How risky is using cannabis?

In a previous post, we explored paternalism and its longstanding and influential role in most drug policies. States have a legitimate interest in promoting the health of citizens. However, worries about the dangers of cannabis, rooted in racist research, have led to a problematic evidence base. Based on insufficient data, inappropriate methodologies, and misleading conclusions, we have argued that many existing policies embrace public safety and public health assumptions in problematic ways.

Exactly how dangerous is using cannabis? It is certainly less risky than many other things like drinking alcohol or consuming tobacco. However, it is not a totally risk-free activity. It can enhance some experiences and diminish others. Inhaling burning things into your lungs? Not usually considered healthy. The problem is that cannabis has been socially constructed as far more dangerous than it is for more than a century. Linked to moral failings, mental illness, crime, and laziness, cannabis is used as a laugh line while remaining the object of unconscious aversion, dislike, and antipathy.

Lurking in the shadows of some of the worries about commercial cannabis are fears that more cannabis will result in increased adverse outcomes. As repeatedly shown, efforts to control cannabis are far more dangerous than consuming it. However, many critiques of commercial cannabis begin from the now disproven notion that cannabis use represents a significant public safety or public health risk. If this were so, there should be unequivocal findings from Colorado, Washington, California, and Canada.

With apologies to my second-grade teacher: there ain’t.

In a recent Newsweek Op/Ed, Kevin Sabet repeats much of the same disproven nonsense that has animated the War on Cannabis. He states legalizing cannabis increases use, increases potency, increases crime, leads to mental health disorders and addiction, and generally is responsible for the collapse of civilization. As we have argued, Sabet and his organization, Smarter Approaches to Marijuana (SAM), appear to be part of a group we call the “new prohibitionists.”

They tend to exaggerate.

Legal cannabis is not linked to increases in crime, violence, or automobile accidents. The vast majority of research suggests legalizing cannabis in Canada or Massachusetts, Connecticut, Rhode Island, Vermont, Maryland, and Washington has not increased cannabis use among youth. In fact, evidence is emerging that legal cannabis is associated with reduced youth consumption.

Sabet also reports that legalization is “associated with a 25 percent increase in adolescent marijuana use disorder, also known as addiction to marijuana.”

Informed readers are by now aware that this use of “addiction” is a throwback to the Reefer Madness days. By contrast, the authors of the study Sabet references actually focus on Cannabis Use Disorders (CUD), not addiction. CUD expands on older descriptions of problem cannabis use. It includes more than ten symptoms which range from using it for more than a year to adverse impacts at school or work to measures of increased tolerance and withdrawal. The nonexpert use of terminology related to the psychiatric effects of cannabis is a problem. As has been shown, even for experts, these are notoriously difficult concepts to operationalize and compare.

The real problem for those who exaggerate and distort research is findings from jurisdictions with legal cannabis. Where cannabis has been decriminalized and legalized, cannabis use disorder (CUD) treatment admissions for adolescents did not increase. Overall, cannabis treatment utilization is on the decline, and this finding appears true for admissions to treatment facilities as well. According to SAMHSA (2020), just over 5% of people 12 and older who use cannabis may meet the criteria for a CUD.

This statistic is a reminder of the need to distinguish absolute risk and relative risk. Small increases in the risk of something occurring, when it rarely occurs in the first place, can easily be presented in ways that distort meaning. Of course, people do risky things all the time. The idea that using some drugs is less risky than riding a horse can cause cognitive confusion. The most dangerous thing most people do, of course, is drive in a car.

So how risky is using cannabis?

Well, as stated above, it is not risk-free. The most significant risk is for the small number of youth with pre-existing risk factors associated with schizophrenia. However, cannabis use has never been shown to be a causal factor for schizophrenia. For a small group of people in distress, cannabis and other drugs may become a means to manage their distress. This can result in problem use. These fears have long been a feature of risk assessments of cannabis, especially by public health organizations. Focused on harm-first and the negative side of substance use, some organizations “look for harm in the name of health. Through this lens, potential benefits don’t track.”

This is starting to change.

In a forthcoming book, physician and cannabis specialist, Peter Grinspoon, notes that while there are still questions to be explored, cannabis is far less dangerous than many medications doctors manage. In addition, it has several benefits. Cannabis serves as a means of harm reduction to transition patients away from prescribed opioids and other street drugs. It is used medicinally for a variety of ailments. As Dr. Grinspoon points out, you can’t kill someone with cannabis as you can quite easily do with a blood thinner, the wrong dose of insulin, or even antibiotics. Cannabis can also augment experiences, promote reflection, and help people to access emotions and insights which sometimes remain hidden. Grinspoon’s examination of how poor research and ideological mindsets have limited the therapeutic uses of cannabis is personal and profound. He offers a very useful way to think about addiction in the context of cannabis, as well. More on that in the weeks ahead.

For now, I suggest you pre-order the book here. Seriously.

As Grinspoon points out, those who seek to control cannabis often perpetuate stigma for those who benefit from using it. This drives some into the illicit market, where any risks of cannabis are inevitably amplified. What is required are approaches to consumer education that focus less on risk and more on how people can responsibly use cannabis. This could help reduce the reported rise in cannabis-related hyperemesis, which presents as uncontrolled vomiting, among an incredibly small group of people who consistently use cannabis daily. It is certainly not pleasant. Thankfully it appears to be quite rare, even where cannabis is legal and widely available.

The treatment? Take a break from consuming cannabis.

NBD.

As cannabis use becomes more accepted in society, there is a need for responsible messaging on cannabis, especially for youth. Fears about the impact of cannabis on youth have historically been weaponized in ways that have left some skeptical of other kinds of public health messaging. How can you trust a system in which messages about the risks of cannabis fail to conform in any way to your own experience and that of your friends? Weed Out Misinformation is one resource deserving of more attention. In the place of abstinence-focused, risk-laden messaging, Professor Dan Bear argues we ought to focus on minimizing harm by sharing credible evidence to help youth make informed decisions and maximize benefits if they choose to consume cannabis.

I think he is right.

The risk of cannabis is less about what happens when people consume it and more about the harm that results from those who seek to stop people from using it. Exaggerations, distortions, and the weaponization of stigma are corrosive forces that must be resisted. As Dr. Grinspoon notes:

We must acknowledge all who needlessly suffered under the criminalization of cannabis, and those who fought to change this. It is an extraordinary tale of how ordinary people stood up, over several generations, to stigma and repression and faced down the combined forces of the government, corporations, and, unfortunately, much of the medical profession. Many paid a steep price, including arrests, loss of assets, jail time, and criminal records.

Those who seek to constrain commercial cannabis and further ingrain paternalistic public health policies might wish to consider the history of prohibition and the damage inflicted by the culture of cannabis control. In many ways, anti-consumer cannabis policies and the attitudes upon which they are based represent a direct threat to new social equity programs that seek to right the wrongs of the past. Perhaps this is the biggest emergent risk.

We turn to this issue next.