarettes, too.
pills prescribed by their physicians often did not work. The oldest among
the 104 patients - a 71 year old who did 150 pushups and 50 curls in the
morning - described how he came to marijuana:
psychiatrist told me my alcohol was killing me. He prescribed every kind
of tranquilizer possible and nothing worked. My niece (suggested) marijuana
to calm me down, and it worked like a miracle. Cannabis was the only thing
lot of times those prescribed pills had terrible side effects. And, so too,
the ones prescribed after that. One patient, who had an accident which injured
his skull, said the medications prescribed for him "made me paranoid
and mean." Another, with chronic back pain, commented:
hurt a lot more without cannabis, and can't function as well. It seems to
relax me so the medicines work better and faster. Additionally, cannabis
is natural, and all these other drugs - Vicodin, Soma, Aleve, Librium, Baclofen
- have lots of side effects.
drug sensitive and with histories of problem drinking, many patients returned
to alcohol if no prescribed drug would control underlying problems,. Maybe
they used a little pot, here and there, but essentially they turned to alcohol.
For the selected 104 patients, alcohol controlled something powerful and
unwanted, but as a way of life it was not sustainable. There was so much
alcohol, so many fights, so many scrapes and bruises, mental and physical,
that the alcohol and the scars built up, and if, God willing, they lived
long enough, new physical problems developed - with the liver, stomach, spine,
A cannabis regimen replaces alcoholism:
some point, many patients come to marijuana and find that they fit into two
life-styles; their central medical problems can be addressed in two very
different ways - an alcohol and a cannabis mediated style. A few statements
in the patient records show the contrast between the worlds.
of cannabis?) Stopped drinking. . . anger? Intermittent outbreaks, less severe;
paranoia is now mostly realism. Restarted walking my dogs, weight-lifting,
exercise, dance. I'm able to complete projects now.
depression my whole life. Years ago, I smoked marijuana and I could stay
off alcohol and could come out of my depression from it. I quit all the pills
(for depression) because they didn't work for me. Cannabis has helped me
with my depression better than I'd hoped. It sparked my creativity, released
the internal pressure caused by the anxiety of having no purpose. I don't
fight with my wife and I find it easier to handle my children.
has reduced my alcohol consumption by about 85%, and when this phase is over
I would like to reduce my cannabis consumption as well. I'm also interested
in other treatments for depression and anxiety.
does life look like after cannabis becomes part of the Daily Regimen? The
average amount smoked by the senior author's patients is 2 joints a day (assuming
7 joints per eighth of an ounce of high quality marijuana). Almost half the
104 cases smoke more than that. Many of these patients are self-medicated
as a rule, from not that late in the morning to not that early at night.
And they do it for years.
smoke continually with no apologies, no intention of quitting or even cutting
back. Several recall what happened when they quit, voluntarily or otherwise.
I quit using cannabis while I was in the army, and my drinking doubled. I was involved in several violent incidents due to alcohol and I was arrested. None of the problems (with violence and alcohol) occur while using cannabis. Not only does cannabis prevent my violent tendencies, it also keeps me from drinking.
eased, if not voided, my depression. I stopped drinking abruptly on receiving
my first marijuana, but resumed when my (cannabis club) card expired. This
treatment works for me. Only gains; no losses.
Marijuana simultaneously removes the craving for, & relieves the
symptoms masked by, alcohol:
will be interesting, as we gather more research information, to see how many
of the 104 patients, primarily ex-alcoholics, smoke marijuana only to relieve
pain, or induce and assist sleep, or calm the jitters, or break out of and
stay out of depression, as well as replace alcohol. . . and how many smoke
marijuana to do several of those things, as well as replace alcohol. Hardly another
drug touches so many aspects of disease concurrently as marijuana.
has allowed me to significantly lower my stress levels, which has directly
reduced my back problems and enabled me to make positive lifestyle changes
as well. I am focused more than before and have dropped excessive commitments
and projects from my agenda, reducing stress even more. A magical herb; the
best herbal therapy I've ever used.
greatly improved the pain in my back and consequently my sleeplessness, which
has been directly related to my desire to drink alcohol. I have not been
using alcohol to combat discomfort, physical or otherwise. As a result, I
have kept my motivational level up and have applied myself to school and
my life in general more than in past years.
4. HISTORICAL CASES: CANNABIS FOR ADDICTION IS LIKE DAY
FOR NIGHT. . . AND MISREAD FOR A CENTURY
substitution of marijuana for alcohol, the replacement of a life dominated
by one drug vs. the other, is conventionally and simplistically described
as just "one drug replacing another." Lives mediated by cannabis
or alcohol tend to run very different courses. The earliest description of
cannabis as therapy for addiction to other drugs in an English-language medical
journal, to our knowledge, captured the contrast between habitual alcohol,
opium and chloral use and subsequent long-term cannabis use. (Birch 1889)
The first patient:
. . could not live without chloral and he was utterly miserable. His depression
of spirits he described as being terrible; he had frequently contemplated
suicide; insomnia was almost complete. He agreed voluntarily to place himself
under circumstances which admitted of surveillance and restraint. His chloral
was peremptorily stopped, and he was prescribed a pill containing half a
grain of ext. cannabis ind. to be taken three times a day. The craving for
the chloral had almost vanished in twenty-four hours, natural sleep returned
after a few days. Eventually he returned to his home and work, a happy man;
but much disappointed because the name of the drug used was not communicated
second case, a most miserable object, intensely anaemic, and extremely emaciated
- an "exhumed corpse", suffering acute agony in every limb. His
liver and spleen were both materially enlarged. His history was shortly this.
. . . he became a confirmed and very excessive spirit drinker till, fearing
the consequences, he resolved to conquer the habit, and did so most thoroughly,
but with opium, Laudanum. His friends who had only just rescued him from
his isolated position, were quite hopeless of the possibility of recovery.
There was insomnia, anorexia, disordered bowels, conscious delusions. Again
cannabis - a quarter of a grain of the extract, gradually increasing to half
a grain, one grain, and one grain and a half three times a day, with the
happiest result. Ability to take food returned; an appetite appeared; 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.
after describing two extraordinary cases of cannabis, not just painlessly
detoxifying two hope-to-die drug habitués, but enabling and generating happy,
economically productive results, Birch threw away whatever impact he might
have had on the therapeutic use of cannabis1 by
giving equal weight to prevailing horrific myths about cannabis in contrast
to his own eye-witness experiences.
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. Hence the prescription should be made as complex as possible, and at the earliest moment the dose of the extract should be diminished gradually till eventually it is withdrawn altogether.
5. LATE 1960’s CASE: CANNABIS FOR ALCOHOLISM IS LIKE DAY FOR NIGHT
many authors recommended cannabis to relieve delirium tremens or the immediate
symptoms of drug detoxification prior to marijuana prohibition in the 1930’s,
nothing in the medical literature until the end of the 1960’s built upon
the two cases of long-term substitution reported by Birch. In 1970, Medical
Times published the senior author's notes of a patient who "when
she smoked marijuana she decreased her alcoholic intake." (Mikuriya
1970) The "Discussion" (the final two paragraphs) opened:
would appear that for selected alcoholics the substitution of smoked cannabis
for alcohol may be of marked rehabilitative value.
cannabis is not a panacea, but it warrants further clinical trial in selected
cases of alcoholism.
Since 1970, the medical literature on cannabis
sometimes noted that marijuana replaced alcohol abuse but, to our knowledge,
there were few descriptions of the long term replacement of alcoholism by
marijuana smoking. It has been a long time since federal funds were granted
research on the positive effects of smoked marijuana, if ever. Medical journals,
it seems to us, have had very few articles, ever, about smoked marijuana
as a substitute for alcoholism. The major National Commissions, governmental
and otherwise, and medical panels or collections of articles on marijuana,
haven’t been the forum for describing those alcoholics who find it in their
interests to replace alcohol with marijuana as their dominant mind altering
6. THE IMPLICATIONS OF THERAPEUTIC CANNABIS
the moralist sees abstinence as the only wise course in cases of debilitating
drug use, abstinence seems impossible for most of the 104 patients in our
study. Given the underlying problems of most of them, offering nothing -
abstinence - would be a violation of the Hippocratic Oath. When pain salvers
are around, "Do No Harm" means prescribing drugs.
from toxicity afforded by cannabis compared with alcohol is the simple physiologic
reality. The problematic biphasic chronic alcohol inebriation-withdrawal
cycle ceases with cannabis substitution. Sleep and appetite are restored,
ability to focus and concentrate is helped, energy and activity levels are
improved, pain and muscle spasms are relieved. Family and workplace relationships
are restored as long term goals replace crises and apologies. Sobriety through
cannabis substitution for some is not unrealistic. In providing a substitute
for alcoholism and other drug habits, cannabis restores normal physiologic
functioning of CNS, GI, hepatic, orthopedic, and endocrine systems.
has long been described as creating a unique dual consciousness, its users
simultaneously in and outside the "real world." Contrast this to
the world surrounding users of large amounts of alcohol. For many of the
patients in this study, the shift from alcohol to cannabis opened a new option
on what had been an intractable and worsening problem. In using cannabis
as a substitute for alcohol, the cumulated problems of a hard alcoholic life
did not disappear; but they could be seen and act upon from a distance,
and soberly. At minimum, more effective coping and control resulted from
cannabis substitution. Hope is restored with relief from chronic poisoning,
and a life line back to functionality and dreams replaces injuries and nightmares.
the senior author, as a physician, another duality regarding cannabis has
often become more important, urgent, and threatening than any caused by smoking
cannabis per se. That
duality is imposed by federal prohibitory laws. For physicians to alleviate
the problems that patients with long-standing alcoholism bring to them, is
to risk being defined and treated as a criminal. The commission of acts of
civil obedience under California law constitutes federal civil disobedience.
the experiences of alcoholics, described above, are not unique to the geographic
range of the author's medical practice, then there are tens of thousands
of persons in the U.S., alone, who could benefit from cannabis substitution
for alcoholism. Many patients remark that other physicians will not hear
of the curative value of cannabis for debilitating drug problems, or will
not recommend cannabis because of fears of legal repercussions. (Medicinal
marijuana is legal in California and seven other states in the U.S., but
it is illegal under federal law.) So, along with advocating drug treatment
instead of arrest, we urge the restoration of cannabis to our arsenal of
drug treatments. (Cannabis products were available from the middle 1840’s
through 1940.) To do otherwise is to concede victory to the dogmatic moralists’ dictation of
medical standards against the best interests of physicians and their patients.
Amer J Psychiat. 1971. Special Section Marijuana. 128(2):189-219
Birch, E.A.. 1889. The Use of Indian Hemp in the Treatment
of Chronic Chloral and Chronic Opium
Poisoning. Lancet i:625. (Reprtd
in T. Mikuriya, ed. 1973. Marijuana: Medical Papers 1839-1972,
Oakland, CA: Medi-Comp Press.)
Mikuriya, T. 1970. Cannabis Substitution: An Adjunctive
Therapeutic Tool in the Treatment of
Alcoholism. Med Times 98(4):187-191.
(Reprtd in T. Mikuriya, ed. 1973. Marijuana: Medical Papers
1839-1972, Oakland, CA: Medi-Comp
T. 2002. Cannabis an Easement;
a Proposed Unique Drug Category (in press) J. Cannabis Therapeutics
Tamert, J.S., Mendelssohn, J.H. 1969.
The Psychodynamics of Chronic Inebriation: Observation of
During the Process of Drinking in an Experimental Group Setting. Am J.
Van Der Spuy, H.I.J. 1972. Influence of Alcohol on
the Mood of the Alcoholic. Br J Addict 67:255-265.