Social attitudes exist on a pendulum that swings back and forth. Often, after a period of prohibition and stigma, the pendulum swings in the other direction, opening a period of tolerance and then, even enthusiasm. Such is the case with cannabis. After a period of staunch prohibition in the 1930’s, 40’s and 50’s, the 60’s and 70’s ushered in a wave of progressive action including greater tolerance of cannabis use. Then, of course, came the height of the War on Drugs in the 1980’s and 90’s and the swing back towards prohibition. The pendulum began to head back the other way with the visibility of medical cannabis in the 1990’s and the steady stream of legalization in the years since. As an advocate, the hope is that, when the pendulum swings in your direction, you make enough gains so that even when it does head the other way, not all of those gains are lost. Even though society took a more permissive stance on cannabis in the 1960’s and 70’s, there were not enough policy changes to withstand the militarization of drug policy and the Just Say No era. This time, however, numerous states have changed their cannabis laws, and even the Schedule I status of cannabis is being challenged. To me, as an advocate, this means that even when the pendulum heads back towards conservatism on this issue, we have made enough progress to keep current legal programs in tact. In other words, I don’t see legal states passing laws to go back to prohibition. And even if it’s only because of the tax revenue, it’s enough to keep progress alive.
Something else happens in this tug of war for American values and that is a lack of consistent and evidence-informed information about the risks and benefits of the behavior in question. When the pendulum swings towards prohibition, the majority teaches the public that the behavior is bad and wrong and should be avoided, while the minority fights to counter those messages with a much smaller bull horn. In times of acceptance and progressive action, the majority espouses the benefits of the behavior while downplaying the risks. This is understandable as a tactic to prevent giving the other side any fuel for their fire. But, as a result, the public is left with emotionally and politically charged information that rarely comes from a place of science.
The back and forth of social policy has another effect. During alcohol prohibition, the liquor was strong and unregulated. People wanted to get the most bang for the risk they were taking in accessing something that was against the law. Now, 100+ years after alcohol prohibition, we see a market with a wide variety of products at varying levels of potency, from light beer to liquor. Decisions about consumption come from personal preference, and not from the desire to consume as potent a product as possible (unless you are underage, in which case you may make choices more like under prohibition times, based on potency and availability). Basically, for a time after prohibition ends, consumers still make choices with a prohibition mind set. This, combined with a lack of balanced information about the risks and benefits of the behavior, and sprinkled with a healthy (or unhealthy) dose of capitalism, creates a situation that could result in the pendulum swinging back.
Recently, Malcolm Ferguson wrote an article for the Atlantic entitled: Marijuana is Too Strong Now. As can be expected, one side applauded the article and said that it did not go far enough, while many on the other side dismissed it out of hand as nothing more than propaganda. So, in the interest of breaking the cycle of all or nothing thinking about cannabis and the feast or famine approach to consumption. I am going to review some of the article's main points from a public health perspective. To be clear, I completely support legalization and an end to cannabis prohibition. But, as a public health professional and cannabis researcher, I know that if we don’t get real about our approach to the widespread availability of cannabis, the pendulum might swing back faster than we think.
Potent cannabis has always existed, and, in some parts of the country and the world, the same, high THC cultivars have been growing for a very long time. However, for most of us, prohibition meant that we only had sporadic access to cannabis that was grown without much personal attention (too risky) harvested according to demand and risk minimization (not craft) and well-traveled with high exposure to heat and air. The result was the baggie of seeded and smashed flower that we were used to getting in the Midwest. This cannabis was not only low on potency, it was low on quality. Making those of us who grew up in the DARE times develop an extra appreciation for the flower and variety of products available post prohibition. Bringing cannabis into the open has allowed breeders and farmers to shoot for the THC stars and produce a highly potent product available in dispensaries in states across the US. So yes, unless you were growing it yourself, had a close relationship with a grower or lived in the Emerald Triangle, the cannabis you get now is likely more potent than the cannabis of yesteryear. This is especially true for those of us who came of age during prohibition.
You know I am a huge fan of differentiating correlation from causation. While it is true that we are hearing more about Cannabis Hyperemesis Syndrome (CHS) and negative mental health events for people who use cannabis, this does not mean that the presence of higher potency products is causing these things to happen. Now that cannabis use is legal in many places and destigmatized in even more, its visibility has increased. People are more willing to divulge their use to health professionals. And, said professionals are more likely to consider cannabis after observing the symptoms of CHS. This may make it appear that these things are connected to the availability of high potency cannabis, but they may in fact be connected to the discourse and transparency around cannabis use. That being said, we really don’t know. While cannabis has been used across the world for thousands of years, never in the history of humankind has it been THIS available in this many forms and with this degree of potency to a mass audience. And, given the research restrictions on cannabis, it has been all but impossible to design and carry out rigorous, longitudinal studies in humans. We do know that we all have an Endocannabinoid System (ECS), and that this system regulates important functions in the body. We also know that we have receptors throughout the body, including the brain, that accept cannabinoids whether they be from us or from the plant. To think that we could introduce high levels of one cannabinoid (THC) into our bodies for a long period of time and NOT see an effect is unlikely. But the extent of that effect and the long term ways in which it impacts the ECS has not been determined.
Again, there is a lack of research on the causal impact of cannabis and teens as they grow into adulthood. It is true that our brains continue to develop into our 20’s and therefore, the use of any mind altering substance is a bad idea for that age group. Not just because of the potential biological impact, but because while our brains are maturing, so is our decision making ability and rationality around risk. However, the fact that we have cannabinoid receptors in our brains means that introducing large amounts of THC during this phase of growth may have very real consequences. But, that should not distract parents and others who work with teens from recognizing that using large amounts of cannabis on a regular basis as a teen is usually a symptom of another issue. One that the teen is using cannabis to self medicate for. Instead of punishment, care should be taken to make sure the teen is getting the support they need.
As is the case with all other drugs, legal and illegal, the heaviest consumers buy the largest share of the supply, even though they make up the smallest part of the population. A study conducted in the UK found that, although harmful and hazardous drinkers made up 25% of the population, they accounted for 68% of the alcohol revenue. Therefore, cigarette companies are not marketing to the person who has one per year on their birthday, and alcohol companies are not making their money off of the person who has one glass of champagne on New Years Eve. They make their money off of those who use their products regularly, usually several times per day. The same is true for cannabis. And although we have seen a market for low dose products emerge in the hemp space, when you walk into a cannabis dispensary, finding flower that is lower than 20% THC is unlikely, and finding high CBD flower is nearly impossible. Dispensaries will say that this is because there is no demand for these products. I refer back to the beginning of this article where I wrote about the effects of prohibition. I think some of that is at play here. People finally have access to legal cannabis, but their mindset is still in the days of feast or famine. This is a phenomenon observed in people who lived through the Depression. Even after they had abundant access to food again, they may hoard food or insist that their kids clean their plates so as not to waste anything. Like alcohol, I do believe this mindset will pass and people will become more balanced with their desired potency. But, I think something else is also going on here…tolerance. Building up tolerance to THC is a process, but it is inevitable for people who use cannabis regularly. When someone refers to themselves as a “functional stoner” what they are really saying is that they can consume large amounts of cannabis without being impaired. The reason for that is tolerance. Building up a tolerance to THC comes from regular consumption, partly because the effects of using too much are benign for most people. When it comes to alcohol, you know when you have had too much, and after one or two of those experiences, you learn to stay within your limits. If you don’t, the sickness and hangover that follow serve a lesson that is hard to forget. With cannabis, not only is there no fatal overdose, the effects of an overdose are usually quite mild. While, for some, a THC overdose can lead to anxiety and discomfort, for most regular consumers, it just means getting really tired and sleeping for a while. With this being the only guardrail for moderate use, those who use a lot of THC and build up a tolerance, may never feel like they need to cut back because they don’t become impaired and even when they take more than usual, nothing bad happens.
While states have instituted testing and labeling requirements for cannabis, they are inferior to how we label other food and medicinal items. Edibles are the closest thing to standardized as many states cap their potency at 10mg of THC per piece with a max of 100mg of THC per package (which is still A LOT). Connecticut and Vermont limit the THC in flower to 30% and most states have limits on how much cannabis weight you can purchase at a time. However, I believe that bans do not eliminate certain products, they only drive them underground and make them less safe for consumers. While quality and uniform testing and labeling addresses supply, we are doing little to address demand. We don’t teach people how to use cannabis safely and moderately. We don’t incentivize retailers to carry lower potency products or for people to buy them. Cannabis tax is usually flat, meaning it is figured as a % of total price regardless of potency. A tax based on potency might do more to encourage the purchase of lower potency products, as long as it does not negatively impact medical patients who need high THC options (patients should not be taxed at all). As long as the Federal government upholds its stance that cannabis is federally illegal, we will not see the standardization and oversight needed to ensure that consumers have access to well tested products of varying potencies, science informed dosing guidelines, or that they are informed about the risks of high THC products. Of course, we also need research to be able to clearly articulate what those risks are and who is most vulnerable to them.
So there you have it. While the pro cannabis crowd may be decrying this article as propaganda, I think the author makes some solid points about how legalization and commercialization have changed the face of the product that many of us grew up using once in a while, when we could get it. As I said before, cannabis should not be illegal. Using it, growing it for yourself and sharing it with others should not be a crime. It should not be a Schedule I drug. It should be available to those adults who want to use it and systems should be put in place to ensure that those products are safe and that people know what is in them and how potent they are. The point in the Atlantic article that I most agree with is the last one. Many of the issues we are observing are not because of cannabis or those who use it, they are because of prohibition. Barriers to research, the unwillingness of the government to openly develop public health based policies and educators and doctors to have science based conversations about healthy use created the problems mentioned in the article. The pendulum has swung in our favor, but if we don’t take this opportunity seriously and approach it rationally, it will swing back before we have the chance.
