235
Drug and Alcohol Dependence, 3 (1978) 235 - 241 @ Elsevier Sequoia S.A., Lausanne -Printed in the Netherlands
PSYCHOSOCIAL
R. RAY,
D. MOHAN,
Department (India) (Received
CORRELATES
G. G. PRABHU,
of Psychiatry, June 9, 1977;
OF CHRONIC
L. M. NATH
All India Institute accepted
February
CANNABIS
USE
and J. S. NEKI
of Medical Sciences,
New Delhi 110016
13,1978)
Summary The psychosocial effects of chronic heavy use of cannabis were studied in a rural population of males in north India. The user group comprised thirty persons who had been taking only cannabis at least 11 times a month over a period of five years or more. The controls were fifty subjects selected from among the general population to which the users belonged. The controls had not been using any drugs. The subjects had similar age distribution, occupation, socioeconomic status, and educational background. Psychosocial adaptation was assessed by enquiries into such areas as self-aspiration, present occupation, occupational satisfaction, marital status, marital relationships, sexual behaviour, self-reported deviant behaviour, and future planning for children. On no variable were the present users found to be different from the non -user control group.
Introduction The issue of adverse effects related to long-term cannabis use is of continuing concern. The distinctive feature of cannabis use in India has been its cultural sanction and association with social and religious activities [ 1, 21. Hence, India provides a fertile ground for testing various issues related to long-term cannabis use. One of the earliest enquiries related to adverse effects of long-term cannabis use noted that though it could intensify moral weakness (a value judgement) it caused no adverse sequel either to the individual or to society [3] . More recent studies from the West as well as from India have shown controversial results relating to adverse effects associated with long-term cannabis use. It has been suggested that chronic cannabis users demonstrated social decay, loss of effective functioning and low productivity [4 - lo] . An amotivational syndrome following cannabis use, although reversible, has been reported by Kolansky and Moore [ll] and Sharma [12]. Other studies have shown no adverse sequel [13 - 161.
236
The present study attempted to explore the issue of adverse aftereffects associated with long-term cannabis use by employing a slightly different approach in terms of selection of controls. Long-term cannabis users were compared with non-users from a representative sample of the same population to which the users belonged. The psychosocial sequels were assessed against the broader level of functioning of the control group rather than that of matched individuals. The present communication is part of a larger study which also focused on cognitive deficits associated with longterm cannabis use and social perception of cannabis use,
Method Definition of terms. Cannabis use means ingestion of either bhang (a concoction made with cannabis leaves), ganja (dried flowering tops), charas (hashish) or sulfa. Chronic cannabis users were defined by the following criteria: duration of use - 5 years or more; frequency of use - minimum of 11 times per month to once daily or more [ 131 . Sample. The subjects were selected from one of the three primary health centres run by the All India Institute of Medical Sciences. The users and non-users were from the same general population and consisted of males of 25 - 50 years of age who were carefully screened to exclude people with defective cognitive functions due to any prior physical illness not related to cannabis use. The non-users were totally abstinent. Tobacco smoking was not considered in either of the groups. Thirty cannabis users were selected according to the above criteria with the help of the Primary Health Center staff and villagers, and also by contact tracing. The first author made “non-participant” observations in the area for the duration of the study. Since cannabis smoking was a group activity, cross-validation of duration and pattern of use was possible. Otherwise the users were self-defined. The fifty non-users were also selected from the same caste group as the users, by systematic sampling with a random start of the houses in the village. The individuals selected were approached for their consent. The refusal rate was minimal. The subjects were interviewed with the help of a semi-structured schedule to study various aspects of cannabis use in relation to family life and psychosocial adaptation. A clinical examination was carried out to detect any physical or psychiatric abnormality. A set of psychological tests was administered to assess their cognitive functions (to be reported separately). Observations. Sixty-six per cent of the users and sixty-four per cent of the non-users belonged to the age group 25 - 35 years. The oldest person in either group was 46 years. Both groups were comparable in respect of educa-
237
tion and socioeconomic status as judged on a scale developed for rural populations [ 171 . Twenty-five per cent of each group were illiterate. In fact, the highest educational status was seen in the user group, though the difference in educational status was not significant. The users and non-users had the same occupation, largely farming (Table 1). Seventy per cent of the subjects in either group were satisfied with their current occupation. TABLE
1
Occupation Occupation
Service Cultivation Petty employment Trade/small business Unemployed
User
Non-user -_
N
%
N
%
21 9 -
70 30
1 40 7 1 1
2 80 14 2 2
-
Characteristics of drug use. Table 2 shows that almost half of the current users were taking both ganja and bhang. The group had been using predominantly cannabis as the sole drug. Sixty per cent of the users had also been consuming alcohol occasionally, none exceeding 3 - 4 times per month. Sixty per cent had their first exposure to cannabis at the age of 15 - 20 years (Table 3). The frequency of drug use did not correlate with the duration of use (Table 4). Half of the users reported that the drug did not effect their job efficiency and one-third reported increased efficiency. One-third of the users reported increased libido and better performance assigned to the effects of cannabis. Eighty-three per cent of the users felt that the drug was in no way (physically, mentally, socially, or economically) harmful and that they were not dependent on it. Family history. On detailed enquiry about the family history of drug use and other mental illness it was observed that an equal number of family TABLE
2
Current
drug used
Drugs used
N
Ganja and bhang Ganja Ganja and charas Ganja, bhang and charas No drug at present
13 7 3 4 3
238 TABLE
3
Age of first experience Age range (years)
N
15 - 20 21 - 25 26 - 30 31- 35
18 I 4 1
TABLE
4
Frequency Duration (years )
57 8 - 10 ll13 14 - 16
and duration
of use
Frequency
month
11 - 15 times/
16 - 20 times/ month
21 - 30 times/ month
Over 30 times/ month
N
N
N
N
4 1 -
6 1 -
2 2 -
4 5 1 4
members in each group had a history of drug use (20%) and mental illness (23%). Regarding parental deprivation by the age of fifteen years, the user group (23%) did not differ much from the non-user group (30%). Twentyeight users (93%) and forty-three non-users (86%) were married. The current family (marital) maladjustment was more among users (16% among users compared with none among non-users). Personal history. The two groups did not differ significantly in their educational history reflected in failure in school. The future planning aspiration level for children and level of self-aspiration (Table 5) among users was not different from that among the non-users. The two groups did not show any difference in self-reported deviant behaviour (Table 6). There were no significant differences between the two groups regarding pre-marital and extra-marital heterosexual relationships. There was no clear preponderance of psychotic features among the users (Table 7). Both the users and non-users had been physically healthy, as indicated by their past and present medical history. The most frequent sign detected among the users was bilateral conjunctival congestion. No major physical illness was detected on clinical examination.
239 TABLE
5
Aspiration
(self) User
Response
Non-user
N
%
N
Nothing as such Fate/God’s grace
4 3
13 10
-
Petty employee in factory Petty employee in Govt. office/bank Professional wrestler Cultivator Jawan/police constable Army/police officers Teacher Government officer Political leader Medical/legal/engineering professions
3 3 4 9 2
10 10 13 30 7 3 3 -
TABLE
6
Deviant
behaviour
User
Nil Quarrel resulting In police custody In police custody In police custody
Mental
5
10 -
8 4 2 10 14
16 8 4 20 28
3 1 1 2
6 2 2 4
(self-reported)
Response
TABLE
1 1 -
%
in physical injury for less than 24 h for 1 - 7 days for more than 1 year
Non-user
N
%
N
%
21 5 3 2 1
70 17
39 10 5 -
78 20
7 status
examination User
Anxiety neurosis Simple schizophrenia Loss of interest with excessive religiosity Excessive religiosity, grandiosity
Non-user
N
%-
N
%
4 1 1 1
13 3 3 3
1 1 -
2 2 -
Discussion In the present study the long-term cannabis users were indistinguishable from non-users on any of the sociodemographic correlates studied. The rela-
240
tionship between cannabis use and occupation is difficult to judge in the rural Indian context because most of the people are employed in agriculture which provides seasonal employment. Additional opportunities for regular employment are limited, hence it is difficult to assess the decline (if any) associated with long-term cannabis use. Only five of the thirty users reported decreased efficiency following drug use. Deviant asocial or antisocial behaviour was not preponderant among the users, tending to confirm the belief prevalent in the literature that cannabis use per se does not lead to deviant behaviour. It seems that family life disturbance was more pronounced among the users. This has also been reported by Mehndiratta and Wig [lo] . Marital maladjustment as reported may reflect a basic disapproval by the spouse of a habit which would keep the husband away from home on a regular basis. All users considered the use of the drug desirable, which was further confirmed by the close relatives of the drug users. Similar observations were made by Hochman and Brill [18] and by Fisher and Steckler [19] . There was no definite sign of poor nutritional status or emaciation among the users as compared to the non-users. This may be due to the fact that 80% of both groups belonged to the middle class and not to the extreme poverty stricken class. It appears that there is no cause and effect relationship between longterm cannabis use and decline in the level of social functioning. It is possible that such a decline when observed may be related to other factors such as poor motivation or poor adaptive capacity rather than to drug use alone, as was suggested by Hochman and Brill [18] .
References 1 WHO Scientific Group, The use of cannabis, World Health Organization, Rep. Ser. No. 478 (1971). 2 P. Wahi, Seminar on long term effectsof cannabis use in India, ICMR, New Delhi, 1972. 3 0. J. Kalant, Report of the Indian Hemp Drug Commission, 1893 - 94. A critical review. Int. J. Addictions, 7 (1972) 77. 4 J. E. Dhunjibhoy, A brief resume of the types of insanity commonly met with in India with full description of “Indian Hemp Insanity” peculiar to the country. J. Mental Sci., 312 (1930) 254. 5 M. I. Soueif, Hashish consumption in Egypt with special reference to psychosocial aspects. Bull. Narcotics, 19 (1967) 1. 6 A. Lewis, Cannabis: A Review of International Clinical Literature, submitted to Advisory Committee on Drug Dependence, Her Majesty’s Stationery Office, London, 1968. 7 W. H. MacGlothin and L. J. West, The marihuana problem: an overview. Amer. J. Psychiat., 125 (1968) 370. 8 F. S. Tennant, Jr. and C. J. Grossbeck, Psychiatric effect of hashish. Arch. Gen. Psychiat., 27 (1972) 133. 9 G. S. Chopra, Studies on psycho-clinical aspects of long term marihuana use in 124 cases. Int. J. Addictions, 8 (1973) 1015.
241 10
11 12 13
14 15
16 17 18 19
S. S. Mehndiratta and N. N. Wig, Psychosocial effects of long term cannabis use in India. A study of fifty heavy users and controls. Drug Ale. Dependence, 1 (1975/ 76) 71. H. Kolansky and W. T. Moore, Toxic effects of chronic marihuana use. J. Amer. Med. Ass., 222 (1972) 35. B. P. Sharma, Cannabis and its use in Nepal. Brit. J. Psychiat., 127 (1975) 550. National Commission on Marihuana and Drug Abuse, First Report: Marihuana, a Signal of Misunderstanding, U.S. Government Printing office, Washington, D.C., 1972. M. H. Beaubrun and F. Knight, Psychiatric assessment of 30 chronic users of cannabis and 30 matched controls, Amer. J. Psychiat., 130 (1973) 309. M. Bowman and R. 0. Pohl, Cannabis-psychological effects of chronic heavy use. A controlled study of intellectual functioning of chronic heavy users of high potency cannabis. Psychopharmacologia, 29 (1973) 159. N. Q. Brill and R. L. Christie, Marihuana and psychosocial adaptation. Follow up study of a collegiate population. Arch. Gen. Psychiat., 31 (1974) 713. U. Pareck and G. Trivedi, Manual of Socioeconomic Status Scale (Rural), Manasyan, Delhi. J. S. Hochman and N. Q. Brill, Chronic marijuana use and psychosocial adaptation. Amer. J. Psychiat., 130 (1973) 132. G. Fisher and A. Steckler, Psychological effects, personality and behavioural changes attributed to marihuana use, Int. J. Addictions, 9 (1974) 101.
Drug and Alcohol Dependence, 3 (1978) 235 - 241 @ Elsevier Sequoia S.A., Lausanne -Printed in the Netherlands
PSYCHOSOCIAL
R. RAY,
D. MOHAN,
Department (India) (Received
CORRELATES
G. G. PRABHU,
of Psychiatry, June 9, 1977;
OF CHRONIC
L. M. NATH
All India Institute accepted
February
CANNABIS
USE
and J. S. NEKI
of Medical Sciences,
New Delhi 110016
13,1978)
Summary The psychosocial effects of chronic heavy use of cannabis were studied in a rural population of males in north India. The user group comprised thirty persons who had been taking only cannabis at least 11 times a month over a period of five years or more. The controls were fifty subjects selected from among the general population to which the users belonged. The controls had not been using any drugs. The subjects had similar age distribution, occupation, socioeconomic status, and educational background. Psychosocial adaptation was assessed by enquiries into such areas as self-aspiration, present occupation, occupational satisfaction, marital status, marital relationships, sexual behaviour, self-reported deviant behaviour, and future planning for children. On no variable were the present users found to be different from the non -user control group.
Introduction The issue of adverse effects related to long-term cannabis use is of continuing concern. The distinctive feature of cannabis use in India has been its cultural sanction and association with social and religious activities [ 1, 21. Hence, India provides a fertile ground for testing various issues related to long-term cannabis use. One of the earliest enquiries related to adverse effects of long-term cannabis use noted that though it could intensify moral weakness (a value judgement) it caused no adverse sequel either to the individual or to society [3] . More recent studies from the West as well as from India have shown controversial results relating to adverse effects associated with long-term cannabis use. It has been suggested that chronic cannabis users demonstrated social decay, loss of effective functioning and low productivity [4 - lo] . An amotivational syndrome following cannabis use, although reversible, has been reported by Kolansky and Moore [ll] and Sharma [12]. Other studies have shown no adverse sequel [13 - 161.
236
The present study attempted to explore the issue of adverse aftereffects associated with long-term cannabis use by employing a slightly different approach in terms of selection of controls. Long-term cannabis users were compared with non-users from a representative sample of the same population to which the users belonged. The psychosocial sequels were assessed against the broader level of functioning of the control group rather than that of matched individuals. The present communication is part of a larger study which also focused on cognitive deficits associated with longterm cannabis use and social perception of cannabis use,
Method Definition of terms. Cannabis use means ingestion of either bhang (a concoction made with cannabis leaves), ganja (dried flowering tops), charas (hashish) or sulfa. Chronic cannabis users were defined by the following criteria: duration of use - 5 years or more; frequency of use - minimum of 11 times per month to once daily or more [ 131 . Sample. The subjects were selected from one of the three primary health centres run by the All India Institute of Medical Sciences. The users and non-users were from the same general population and consisted of males of 25 - 50 years of age who were carefully screened to exclude people with defective cognitive functions due to any prior physical illness not related to cannabis use. The non-users were totally abstinent. Tobacco smoking was not considered in either of the groups. Thirty cannabis users were selected according to the above criteria with the help of the Primary Health Center staff and villagers, and also by contact tracing. The first author made “non-participant” observations in the area for the duration of the study. Since cannabis smoking was a group activity, cross-validation of duration and pattern of use was possible. Otherwise the users were self-defined. The fifty non-users were also selected from the same caste group as the users, by systematic sampling with a random start of the houses in the village. The individuals selected were approached for their consent. The refusal rate was minimal. The subjects were interviewed with the help of a semi-structured schedule to study various aspects of cannabis use in relation to family life and psychosocial adaptation. A clinical examination was carried out to detect any physical or psychiatric abnormality. A set of psychological tests was administered to assess their cognitive functions (to be reported separately). Observations. Sixty-six per cent of the users and sixty-four per cent of the non-users belonged to the age group 25 - 35 years. The oldest person in either group was 46 years. Both groups were comparable in respect of educa-
237
tion and socioeconomic status as judged on a scale developed for rural populations [ 171 . Twenty-five per cent of each group were illiterate. In fact, the highest educational status was seen in the user group, though the difference in educational status was not significant. The users and non-users had the same occupation, largely farming (Table 1). Seventy per cent of the subjects in either group were satisfied with their current occupation. TABLE
1
Occupation Occupation
Service Cultivation Petty employment Trade/small business Unemployed
User
Non-user -_
N
%
N
%
21 9 -
70 30
1 40 7 1 1
2 80 14 2 2
-
Characteristics of drug use. Table 2 shows that almost half of the current users were taking both ganja and bhang. The group had been using predominantly cannabis as the sole drug. Sixty per cent of the users had also been consuming alcohol occasionally, none exceeding 3 - 4 times per month. Sixty per cent had their first exposure to cannabis at the age of 15 - 20 years (Table 3). The frequency of drug use did not correlate with the duration of use (Table 4). Half of the users reported that the drug did not effect their job efficiency and one-third reported increased efficiency. One-third of the users reported increased libido and better performance assigned to the effects of cannabis. Eighty-three per cent of the users felt that the drug was in no way (physically, mentally, socially, or economically) harmful and that they were not dependent on it. Family history. On detailed enquiry about the family history of drug use and other mental illness it was observed that an equal number of family TABLE
2
Current
drug used
Drugs used
N
Ganja and bhang Ganja Ganja and charas Ganja, bhang and charas No drug at present
13 7 3 4 3
238 TABLE
3
Age of first experience Age range (years)
N
15 - 20 21 - 25 26 - 30 31- 35
18 I 4 1
TABLE
4
Frequency Duration (years )
57 8 - 10 ll13 14 - 16
and duration
of use
Frequency
month
11 - 15 times/
16 - 20 times/ month
21 - 30 times/ month
Over 30 times/ month
N
N
N
N
4 1 -
6 1 -
2 2 -
4 5 1 4
members in each group had a history of drug use (20%) and mental illness (23%). Regarding parental deprivation by the age of fifteen years, the user group (23%) did not differ much from the non-user group (30%). Twentyeight users (93%) and forty-three non-users (86%) were married. The current family (marital) maladjustment was more among users (16% among users compared with none among non-users). Personal history. The two groups did not differ significantly in their educational history reflected in failure in school. The future planning aspiration level for children and level of self-aspiration (Table 5) among users was not different from that among the non-users. The two groups did not show any difference in self-reported deviant behaviour (Table 6). There were no significant differences between the two groups regarding pre-marital and extra-marital heterosexual relationships. There was no clear preponderance of psychotic features among the users (Table 7). Both the users and non-users had been physically healthy, as indicated by their past and present medical history. The most frequent sign detected among the users was bilateral conjunctival congestion. No major physical illness was detected on clinical examination.
239 TABLE
5
Aspiration
(self) User
Response
Non-user
N
%
N
Nothing as such Fate/God’s grace
4 3
13 10
-
Petty employee in factory Petty employee in Govt. office/bank Professional wrestler Cultivator Jawan/police constable Army/police officers Teacher Government officer Political leader Medical/legal/engineering professions
3 3 4 9 2
10 10 13 30 7 3 3 -
TABLE
6
Deviant
behaviour
User
Nil Quarrel resulting In police custody In police custody In police custody
Mental
5
10 -
8 4 2 10 14
16 8 4 20 28
3 1 1 2
6 2 2 4
(self-reported)
Response
TABLE
1 1 -
%
in physical injury for less than 24 h for 1 - 7 days for more than 1 year
Non-user
N
%
N
%
21 5 3 2 1
70 17
39 10 5 -
78 20
7 status
examination User
Anxiety neurosis Simple schizophrenia Loss of interest with excessive religiosity Excessive religiosity, grandiosity
Non-user
N
%-
N
%
4 1 1 1
13 3 3 3
1 1 -
2 2 -
Discussion In the present study the long-term cannabis users were indistinguishable from non-users on any of the sociodemographic correlates studied. The rela-
240
tionship between cannabis use and occupation is difficult to judge in the rural Indian context because most of the people are employed in agriculture which provides seasonal employment. Additional opportunities for regular employment are limited, hence it is difficult to assess the decline (if any) associated with long-term cannabis use. Only five of the thirty users reported decreased efficiency following drug use. Deviant asocial or antisocial behaviour was not preponderant among the users, tending to confirm the belief prevalent in the literature that cannabis use per se does not lead to deviant behaviour. It seems that family life disturbance was more pronounced among the users. This has also been reported by Mehndiratta and Wig [lo] . Marital maladjustment as reported may reflect a basic disapproval by the spouse of a habit which would keep the husband away from home on a regular basis. All users considered the use of the drug desirable, which was further confirmed by the close relatives of the drug users. Similar observations were made by Hochman and Brill [18] and by Fisher and Steckler [19] . There was no definite sign of poor nutritional status or emaciation among the users as compared to the non-users. This may be due to the fact that 80% of both groups belonged to the middle class and not to the extreme poverty stricken class. It appears that there is no cause and effect relationship between longterm cannabis use and decline in the level of social functioning. It is possible that such a decline when observed may be related to other factors such as poor motivation or poor adaptive capacity rather than to drug use alone, as was suggested by Hochman and Brill [18] .
References 1 WHO Scientific Group, The use of cannabis, World Health Organization, Rep. Ser. No. 478 (1971). 2 P. Wahi, Seminar on long term effectsof cannabis use in India, ICMR, New Delhi, 1972. 3 0. J. Kalant, Report of the Indian Hemp Drug Commission, 1893 - 94. A critical review. Int. J. Addictions, 7 (1972) 77. 4 J. E. Dhunjibhoy, A brief resume of the types of insanity commonly met with in India with full description of “Indian Hemp Insanity” peculiar to the country. J. Mental Sci., 312 (1930) 254. 5 M. I. Soueif, Hashish consumption in Egypt with special reference to psychosocial aspects. Bull. Narcotics, 19 (1967) 1. 6 A. Lewis, Cannabis: A Review of International Clinical Literature, submitted to Advisory Committee on Drug Dependence, Her Majesty’s Stationery Office, London, 1968. 7 W. H. MacGlothin and L. J. West, The marihuana problem: an overview. Amer. J. Psychiat., 125 (1968) 370. 8 F. S. Tennant, Jr. and C. J. Grossbeck, Psychiatric effect of hashish. Arch. Gen. Psychiat., 27 (1972) 133. 9 G. S. Chopra, Studies on psycho-clinical aspects of long term marihuana use in 124 cases. Int. J. Addictions, 8 (1973) 1015.
241 10
11 12 13
14 15
16 17 18 19
S. S. Mehndiratta and N. N. Wig, Psychosocial effects of long term cannabis use in India. A study of fifty heavy users and controls. Drug Ale. Dependence, 1 (1975/ 76) 71. H. Kolansky and W. T. Moore, Toxic effects of chronic marihuana use. J. Amer. Med. Ass., 222 (1972) 35. B. P. Sharma, Cannabis and its use in Nepal. Brit. J. Psychiat., 127 (1975) 550. National Commission on Marihuana and Drug Abuse, First Report: Marihuana, a Signal of Misunderstanding, U.S. Government Printing office, Washington, D.C., 1972. M. H. Beaubrun and F. Knight, Psychiatric assessment of 30 chronic users of cannabis and 30 matched controls, Amer. J. Psychiat., 130 (1973) 309. M. Bowman and R. 0. Pohl, Cannabis-psychological effects of chronic heavy use. A controlled study of intellectual functioning of chronic heavy users of high potency cannabis. Psychopharmacologia, 29 (1973) 159. N. Q. Brill and R. L. Christie, Marihuana and psychosocial adaptation. Follow up study of a collegiate population. Arch. Gen. Psychiat., 31 (1974) 713. U. Pareck and G. Trivedi, Manual of Socioeconomic Status Scale (Rural), Manasyan, Delhi. J. S. Hochman and N. Q. Brill, Chronic marijuana use and psychosocial adaptation. Amer. J. Psychiat., 130 (1973) 132. G. Fisher and A. Steckler, Psychological effects, personality and behavioural changes attributed to marihuana use, Int. J. Addictions, 9 (1974) 101.
