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Finding the Middle: Real talk about cannabis

In the last 100 years, cannabis has gone from a common medicinal ingredient, to the devil incarnate, to a counter culture icon, to a modern miracle. Cannabis legalization and the progress of cannabis research is showing us that is both none and all of those things.
Written by
Dr. Amanda Reiman
March 3, 2023

Cannabis is a gateway drug… all cannabis use is medical…. cannabis will prevent you from being a successful person… you can’t overdose on cannabis.

We are bombarded with extreme messages about cannabis from both sides. Decades of propaganda and policy decisions made based on social control instead of science has created an all or nothing view of the cannabis plant. During the 1980’s and 90’s, the prevailing message was that cannabis was always harmful and not able to be used in a beneficial way. This messaging was supported by its Schedule I status, claiming no medical use, a high potential for abuse and minimal safety profile.

As medical cannabis emerged in the mid 1990’s, advocates took this belief system to task and slowly dismantled it, supported by the anecdotal evidence from early patients, many of whom were using cannabis to ease the symptoms of life threatening illnesses like HIV and cancer. At this time, any admittance of potential harm on the part of activists left them vulnerable to prohibitionists, and so the messaging to counter prohibition took on the form of the polar opposite: if cannabis isn’t all bad, then it must be all good.

Claims about all use being medical, a lack of addiction potential and non-existent overdose were common among those fighting for legalization. I know because I was one of those people. I started working on cannabis reform in the late 90’s, and understood that one of the only messages we could use to counter the prohibitionists in the eyes of the public was to promote the benefits of cannabis while denying harms that the prohibitionists claimed were reasons to keep locking people up. 

Now, decades later, we’ve learned a lot about how cannabis is being experienced by consumers. It's time to replace the all or nothing approach to cannabis with one that is reflective of all we have learned in the past 25 years, as well as one that provides actual, useful, harm reduction based information for cannabis consumers. Very few things are all good or all bad, and the cannabis plant itself is a neutral presence; what matters is how we approach use, and the set and setting with which we consume.

To jumpstart a realistic and evidence informed view of cannabis, I take on the main arguments made by both sides, and uncover that, as to be expected, the truth is somewhere in the middle. I want to stress that even with the potential harms of cannabis consumption, IT SHOULD NOT BE ILLEGAL. Nothing we have discovered about cannabis suggests that criminal justice is the right approach. And, as you will see, the criminal justice approach has actually exacerbated some of the harms that prohibitionists claim exist. This is also not meant to diminish the work of activists (I consider myself one) or to place blame for inflated claims and downplaying harm. I was there. I did it too, and at the time, for good reason. 

Their Claim: Cannabis is a gateway drug

Growing up in the 1980’s the gateway theory was the predominant explanation for “hard” drug use. The idea was that teens started on cannabis, and that experience somehow “caused” them to move onto other drugs like cocaine and heroin. The gateway theory had its heyday in the 80’s, but was introduced to the public way before that. Anti-drug propaganda films from the 1950’s and 60’s often portrayed young, innocent teens as being lured into trying a “marijuana cigarette” only to show them injecting heroin in the next scene. This was obviously to scare parents into thinking that even one time use of cannabis would lead to a dangerous situation for their teen, but also to message to teens that something about using cannabis made them unable to make good decisions about drug use, and that cannabis use meant giving up control of yourself to disastrous ends.

So, is the gateway theory real? No, it’s not, at least not in the way it was represented. Yes, it is true that most people use cannabis before they use cocaine, heroin or other drugs. But, when we take into account the full spectrum of psychoactive substance use, cannabis is rarely the first substance that provides an altered state. In reality, this is sugar. Sugar, often first consumed in childhood, provides a feeling of energy and euphoria followed by a crash and cravings. As someone on Day 6 of a month-long sugar hiatus, I can tell you that the withdrawals are REAL. If you have ever been around a small child a few hours after they eat a sugary treat, you know that crankiness, irritability and sleepiness usually follow, as does a desire for even more sugar. After sugar, caffeine is usually the next in line. This doesn’t have to be in the form of coffee. Energy drinks like Monster and RedBull are not age restricted.

Once a young person enters adolescence, nicotine and alcohol usually come next. The average age of a first cigarette and alcoholic drink is 15. Around age 16-17, we usually see initiation of cannabis. However, most people stop at cannabis and do not progress onto other drugs. According to the National Household Survey on Drug Use and Health, in 2021, 13% of those 12 and older reported last month cannabis use, compared to .7% for cocaine use and .2% for heroin use. If using cannabis CAUSED you to move on to harder substances, we would see more people doing it.

In fact, when people DO move onto other substances after cannabis, the opportunity to do so is usually related to the fact that those who sell cannabis on the illegal market may also sell other drugs, drugs that the consumer would not be exposed to if all cannabis were available in a regulated environment. The reality is, the gateway theory is a myth, and prohibition may actually make accessing other drugs easier. 

Our Claim: All cannabis use is medical

While I never completely adopted this stance, I was someone who said that “all use is therapeutic.” My reasoning for this was that even if someone is using cannabis to relax, stress can be a precursor to several diseases, and, if that person is using cannabis to relax rather than alcohol or other drugs, the harm reduction aspect is a therapeutic benefit. However, after completing a series of interviews with cannabis consumers who say their use is NOT medical (publication forthcoming), I realized that not everyone views their consumption as a therapeutic experience, nor should they.

In our efforts to justify use as a medical act, we have forced all consumption into the umbrella of wellness. And while I do think that the majority of people who consume cannabis have at least some intentions connected to wellness, this way of thinking eliminates both those who self-identify as non-medical consumers, as well as those whose use is not benefiting them therapeutically and can potentially be hazardous. If someone is using cannabis in a way that does not enhance their life, but rather detracts from it, forcing it into the wellness bucket is not doing them any favors.

The sub-Reddit r/leaves has 274K members and states its purpose as “A support community to help stop smoking cannabis, marijuana, pot, weed, edibles, or getting high.” I am not going to provide quotes from the participants due to privacy, but the group is full of people for whom cannabis was not/no longer therapeutic and was causing various levels of disruption in their lives. The claim that “all use is medical” is what kept some of these folks going when they knew they should be reducing or eliminating their use. Now yes, prescription drugs can also lead to dependence and withdrawals, and cannabis has a better safety profile than most of them. Cannabis is also a legitimate medication for a variety of symptoms and illnesses. But, like I said earlier, very few things are all good or all bad.

Our society is pretty terrible at consuming anything in moderation, and framing use as a monolith, whether good or bad, does not account for the myriad of ways that people interact with the plant. For some, opiates can provide an immense amount of relief, for others, great pain and struggle. It is not that different from one person finding great effects from using cannabis to treat PTSD, and another experiencing negative effects and outcomes because of their use. If we truly view cannabis in a harm reduction/benefit maximization framework, we need to accept that there are both benefits AND harms.

The Takeaway

In the last 100 years, cannabis has gone from a common medicinal ingredient, to the devil incarnate, to a counter culture icon, to a modern miracle. Cannabis legalization and the progress of cannabis research is showing us that is both none and all of those things. Like I said earlier, the plant is a neutral entity. It does not wish us harm, nor does it avail itself as a miracle cure. It’s us. We’re the ones who assign the villain or hero character to the cannabis plant. I am suggesting that there are no villains and heroes, only people trying to do the best they can. The best we can do for them is tell the truth. 

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