There’s probably two issues being talked about in addiction today more than any other. The first is the epidemic of opioid overdose deaths and the second is the legalization of marijuana by some states. I haven’t heard of anyone in favor of opioid overdoses so that has little controversy. The same cannot be said for legal pot.
One of the reasons for the controversy in this issue is that it’s really the amalgamation of more than one issue. The arguments I’ve heard both for and against have all been the conflation of arguments for and against four separate proposals. They are: legalizing marijuana for medical use (medical marijuana), local and state decriminalization of marijuana (decriminalization), state legalization of personal use marijuana (personal use legalization), and full federal legalization of marijuana (repeal of prohibition). The mixing and matching of these arguments adds to confusion. It isn’t uncommon, for example, for a person arguing for repeal of prohibition to use arguments for medical marijuana and be answered by the arguments against personal use legalization. In this case neither debater is actually debating the question they think they’re talking about.
Please understand, I actually am quite neutral on this issue. All I do is treat addiction and it’s just as easy for me to treat a patient using a legal drug as an illegal drug. I really don’t care one way or the other.
This was going to be a large opus listing all the pros and cons of the various proposals above, and it has sat in draft form for over a month, but time has gotten ahead of me. Two things have prompted me to wrap this up and put it out in a smaller form: the increasing negative health affects of synthetic cannabinoids and the recent editorial in the New York Times supporting repeal of prohibition.
Anyone who’s read my book or has followed my blog knows that I see addiction as a single illness. The effect of prohibiting a drug is to increase the cost (both economic and social) of using that drug. People with and without addiction will be incentivized to not use it, however people with addiction will just switch to another drug – unless we treat the illness. And make no mistake, cessation of drug use is not treating the illness; neither is putting people in jail. So prohibiting a drug, any drug, is not helpful to addicted patients.
But then I hear the arguments from colleagues “Repealing prohibition of cannabis will make it harder to treat addiction because people will claim they should still be able to smoke it like cigarettes.” I think that’s ridiculous. If you have to threaten your patients with legal consequences you probably don’t know how to treat addiction. If you aren’t addressing smoking as part of the illness, you probably don’t know how to treat addiction. Okay, I say to patients everywhere, “Maybe it is just like smoking cigarettes, and there’s good evidence that if you continue to pop your dopamine with cigarettes you’re more likely to restart the use of the thing you just went to treatment for. We’re not asking you to stop smoking and be miserable; we’re asking you to let us help you with medication and other treatments to improve the state of your illness so that your brain no longer wants to smoke.” I really don’t care that tobacco is legal; it’s not a good idea for someone with addiction to smoke. I don’t care that sugar is legal; it’s not a good idea for someone with diabetes to eat it.
So really, purely as an addiction doctor, I can’t say that repeal of prohibition would make my job any harder. Are there going to be social consequences? Quite likely. But I think society gets to make that choice, and does so, with all sorts of things. What society is doing when it says one drug is legal and another isn’t, is choosing the social consequences. All drugs have them, and democratic society has a right to pick which ones it will tolerate and which it won’t. I’ll never live in a society free from social consequences of drug use, so I’ll get used to whatever you guys choose. The real choice society hasn’t faced yet is whether we’re going to continue on this prohibition marry-go-round regulating one drug or the other while the disease goes undressed or if we’re tired of 50 years of a drug war and want to start actually addressing the illness.
And speaking on consequences, there’s one we should ask ourselves about concerning cannabis prohibition. THC is a partial agonist at the Cannabinoid Receptor Type I (CB1), that means that it turns on the receptor part of the way. Cannabis has been grown so that it’s more potent per gram than it was 30 years ago but THC is still a partial agonist, and cannabis still has more than THC in it. There are many cannabinoids in cannabis, and some may counter the effects of THC. It’s not completely known. But one thing is certain, it’s not like pot is a pure agonist at CB1, but the synthetic cannabinoids being marketed in convenience stores are.
With the rise of an internationalized world, chemists in the eastern hemisphere were able to synthesize an increasing number of pure full agonists at CB1 that are far more powerful than even the most potent cannabis out there. The first synthetic cannabinoids were the JWH compounds and after a couple of years they were made illegal. Before they even were, the chemists had the next set ready, and the next. We will never be able to make new chemicals illegal faster than scientists in another country can make new ones we’ve never heard of. On top of that, we can’t create confirmatory tests to use for these things at anywhere near the pace of their invention so we’ll always have people in treatment who are negative for existing tests even though they are using. That’s new, and that does make treating addiction harder. Now we aren’t dealing with a readily available partial agonist with known effects and a good way to track its use, but a range of unknown full agonists that are causing an increasing number of catastrophic health effects (this will be the next epidemic after opioids calm down).
So the question society needs to ask is this, “Would there be as much use of synthetic cannabinoids with the attendant psychosis, suicides, and homicides we’ve been seeing lately if cannabis itself were legal and regulated?” I won’t pretend for a minute that if we repealed prohibition that synthetic cannabinoids would go away; that genie is out of the bottle, but would there have been as much economic incentive to create these things if cannabis had been legal? We need to take a look at the second order costs of our decisions, and so far, we only look at the first order savings. We see there are problems with pot and we make it illegal to save those problems. Now we have bigger problems that we didn’t see coming.
The real problem is how we look at costs and benefits. We keep thinking that the choices for people are between using this bad thing and not using anything. That’s never been the choice. The overwhelming amount of drugs used are used by the few people who use a lot and those people, mostly, have addiction. For them not using isn’t an option without treatment and recovery, so the choice we are really making with prohibition is this, take legal risks and keep using this or go find something else. We might even like what they find (smoking cigarettes, over work, eating too much), but the disease, without treatment, just gets worse regardless of the social acceptability of the drug used. Whether pot is legal or not, the real question before is whether we’re ready to look at this disease the way it exists in nature and deal with it, or if we want to continue our half-century of delusion and continue to complain.