Has cannabis legalization resulted in an increase in the prevalence of cannabis harms? According to a recent article in the New York Times, the rising availability of legal cannabis is the root cause of noted increases in Cannabis Use Disorder, psychosis and Cannabis Hypermesis Syndrome. The article further claims that these issues can be traced to the availability of high potency products on the cannabis and intoxicating hemp markets. Claims tying cannabis to harm are not new. And cannabis industry members and other cannabis advocates were quick to discount the claims made by the NYT. So, let’s take a look at these claims from an objective and pragmatic point of view. Social change is never a straight line, and, when mired in decades of propaganda, getting to the truth is complicated. But, we owe it to ourselves, and plant and future society to ignore the hype and uncover the facts.
Claim 1: The increased availability of cannabis due to legalization is resulting in an increase in cannabis related harms.
I think the overall basis of the claim is flawed. Yes, more adults are using cannabis and being open about their use. According to the National Survey on Drug Use and Health, in 2018, 18.8% of 26-29 year olds claimed cannabis use in the past month. That number was 27.2% in 2023. And past month use among those 65+ almost tripled, going from 2.5% in 2018 to 6.9% in 2023.The bottom line is, more people are using cannabis now that it is legal, and some are just more willing to admit their use than they were when it was illegal. By the law of numbers alone, we can expect to see a rise in cannabis related problems as there are more people consuming cannabis. If there was a huge increase in the number of people jogging, we would expect to see a rise in jogging related injuries. But does this mean that consumers are more likely to experience problems now than they used to be? We’ll get to that in a minute.
Claim 2: More people are meeting the criteria for Cannabis Use Disorder.
Cannabis Use Disorder is a fairly new diagnosis. Traditionally, the two levels of substance issues diagnosable by the DSM were substance abuse and substance dependence. However, in 2013, cannabis abuse and dependence were combined under the catchall of Cannabis Use Disorder. This was because cannabis use, even habitual use, does not completely jive with how we define addiction when it comes to other drugs. A third of consumers use cannabis everyday, but that is not a good marker for dependence, especially if they are using cannabis for medical purposes and instead of other, more harmful pharmaceutical drugs. Many people are “dependent” on their medications, meaning that they must use them regularly or experience a return of symptoms. For many medical cannabis consumers, this is what their dependence looks like. Does that mean that people cannot become dependent on THC? No, they can. And they can experience withdrawals when stopping use. But, even among regular consumers, cannabis does not cause life disruption for most people. There may be a lot of people out there dependent on THC. But there are also a lot of people dependent on caffeine.
Claim 3: We are seeing an increase in cannabis-induced psychosis.
There is a chicken or egg issue with cannabis and psychosis because of the common overlap between time when cannabis initiation happens and time when mental health issues begin to present themselves (late teens). Cannabis is a common way for young people who are experiencing mental health disturbance to self-medicate. So, when someone experiences "cannabis induced psychosis", it is almost impossible to disentangle the experience of mental health symptoms with cannabis self medication. We may often see people who have had mental health issues, or a family history of mental health issues seemingly worse when they use cannabis. But did cannabis cause mental health issues in the first place? Or was cannabis just the wrong medicine for them and their symptoms? Rather than claim that cannabis causes these issues, I think the safer claim is that, for some people, cannabis can bring on or exacerbate issues that were already present. Because of this, we should be educating consumers on the risks, and when a teen is using large amounts of cannabis, rather than punish them, we should use it as a clue that something else is going on that they may need support for.
Claim 4: We are seeing an increase in Cannabis Hyperemesis Syndrome (CHS) because of the presence of high potency products in the legal market (including the intoxicating hemp market).
Here’s where I am going to lose the cannabis evangelists. I do see potential risks and harms stemming from the high potency products on the market. Although the Endocannabinoid System (ECS) was discovered in the mid 1990’s the Schedule I status of cannabis has greatly impacted the ability to do meaningful research on the ECS and how it is impacted by the ingestion of THC in humans. Our ECS is about maintaining balance in the body, and I can imagine that flooding it with THC from the plant is impacting that balance. For some people, this imbalance presents as CHS. CHS is marked by severe vomiting where the only relief comes from hot water and possibly other sources of heat. It can lead to dehydration and malnourishment, and in rare cases, death. CHS is not new, but, in the past, it was likely misdiagnosed. The increased prevalence in hospitals of CHS is partly due to better diagnostic processes, AND, sorry to say, the rise in the increased use of high potency cannabis products. We will likely see instances of CHS increase unless we educate people on the risks of high potency products. I do not think that using 75% and higher concentrations of THC throughout the day is good for you, unless you are specifically trying to replace opiates or are treating a very severe condition. And even then, I would suggest limiting this practice as much as possible. Banning these products from the market will not make them go away, but helping people understand the risks and make better choices will change overall consumption patterns. We’ve done it before, with cigarettes. Unfortunately today, like smoking in the 1950's, very few people are calling attention to the risks of high potency products. And, those who do are accused of being prohibitionists who want to continue the drug war. But it's not that simple. Personally, I think cannabis should be legal, but I also think frequent consumption of high THC products can be harmful and I would advise against it.
Where do we go from here?
Unfortunately, if we don't become more pragmatic in our conversations about cannabis and continue to make it all about legal vs. illegal, we will lose the opportunity to take a public health based approach. Right now, society believes that our only choices are capitalism or criminal justice, and they are choosing capitalism. But if the problems persist, we may see a cry to make cannabis illegal again. That would be a shame since all we really need to do is be honest about the risks and benefits and help people adopt healthy relationships with the plant. Last summer, I launched a new program called Cannabis in Balance. The goal is to help people develop and maintain moderate cannabis use by implementing mindfulness and harm reduction. We have to move past the “do it”/”don’t do it” dichotomy and focus on teaching people how to use safely, responsibly and in a way that supports their health and well-being. Cannabis is much like exercise. Both can be part of a healthy lifestyle, but both can cause harm and injury if overdone or done recklessly.
