water, unemployment is rife, and crime, poverty andhomelessness are a reality in our daily life." The perceptionthat the government or the ANC should solve all the problemsis misplaced. These are complex national problems broughtabout by decades of deliberate and systematic neglect. Forthese problems to be addressed effectively we require jointeffort by all stakeholders including tertiary institutions.]

Clearly the situation as it exists cannot be allowed tocontinue. Not only should we begin to change norms andvalues within these institutions, but there is also an urgentneed to change their human character, such that they beginto reflect the demographic nature of our society. In so doingI believe we shall see the process of democratisation andlegitimisation take root within these institutions, and they willbecome true people's institutions. It is my sincere belief thatonce this foundation has been successfully laid, we shallbegin to see emerging from these institutions diplomatesand graduates with a sense of community consciousness.'So too shall we start to see a change in research prioritiessuch that academic research is geared towards addressingthe real needs of our people.

If the American 'project 3000 by the year 2000' is anythingto go by, perhaps our tertiary institutions have a lesson tolearn from the Americans." (This project is an initiative of theAssociation of American Medical Colleges. Its goal is toenroll 3 000 students from under-represented minoritygroups annually in US medical schools by the year 2000.It is essentially an acknowledgement of racial imbalancesbrought about by past policies and a commitment to redressthem.) After all, our standing in the world community ofnations will be judged less by our ability to master the art ofscience than by our determination to address the basicneeds of all our people effectively.

M. R. NethonondaArgyle Clinic5th floor Baker HouseHospital HillBraamfonteinJohannesburg

1. Soni PN. Academic health complexes - ivory towers or national resources?S Atr Med J 1993; 83: 464-465.

2. Zwi AB. The introverted medical school - time to rethink medical education.S Atr Med J 1994; 84: 424-426.

3. Nightingale EO, Hannibal K. Geiger J, Hartmann L, Lawarence R, Spurlock J.Apartheid medicine - health and human rights in South Africa. JAMA 1990; 264:2097-2102.

4. Van Rensburg HCJ. The legacy of apartheid in health and health care. S Atr JSocio/1993; 24: 99-111.

5. Benatar SA. Medicine and health care in South Africa. N £ngl J Med 1986; 315:527-532.

6. Vach D. Towards health for all South Africans. S Afr Med J 1994; 84: 250-253.7. Klugman KP. Centres of excellence for academic medicine in South Africa

(Letter). S Afr Med J 1994; 84: 44.8. Nickens HW. Project 3000 by 2000 - racial and ethnic diversity in US medical

schools. N £ng/ J Med 1994; 331: 472-476.

GREAT DEBATES

Cannabis sativa - a pleafor decriminalisationDagga (marihuana, ganja (the 'holy weed' of theRastafarians), bhang, hashish, etc.) is the psycho-activeingredient obtained from the enVironment-friendly hempplant, Cannabis sativa. It has been used for centuries too.induce happiness, relieve suffering and promote spirituality.In the 19th and early 20th centuries it was frequentlyprescribed by Western medical practitioners for 'nervousailments'. Its use in Western countries has been banned forabout 60 years, but it remains the most widely used;illicitrecreational drug in the world. An earlier (1920 - 1933)attempt by the USA to prohibit the use of alcohol also failed.The predictable result of such ill-conceived legislatiQn is thecreation of criminal drug trafficking. .

The most psycho-actively potent of the more than 60known cannabinoids in the hemp plant istetrahydrocannibinol (THC). This highly lipophilic substancewas first isolated and synthesised in 1964' and, unlike thewhole plant extract, has been extensively studied inpharmacological laboratories. During the last 7 years theexistence of a natural cannabinoid system in the brain hasbeen firmly established! This discovery is of greatneurophysiological interest and may help to elucidate someof the enigmatic aspects of cerebral functioning. Thepresence of abundant cannabinoid reeeptors in the limbicsystem, for instance, is compatible with the fact thatcannabis affects predominantly mood, memory andperception. A striking recent finding3 has been the virtualabsence of cannabinoid receptors in the substantia nigra ofsome patients with Huntington's chorea. This may eventuallylead to effective treatment of the involuntary movementdisorders which are currently intractable to conventionaldrug treatment.

Cannabis, like all intoxicants, obviously causes an acuteencephalopathy, the manifestations of which vary accordingto the potency of the drug. D~gga (marihuana) provokesmild and hashish severe intoxication. Mild intoxicationcannot be detected by observers unless the characteristicdefect in short-term memory retention is specificallysought.'·s Allied to this is an alteration of time sense;seconds are perceived as an eternity. The subject iseuphoric and the pulse rate is increased. Some subjectsbecome very anxious as they become aware of weakeningof their ego defences."

Severe intoxication augments these effects, and ahypomanic state may develop.] A suba.clJte encephalopathyreSUlting from regular excessive use has been described."A study of American soldiers based in West Germanyidentified a group of 110 men dubbed 'hashoholics' who .were using over 50 g a month of Lebanese hashish with thephenomenally high THC content of 5 - 10%; dagga containsabout 1%. Nine of them were studied before, during andafter 2 - 3 months' smoking of 50 - 250 g of hashish amonth. The period of observation was 2 years. Six becamesymptom-free within 4 - 5 weeks of discontinuing hashishabuse, but 3 had intermittent residual symptoms for several

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EDITORIAL

months. The Iipophilicity of THC accounts for its delayedexcretion.

Some observers have reported that cannabis can cause achronic irreversible encephalopathy, but a recent review ofthe literatureS has not substantiated this. Studies ofcommunities where the use of cannabis is endemic have notshown any convincing evidence that it causes intellectualdecline.'°It should be remembered, however, that youngpeople who abuse cannabis for prolonged periods duringcritical periods of learning may jeopardise their emotionaland cognitive maturation.

There have been many claims" for the therapeutic efficacyof cannabis, and it is reputed to be used in a wide variety oftraditional medicines in South Africa. Currently great interestis being shown in its effect in reducing the nausea andvomiting that almost invariably accompany chemotherapy.It is claimed to be more efficacious and a great deal cheaperthan orthodox medication, which also has the disadvantageof having to be administered orally or by injection. Appetitepromotion and weight gain have been reported in patientswith AIDS. It has been shown to be a useful adjunct toconventional anticonvulsant therapy in temporal lobeepilepsy, which is notoriously difficult to control. Itsanalgesic and hypnotic effects have frequently been cited.It can reduce intra-ocular pressure in glaucoma. It has localantibacterial action. Some chronic asthmatics reportdramatic relief from bronchospasm. It diminishes spasticityand tremor in some cases of multiple sclerosis.

The effect of cannabis in improving mood may make it auseful antidepressant. Some schizophrenic patients claimrelief of 'negative' symptoms from its use. Contrary topopular belief it does not cause violence but, if used in pureform, reduces violence and may prove of value in controllingthose unfortunate patients who suffer from rage attacks andepisodic dyscontrol.

Careful, well-controlled studies of cannabis have beenmuch hampered by legislation prohibiting its use. SurelySouth Africa should follow the example of Australia, whichhas recently decriminalised it for medical use. The facts, asopposed to myths, can only be established by well­controlled scientific study.

Fances R. AmesGaylands7 Locarno RoadRondeboschCape Town

1. Gaoni Y, Mechoulam R. Isolation, structure and partial synthesis of an activeconstituent of hashish. J Am Chemistry Sac 1964; 86: 1646-1648.

2. Devane WA, Hanus L, Breuer A. et al. Isolation and structure of a brain constituentthat binds to the cannabinoid receptor. Science 1992; 258: 1946-1949.

3. Glass M, Faull RLM, Dragunow M. Loss of cannabinoid receptors in the substantianigra in Huntington's disease. Neuroscience 1993; 56: 523-527.

4. WeB AT, Zinberg NE. Acute effects of marijuana on speech. Nature 1969; 222:434-437.

5. Zimmerberg 8, Glick SO, Jarvik ME. Impairment of recent memory by marihuanaand THe in rhesus monkeys. Nature 1971; 233: 343-345.

6. Ames F. A clinical and metabolic study of acute intoxication with Cannabis sativaand its role in the model psychoses. J Ment $ci 1958; 104: 972-999.

7. Rottanburg 0, Robbins AH, Ben-Arie 0, Teggin A, Elk A. Cannabis-associatedpsychosis with hypomanic features. Lancet 1982; 2: 1364-1366. .

8. Tennant TS, Groesbeck CJ. Psychiatric 'effects of hashish'. Arch Gen Psychiatry1972; 27: 133-136.

9. Hollister LE. Cannabis. Acta Psychiatr Scand 1988; 78: 108-118.10. Schaeffer J, Andrysiak T, Ungerleider JT. Cognition and long term use of ganja

(Cannabis). Science 1981; 213: 465-466.11. Grinspoon L, Bakalar JB. Marihuana, the Forbidden Medicine. New Haven, Conn.:

Yale University Press, 1993.

Cannabis sativa ­'deceptive weed'?1Drugs that affect behaviour have been known sinceantiquity. Various 'fashionable' substances are used indifferent age or socio-economic groups, dagga being onesuch among adolescents. Only in relatively recent yearshave the serious social and medical consequences of drugabuse and the resulting drug dependence been widelyrecognised. The drug abuse problem is becomingincreasingly complex and no simple solution is possible.Cannabis abuse is no different.

Cannabis (dagga) is a hallucinogen. The derivatives ofCannabis sativa owe their intoxicating properties to apsycho-active substance, delta-9-tetrahydrocannibinol(THC). The concentrations vary widely, and this may explainthe variety of effects reported. The very high fat solUbilityresults in persistence of the metabolites and the potential foraccumulation with regular use. With the use of cannabis, itsdose cannot easily be established owing to amounts usedand varying potency of the materials consumed. It is alsoalmost inevitable that the drug will not be taken by itself.Often the cannabis abuser finds it necessary to mix the drugwith other substances, including nicotine or methaqualone(Mandrax), which have powerful effects on their own andextreme effects in combination. This combination with otherpreparations is presenting a whole new range of problems(particularly with Mandrax) on the contemporary scene.

As far back as 2700 BC cannabis was known to theChinese and recommended for various uses. It has beencultivated as a drug for many centuries and in Arabia isknown as 'hashish', which is said to have given rise to theword 'assassin' - stemming from a murder reported byMarco Polo to have been committed under the influence ofthe drug.

Suggestions that cannabis may have a place in thepractice of modern medicine are frequently offered andinvestigated but should be approached with caution, in viewof inadequate research and contraindications due to variousand significant side-effects. The notion that cannabis isharmless has enjoyed a high degree of acceptability in thepast, with only a minimum of scientific support. It has nowbeen suggested that 'the grass may no longer be greener'.'Several respected groups and many individuals have in thepast advocated delegislation of cannabis on the basis thatsmall amounts may not be hanmful. At least some of theseindividuals seem to have ignored the evidence availablefrom clinical practice. In the past few years, evidence hasaccumulated to suggest considerable potential hazards ofcannabis in its various forms. That is not to say that onejoint of dagga, or even a few joints, will definitely causesignificant harm - the chances are that it will not. Theeffects of cannabis are cumulative and dose-related, andprolonged heavy use or less frequent use of a more potentpreparation are associated with many different problems.

Cannabis may be described as having immediate or latereffects.3 Acute effects are experienced most quickly when itis smoked. Smoking brings on intoxication of short duration.The degree of intoxication depends on the dose taken, theindividual characteristics of the user, the social culture and

SAMJ Volllme 85 No. /2 December 1995 1269

the circumstances under which it is taken. The mentaleffects described include a feeling of euphoria, exultationand a dreamy sensation accompanied by a free flow ofideas. Senses of time, distance, vision and hearing aredistorted. Sometimes panic and fear are experienced.Hallucinations develop with large doses. In the company ofothers, the cannabis user is talkative and laughs easily, butwhen alone is more often drowsy and quiet. The initialperiod of stimulation is frequently followed by a moodyreverie and drowsiness. The user's ability to perform manytasks normally or safely (particularly driving a motor car) maybe seriously impaired. Other effects include dizziness, drymouth, dilated pupils, burning or bloodshot eyes, urinaryfrequency, diarrhoea, nausea, vomiting and hunger. Smokingalso frequently produces chronic laryngitis and bronchialirritation. Cannabis inhibits testosterone, but sexual potencyappears unaffected. Cannabinoids cross the placenta and inview of their long elimination time may have adverse effectson the fetus; they also inhibit DNA synthesis, increasingmutation potential and the risk of spontaneous abortion.'

Present clinical experience suggests that cannabis doesnot produce physical dependence or an abstinencesyndrome, but Jones et al. 5 report a mild withdrawalsyndrome with irritability, anorexia and insomnia withrebound REM in cases of heavy regular consumption todaily doses of 200 mg THC. The mild nature may be due tothe store of THC in the lipid tissues. Once the user hasestablished the amount of cannabis necessary to achievethe euphoria there is little tendency to increase the dose,which probably explains why tolerance does not usuallydevelop. Moderate to strong psychological dependence maydevelop in' accordance with the user's appreciation of thedrug's effects. As a result of that dependence, the user maybe motivated to increase the number of daily doses.

Cannabis tends to reduce inhibitions and increasesuggestibility, which explains why the individual under itsinfluence may engage in an activity he would not ordinarilyconsider. Although the cannabis smoker sometimes feelshimself capable of extraordinary physical and mental feats,he seldom acts to accomplish them for fear of disrupting hiseuphoric state. But what is clear is that the drug can havean unpredictable effect, even on persons accustomed to itsuse. Whether dagga can cause unpredictable violence is notcertain, but particularly in association with alcohol and otherdrugs there is an increased risk. Dagga probably merelyfacilitates violence. Prolonged, heavy use may result in adelirious state, which may lead to a violent act. The questionwhether a person should be considered to be lessresponsible while under the influence of drugs is bound toarise with increasing frequency in the criminal courts in thefuture. Abuse of cannabis facilitates association with socialgroups and subcultures involved with the more dangerousdrugs. Transition to use of such drugs would be aconsequence of this association, rather than an inherenteffect of cannabis. The harm to society derived from theabuse of cannabis rests in the economic consequences ofthe impairment of the individual's social functioning and hisenhanced proneness to asocial and antisocial behaviours.

Adverse psychiatric side-effects vary in intensity fromanxiety states and panic reactions to acute toxic psychosis. 6

The psychotic state may be dose-related or act as aprecipitating factor in a susceptible person. Co-morbidity

studies in psychiatric patients demonstrate a poor prognosisand outcome. Cannabis intake may precipitate episodes ofacute mental confusion reminiscent of an acute brainsyndrome, which may be linked to reports of a destructiveeffect on the creative faculties of the mind and possibleirreversible brain damage. It also results in personalitychanges that lead to marked deterioration of what isconsidered good mental health. Clinical descriptions of'amotivational syndrome' and 'flash-backs' may be part ofthe spectrum of effects.

As regards the social effects of cannabis, one asp~t isclear. If the drug is smoked in solitude this is almost'invariably a sign that the user is already disturbed, althoughwhether he was so before reaching this point or beforetaking cannabis is almost impossible to say. There is usuallya marked social ritual in the use of cannabis. Th~ role of thepremorbid mental make-up in the causation of pfugdependence is generally accepted in a high proportion ofcases. It stands to reason that the greater the pqychologicalpersonality defects, and the greater the person's difficultiesin establishing and maintaining interpersonal relationships,the more likely it is that he may find some emotional relief byusing drugs to which access is easiest.

The outlook tends to be less good for young addicts thanfor more mature drug abusers, probably because of theirgreater personality maladjustment or their lesser socialstability. Clearly many other environmental and social factorsare involved. It is deceptive to consider cannabis use asmerely a passing youthful fad.

Cannabis use, particularly among the youth today, is partof the pandemic toxicomania that has developed in thesecond half of this century. Cannabis is a potentiallydangerous drug and as such a public health concern,especially with regard to the increased use evident inadolescents.

Tuviah ZabowForensic Psychiatry UnitUniversity of Cape Town

1. Nahas GG. Marihuana - Deceptive Weed. New York: Raven Press. 1984.2. Research news: Marihuana. Science 1974; 185: 683-685.3. Raistrick O. Davidson R. Alcoholism and Drug Addiction. Edinburgh: Churchill

Uvingstone, 1985.4. Hayt LL. Effects of marijuana on fetal development. J Alcohol Drug Education

1981; 26: 30-36.5. Jones RT, Benowitz N. Bachman J. Clinical studies of cannabis tolerance and

dependence. Ann NY Acad Sc; 1979; 282: 221-239.6. Ghodse A. Cannabis psychosis. Br J Addict 1986; 81: 473-478.

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