Some addiction psychiatrists and researchers claim that 30% of adults who use cannabis in the United States develop cannabis addiction, which they call “cannabis use disorder”. This number is exaggerated, and this exaggeration harms medical cannabis patients.

There is no question that cannabis can be addictive. This addiction can derail lives and must be treated with empathy and skill. However, rates of cannabis addiction are much lower than stated by the “experts”.

Our definition of “cannabis use disorder” is broken (see below) and inadvertently ropes in many medical marijuana patients that couldn’t possibly qualify as being addicted. In my clinic, I have had patients who are thriving on medical cannabis, for insomnia or chronic pain, only to see the diagnosis “cannabis use disorder” added to their medical record after they visit with another doctor.

This heightened attention to cannabis addiction comes from a place of concern. People can lose control of their cannabis use. Younger people are more vulnerable to all sorts of addictions, including to cannabis. Instead of learning to self-sooth negative emotions, teens can learn to smoke them away.

Cannabis addiction can negatively impact education, employment, and social connections. Some cannabis advocates don’t believe in the existence of cannabis addiction, even though this is not in doubt by any medical professionals. As an addiction specialist, I often treat cannabis addiction. This can be extremely challenging because this condition has no FDA approved medicines to help address it.

An example of cannabis addiction that I might see in my clinic might be a patient who spends several nights per month in the E.D. due to a condition called “Cannabis Hyperemesis Syndrome” (CHS). CHS occurs when a heavy cannabis user has a paradoxical reaction to cannabis and ends up with extremely severe nausea and vomiting. CHS is absolutely miserable, difficult to treat, and can be medically dangerous. My quick definition of addiction is “continued use despite negative consequences.” If this patient continues to use cannabis, despite getting so sick from it, repeatedly, that would be an obvious case of cannabis addiction.

How is the definition of cannabis addiction broken?

There are specific criteria which define which patients have a “substance use disorder” (which is the medical name for an addiction). Typically, in these definitions, a patient must meet two out of eleven criteria over a twelve-month period. For cannabis use disorder, it looks like this:

The problem with this definition is that you can qualify for a cannabis addiction solely by having the two criteria “tolerance” and “withdrawal” (numbers 10 and 11 above). Most medicinal cannabis patients have “tolerance” and “withdrawal”. This is also true for patients being treated with opioids, benzodiazepines and other drugs. These are known physiological effects of the drugs and might indicate a physical dependence, but are not indicative, by themselves, of addictive behavior. For these other medicines, we don’t consider a person to be addicted if they just have tolerance and withdrawal.

Take opioids for example. There is an “opioid exclusion” which states that, if a person is taking opioids for medical purposes, under medical supervision, and they have tolerance and withdrawal (but meet no other criteria of addiction), than that they are not addicted. This summary explains this in more detail.

Where we go wrong is simply that there is no “cannabis exclusion.” As such, we are saddling people with a diagnosis of marijuana addiction just for having tolerance and withdrawal (which are physiological effects of the medicine). This harmful double standard exists because some of the old guard addiction psychiatrists don’t view cannabis as a medicine. In some cases, they put derogatory quotation marks around the words, “medical marijuana.” Therefore, they allow no “exclusion” for tolerance and withdrawal when patients are treated with medical marijuana. Therefore, we are erroneously diagnosing many/most medical patients with an addiction that they don’t have.

It is important to remember that people who use medical marijuana can get addicted. Any substance that causes relaxation and euphoria can cause addiction. Medical patients have a lower rate of addiction than do adult use or recreational patients. This is because recreational users tend to use more concentrated cannabis products, with fewer medicinal components, and they do so without medical supervision. At times, with cannabis, it can be very difficult to disentangle what is legitimate and helpful use from what is addictive use.

How does it harm people to label them as “addicted” if they aren’t addicted?

It has been shown to harm a patient to erroneously give them a diagnosis of addiction. If doctors see the word “addiction” anywhere in the chart, patients are treated with less compassion and respect. For example, they are less likely to be given painkillers if they are suffering from chronic pain, for fear of worsening an addiction (that they don’t have). It can also lead to medical neglect and mistreatment if the caregivers assume the symptoms are due to an addiction (that they don’t have) instead of due to another condition that they might have. This is called “diagnostic overshadowing.” A misguided label of addiction can greatly undermine trust between doctor and patient.

A false label of addiction can also interfere with employment and can cause or worsen legal problems. It can also saddle the patient with stigma and can cause psychological distress and feelings of low self-worth. It can interfere with custody of children if, for example, the patient is given a drug screen (to monitor an addiction they don’t have), which can be falsely positive. This means that the test erroneously shows the presence of a drug (that was never consumed). This happens not infrequently, because other prescription and over the counter drugs can cross react and can make it look like a drug was taken. A “false positive” drug test result can then trigger a cascade of negative consequences including loss of custody of children.

A path forward

How can we move beyond all this confusion about cannabis addiction? A good place to start would be to acknowledge that cannabis is a vital medicine for tens of millions of Americans with conditions such as pain, anxiety, insomnia and cancer-related symptoms. Then, we can add a “cannabis exception” to our definitions of cannabis addiction, just as we do for opioids and other medications. This would make our definitions of cannabis addiction much more accurate, especially for medical marijuana patients.

We can’t continue to unjustly label patients as addicted to cannabis when they are using it medically, without problems. This is an extremely destructive practice. At the same time, we do not want to miss genuine cannabis addiction which needs to be addressed and treated. By fixing our definitions of cannabis addiction, and by educating doctors and patients alike on this issue, we can avoid a tremendous amount of unnecessary suffering.

Many physicians still think cannabis isn’t a medicine because people smoke it. Or, that smoking is the only way to consume medical marijuana. One friend of mine, a psychiatrist at Harvard Medical, bellowed at me, “how can a burning plant material be a medicine?” He then stormed away.

To be fair, the majority of patients who use currently use medical marijuana smoke it. Often, when medicinal cannabis is shown in a news article, the picture that accompanies it is that of someone smoking a joint and exhaling a huge plume of marijuana smoke. This furthers the erroneous belief that using medical marijuana is equated with smoking marijuana.

The concern about people smoking cannabis comes from a genuine worry about the effects of smoking. Cannabis smoke, just like tobacco smoke, contains harmful combustion products such as tar and polycyclic aromatic hydrocarbons. These can be dangerous for one’s heart and lungs, potentially causing chronic bronchitis and coronary difficulties. Many of the harms of cannabis come from the smoking of cannabis, not from the use of cannabis itself. There are few circumstance where it is, on balance, a reasonable idea to expose one’s lungs to toxic combustion products. (If someone is dying of cancer and finds smoking to be the most effective way to alleviate the nausea and vomiting of chemotherapy, or the pain from the cancer, then obviously, smoking is reasonable.)

There are many other, commonly used, and safer ways to consume medical cannabis. For example, people often use edibles, such as pills, gummies, or chocolate. These do not provide the instant symptom relief that smoking cannabis does.

The effects of smoking are felt immediately, where as an edible can take up to an hour to kick in. Edibles provide much longer lasting relief. Smoking typically alleviates symptoms for 2-3 hours while edibles can provide relief from conditions such as pain or insomnia for 6-8 hours. The only challenge with edibles is finding the correct dose as you do not want to take too high of a dose. This can cause extreme anxiety and, potentially, other health problems such as arrythmias. This is why, when we start people on medical marijuana, particularly edibles, we “start low and go slow” to get people to a safe and effective dose. Once you know the dose of edible that works for you, that typically remains the same and remains an easy, reliable consumption method.

(Note: people must store their edibles safely, away from small children, especially if they are in the form of gummies or chocolate.)

Under the tongue tinctures are also a safe and effective way to consume cannabis. You just put a few drops under your tongue, and it takes effect within 20-30 minutes. Tinctures provide relief for 4-6 hours and, as such, are an intermediate option between smoking and edibles. Tinctures provide a very easy way to precisely calculate the dose you are taking by reading the label and calculating how many drops you need. And they conveniently can be mixed with other components of cannabis besides THC, such as CBD. CBD and THC work extremely well together. For example, one might buy a tincture with a 4:1 ratio of CBD:THC and then work one’s way up slowly to an effective dose.

In my clinical practice, I try to steer patients away from smoking cannabis. I explain in detail how tinctures and edibles are safer and can provide longer-lasting symptom relief. As always, as a primary care doctor, some patients choose to listen to me and others don’t. I have had many chronic pain patients who have discovered that edibles are far more effective than smoking because they provide pain relief for 6-8 hours. This results in an improved quality of life as one isn’t puffing on one’s vape pen every few hours for symptoms relief.

Besides edibles and tinctures, there are many other methods of cannabis consumption. Topical formulations, such as creams and ointments with THC or CBD in them, when rubbed on painful joints, can help alleviate arthritis pain. Topical preparations have no psychoactive effects (no “high” that accompanies their use). People are increasingly using vaginal suppositories (e.g., for endometriosis) or rectal suppositories (e.g., for Ulcerative Colitis) under the theory that it is effective to put the medicine directly where it needs to go. There are also inhalers (just like for asthma), skin patches, and seltzers and sodas. With some guidance and careful experimentation, each person can find what works best for them.

About ninety percent of Americans support legal access to medical cannabis. It is difficult to think of any other issue that ninety percent of Americans agree upon. Fewer doctors remain opposed to medical marijuana each year as they learn more about it, and witness how effectively their patients use it to treat their chronic pain, anxiety and insomnia. Yet, many stigmas and misperceptions remain, mostly from the long shadow of the War on Drugs. The stigma is being lessened as an increasing number of patients find cannabis to be safer and more effective than traditional pharmaceuticals.

While many people do smoke cannabis, this is by no means the only, safest, or most effective way to consume it. There are many other healthier, more convenient, and effective options.

As our society continues to view cannabis as less of a harmful drug and more of a useful medicine, we will continue to make progress in educating patients on the benefits of using these alternatives to smoking cannabis.

One of the reasons I wrote Aging Well with Cannabis is that countless people are struggling to learn how to safely incorporate cannabis into their medical care. Whether it is an aging parent, a spouse or a friend, many patients are eager to address their chronic pain, their poor sleep, or their anxiety with cannabis.

The cannabis conversation gets confusing very quickly: THC, CBD, edibles, tinctures, dosing, side effects, drug interactions. All of these factors are important. But the real question is: how can cannabis help someone suffer less and live more fully?

That is why I want to share a few disguised patient stories from my clinical practice to show what thoughtful cannabis use can look like.

Anne was in her early fifties, and in excellent health, when she started to develop angry red bumps on her torso, back, and arms. The bumps continued to spread over several other parts of her body as well and began to keep her up at night because they were so itchy. Antihistamines such as Allegra, Zyrtec, and Benadryl had little effect. The more Anne scratched, the more the bumps itched, but she couldn’t help scratching them. She was going out of her mind. The lack of sleep and constant torture affected her mood. Her anxiety and depression started to skyrocket, and she was snapping at the people she loved.

Anne tried to see her dermatologist, but he was busy and pawned her off on an inexperienced nurse practitioner. Anne was misdiagnosed as having eczema and was given a moderate-strength steroid cream that didn’t do much. She saw the nurse three times, who reiterated the misdiagnosis and slightly increased the strength of the ineffectual creams she’d prescribed. The problem went on for over a year and even turned a highly anticipated family vacation to Europe into a disaster. Nothing worked to help alleviate the itchiness. The industrial strength steroid pills Anne was eventually given didn’t do ­anything, either.

The only thing that provided relief was smoking cannabis, although I recommended that she use an edible or a tincture instead, as these are easier on the lungs. Within seconds to minutes of Anne’s taking the first puff, the itchiness would get much better.

It didn’t go away entirely, but it was diminished to the point where Anne could ignore the itching for hours on end. She was even able to get some sleep at night, although it was often intermittent, as smoked cannabis only lasts for several hours. After a while, Anne started taking edibles before bed, which gave her more long-lasting relief.

Finally, tired of this chronic condition, and of needing to rely on cannabis every night for partial symptom control, Anne insisted on seeing her physician dermatologist. After looking at her skin for two minutes and doing a quick biopsy, he diagnosed her with guttate psoriasis, a super-itchy, inflammatory type of psoriasis. He gave her an effective pharmaceutical regimen for this condition, which cleared it up right away. Now, Anne only uses cannabis when she has a flare-up while she is waiting for her traditional meds to beat back the psoriasis.

Judith is a spry ninety-three-year-old, who is active and mentally clear at baseline. Each day, she walks farther than most twenty-year-olds. She started having severe upper back and neck pain, which was keeping her up at night. I advised her to see her primary care doctor to make sure that nothing serious was going on and to purchase an ergonomic pillow. She was diagnosed with cervical arthritis.

Because Judith was on a blood thinner, she couldn’t take NSAIDs, and she didn’t wish to get a steroid injection. She was afraid to try opioids due to noxious side effects, which included falls and constipation. Tylenol didn’t have the slightest impact on her pain. Her doctor tried Tylenol with a small dose of codeine, and also tried gabapentin. Although those medications succeeded in blunting Judith’s symptoms, they also saddled her with unpleasant side effects, such as excessive daytime grogginess and constipation.

I started Judith on one-half of a 5-milligram gummy, a mere 2.5 milligrams of THC. For context, one puff of today’s strong marijuana contains about 5–10 milligrams of THC. I reminded Judith that it would take forty-five to ninety minutes to absorb the gummy and feel the effects. I warned her not to take a second dose that evening. I didn’t want her to make the rookie mistake of taking a second dose of an edible before the first one kicks in, because that can make you feel unpleasantly and overly intoxicated.

I nag patients about this all the time, as I don’t want them to take too large a dose, have a bad outcome, and then be turned off from the entire endeavor. If you wish to increase the dose of your edible, it is best to do so the next day, not thirty minutes after taking the first dose, because it can take up to ninety minutes to be fully absorbed.

When purchasing gummies, or if your kids provide them, or if someone hands you a marijuana brownie, please confirm the dosage before consuming them, and confirm that they are, in fact, the dose you are expecting. You do not want to take too much.

Standard gummies contain 5 milligrams, which is in the right vicinity of the dosage you’d want to start with, although I often have people start with half of one gummy, 2.5 milligrams. Marijuana dispensaries sell much stronger gummies, so it is imperative to confirm the dose before purchasing them. Avoid homemade edibles, especially if you aren’t absolutely clear on the dose.

With the gummy, Judith’s back and neck pain was completely alleviated. She could wake up without pain, enjoy her yoga and exercise classes, and walk around without suffering. As for side effects, she said, “I haven’t slept this well since I was a teenager, and I wake up in such a good mood.” She no longer needs Tylenol with codeine or the gabapentin that her doctor gave her—which were unpleasant to take.

Judith’s back pain got somewhat better with physical therapy and, as time went on, she only needed to use one gummy about three times per week, which was an improvement for her pocketbook. Judith had no negative side effects from the gummy and reported being mentally clear upon awakening.

In the end, medicine is just as much about alleviating suffering as it is about diagnosing and treating diseases. Medical cannabis has tremendous potential to help us do this. Doctors are seeing their older patients do well on medical marijuana and are learning from them. Aging has specific maladies and symptoms. Joints ache and sleep becomes more difficult.

With the use of cannabis, millions are becoming more comfortable and more able to pursue the activities they most enjoy. I am looking forward to medical marijuana being increasingly incorporated into modern medical care.

Most of us have experienced insomnia and know what a miserable experience it is. I have been an insomniac my entire life and am familiar with lying in bed waiting for sleep to arrive much as Linus waits for the Great Pumpkin to appear.

Insomnia is a particularly common problem for older adults, because our sleep worsens with age. Up to 50% of seniors report symptoms of chronic insomnia. Very few doctors will consider using medical marijuana to help seniors with this excruciating condition.

Is this a mistake? Can medical cannabis safely help elders overcome insomnia?

The hesitancy to recommend medical cannabis comes from a place of genuine concern. Cannabis, like all other medications, has side effects and potential harms. Some of these can particularly affect older patients, such as temporary effects on short-term memory and on balance and coordination. Many doctors don’t possess much practical information about medical marijuana, which makes it difficult for them to helpfully advise patients about it. When patients ask about it, the doctors are usually caught flat-footed, leaving patients without a reliable source of information. This leads to a big disconnect between the 22 million adults that are currently using medical marijuana for sleep and their care providers.

Current options for insomnia

When treating insomnia, doctors start with lifestyle interventions. My first step is to always counsel people to exercise and to avoid excess caffeine. I make sure that they are doing something relaxing before bedtime. I inquire about medical conditions that might interfere with sleep such as needing to get up during the night to go to the bathroom or suffering from chronic pain. There are effective behavioral treatments for insomnia such as “Cognitive Behavioral Therapy for Insomnia”, but these can be time-consuming and difficult to access. Most patients are eventually interested in a pharmaceutical treatment for their insomnia.

Most of the medications we prescribe for insomnia succeed in putting people to sleep but are plagued by very severe side effects. All of these medications are more dangerous in older adults.

Take for example, drugs like Ambien (zolpidem) and the other “Z-drugs” (Lunesta, Sonata). These can potentially cause worsening dementia, falls, confusion, and amnesia. They also can cause complex sleep behaviors such as sleepwalking, sleep-eating, and sleep-driving. Not safe for elders! Likewise, common drugs like trazodone (Desyrel) can cause falls, lightheadedness, morning grogginess, dry mouth, and, potentially, cardiac arrhythmias. If you look at the other common sleeping medicines that are prescribed for older patients, such as the new orexin inhibitors (like Belsomra or Dayvigo), or benzodiazepines like diazepam (Valium, Ativan), or even the commonly used diphenhydramine (Benedryl/Tylenol PM), they all have similar, worrisome side effects.

Clinical successes with cannabis

I have been treating patients with medical cannabis for a quarter of a century. The most common ailments I recommend it for are chronic pain, anxiety and insomnia. After decades of stigma and silence, it is amazing to see how enthusiastic older patients are about discussing medical marijuana. And – this is for good reason. It is helping them with their arthritis pains, their anxiety, and their sleep. This is why the fastest growing demographic of cannabis users currently is patients over 65 years old.

Many of my older patients are rightfully leery of the side effects of their traditional sleep medications. The don’t like the confusion, the “hangover” the next day, the dizziness when they get up to go to the bathroom at night, or the dry mouth. They are increasingly concerned about the risk of falls or worsening dementia.

With a modest but appropriate dose of medical cannabis, patients often find themselves enveloped in a gentle, relaxed euphoria as they drift off to sleep. We usually start with just CBD which is a non-intoxicating component of cannabis that helps people to relax and fall asleep. CBD is extremely well-tolerated. If the CBD alone does not work to provide the patient with a restful night’s sleep, we often add just a little bit of THC, which works well with the CBD. THC is the main intoxicating component of cannabis, so we keep the dosages low when treating insomnia.

I can’t tell you how many patients I have successfully transitioned off these more dangerous pharmaceutical sleeping pills by introducing them to medical cannabis. Patients rarely, if ever, complain about any kind of hangover the next morning. Cannabis is particularly effective when insomnia is accompanied by chronic pain, as it works to alleviate the symptoms of both conditions simultaneously.

We don’t recommend smoking cannabis as it is much better for the lungs to use an edible or a tincture. The most important rule when starting medical cannabis is to manage the dose carefully, to “start low and go slow”. It is extremely important to avoid taking too high a dose of cannabis right away as this can be uncomfortable and, possibly, dangerous.

Harms to avoid with medical cannabis

There is no free lunch with any medication. All medications have side effects and harms to watch out for. Cannabis is no different. These side effects are much more likely to occur when using THC than when using just CBD. With cannabis, one might experience any of the following:

• Temporary change in mental status

• Lightheadedness that can affect balance

• Temporary worsening of short-term memory

• Potential cardiac events such as arrhythmias (especially with a large dose of THC)

• Anxiety and spaciness (if the dose of THC is too high)

• Medication interactions (especially with high doses of CBD)

• Addiction

Older adults don’t process any medications as well as younger patients do due to changes in their livers and kidneys as they age. They have to be particularly careful with cannabis – as well as with other medications, to avoid side effects. We also don’t yet have adequate research into how cannabis affects the different cycles of sleep or how it effects sleep over the long-term.

In my experience treating people medically, using low-ish dosages of THC, these side effects are rare, and when they occur, quite modest. We tend to see them more commonly in “recreational” cannabis users who pursue much higher doses of THC. For example, I haven’t had a single patient fall down or develop a cardiac complication when using a modest dose of medicinal cannabis. I find that these side effects can be minimized with a couple of common-sense measures:

1. Close follow up of patients by provider

2. Careful communication between providers and patients

3. Starting with CBD only

4. Keeping the doses of THC on the low side

5. Very slowly advancing the dose of THC at the beginning of treatment

6. Educating patients on what to expect and what to watch out for

7. Consideration of any potential medication interactions such as if taken with other sedating medications

Over the years, I have had better luck treating patients with medical cannabis than I have, overall, with traditional pharmaceutical sleeping pills. I also transition patients from Ambien, Benadryl, or trazodone to medical cannabis when they are experiencing side effects. There is no concern that cannabis contributes to dementia.

Let’s change our framework

It doesn’t make sense that physicians recommend more dangerous medications to alleviate insomnia. They do this for a variety of reasons: habit, pharmaceutical company influence, hangover from the War on Drugs, and a deficit of knowledge around how medical cannabis can be helpful.

Cannabis, like other medications, is a tool. It is not a cure all. It doesn’t work for some patients. Others hate the feeling of being impaired (if THC is used). Some patients develop side effects from cannabis and simply can’t tolerate it.

Yet, as millions of patients are discovering, cannabis can help seniors flourish by enabling them to sleep well, without hangovers, and without many of the common, noxious side effects of traditional pharmaceuticals.

Quality sleep is the key to cognitive health, good mood, and physical well-being. It is essential to one’s quality of life. All doctors who treat insomnia ought to have cannabis in their toolbox and need how to utilize it effectively with patients.

(This blog is not meant as an inducement to try or use recreational drugs. Rather, it is intended as more of a reality check on prevailing professional attitudes toward these behaviors.)

When studying for my addiction boards last year, it would have been hard to miss a strong ingrained bias in the addiction medicine curriculum, which runs along the lines: “all drug use is misuse.” This attitude, which comes from a place of deep concern, doesn’t reflect how people use drugs, including cannabis, in the real world. This framework seemed to be applied to most of the drugs we studied in the addiction curriculum – except for alcohol, where misuse was defined as excessive use, and modest use wasn’t criticized.

Addiction specialists, among other clinicians, witness the ravages that extreme drug use can cause, including the harms from cannabis addiction. We tend to see, in our addiction clinics, the most extreme, life-threatening cases that reach the level of needing urgent, intensive care.

What is overlooked is that some people who use cannabis, as well as other drugs such as MDMA, magic mushrooms, and other psychedelics, use them without harm, and often with benefit.

One can also miss the fact that not every person who tries cocaine, heroin, and even methamphetamine gets addicted. For example, an estimated 41 million people aged 18 years or older reported lifetime cocaine (and 5.4 million people used cocaine in 2019), and there are an estimated 1.1 million Americans who are classified as addicted to cocaine.

One exception is tobacco, as, according to this paper, “Over two-thirds of people who try one cigarette become, at least temporarily, daily smokers.” It is difficult to not agree with the idea that with tobacco, all use is misuse

The idea that “all use is misuse” ignores the broad spectrum of drug use and doesn’t account for several important facts:

1. Most people who use drugs, most commonly alcohol and cannabis, and particularly psychedelic drugs, do not get addicted.

2. People often use cannabis, and other drugs, such as psychedelics with perceived benefit, both medically, and in terms of social growth and lifestyle enhancement.

3. Most people who try cocaine, opioids, or even methamphetamine, do not get addicted to them (although, these are obviously extremely dangerous drugs and their recreational use ought to be avoided).

4. There is a wide spectrum of use for each of these drugs, which ranges from occasional, recreational use, to damaging chronic, addictive use.

5. Caffeine is a drug that many of us are addicted to, and which can cause heartburn, anxiety, palpitations and insomnia. No one is judging or trying to shame caffeine users, or to suggest that all use is misuse.

It is interesting to me that alcohol didn’t appear to be discussed in the context of “all use is misuse”, even though alcohol is a far more dangerous drug than cannabis. Alcohol contributed to 178,000 deaths in 2024 while cannabis use is not deadly. Alcohol is discussed more in terms of, “use is OK as long as you don’t use too much or get addicted.” Is alcohol treated differently from the other drugs because it is socially acceptable, after a century of its being legal? Is it because alcohol is the only mind-altering drug that doctors (who decide these norms…) are allowed to consume? Moderate alcohol use is widely accepted – even among clinicians – despite increasingly clear risks, including, recently, a focus on the carcinogenic nature of even low levels of consumption.

Cannabis, and most other drugs, are held to a different standard.

In my experience, drugs and medicines are almost always a double-edged sword. At the addiction clinic where I work, we see the worst-case scenarios of all kinds of substance misuse gone amok. The worst culprits are alcohol, opioids (including kratom), methamphetamine, cocaine, and other stimulants.

We treat cannabis addiction as well, with compassion and skill, though cannabis misuse is often obscured by the mayhem caused by these harder drugs. If one were to shadow a clinician at the addiction clinic, and to witness these broken lives, one could easily conclude that “all drug use is misuse.” There is no silver lining to these cases. There is no benefit whatsoever. The drugs worsen everything in these patients’ lives, including their health, their employment, their family and social ties, and their housing. It is miserable and ugly. It is from an incredibly compassionate place that the addiction physicians want to protect people from these horrible outcomes.

At the other edge of the spectrum, in my primary care practice, I have treated thousands of patients over the years with medicinal cannabis. Cannabis is obviously not without potential harms, including addiction, hyperemesis, accidental overconsumption, and mental status changes. Yet - this is only part of the picture.

I routinely treat a variety of conditions with medical cannabis in a way that is highly beneficial to patients, and which requires the use of fewer traditional pharmaceuticals. Traditional pharmaceuticals can often have more noxious side effects and can be more dangerous than cannabis. For example, it is a win when we can treat chronic pain with cannabis instead of with opioids, which can cause overdoses, falls, addiction, and constipation. I think cannabis is safer than many of the over-the-counter NSAIDs (such as ibuprofen/Advil or naproxen/Aleve) as these frequently cause gastritis, ulcers, heart attacks, and kidney damage. Cannabis is often the safer choice, especially if used cautiously, in low dosages and with careful monitoring. The use of cannabis, in this context is counter to the notion that “all use is misuse”.

I have always believed that people should have the right to experiment with their own consciousness so long as they are not harming others. In other words, if they are not driving under the influence, shirking responsibilities, or becoming violent, obnoxious, or disruptive. I have written elsewhere why I think most drugs, including opioids, should be decriminalized. The costs of the War on Drugs, and on arresting people for using them (historically, mostly people with Black and brown skin…) usually outweigh the harms, overall, from the drugs themselves. In many cases, the criminalization makes the drugs more dangerous. Prohibition makes the drug supply unsafe (i.e., much of it is now contaminated with deadly fentanyl), drives the drug use underground, and makes it more difficult for people to ask for help if they are losing control or suffering adverse consequences.

Many people who consume recreational drugs use them in a self-directed, medicinal, or spiritual way without problems. For example, there is a large psychedelic community that uses MDMA (“ecstasy”), psilocybin (“shrooms”) and other psychedelics, including ketamine, with great benefit in many different spheres of life (medical, social, spiritual).

There certainly are potential harms, and people can have awful, even traumatic experiences. But, overall, people use these substances willfully, are educated about the risks, and have positive or meaningful experiences, or at least experiences that they find valuable and learn from.

There are drugs and there are drugs. It is difficult to argue that any methamphetamine or PCP use is beneficial. Arguably, one could say the same thing about cocaine, which is a selfish drug if there ever were one. I obviously don’t recommend cocaine use, which can cause coronary issues and paranoia/psychosis among a wide array of other health effects. However, I have known many people over the years who have done it without problems and have enjoyed it. Should it be criminalized? Probably not, as criminalization causes more problems that it fixes.

Alcohol is nuanced. Of course, prohibition of alcohol was a disaster which resulted in poisoned supplies and wealthy criminals (just like today’s prohibition of other drugs does). No one wants to recriminalize alcohol. Alcohol can help people to relax, to blow off steam, and to overcome social anxiety and awkwardness. It is also incredibly addictive (though only a fraction of people who try it get addicted). I agree with the addiction field that “not all use of alcohol is misuse”, but it’s odd how this applies to alcohol and not to many of the other drugs, which may have lower hazards associated with their use.

Here if a recent chart where experts ranked the relative risks of all drugs. Alcohol is on the top of the list, above heroin, crack, methamphetamine, and cocaine.

Some of this is a question of framing. Substance use exists on a spectrum. Reducing it to “all use is misuse” may sound straightforward, but it doesn’t reflect how people actually live — or how we should be thinking about their care. This kind of binary thinking may feel decisive, but it obscures more than it clarifies. It can make it harder for patients to have honest conversations about their use and to get the help that they need.

Instead of anchoring ourselves to an outdated notion, heavily influenced by the War on Drugs, that “all use is misuse”, maybe we should focus on the difference between controlled versus worsening use. How do you know when drug use is getting out of control? (We addressed this in an excellent blog written with the help of my wonderful wife Lizzi).

Are the drugs helping or harming the situation? According to whom? (Many people who are addicted will erroneously claim the drugs are beneficial – I certainly would have claimed that during my opioid addiction twenty years ago). Are there any objective benefits to the drug use (e.g., like overcoming trauma with MDMA or overcoming a depressive episode with ketamine)? Is the quality of life improving, staying the same or worsening? How about one’s physical health?

There would be many benefits to pursuing a less judgmental, and more realistic, attitude towards the reality of the drug use. In the United States alone, tens of millions of Americans yearly use illegal drugs. If you include the “good” or “accepted” drugs such as coffee and alcohol, hundreds of millions of Americans regularly consume drugs in the United States.

We can narrow the current divide between seemingly out of touch healthcare providers and patients who feel judged and misunderstood. This would open avenues of communication. It would help bring drug use out into the open and make it easier for people who are struggling to ask for assistance. It would lessen stigma. It would open the door to harm reduction – helping people who use drugs avoid negative outcomes like infections and overdoses. A frame shift in our attitude toward drug use and users would save lives.

As we age, we accumulate wisdom and life experience. Unfortunately, we also accumulate medical symptoms, diagnoses and prescription medications. This is why it is commonly said that “aging is not for the faint of heart.” With advancing age, our joints ache and it is increasingly difficult to get a good night’s sleep. We contend with anxieties around our kids, our health, and our finances. Senior years can be a lonely, isolating time. We are susceptible to developing diseases such as Parkinson’s Disease, arthritis, or God forbid, some type of cancer. We even deal, in the back of our minds, with the eventual specter of end-of-life care.

These conditions are extremely uncomfortable to go through. Modern pharmaceuticals treat these symptoms imperfectly at best – and can have a whole host of uncomfortable and potentially dangerous side effects. This is where cannabis comes in.

Medical cannabis is a plant-based product that has been used by humans for at least five thousand years to successfully treat symptoms of various diseases. In the United States, marijuana is legal for medical use in forty states. While it can be smoked, this is not healthy for your lungs or your heart. Most doctors recommend an under the tongue tincture, a small-dose edible (such as a gummy), or a topical preparation.

The key to starting medical cannabis is to “start low and go slow.” We often start patients off with just CBD. CBD is the non-intoxicating component of cannabis that people find helpful for anxiety, insomnia and chronic pain. If CBD alone isn’t strong enough, we add a small dose of THC. We do this cautiously.

It can be uncomfortable to take too high a dose of medical cannabis when just getting started. For example, one puff of the cannabis that you would buy in a store has about five to ten milligrams of the active ingredient THC in it. With older patients, I often start them on 1-2.5 milligrams of THC, using a tincture or a low-dose edible. They then work their way up slowly from there.

Chronic pain

One of the most common symptoms that I treat with medical cannabis is chronic pain. Modern medicine doesn’t have many safe and effective tools for treating chronic pain. No one wants to be on opioids these days if they can avoid it, with the addiction, the constipation, and the overdoses.

Tylenol often doesn’t have much of an effect. The non-steroidal drugs like ibuprofen (Advil), naproxen (Alleve), or diclofenac (Voltaren) can cause heart attacks, bleeding, ulcers and kidney damage. Gabapentin isn’t particularly effective and makes people feel as if their brains have been plucked from their bodies.

Patients often find that a modest dose of medical cannabis can “take the edge off the pain”. They find that they can still feel the pain, but they are not nearly as bothered by it. This helps them participate in activities that are meaningful to them which means that they are focusing even less on their pain. One’s quality of life can be drastically improved.

Cannabis is certainly not free of side effects and potential risks – no medication is. Yet, cannabis is often better tolerated and more effective than these other options for pain control. This is why so many seniors are embracing medical cannabis. It is particularly helpful for nerve pain, the types of pain that come with conditions such as fibromyalgia, arthritis, and migraines, and for cancer-related pain.

Anxiety and depression

Many people use cannabis to help alleviate their anxiety and depression. With anxiety, cannabis is “biphasic”, meaning that it tends to alleviate anxiety at low doses and can potentially worsen it at higher doses. This is, again, why it is important to “start low and go slow” when you are getting started on medical cannabis. Many people report an immediate decrement in their anxiety and a gentle euphoria which uplifts their mood. However, it is not clear what cannabis does over time to one’s mood and anxiety level. This is also the case with the common anti-depressants we use to treat mood and anxiety such as Prozac, Celexa, Effexor, or Lexapro. People with mood disorders need to be aware of the possibility of becoming overly dependent on cannabis. If they start using more or losing control of their use, they should speak with their physician immediately.

Cannabis can also serve as a social lubricant which can help people get out of their homes, out of their shells, and out of their ruminations. All of this can be immensely helpful for one’s mood.

Insomnia

Insomnia is a painfully common condition in our society, especially for elders. They can have more trouble falling asleep and staying asleep. They can wake up early. They may have to use the bathroom in the middle of the night. Traditional sleeping pills like zolpidem (Ambien) or diphenhydramine (Benedryl/Tylenol PM) can cause falls, confusion and can worsen dementia. The tricyclic antidepressants we use to help elders sleep (Elavil, Trazodone) can cause dizziness, falls, arrythmias, and dry mouth.

Many people find that, if they take some gentle, non-intoxicating CBD, they can drift right off to sleep. If this isn’t strong enough, they might add a small amount of THC to help them turn off their minds. Unlike with traditional pharmaceuticals, people tend to wake up relaxed and not hung over when they use cannabis for sleep. Of course, cannabis, particularly the THC component, can cause a “high” and must be used with extreme caution in patients with memory or balance issues (especially, for example, with patients who have to get up and walk to the bathroom in the middle of the night).

Other uses

Cannabis can be extremely effective at alleviating the nausea and vomiting that accompany chemotherapy, or radiotherapy, when cancer is being treated. It can also help with the pain, anxiety and insomnia that accompanies a diagnosis of cancer. It has also been proven effective for the alleviation of muscle spasticity in multiple sclerosis. People with Irritable bowel syndrome and other types of maladies that affect the colon find that it can give symptomatic relief. It can also help with poor appetite and weight loss.

Future directions

Patients over sixty-five years old represent the demographic where cannabis use is growing most rapidly. This is because they are discovering that cannabis can help alleviate many of the above symptoms.

It also can help elders with the “polypharmacy” that older patients are subject to – the proliferation of prescription medications that one is supposed to take. Polypharmacy can be dangerous, confusing and expensive – it is easy to make a mistake if your medication regimen is complicated. Cannabis can often help treat several symptoms at once and it might replace some of their more traditional pharmaceuticals.

Due to our unfortunate War on Drugs, there has not been enough research on the safety and efficacy of cannabis in elders. Much of the above information that we have comes from reliable patient reported outcomes and population data. We need to better study and monitor how cannabis can be used safely in an older population to avoid potential pitfalls such as dizziness, falls, confusion, and accidental overconsumption. As time goes on, I am looking forward to the appearance of more rigorous scientific testing.

We also need to educate doctors – who are woefully ignorant about cannabis. If doctors knew more about cannabis, they could be more active in sensibly helping and advising patients. Despite this lack of knowledge, I still strongly encourage you to let your doctor know about your cannabis use, so they can help you watch out for drug interactions and side effects.

Cannabis is a new frontier in the treatment of the torturous symptoms of aging. I am unbelievably excited to continue to work with older patients. We will continue to fine tune this treatment so that we have even better outcomes.

The idea for this piece came from my incredibly brilliant wife Lizzi. The ideas are mostly hers. She has been with me for the addiction journey since we first met in 2009 and has developed a unique, intuitive knowledge of these issues. Her day job is as a Data Engineer (whatever on Earth that is!) and her passion is as a licensed wildlife rehabilitator (her expertise is in Southern Flying Squirrels) at Return2Wild.

Most of the tens of millions of Americans who use illegal drugs every year don’t get addicted. Most of the 174 million people who use alcohol don’t get addicted. Yet, millions of drug and alcohol users do get miserably, even fatally addicted.

How can you tell if your family member is reasonably enjoying alcohol or illicit drugs responsibly - or if they are developing a major problem?

If you follow the literature of addiction medicine, there is a judgmental undertone, that “all drug use is misuse.” Of course, they don’t have this double standard for alcohol, which has become so normalized that most people don’t remember that it is a drug. In the world of actual people who use drugs (including alcohol), it simply isn’t the case that all use is misuse. Far from it.

While this blog does not advocate the use of illicit drugs per se, the author truly believes that people have the right to experiment with their consciousness -- as long as they aren’t hurting themselves, others, or shirking responsibilities. In the author’s humble opinion, drugs should be legalized, regulated, and openly discussed, not criminalized. People use drugs anyway, and the illegality of drug use makes it much more dangerous (I have discussed this in detail in other blogs).

Many drugs are exceedingly reinforcing. To name a few, cocaine, opioids, methamphetamine and Ecstasy, can cause relaxation and euphoria. Why some people get addicted, and others don’t, from the same drug use, is an open question. A person’s use may start out as a welcome relief from the stresses of daily life, but it can quickly devolve into a serious, even life-threatening addiction. Tens of millions of Americans suffer from one or another substance use disorder during their lifetimes. These can be life threatening, especially if they involve alcohol, methamphetamines, or opioids. Cannabis addiction is also a serious problem that can derail lives, even if it isn’t life-threatening like the others.

The field of addiction medicine has formalized ways to diagnose addiction, or “substance use disorders”. These criteria have to do with qualifying for a certain number of categories that generally revolve around loss of control and usage despite negative consequences.

On an interpersonal level, it can be extremely difficult to determine whether someone close to you is using drugs or alcohol is a way that is reasonable, or which is potentially harmful. What are ways to determine if your loved one is using, and can use, different drugs, in a way that is (relatively) safe and sustainable to the relationship?

Here are some thoughts written down by my wife Lizzi (with some light editing).

Whether one is talking about chocolate ice cream or illicit drugs, the relationship of the person to the substance—not the substance itself—distinguishes substance use from disorder. (The analogy to chocolate ice cream would be binge eating.)

Key categories to consider relate to how you and your partner/family manage substance use.

Openness

Is there openness about the use? Do you have an open, transparent dialogue about the substance or does it involve ongoing struggles marked by secrets. The cornerstone is loving kindness and empathy regarding choices, even if you don’t agree with them. The goal is not to control the person choosing to use a substance, but, rather, to develop the language and reasonable expectations around how to communicate and proceed.

Trust and Transparency

Is there trust and transparency? Having transparency and discussions before acting is integral to building a trusting relationship around substance use. This gives agency to the partner and avoids ugly surprises. Is there open discussion of the challenges of substance use between the individual and their partner? (or, possibly, with other family members such as adult children). This criterion is necessary to establish whether the use is healthy or disordered. Things to pay attention to are any instances of being secretive. If you aren’t acting addictively, why would you be hiding bottles or pills from your partner?

Is it real, sincere transparency? Some people get very good at discussing their “problem”, as a way to justify and maintain it. This might involve continuing to use the drug harmfully while openly discussing how you are experiencing negative consequences. (When I was at Rehab, these were called “professional patients.”)

A good rule of thumb, for healthy drug use, is to discuss before acting. Before contacting anyone about supplying substances, be fully transparent with your partner and have a thorough discussion about the challenges and the risks. (The risks can be legal, financial or medical – risks that have ramifications for the entire family).

Urgency

Urgency is a red flag. Pressure surrounding a substance is a key factor distinguishing disorder from use. If use is simply pleasurable and fun, there is no urgency to obtain or use it. Use could be a fun option to share with close friends in order to build intimacy and connection. It should not be an urgent need that must happen today regardless of your commitments.

Documentation

Be open to fully documenting the experience. Anyone directly touched by your drug use, especially your partner, needs the opportunity to contribute to and discuss documentation, so that, for example, your mood can be tracked over time. (One common misunderstanding is that people feel that their drug or alcohol use is improving their mood, but use is actually worsening their mood over time). Be receptive to your partner’s observations. A loving partner can notice and provide the elements that help you develop insight. Use your partner’s observations to be curious about your use. Do not be in denial or closed off. Documentation can help distinguish any fears your partner has about your use from true observations.

Remaining stable and reliable

If a substance impacts your ability to be stable and reliable, especially during a time of intense challenge, it is unreasonable to independently decide to take a destabilizing substance and then expect your partner to provide support. Planning with your partner days or weeks ahead of time, provides your partner the ability to support you (i.e., to get you through the aftereffects of your drug use), and preserves your partner’s ability to accomplish their own priority projects. Repeated expectations that cause stress for your partner during your substance use—leading to periods of inability to work or focus, and subsequent stress where your partner must step in to help—are not fair without advanced planning and discussion. An example of this might be “Blue Monday” after Ecstasy use.

Communication

Be open and curious about how others experience you while you are using substances. Are they repeatedly expressing concerns or feeling frustrated because you are unavailable, or because you seem like a different person? Are you then stressed about falling behind on your goals or experiencing symptoms of anxiety, depression, or frustration? A continuous, documented dialogue allows everyone to help the person who might be struggling -- by providing insights to explore and ongoing measures, that distinguish unfounded worries from true experience.

Time

How much time do you spend thinking about, seeking, consuming, and dealing with the impacts of drug consumption? How much time does discussing the substance and managing its use take for both you and your partner?

Purpose

Are you seeking this substance because you feel stress, anxiety, or pain and want to avoid feeling alone? Or is it simply pleasurable without any consequences for its use?

Goals

Does this substance help you achieve your goals or hinder them? Think of your professional goals, or the goals you have forming a community or pursuing hobbies.

Connection

Does using the substance impact your connections? Are you using the substance instead of spending time seeking out community and developing healthy outlets? Are you consuming a substance alone, feeling alone, and then feeling desperate to be around others after use? Equally problematic: is the substance use done with a group you would not spend time with if you were not using the substance? Are you spending time with people that you aren’t truly interested in, because they facilitate your access to drugs? An example of this would be engaging in a conversation you have no interest in, in order to bum a cigarette.

Avoiding harms

If you are committed to using illegal drugs, you need to use precautions. You simply can’t afford to get into legal trouble or have a medical emergency while using them (such as an accidental overdose). The illegality of drugs makes it impossible to know if you truly have a safe supply. If you have any doubt that you have a safe, reliable source, it is not worth the risk. Always test your drugs with fentanyl test strips! (Even cocaine can be contaminated with fentanyl these days.)

The illegality of drugs is so profoundly counterproductive. If we provided a pathway toward a safe supply for those committed to consuming drugs, we could focus on substance use disorder treatment and more effectively help those who struggle.

Using drugs can profoundly impact those who care about you. Drugs are never used in a social vacuum. The above insights can serve as helpful guidelines. They can contribute to a shared understanding, and a shared belief system, about the drug use. They can help families and couples come to an understanding of whether the drug use is sustainable or destructive. Drug use impact can change over time, which is why it is important to keep communicating and being transparent.

These discussions are best conducted early in the process, before one starts to get addicted (and develops denial), lands in front of the judge, or finds themselves unemployed, divorced, or unhoused. Openness and honesty are critical factors in any recovery from addiction. The same principles, used far upstream in the process, can go a long way towards recognizing and addressing problematic drug use, before it eats its way through your life and family.

Thanks for the help and the idea Lizzi! Here is a photo.

Disclaimer: the cannabis industry is not one homogenous entity. This article is concerned with the corporate behemoths, the Multi-State Operators (MSOs,) such as Curaleaf and Trulieve, that are trying to dominate the cannabis market. It is not aimed at the almost 10,000 small businesses that make up most of the legal market in states and the hundreds of thousands of well-intentioned workers who participate in this industry and who help promote social equity.

In what universe does it make sense for the cannabis industry to be funneling millions to Trump? To help sway Trump towards his recent rescheduling of cannabis, in our current “pay to play” environment, different leaders of several different cannabis companies have donated huge sums of money to various of Trump’s Super PACs. It is beyond the scope of this article to discuss how Trump is destroying the very fabric of our democracy that supports any popular movements for social justice. The cannabis industry’s capitulation to, and support of Trump, is a profound betrayal of the millions who have made deep sacrifices to legalize cannabis over the last half-century. It blurs the once-simple battle lines of this immensely complex issue, at the worst possible time.

The present moment is a fraught time for the legalization of cannabis. We are currently suffering through a massive, nationwide anti-cannabis campaign. This blitz is being led by industry and Law Enforcement-funded Prohibitionists who wish to take away the freedom of responsible adults to consume cannabis. They are joined by a small but vocal group of opportunistic doctors who have no experience treating any of the millions of patients who benefit from medical cannabis. These Prohibitionist physicians magnify each of the potential harms of cannabis to the media. They do this in a way that distorts the context that most (but not all) people use cannabis helpfully and without problems — as is the case with all other medications.

The harms they cite, such as addiction, hyperemesis, psychosis, and accidental overconsumption are all legitimate medical concerns that we must monitor, prevent and treat. However, they make these side effects look like the rule not the exception. Just as is the case with cannabis, all medications have benefits and side effects. If, for example, with aspirin, we were subject to hysterical television commercials screaming about bleeding, ulcers and anaphylaxis, without the context that, overall, aspirin prevents millions of strokes and heart attacks, aspirin would soon be demonized and likely made illegal.

There are upcoming ballot initiatives in Massachusetts, Arizona and Maine to recriminalize cannabis. The last thing we need is to strip legal protections and access to a safe supply from millions of responsible adult cannabis users. These Prohibitionists seem to wish to return to the dark days of arresting Black people for cannabis possession, as Blacks are arrested four times as often as whites for this, despite similar rates of cannabis use. Over the last fifty years, more than 20 million people have been arrested for simple cannabis possession, mostly people with dark skin. This has been an unimaginable failure on all levels, a failure which legalization largely (if imperfectly) alleviates.

A half-century ago, the legalization movement, spearheaded by my father, Dr. Lester Grinspoon, consisted entirely of dedicated social justice activists. This is still true, to a significant extent, with wonderful groups like NORML, the Marijuana Policy Project, The Last Prisoner Project, and the Drug Policy Foundation working to maintain sensible drug policies.

However, with some large cannabis companies donating to Trump, and acting, in other ways, counter to social justice and the public good, the ethical landscape has become more nuanced.

What is ‘Big Cannabis’

The Prohibitionists argue that the cannabis industry is one homogenous entity that is fixated on getting teenagers addicted to cannabis so they will have abundant market share for generations to come. [It is unclear whether there are elements of the cannabis industry who are gunning for teens, and this must be monitored carefully. Teenage use has remained stable as we legalize cannabis.] The cannabis industry is more multifaceted than this. It is comprised of thousands of small businesses, many/most of which are ethical and pro-social. Many social equity licenses are involved in redressing the racial and economic abuses of the War on Cannabis.

According to a piece, written by one of my heroes, Shaleen Title, a tireless and brilliant advocate for social justice in the cannabis space (and director of the Parabola Center):

While states are making historic progress creating paths for small businesses and disenfranchised groups, larger companies are expanding, consolidating, and lobbying for licensing rules to create or maintain oligopolies.

So, several things are happening at once. “Big Cannabis”, a handful of large unhelpful companies, is trying to gobble up market share and to force all of the good players out. The Parabola Center has an “anti-monopoly tool kit”, which suggests ways to prevent the continued corporate consolidation of Big Cannabis, and which attempts it from being dominated by Big Tobacco, Big Alcohol, and Big Pharma.

Path forward

The fight against cannabis criminalization has always been a part of my life. I remember watching my dad work toward cannabis legalization throughout my childhood. I witnessed the transformative effects that medicinal cannabis had on my brother Danny, who was dying from leukemia. I have treated thousands of patients with cannabis, with gratifying results, getting them off alcohol, opioids, benzodiazepines, and other dangerous pharmaceuticals. Legalizing cannabis has been an almost unqualified success, with tax revenue and job created, arrests dropping sharply, and teen usage stable.

Anyone who believes in sensible drug policy, or in basic social justice, is currently gearing up for a fight in the three states where they are trying to strip away legalization. Legalization of cannabis is the right thing to do, ethically, politically, socially and medically.

What is complicated is when you have people you can’t and won’t work with on your “team” fighting alongside you. Big Cannabis companies that donate to Trump? No thank you. I likely wouldn’t share the stage with them or participate in any events they sponsor. (Like all corporations, they do a lot of virtue signaling.)

In the hierarchy of issues we face, some issues are far more important than others. I have fought for cannabis legalization my whole life, but one must look carefully at the present moment. Trump is actively pursuing the destruction of our democracy, the destruction of our climate, the unbelievable cruelty and human rights abuses of ICE, and the deliberate destabilization of our alliances (as of this writing he is trying to acquire Greenland at the expense of NATO). For these cannabis companies to support Trump is to wholly abandon any connection to the social movement that legalized cannabis in the first place.

This puts many of us in a bind. We need to support legalization without supporting these unethical companies, including but not limited to Curaleaf and Trulieve. Consumers can do their share. They can only buy from ethical companies. They can support small businesses that foster local economic growth and contribute to the public good. They can shun these large corporations. We need to force the cannabis industry to be ethical, including no advertising to teens, no unsubstantiated claims, lots of safe packaging, and responsible products. Otherwise, we risk losing momentum on legalization, which would be a disaster for millions of patients. And we will have to witness the ugliness of Big Cannabis continuing to devolve into the corruption, sleaze and anti-public malevolence of Big Pharma, Alcohol and Tobacco.

There is a big difference between the immense benefits of cannabis legalization and the potential harms of segments of the cannabis industry that are running amok.

Twenty years ago, when I was addicted to prescription painkillers, a pill was just a pill. If you crushed up and snorted a thirty milligram Oxycontin, the effects were predictable, even if the addiction itself was soul-crushing and life-destroying. It was difficult to overdose or to have a blackout if you knew what you were doing. I managed to have only one blackout during a decade of addiction…this is all in my memoir, “Free Refills” (spoiler: it was a disaster).

The current drug supply, the street supply, of pills ranging from oxycodone to Xanax (alprazolam), as well as other drugs, such as cocaine, is dangerously contaminated with fentanyl and dozens of other adulterants. People are literally dropping dead after taking one of these pills, or after one bump of cocaine. It is a lurid yet true demonstration of how the illegality of drugs, and the unregulated nature of the illicit market, are putting hundreds of millions of lives needlessly at risk.

Pressed pills from Hell

How do you end up with a pill that looks and feels exactly like a 30 milligram Oxycontin, but which is laced with fentanyl? Drug dealing, like all Capitalist enterprises, is strictly about the money. Fentanyl is not that expensive, and it is not that difficult to procure, in the big scheme of things. Drug distributers happened upon the idea that you can purchase machines that press powder into the shape of any specific pill you wish to sell. You then get a bunch of inert substances binders and fillers, such as talc or lactose, sprinkle some fentanyl in and, voila, you have a salable pill. It will look exactly like a Xanax or an Oxycodone.

This is a photo from a lab (that was busted…) where they were manufacturing some of these illegal drugs. Look at all the different ingredients they use, some of which are filler, and many of which are dangerous contaminants.

Many of these pressed pills are contaminated not just with potentially lethal levels of fentanyl, but are also adulterated with:

• Xylazine (a.k.a. “tranq”), which is a non-opioid sedative often used in veterinary medicine. It can contribute to overdoses and can also cause ghastly ulcers on the extremities that are extremely complex to treat (I’ll spare you the pictures of these wounds – I am a doctor, who is supposedly used to this stuff, and they gross me out…)

• Nitazines, which are an extremely potent illicit-market class of opioids, that are not approved for clinical use, which can be even stronger than fentanyl and which lead to a very high overdose risk

• Cocaine (yes, the pills are contaminated with cocaine, and the cocaine – see below – is contaminated with fentanyl)

• other substances such as methamphetamine, heroin, benzodiazepines (e.g., Valium, Xanax, Ativan)

It is impossible to overstate how risky this toxic brew of drugs is. These pills are abundantly available. We see people who use them all the time in the addiction clinic where I work. In 2023, 115 million counterfeit pills were seized by authorities. According to one report,

“At least one substance other than fentanyl^§§ was detected among the majority of patients (322; 91.5%). The substances most commonly detected with fentanyl were amphetamine/methamphetamine (66.2%), benzodiazepines (17.0%), and cocaine (5.1%).

Contaminated cocaine

Cocaine is a potent stimulant with many risks that accompany its misuse. It can be extremely addictive, and it can cause other medical problems such as psychosis, stroke, heart attacks, arrythmias, and seizures. Like all other drugs, it’s use would be far safer if it were legal and regulated, so that people don’t have to buy and use a contaminated product on the illicit market. Despite its illegality (because the “War on Drugs” doesn’t work…), millions of Americans use cocaine every year. The rates of cocaine use have stayed relatively constant, with past-year cocaine use around 1.4-2%. Yet, the number of overdoses has skyrocketed, due to a contaminated supply.

Take for an example an unfortunate doctor that I know. She recently did a line of cocaine, to get a lift when she arrived home after the end of an impossible shift. She ended up unconscious, only to wake up in the hospital about 8 hours later, after being resuscitated. Now, one can argue about the advisability of a physician using recreational cocaine. (Though, of course, one could argue that people should, in theory, be allowed to alter their consciousness as they wish, as long as they aren’t hurting anyone or shirking responsibilities – this debate is for another day). Sadly, this type of story of unintentional overdose is becoming increasingly common. For example a recent article in the LA Times, “Think you’re snorting a line of cocaine at that party? Think again,” discusses how,

• In a house on a Venice canal, three people who reportedly thought they were using cocaine died after apparently ingesting the powerful synthetic opioid fentanyl. A fourth person was hospitalized and survived.

It is not just potentially lethal fentanyl that is contaminating the illicit cocaine supply. There are dozens of other contaminants. One of the major ones is levamisole, which is used by veterinarians as a deworming agent. It is estimated to be in 69-80% of all cocaine entering the United States. It is a crystalline white power that looks like cocaine (so it is a convenient cutting agent) yet it is far from inert: it can cause a drop in your white cells (part of your immune system) and can cause rotting of the skin, especially on the ears and the nose.

No, the marijuana isn’t contaminated with fentanyl

One drug that hasn’t been shown to be widely contaminated with fentanyl is cannabis. The Prohibitionists/Law Enforcement Propaganda Machine has been citing cases of this for decades, but the reports are universally retracted. The police routinely state that there is fentanyl-contaminated marijuana, it gets into the media and scares people, and then the police are forced to retract it when the testing shows that there wasn’t ever any fentanyl. A recent example of this, “Police: Marijuana in Deadly Warwick Overdose Was Not Laced with Fentanyl” [as they had originally claimed, with no evidence, for the purposes of misinformation and propaganda]. (I fixed the headline!)

It doesn’t make any sense to put fentanyl in cannabis. It would be a waste of money for the dealers. It’s not what cannabis users are looking for. It’s not as if there aren’t enough cannabis users so that dealers need to put fentanyl into the cannabis to somehow get them addicted, in order to create more business (which is what law enforcement seems to be arguing). Further, you can’t really smoke fentanyl efficiently because it vaporizes at a relatively low temperature, which is why people typically inject or snort it. There is simply no incentive for anyone to waste their fentanyl by surreptitiously putting it into the weed they are selling. When we are discussing how fentanyl contaminates the street drug supply, we are not including cannabis.

Why do people keep taking these pills knowing they can be deadly?

This has to do with some of the basic hallmarks of addiction: loss of control and continued use despite negative consequences. When I was addicted, I would do the most irrational and dangerous things imaginable, out of sheer desperation, to avoid the miserable withdrawal symptoms. Our brains change with addiction, and immediate rewards become weighted much more heavily than longer-term consequences. People feel so awful when they are withdrawing, for example, from opioids, that they will take illogical risks to feel better immediately. That’s why people use dirty or shared needles, for example, and risk getting HIV or hepatitis C when, logically, this is a suicidal thing to do. It is the same phenomenon with pressed pills or with cocaine. Hypothetically, they can be contaminated or deadly but, immediately, people feel that they need relief from the misery they are suffering through.

What to do?

We need to decriminalize drugs! This is a complicated argument that I made in a piece in Time Magazine. In short, very few people would be dying from illegal fentanyl overdoses if patients with addiction and/or chronic pain had legal access to opioids - so that no one has to buy contaminated fentanyl on the streets. We can control and regulate this: we save suffering, save money, and save lives.

We also need to spend far more money on addiction treatment and much less on our utterly failed War on Drugs. Sadly, under Trump, despite a lot of virtue signaling on this issue, we are heading in the wrong direction. (Blowing up random ships in the Caribbean and murdering random people is not going to put a dent into our drug supply.)

People need to be encouraged to test their drugs. We should be passing out fentanyl test strips left and right. This is a misunderstanding that using things like test strips, to avoid overdoses, somehow encourages drug use. This is false. The Prohibitionists make the same argument against giving people clean needles to prevent HIV and Hepatitis C. There is not a shred of evidence that providing the means (i.e., harm reduction) to use drugs safely does anything except save lives. Providing safe supplies does not increase drug use. We also need to make Narcan readily available. This is the medicine that any bystander can spray into the nose of someone who is overdosing to rapidly reverse the overdose. This buys time until the ambulance arrives. I carry Narcan in my bag, wherever I go. There’s no reason not to.

In the United States, 29% of U.S. adults say they or a family member have ever been addicted to opioids. By treating people who are addicted, or who use drugs recreationally, with dignity and compassion, and by enacting the policy changes discussed above, we can save the lives of those who matter the most to us, or to some other family. We can do a lot better.

Thank you so much for supporting my blog “Grinspoon on Drugs”!

2025 has been an amazing year. To start, I am unbelievably excited about my upcoming new book, “Aging Well with Cannabis and CBD”. It which comes out on May 5^th, 2026, and addresses how seniors can use cannabis safely and effectively. One of my heroes, Dr. Staci Gruber, a wonderful person and a renowned cannabis researcher at Harvard, has written a lovely forward. Here is the cover:

This year included a host of great speaking opportunities. It was eye-opening to speak at the concierge practice at my hospital. They were incredibly nice, humane doctors, who were interested in learning more about cannabis. Yet, it saddened me to see how different this experience (for the super-wealthy) was from my work at an inner-city primary care doctor (for the poor). It was insanely unfair and, unfortunately, represents where we are heading with primary care. If you can pay $10,000 a year, you get far better care. Please read my blog about these differences in quality and outcomes. It isn’t right. We are becoming an Oligarchy when it comes to primary care.

I had many other speaking opportunities including appearing as a featured guest at the Global Health Catalyst conference, organized by staff at John’s Hopkins. This featured doctors and experts from all over the world. We had a fascinating discussion about how people are using medicinal cannabis across the globe.

My favorite speaking gig? Well, it’s hard to beat the “United in Compassion” medical cannabis conference in Brisbane, Australia. Even though it looks fake, this photo is real:

This friendly koala didn’t attend medical cannabis conference. We met him at the Australia Zoo. His favorite botanical leaf is Eucalyptus and he is a non-smoker.

Here is a photo of me speaking at the conference, as usual, without any notes (though with near-lethal levels of caffeine).

I am sunburned, and I was barely alive from going to a huge outdoor concert by the band named after my dad, “Grinspoon”, the night before. Hanging out with the band backstage was a highlight!

The best part? Liz and I are traveling back to Brisbane for the same conference in February, 2026.

2025 was another great year for media coverage. Earlier in the year, I was on Bill O’Reilly’s show, pushing back on claims that cannabis is Satanic Lettuce that is poisoning the minds of our youth. I also went back to my roots on the topic of physicians and addiction in a featured piece in Carlot Psychiatry. I had a recent piece in the WSJ (see below).

My favorite piece? I wrote an op-ed in the Boston Globe titled, “I’m a Mass. General primary care doctor. And I need a union.” Amazingly, due to a huge, concerted effort, 88% of our primary care doctors voted in favor of a union. This is truly the only mechanism to save primary care as the hospitals corporatize medicine and suck every penny out of the system. Unfortunately, the unionization effort is locked up in a legal morass, so things haven’t started to improve yet. The energy and enthusiasm of my fellow doctors has been truly inspiring, and I am proud to be one of the leaders in this effort.

2025 also had several high-magnitude political developments. The most significant one, from the point of view of cannabis policy, was the rescheduling of cannabis from Schedule 1 to Schedule 3 under the Controlled Substances act. This represents an acknowledgement, finally, after 70 decades of propaganda (which most of the doctors brainlessly went along with), by the U.S. Government, that cannabis is, in fact, a medicine. The rescheduling will help medical patients use cannabis with less stigma and will help unfetter researchers who are trying to unlock how we can use cannabis safely and effectively. As mentioned above, I had a letter to the editor in the Wall Street Journal on this issue last week (in response to reactionary and ill-informed editorial they wrote):

The Medical Case for Rescheduling Cannabis

Dr. Peter Grinspoon replies to the editorial board.

Your editorial “Trump Goes for the Stoner Vote” (Dec. 20) misses some important aspects of cannabis use in the U.S. Among them: There is no evidence that teenage use has risen with legalization. Dispensaries are extremely careful in checking identification, and smoking simply isn’t as cool when grandma is a taking a puff or two for her arthritis.

The medical review you cite, which claims “no medical benefit” to use, is one study among thousands. It was performed by researchers who, to my understanding, haven’t treated a single medical cannabis patient to alleviate symptoms. The doctors who directly help patients use cannabis have a different vantage. There is abundant evidence for the efficacy of medical cannabis for most, if not all, of the claims patients make. The 2017 report by the National Academies of Science, Engineering and Medicine concluded there was “conclusive” evidence of effectiveness in treating chronic pain and other conditions.

Cannabis doubtless has several potential harms, and certain people should stay away from it—e.g., teens, pregnant women, those with a history of psychosis. We don’t want an unregulated industry running amok, either, as we experienced with tobacco and alcohol. Yet cannabis is less dangerous than both substances—both of which are excluded from the Controlled Substance Act and contribute to hundreds of thousands of deaths per year. We shouldn’t treat cannabis any different.

As a physician, I suggest we primarily look at how we can reduce patients’ suffering. With education and careful regulation we can avoid or minimize many of the harms associated with cannabis use, which is already helping Americans with intractable chronic pain, nausea, anxiety and insomnia. A majority of Americans support legal access to medical cannabis—so a baby step in this direction, rescheduling cannabis into a less restrictive category, is a step in the right direction.

Dr. Peter Grinspoon, Harvard Medical School

In a different, but equally impactful, political development, congress recently voted to recriminalize the hemp-derived products that were legalized in 2018 with the Farm Bill. This will outlaw delta-8 THC, some CBD products, and several other synthetic cannabinoids (of undetermined safety…) that so many millions of Americans have come to depend on. This especially true in parts of the country where isn’t legal access to medical marijuana. Please see my recent blog to understand what exactly is banned and what the implications are.

I have been enjoying working at my hospital’s state of the art addiction clinic, a low-threshold clinic that helps people with vicious addictions to opioids, alcohol, and methamphetamine. We treat some extremely down and out people. It is inspiring to see them overcome these addictions despite the unfortunate cards they have been dealt – traumas, poverty, homelessness, human trafficking. While studying for the addiction medicine boards – the stupidest test I have ever taken in a 25-year medical career -- I came to a deeper understanding about how and why the entire field of addiction medicine misses the boat on cannabis. Please see this blog, “What we’re still getting wrong about cannabis in addiction medicine”.

As for leisure, I have been swimming, playing some ultimate frisbee, and seeing many kind friends. During every free moment, I read. I get up at five in the morning to read. I stay up late to read. I mostly read literary fiction as good writing is the artform that I most admire.

One fun adventure: my medical school roommate Christos has been inviting me to visit him in Cyprus since we first started medical school in 1993. Liz and I finally made the journey. Highly recommend! It is a spectacular beautiful, democratic and sensible country. We swam with sea turtles and Liz got to hold an octopus – very velvety!

We got to spend a nice Thanksgiving with our family including my 95-year-old mom Betsy. She looks great for 95 and you can see how deeply cannabis runs in family.

I spend a lot of time with my lovely wife Liz, who is a wildlife rehabilitator. Flying squirrels have, on occasion, been seen zooming around our basement. I once had an over-zealous squirrel jump on my neck. Liz and I have discovered the secret to a happy marriage: you just have to each marry someone miserable the first time and the next person will seem unbelievably nice in comparison!

I can’t wait for 2026. I’m particularly looking forward to improving my fiction writing through various workshops, including the “Love Comes In At The Eye” workshop in Connemara, Ireland in May, with Jacki Leyden and Matt Klam. The comedic novel I am writing slowly progresses…

Thanks for being along for the ride!

It was 1973, two years after Nixon started his War on Drugs, when I first inhaled cannabis smoke. I was seven years old. I remember following my teenage brothers, Danny and David, as little brothers tend to do, like paparazzi, around our childhood home. Our parents were out, and they somehow thought the teenagers would responsibly supervise the younger siblings. Danny, fourteen at the time, casually pulled a thin white twig out of his pocket, lit it with a match in a practiced manner, and started sucking on the end of it, producing sickly sweet fumes. Normally an engaged and dedicated older brother, at this moment his teenage self must have assumed command because, with a mischievous grin, he handed me the white object and instructed me to put the tip into my mouth and breathe in, just as he had done. I would have jumped off a cliff if he had asked me to. I spent the next five minutes coughing and gagging as Danny went inside to get me a glass of water, clearly feeling guilty about his poorly thought-out prank.

Danny’s act of smoking a joint at age fourteen wasn’t as blatantly delinquent as it sounds, because cannabis was helping to sustain him. It was the only thing that allowed him to keep food down given the aggressive chemotherapy regimen he was on during his losing battle against acute lymphocytic leukemia. My parents, after quite a bit of soul searching— and then some actual cannabis searching—eventually sanctioned his usage. I believe that they knew by that point that he was dying, and they had decided to minimize his suffering at all costs.

This culminated in my law-abiding mother going to the athletic field next to the high school in our Boston suburb and asking Danny’s best friend, Mark, to sell her some weed. Mark was so shocked and worried he almost spontaneously combusted. “Oh, Mrs. Grinspoon, I wouldn’t know anything about that.” Mark’s loyalty as a friend and empathy for how sick Danny was must have won out over any fear of potential repercussions. Later that night, Danny announced to my mother, “Oh, Mom, guess what? I have a pipe with some grass in it in my jacket pocket.”

The use of cannabis may only have added months to a year to Danny’s life, but the improvement in his quality of life was incalculable. Instead of barfing, he was eating. Instead of lying in bed in a dark room, he was playing with his little brothers, inventing intricate board games, and strumming on his Fender Stratocaster.

It is true that, at the time cannabis was illegal, and it was front and center in the culture wars in Nixon’s America. If detected by the wrong people, my brother Danny and my parents could have been arrested. Their jobs as teacher and doctor could have been jeopardized. The medical establishment, which included my father, a Harvard psychiatrist, was, at that time, ideologically programmed to be opposed to any cannabis use. But when push comes to shove, most parents will do almost anything to help their children. This was a simple calculus: no cannabis, no appetite, no food, no Danny.

The healing power of cannabis became folkloric in my family. The lived experience of its powers to alleviate suffering, and to prolong and sustain life, was seared into my brain at an early age. I learned to associate the sweet smell of cannabis with healing. This insulated me, as the years went by, from the absolute nonsense of the DARE program. It carried through to a career in medicine and allowed me to see through the misinformation that they teach young doctors in medical school about cannabis. I am proud to say, largely due to Danny’s experience, that I have been treating patients successfully with medical cannabis, for twenty-five years.

Addendum

No one has told Danny’s story more eloquently and clearly than my father Dr. Lester Grinspoon, who was a legend in the psychiatric world and who was the intellectual lynchpin of the campaign to legalize medicinal marijuana. He first started this journey in 1971 when he published his masterpiece, ‘Marijuana Reconsidered’ which fundamentally shifted the national debate on cannabis, and shined a spotlight on how fundamentally ill-informed the U.S. medical establishment was on cannabis. In 1993, he wrote an equally important work, “Marihuana: the Forbidden Medicine”, which explained how and why cannabis worked to help millions of patients. It helped paved the way for California to legalize medical marijuana in 1996.

In a 1987 New York Times editorial, published at the height of Reagan’s catastrophic War on Drugs, my father told Danny’s story and made an eloquent pitch for allowing patients to use medical cannabis. This is a critical piece of intellectual history, a living testament to the power that one dedicated person has to nudge the world’s trajectory. I have included it below.

Cancer Patients Should Get Marijuana

The New York Times, July 28, 1987

Dr. Lester Grinspoon

The widespread abuse of drugs is obviously one of America’s most severe social problems. But society’s justifiable fears about drug abuse are inhibiting the medical profession from exploring ways in which the carefully supervised, rigidly controlled use of some drugs can ease the agonies of patients who suffer from painful and disabling diseases. Marijuana is a case in point.

I began to study cannabis in 1967, and by the time I published my first book on the subject, in 1971, I had discovered that much of what I thought I knew about it had been wrong.

I learned cannabis was used extensively in American medicine from the mid-19th century until the passage in 1937 of laws that effectively prohibited the use of marijuana. Nineteenth century physicians understood the many medical uses of cannabis and had no doubt about its safety. With each passing day I learned more. What I did not know is that I soon would have a personal encounter with cannabis as a medicine.

Early in 1972, after the death of Dr. Sidney Farber, a Harvard child oncologist, for whom the Sidney Farber Cancer Research Center was named, my wife and I were invited to dinner at the home of a fellow Harvard Medical School faculty member who wanted me to meet Dr. Emil Frei. Dr. Frei had arrived from Houston to serve as Dr. Farber’s successor.

At dinner, he told me the story of an 18-year-old Houston man suffering from leukemia who had become more and more resistant to cancer chemotherapy because he could no longer tolerate the nausea and vomiting that went with it. His doctors and his family were finding it increasingly difficult to persuade him to take the drug on which his life depended.

One day, to Dr. Frei’s surprise, the young man willingly agreed to take the drug and from then on offered no resistance to chemotherapy. In time, he confided that he started smoking marijuana about 20 minutes before each chemotherapy session. The marijuana seemed to prevent all vomiting and even the slightest hint of nausea. Dr. Frei asked me if the 19th century medical literature on cannabis supported such a possibility. I told him that it did.

My wife, Betsy, listened to all this with great interest. On the way home, she suggested that we obtain some cannabis for our son, Daniel.

Daniel was first diagnosed as having acute lymphatic leukemia in July 1967. For the first few years, he was good-natured about his trips to the Jimmy Fund Building of the Children’s Hospital in Boston for his treatments and even about the occasional need to be hospitalized. But in 1971 he started taking the first of the chemotherapy agents that cause severe nausea and vomiting.

For many patients, including Daniel, the nausea and vomiting are uncontrollable and not sufficiently alleviated by standard anti-emetics. Daniel would start to vomit shortly after treatment and continue retching for up to eight hours. He vomited in the car on the way home. Once he arrived home he had to lie in bed with his head over a bucket on the floor.

These were awful, demoralizing experiences for all of us. In 1972, Daniel, who had been so courageous about his illness and its treatment, began to resist taking chemotherapy. He would cry and beg us not to insist on any more treatments. It was our practice for my wife to drive Daniel in from Wellesley and meet me at the Jimmy Fund Building. I dreaded those pre-treatment sessions.

Even so, I was shocked that evening when Betsy suggested that we find some cannabis for Daniel. I objected because it was against the law and because it might embarrass staff members at the Farber Cancer Research Institute, who had been so remarkable in their commitment to Daniel’s care. I dismissed the idea.

Daniel’s next treatment was about two weeks later. When I arrived, Betsy and Daniel were already in the treatment room. I shall never forget my surprise. Normally, both my wife and son were in a state of great anxiety before the treatment began. This time they were completely relaxed, and, what is more, seemed almost to be playing a joke on me.

Finally, they let me in on the secret. On the way to the clinic that morning, they had stopped near Wellesley High School. Betsy asked a friend of Daniel to get her some marijuana. Once he recovered from his disbelief, the friend ran off and reappeared a few minutes later with a small amount of marijuana in his hand. Betsy drove to the hospital, and she and Daniel smoked marijuana in the parking lot just before they went into the clinic.

I was surprised but relieved that Daniel seemed so comfortable. He did not protest as he was given the medicine, and he was no less delighted than we were when there was no nausea or vomiting afterward. He asked his mother if he could stop for a submarine sandwich on the way home, and when he got home he did not go to bed but went right to his usual activities. We could scarcely believe it. The next day, I called Dr. Norman Jaffe, the physician at the Jimmy Fund who was in charge of Daniel’s care. I explained what had happened and said that while I did not want to embarrass him or the rest of the medical staff, I could not forbid Daniel to smoke marijuana before his next treatment. Dr. Jaffe was interested in my story and suggested that Daniel smoke marijuana in his presence in the treatment room.

Daniel did that the next time. When the chemotherapeutic was given to him, Dr. Jaffe observed for himself that Daniel was completely relaxed and did not protest at all. Afterward he did not become nauseated and again asked for a submarine sandwich. From then on he used marijuana before every treatment, and we were all much more comfortable during the remaining year of his life.

Dr. Jaffe asked me to join him in reporting our observations to Dr. Frei, who was sufficiently interested to do the first clinical experiment on the use of cannabis in cancer chemotherapy. It saddens me that 15 years later it is still not legally possible to use cannabis in this way, although surreptitious illegal use is widespread, at least among adults with cancer. There is an oral cannabis constituent (tetrahydrocannabinol) that is available to patients. But it is clearly less effective than smoked cannabis, which, shamefully, has not yet achieved its rightful place in our treatment of cancer.

“We can no longer trust federal health authorities when it comes to vaccines.” – Dr. Michael Osterholm, epidemiologist and infectious disease expert.

Naming RFK, Jr. as the Secretary of the Department of Health and Human Services (HHS) is like putting Jim Jones in charge of cult education and suicide prevention. Or it is like putting Hannibal Lecter in charge of the World Vegetarian Society. The paranoid and ill-informed nonsense that RFK is spouting, and the policy changes he is implementing, will needlessly kill a tremendous number of people. How many people end up dying due to RFK’s policies depends on which outbreaks his actions cause, and which other outbreaks he fails to control or prevent.

It is difficult to imagine how many more people would have died – likely millions more -- if RFK had been the head of HHS during the Covid Pandemic. We wouldn’t have developed a Covid vaccine nearly as rapidly, if at all, and it wouldn’t have been widely and rapidly distributed.

RFK has one fixed delusion that is underpinning much of this: he believes that vaccines cause autism. There isn’t a single credible scientist on the entire planet who believes this. There isn’t a shred of evidence to back this claim. It is a weird, neurotic conspiracy theory that is now, being widely bludgeoned into public policy, at unfathomable expense to public health, and to America’s scientific credibility.

In clinical practice, I am seeing an astonishing amount of skepticism and misinformation surrounding the routine vaccines we have always offered in my primary care clinic. It was always the case that a fringe subset of patients didn’t understand vaccines or believe in them. Now it represents a vocal and growing minority. Patients can become angry at the mere suggestion of a vaccine, as if I am trying to poison them.

These days, when I offer vaccines, I frequently hear, “They make me sick.” “I have a good immune system and don’t need them.” “They don’t really work.” “I never catch colds.” “I don’t believe in vaccines.” This never used to be the case – at least not to the degree we are now witnessing.

This ill-informed antagonism to vaccines is especially true of the Covid vaccine, which has been propagandized against by the MAGA-supporting media outlets since day one. As a consequence, there was a 43% higher death rate among Republican voters from Covid. Great job Fox Entertainment! These unvaccinated people tend to infect those around them before they die, sharing the love, all the way to the grave. Some don’t even believe in Covid, but that is a story for another day.

The Covid vaccine is universally believed by the world’s top scientists to be safe and effective. Yet, when I offer the Covid vaccine to my patients in clinic, I have had it declined for the following reasons:

• My church told me not to get it because it is the Devil’s mark.

• I don’t want to become magnetic.

• I don’t want to have a microchip transplanted in me.

• George Soros is trying to make more money.

• Bill Gates is behind this.

• I don’t want my already pregnant wife to give our baby birth defects [from my getting the shot].

True story: imagine an adult son bellowing at me, during a visit, as I’m taking care of his elderly dad, whom I’ve cared for during the last sixteen years, “why would you offer him that crap?” All I did was suggest that an 80-year-old man with emphysema and heart disease would be less likely to be hospitalized (and to die…) if they were immunized against Covid.

To be effective, the doctor-patient relationship must be a trusting partnership. We are a team. It is exceedingly difficult to make progress if either one of the teammates is living in an alternative reality. This disconnect undermines our foundational relationship. It weakens a patient’s belief in our other recommendations, such as the need to get the critically important colonoscopies and lung cancer screenings. It takes a toll on the doctor, who, invariably, these days, is profoundly burnt out. It impacts the amount of emotional energy we are able devote to this patient. We aren’t supposed to have these reactions but, in all honesty, we are human beings not robots, with limited bandwidth, and when we deal with unfounded conspiracy theories, it rapidly starts feeling like we are banging our heads against a wall.

This antagonism to vaccines is spreading, like an infectious disease, from Covid to even more mainstream and basic vaccines like Tetanus, influenza, and measles. We are rolling back hundreds of years of medical progress. We are already seeing something that was utterly unimaginable a decade ago: a deadly measles outbreak in Texas, which killed several children. Instead of vaccines, RFK is advocating that we treat measles with Vitamin A. That is like treating strep throat with broccoli or treating a massive heart attack with yoga. No wonder the life expectancy of American adults is starting to decline. Vaccines prevent millions of deaths per year and are one of the primary reasons that our life expectancy has roughly doubled (from the forties to the seventies) over the last century.

What is RFK doing?

I once heard RFK state that doctors receive $450 for each vaccine they give. He is trying to make it sound like the only reason doctors are providing vaccines is to make money. In truth, we don’t get paid a penny for vaccinating patients. We get paid the same amount regardless of whether the patient does or doesn’t get a vaccine. As such, because it takes time to order and administer a vaccine, we actually get paid less to vaccinate patients. Imagine the harm that these statements do to the credibility of the medical profession. Without credibility, patients don’t listen to us, and they die earlier.

RFK recently fired all 17 (credible and respected) members of the CDC’s Advisory Committee on Immunization practices and, in their place, hired uneducated Luddites who share his medieval vaccine views.

Mr. Kennedy said in a recent interview that he personally directed the C.D.C. to abandon its official position that vaccines do not cause autism. This is equivalent to having the official position of the U.S. Government be that the Earth is flat. (I shouldn’t give them any ideas…).

One of the newly appointed vaccine council advisory members said,

“I suggest to parents to be very, very suspicious when people tell them that something is safe, especially a vaccine.”

Many of my patients aren’t educated or medically literate. If they hear differing messages from the government and from their doctors, they won’t know what to think. Until recently our government represented 21^st century consensus scientific reality. Now, at the hands of RFK, it has given way to conspiracy theories and pseudo-science. (Which irreparably and permanently harms the credibility of the United States. We are doing the same thing with climate science.) This is why parents are refusing to vaccinate their children. This is exactly why we are suffering through a once-unthinkable deadly measles outbreak in Texas. We are also experiencing, in several parts of the country, an outbreak of whooping cough (pertussis) which is entirely preventable. What other outbreaks are around the corner?

RFK and his cabal are deliberately making Covid vaccines much more difficult to obtain, because they are profoundly misinformed about both the effectiveness of these vaccines and their safety. They have narrowed the “official” indications for this vaccine to people older than 65 and those with underlying medical conditions. CVS recently announced that it can only offer Covid-19 shots without a prescription in 34 states; in 16 other states patients may need a prescription (depending on age and health status). In medical reality, everyone should be offered to get this vaccine, with no such barriers. By becoming immune, you protect yourself, your family members, your neighbors and co-workers, and you help eradicate the epidemic in general (society develops “herd immunity”). I wouldn’t be surprised if, with these restrictions, Covid makes a comeback. And, if a newer, deadly strain evolves, we are defenseless.

Not content to merely kill people with measles and Covid, RFK has started gunning for all childhood vaccinations. On December 5^th, his wingnuts voted to stop recommending Hepatitis B shots to most newborns at birth. This recommendation is based on a vast misunderstanding of both how safe the hepatitis B vaccine is and of how hepatitis B is transmitted. Hepatitis B is an ugly, destructive disease that we have been getting under control. The rates of hepatitis B infections in kids have been drastically dropping due to the vaccines we have been giving. In fact, before we routinely vaccinated newborns against hepatitis B, 20,000 newborns a year were becoming infected. With the vaccines, we are down to about twenty cases per year. Why would we want to go back? Hepatitis B is an incurable, life-long, disabling illness that can result in liver failure and cancer.

Potentially worst of all, Mr. Kennedy just canceled a nearly $600 million contract with a major pharmaceutical company that was working on an mRNA vaccine against bird flu. What are we supposed to do without a bird flu vaccine? Take vitamin A? All it takes for a worldwide epidemic to develop is for the bird flu, which is all over the place in animals, to mutate so that it can spread from human to human.

Combine this vaccine insanity with the recent Trump-mandated cuts to agencies such as the U.S. Agency for International Development, which distributed vaccines worldwide, and we have a pending international catastrophe. Do we really want to roll back the last 200 years of medical progress? One of our greatest accomplishments, throughout human history, was announced by the World Health Organization in 1980: we have eradicated smallpox. We have also been keeping many other diseases at bay, including diphtheria, polio, meningitis, cholera, HPV and tetanus. We need to continue to develop and distribute vaccines. They save lives. They save money. They stop suffering.

(Note: in another act of stunning destructiveness, the U.S. recently withdrew from the WHO, and now we have less information on developing epidemics.)

How do we deal with this?

One is tempted to move to another country that isn’t in the thrall of an anti-science MAGA death cult, where the population is too educated and savvy for this nonsense. To flee to a place where they provide exceptional medical care for all, such as in most European countries, as well as countries such as Cyprus, China, Japan, and Australia. Short of that, we all need to stand up for science, to stand up for the medical profession, and to counteract, in any way that we can, this baseless propaganda and nihilism against vaccines. We need to vote out Trump and the sycophantic Republicans so that we can put someone sensible in charge of HHS. Even if we achieve this, it will take decades to fix what has been broken and to restore credibility with patients, and with the rest of the world.

If your doctor offers you a vaccine, against the flu, Covid, tetanus, shingles, pneumonia, HPV, meningitis, or RSV – I would strongly recommend that you accept. Of course, vaccines, like any other medical interventions, have their potential harms and risks. These risks are infinitesimally small compared to the benefits they provide to individuals and to society at large.

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Patients aren’t allowed to bring medical cannabis into the hospital, a circumstance which confuses everyone involved. While medical cannabis is legal in thirty-eight states, it is still federally illegal and is scheduled in the most restrictive category of drug. Because of this illegality, the hospitals could hypothetically lose federal funding if they allow or tolerate the use of an illegal restricted drug by patients, such as cannabis. This is an understandable fear as millions of dollars are on the line, yet it sets up an untenable conflict, and a clinical nightmare, for medical cannabis patients.

Many patients don’t know about this restriction and bring cannabis into the hospital without being aware that they are violating a major prohibition. In many states, they are legally allowed to buy it on the way to the hospital, but can get in trouble bringing it in.

Why would one need cannabis in the hospital?

Tens of millions of Americans use medical cannabis to alleviate symptoms. In many cases people feel that cannabis works better and/or has fewer side effects than traditional pharmaceuticals. As an example, think of a patient on chemotherapy who has nausea and vomiting, and is suffering from cancer-related pain, insomnia, and who is having trouble maintaining their weight. Medical cannabis is often wondrously effective in helping people tolerate these symptoms.

This explains why most Oncologists support the use of medical cannabis. They witness it helping their patients. This was true for my brother Danny, who died at age 16 from leukemia, when I was eight years old. Danny’s life was drastically improved when my parents (illegally) provided him with medical cannabis in the early 1970’s, just when President Nixon was gearing up his War on Drugs. Before initiating cannabis, my brother would return from chemotherapy and lie in bed, alone, in a dark room, barfing into a trash bucket. After starting cannabis, Danny could maintain his weight, eat, strum on his beloved Fender Stratocaster, and, most importantly to me, play with his little twin brothers. Cannabis was transformative to virtually all aspects of his very short life.

People commonly use cannabis to help control chronic pain, anxiety and insomnia, as well as symptoms of colitis, irritable bowel, fibromyalgia and the spasticity associated with multiple sclerosis. The Journal of the American Medical Association recently highlighted the urgent need for doctors to get up to speed on medical cannabis so that they can have helpful conversations with patients.

What happens in the hospital without medical cannabis?

To start, patients abruptly lose access to the medicine that they have found to be most effective to control their symptoms. In hospitals, they are immediately transitioned onto traditional pharmaceuticals (because they aren’t allowed to use cannabis), which often are less effective and have worse side effects. This is a terrible way to start a hospitalization.

The next problem is that many patients will suffer from withdrawal symptoms, about a day or so after they stop using cannabis. These symptoms typically last for one to two weeks, and have to do with temporary changes in our Endocannabinoid System.

If you use cannabis heavily, or even modestly, as a daily user, and then you are forced to abruptly discontinue, you might suffer the following symptoms:

• Poor appetite

• Insomnia

• Grumpiness and depressed mood

• Anxiety

• Cravings

These withdrawal symptoms are exactly the symptoms you don’t want people to experience in the hospital. If you’ve ever been hospitalized you know that even on a good day, it is incredibly difficult to eat, sleep, and maintain a positive mood. Hospital rooms are noisy, the food is unpalatable, and you are likely anxious about whatever has brought you into the hospital. Withdrawing from cannabis makes eating, sleeping, and relaxing much more difficult, and compounds the misery of the hospital experience.

Can you get into trouble for cannabis?

To start, it is important to note that all hospitals are entirely non-smoking institutions. Under no circumstances should a patient smoke or vape anywhere in a hospital. These modalities are off-limits. In this discussion, we are talking about other cannabis preparations such as gummies, pills, or tinctures, which could theoretically be taken in a manner that does not disturb or harm other people.

Patients ask: why not bring in some gummies, and take them surreptitiously? No harm, no foul.

While an understandable thought process, this presents multiple problems. To start, it is dangerous to ingest medications that your doctor doesn’t know about, especially in the hospital. Your doctors have undoubtedly come up with an often-complex plan to treat your condition. Surreptitious cannabis use would introduce a major unknown variable. For example, it might be additively sedating to the sedatives (e.g., opioids) they are already giving you. A related issue is that of drug interactions. Cannabinoids such as THC and CBD have medication interactions and can raise or lower the levels of other drugs in your system. For example, CBD acts just like grapefruit juice in that it competes for liver enzymes and can lead to higher blood levels of other medications. To consume CBD without the doctor’s knowledge is risking an adverse reaction or an overdose.

Finally, you aren’t allowed to sneak cannabis into the hospital and could face confiscation, discipline, or hypothetically hospital discharge or even arrest – if you are in a state where it is illegal. The last thing the hospital security guards want to do is hassle dying cancer patients over cannabis, so surreptitious use puts them in an awful position as well.

Occasionally, you can get buy-in from your medical team. There are some compassionate oncologists who will look the other way, but this is the exception not the rule. Most doctors are in favor of the use of medical marijuana but feel that they need to honor the hospital rules.

What is a way forward?

There is no perfect solution to this issue short of federal legalization of medical marijuana, which would remove the hypothetical penalties that hospitals face. This is something that many major politicians support. A vast majority of American citizens, up to 93% in some polls, support legal access to medical cannabis. Cannabis would also have to be rescheduled, or de-scheduled, and taken out of its current Schedule One status of the Controlled Substances Act, which denotes, “high abuse liability” and “no medical utility” – neither of which is true for cannabis. In this scenario, cannabis use would be transparent, and doctors and patients would be on the same page. Sadly, I am not holding my breath for this to happen.

What to do short of legalization?

One could say to patients, “just don’t bring cannabis into the hospital.” Medical cannabis patients tend to be zealous believers, and in response to this, many patients will simply ignore this advice. Now, the patient is using cannabis, and the medical team is in the dark. In addition to creating a dangerous clinical situation, this undermines the doctor-patient relationship. Some hospitals are experimenting with models for letting patients use cannabis in the hospital, but, at this point, this is only an experimental pilot project.

When my hospital administrators met about this problem, I suggested that the best policy for now is, “don’t ask don’t tell”. The hospital administrators stated (quite correctly…) that my solution doesn’t actually solve any problems. Yet, it is, de facto, what some hospitals are doing, for lack of a better idea or policy.

My idea to help this

I do have one idea to fix, or at least improve, this situation. When patients are addicted to nicotine and they are stuck in the hospital, they are often given nicotine patches to prevent withdrawal. This is not the same thing as smoking, but it removes the most miserable withdrawal symptoms from nicotine, such as cravings, irritation, restlessness, poor concentration, insomnia, and depression. It also gives them a chance to quit cigarettes during the hospitalization.

We can do the same thing to prevent cannabis withdrawal in the hospital. There are synthetic versions of THC (the main component of cannabis), which are legally available, such as Marinol (dronabinol). These can easily be prescribed in the hospital, as they are not nearly as restricted as cannabis itself is. Why not offer this treatment to medical cannabis patients who find themselves in the hospital? This practice would make sense unless it directly contradicts the immediate goals of care, such as reigning in a psychosis, managing a complicated coronary syndrome, or using a complex anesthesia regimen (all of which THC might complicate). We could prevent withdrawal, and we could almost certainly contribute to symptom control, especially pain. For the millions of medical cannabis patients, transparent and dependable access would make hospital stays much more tolerable. Doctors and patients would be on the same page, working together. No one would get into trouble. If patients sleep and eat better, they will heal better. It could also help with pain, nausea, boredom, and many of the other issues that make being in the hospital a particularly unpleasant experience.

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Quick note - you may have received an earlier unedited version of this newsletter on Saturday night - here is the official edited version!

In 2018 the Farm Bill legalized hemp by removing it from the Controlled Substances Act. This was widely believed to be a victory for all parties, and another chink in the wall of the failed War on Drugs. According to the Law of Unintended Consequences, this bill contained a loophole which has legalized a plethora of synthetic and semi-synthetic cannabinoids which were produced and distributed in ways that are often unsafe. This have created a tidal wave of both legitimate concern from public health specialists, and moral panic, from the inveterate prohibitionists. Recently, in November of 2025, Congress passed the “Mary Miller Amendment” which refers to language that was recently included in the FY2025 Agriculture Appropriations bill. This Amendment recriminalizes all of these newer and widely available cannabinoids.

Is this a boon to public health or a large step backwards?

What are these products that are disputed?

To start, please remember that hemp and cannabis are the same plant. The only difference between them is that hemp has less than 0.3 percent THC, which is the psychoactive ingredient in cannabis (This natural THC molecule is called delta-9 THC.) Thus, hemp isn’t psychoactive per se (except that it naturally contains CBD which makes people relaxed and sleepy). Given the low amount of THC in hemp, one would have to smoke ounces upon ounces to get high. This is why in 2018, when the Farm Bill passed – no one was against hemp, or CBD for that matter.

At the time, few people understood that the “THC loophole” would create an enormous industry of new and poorly regulated psychoactive cannabinoids. No one predicted that these synthetic cannabinoids were going to be freely sold at gas stations and smoke shops, as well as over the internet - and more easily get into the hands of minors.

The Mary Miller Amendment reverses much of the 2018 Farm Bill that broadly legalized hemp. It narrows the definition of hemp to only naturally derived, and naturally occurring, and non-intoxicating cannabinoids. It would prohibit the synthetic and semi-synthetic cannabinoids, such as THC-8, THC-10 (which are chemically similar to the natural THC-9 in cannabis), as well as the synthetic and untested cannabinoids HHC, and THCP. All of these are converted or synthesized from CBD through the loophole. It will still be legal to cultivate hemp for seed, grain, or fiber. The enormous hemp-derived cannabinoid industry – which provide intoxicating gummies, vapes, and beverages, and which contain these impairing and untested cannabinoids, would be shut down. This all goes into effect in one year.

This enormous commercial hemp-derived cannabinoid industry exists in parallel to and in competition with, the legal medical cannabis that 38 states have voted approved. It drains people away from a safer system.

Why we SHOULD recriminalize these products

As for the arguments in favor of recriminalizing these products, they are available by mail order, as well as in gas stations and smoke shops. None of these venues provide a consistent protection to prevent teens from accessing these products. In contrast, legal marijuana dispensaries are extremely strict about restricting youth access, but no one can argue the same for the hemp-derived product industry. There is legitimate concern about the effects of cannabinoids on the developing teenage brain, and access needs to be restricted as much as possible. Note: teen cannabis use did not go up with cannabis legalization, but these hemp-derived products are providing the loophole.

Moreover, these products, such as Delta-8 THC, are wholly unregulated and can often be contaminated by industrial byproducts. Some of these new cannabinoids, such as HHC and THCP, are wholly untested in humans. They are profoundly psychoactive and no one knows what their long-term effects will be.

Finally, there is some concern that this gigantic and unregulated hemp product industry competes with, and undermines, participation in the legal medical cannabis dispensary system, which is safer on all metrics. The legal cannabis products are tested, regulated, and accurately labeled (more or less – but astronomically better than the hemp-derived products).

In short, we have unintentionally created, with the 2018 Farm Bill, a toxic mess of unregulated, sometimes contaminated, psychoactive products that are more readily available to teenagers. These are the arguments in favor of the Mary Miller Amendment, which recriminalizes hemp-derived products

Why we SHOULDN’T recriminalize these products

This criminalization of cannabis and other cannabinoids (including hemp and CBD) has been an absolute disaster, by every metric. More than twenty million people have been arrested for non-violent cannabis offenses over the last half century, mostly people with Black and brown skin. The Mary Miller Amendment feels like we are backsliding on our urgent efforts to dismantle the War on Drugs.

To make these substances illegal is to push them further into the illicit market and to make them more dangerous. People will continue to use them, but they will be even more harmful. I argue in Time Magazine for decriminalizing opioids for this very reason – criminalizing any/all drugs makes them vastly more dangerous. People are more afraid to get help, and the products are even more dangerous (if possible). Keeping them legal makes them relatively safer.

This legislation could inadvertently get rid of helpful (nonintoxicating) CBD products, and other hemp-derived products, that millions of people rely on for symptom control. No one has ever overdosed or died from any of these new cannabinoids - very unlike the case with opioids, alcohol, or tobacco.

There is proof that people are using these products medically and it is critical that all patients have access to medicinal cannabinoids to control excruciating symptoms. It has been shown synthetic cannabinoids are used more widely in states that don’t have legal access to medical cannabis, and thus provide the only mechanism by which to get symptom control in these states. We can’t just rip this away from people who are suffering.

Just as with cannabis and CBD, during the War on Drugs, criminalizing and locking away chemicals makes it vastly more difficult to do medical research on them. More likely than not, these synthetic and semi-synthetic cannabinoids are going to prove, just like cannabis and CBD, to have significant medical potential. If properly regulated, they will likely have modest toxicity at best. All cannabinoids have harms (I have written about this elsewhere), but they can be less toxic than many traditional pharmaceuticals.

A final argument (from the Libertarians) is that the Federal Government shouldn’t be deciding this at all and imposing it on all of us. It is a state’s rights issue and should be decided by the citizens of each state, just as has been done for medical and recreational cannabis.

What do I think?

I am conflicted. Many people depend on these cannabinoids, unregulated and untested as they are, especially in states that don’t have medical marijuana. It seems cruel and unusual to rip them away, as they provide unique and effective symptom relief for a variety of maladies. It does seem a step backwards Drug War-wise, as the act of criminalizing substances invariably does little to lessen their use and makes them more dangerous.

At the same time, I worry about the abundant access that teenagers have to these products – the smoke shops and the gas stations (not to mention the internet) are not nearly as careful about checking I.D. as cannabis dispensaries are. I am extremely concerned about the crappy and dangerous nature of many of these products, with poor labeling and some studies showing industrial contaminants. The current “free for all” is not benefitting public health, and is undermining the legal, regulated medical cannabis system in the 38 states that have legalized medical marijuana.

The best way forward would be full federal legalization, and full descheduling (under the Controlled Substances Act), of cannabis, so that medical patients have access and “adult” users can enjoy it responsibly, without fear or stigma. In this scenario, no one would need these hemp-derived products, and we can all continue safely using the natural medicinal plant that we have used for 5000 years.

Short of that, these hemp-derived products shouldn’t be outlawed, but they urgently need to be sensibly regulated. We must come up with a mechanism to accomplish this. We should be researching them to see how they can be of use to medical patients, and how they can be used safely, instead of locking them away.

In addition to my disintegrating job as a primary care doctor, I work at the addiction clinic at my hospital. We take top-rate care of anyone struggling with addiction, no matter what their circumstances. We provide low-barrier access to treatment hoping to prevent overdoses and other complications, such as heart damage, skin ulcers, and blood infections. We help people reclaim their lives from the horrors of addictions which run the gamut from alcohol to opioids, benzos, methamphetamine, and cocaine. Many are simultaneously addicted to several of the above. It can be rough going.

This is a difficult disease to overcome, in the face of stigma and inadequate resources, especially if patients don’t have adequate healthcare, housing, or employment. We do our best.

As a complement to my addiction work, I recently studied for the Addiction Medicine boards, a stultifying and incoherent 4 hour-long multiple-choice test. While studying, I was mystified and blown away how they treated the subject of cannabis. The curriculum focused almost exclusively on harms. There was little acknowledgement that tens of millions of people use cannabis medically without problems. These medical cannabis patients experience significant clinical benefit and with minimal, and tolerable, side effects.

I have been treating patients with medical cannabis for twenty-five years and I know that with the use of cannabis, patients frequently are able to cut down on more dangerous drugs such as opioids, Ambien, or benzodiazepines. This type of harm reduction is a win all around.

The field of addiction medicine hasn’t read this memo yet. They refer to cannabis as an “illicit drug” (putting it in the category of fentanyl and PCP) when it is currently fully legal for adult use in 24 states and is legal for medical use in 38 states. Cannabis is also legal, to varying degrees, in numerous other countries. One is left with the impression that any cannabis use is associated with psychosis, hyperemesis, addiction, tarnished lungs, a “gateway” to opioid addiction, heart attacks, premature babies, and amotivational syndrome.

What was I taught by the addiction specialists

To set the tone, in the main chapter about cannabis, from the textbook “The ASAM Essentials of Addiction Medicine”, the authors refer to “medical marijuana” with derogatory quotation marks, as if to denote that the entire enterprise is fake science that only a deluded hippy would believe in. Next, they state that patients “purportedly” benefit from its analgesic and antiemetic properties. Purportedly? Even the 2017 report from the National Academy of Sciences, Engineering and Medicine stated that there was “conclusive” evidence for these medicinal uses of cannabis.

The practice questions were astoundingly misinformed. Here is one, from the American Society of Addiction Medicine:

To anyone who has ever used cannabis, it boggles the imagination that one might have to change to a job that “requires less technological acuity and is less cognitively challenging” because they use cannabis. In many cases, cannabis can help people think creatively and analytically. This question manages to incorporate two cannabis myths: first, that it makes you dumber and, secondly, that it saps your motivation. As an aside, I don’t think that heavy ketamine use, or particularly DMT, would particularly help your job performance. Hallucinating on the job and communicating with space elves is rarely helpful in the corporate context, but that wasn’t the correct answer,

Myth number one, the theory of “amotivational syndrome” has always been nonsense, a creation of the War on Drugs, with no basis in reality. Some of the most motivated people throughout human history have been cannabis users (think of Astronomer and Pulitzer Prize winner Astronomer Carl Sagan, for one). I address this, and other cannabis misconceptions, in a recent blog.

As for cannabis making you dumber, or causing a drop in I.Q., I thoroughly address this particular false claim in my recent book, “Seeing Through the Smoke: A Cannabis Expert Untangles the Truth About Cannabis.” In short, the reason a group of researchers was able to make it look like cannabis caused an I.Q. drop was that they didn’t factor in other things that can make kids do worse on standardized tests such as poverty, mental health issues, and, in some studies, tobacco, alcohol and other drug use. When a different group re-analyzed the same data, paying attention to these factors, the purported drop in I.Q. vanished.

Another practice question asked how many milligrams of THC in an edible can cause respiratory distress and a coma. The correct answer was that a 7.5 mg gummy (which is about the THC content of one puff of cannabis) is enough to cause respiratory depression and coma. To start, cannabis doesn’t cause respiratory depression or coma. There isn’t a significant concentration of cannabinoid receptors in our brainstems -- which is the part of the brain that controls breathing. By contrast, there are abundant opioid receptors in the brainstem, and this is how opioid overdoes happen: you stop breathing.

During some gruesome experiments during the War on Drugs, the National Institute of Drug Abuse funded research that tried to kill, via respiratory depression, monkeys and dogs with astounding (and cruel…) doses of THC. They were desperate to prove that cannabis could be lethal. Even with hundreds of thousands of milligrams, the monkeys and the dogs lived on. This is the equivalent of something like 100,000 5 mg gummies taken all at once! If five hundred thousand milligrams couldn’t cause respiratory depression in animal species with nervous systems that resemble ours, then 7.5 milligrams of THC taken orally obviously couldn’t cause respiratory depression or coma. (The person who wrote this question might as well have been in a coma…).

There are known harms to cannabis use

It would be more helpful if the addiction curriculum focused the actual harms of cannabis, within a reasonable context of harms versus benefits. These harms are well-documented and well-researched. Anyone (who is sensible) would agree that, with cannabis use, there are:

• Concerns over effects on brain development in teenagers, particularly younger teenagers

• Concerns over safety in pregnant and breastfeeding women, including ill effects on the fetus/newborn

• Concerns that cannabis can trigger or worsen psychotic disorders, especially in young adults

• Concerns that smoked cannabis contains harmful combustion products

• Concerns that people might get addicted to cannabis (though this is complicated; see my blog)

• Concerns that smoked cannabis could help trigger coronary events and arrythmias

• Cannabis Hyperemesis Syndrome

• Concerns about driving under the influence of cannabis

• Concerns about accidental exposures and nonfatal overdoses due to how strong and laxly packaged today’s cannabis is, especially edibles

Again -- it is a question of context.

All medications have unwanted and unintended effects. For example, if I prescribe penicillin to treat a patient with strep throat, most patients will respond well. A small minority could have a serious allergic reaction. That doesn’t mean we don’t use penicillin but, rather, we discuss the potential harms with patients and use it cautiously and mindfully. We monitor them and promptly respond to any problems that arise. If we solely focused on the allergic reaction and didn’t factor in that most people recover from a serious infection, penicillin would look like a horrible drug! The same is true for aspirin: if we only consider ulcers and bleeding, and don’t factor in cardiovascular benefits, it would be considered a noxious poison, not a life-saving medication.

Of note, the problems in cannabis communication do not just lie with the cannabis skeptics and prohibitionists. Cannabis zealots must give up on fanciful claims such as “cannabis is natural and harmless”, “cannabis cures covid”, or “cannabis cures cancer.”

There are harms caused by one-sided and misleading education

It doesn’t help anyone or anything to present a drastically one-sided view of any medicine or medical treatment. It confuses everyone, lessens credibility and believability, and makes it difficult for patients to find and trust physicians as legitimate sources of knowledge. As it is, much of the information out there on cannabis is incredibly contradictory. Why add fuel to this intellectual fire?

The type of misleading presentation of information that I have documented above makes it much more difficult for doctors to advise patients about medical cannabis use. They don’t know enough to even to carry on a sensible conversation. Patients then go elsewhere to obtain their practical information, such as to “budtenders” at cannabis dispensaries. Budtenders tend to be nice and enthusiastic cannabis connoisseurs, but they aren’t medically trained and shouldn’t be giving medical advice. They might not be aware of the harms in pregnancy, or the risks of psychosis, and they certainly wouldn’t know about potential medication interactions.

In this vacuum of knowledge, it is very difficult for doctors and patients to communicate on this issue. Most patients will just clam up in the face of any perceived stigma or judgment. It presents an unnecessary and self-inflicted barrier. If doctors view cannabis along the lines of PCP and heroin, due to a steady stream of misleading education, it is difficult for them not to view all cannabis use with stigma and judgment. Even doctors with extraordinary bedside manner can’t help but convey these feelings on a subconscious level.

This lack of communication is dangerous. Patients are much less likely to ask for help if they start to suffer from any of the harms listed above. If they are slipping into addiction, they won’t feel comfortable bringing this up. If a doctor asks, as part of screening (along with alcohol and tobacco), “do you use marijuana?”, patients will lie.

I know hundreds of cases where this has happened. Without a discussion (and accurate knowledge), doctors can’t warn about potential medicine interactions. Doctors can’t even inform patients about the basic and elemental harms of cannabis – such as harms in pregnancy -- if they aren’t discussing this issue with their patients. If the harms are exaggerated, as they have been during the entirety of the War on Drugs, patients simply won’t believe them.

How to move forward?

We need to come to some sort of middle ground on cannabis. We should all be able to agree on a certain patch of common ground along the lines of:

1. Cannabis can be a helpful in alleviating symptoms of chronic pain, anxiety, insomnia, chemotherapy induced nausea and vomiting, PTSD, fibromyalgia, colitis, and spasticity in multiple sclerosis (though it is often unclear what the long-term impact of the cannabis use is on these diseases).

2. The harms listed above are real and it is vitally important to educate patients on them.

From this growing patch of common ground, we focus on the science that is coming out daily, and we can then evolve our common beliefs about cannabis. This process needs to be insulated from both the industry of prohibition (law enforcement, private prisons, etc.) which profits so much from cannabis criminalization, as well as from the influence of the cannabis industry.

We all agree (except for the RFK wingnuts…) on the benefits of vaccines and antibiotics. Why should cannabis be any different?

We must teach doctors about the endocannabinoid system (the endogenous system of neurons and transmitters via which cannabis works its effects). This would help doctors understand cannabis harms as well as benefits. We need to teach physicians how to advise patients on dosing and potential side effects and drug interactions. All doctors need to find a way create a climate in which patients can talk about cannabis without feeling judged or criticized.

The medical profession as a whole is inching forward. Recently, the Journal of the American Medical Association (JAMA) published an article calling for the development of core competencies for educating medical students about medical cannabis. This both tacitly assents to the idea that cannabis is a helpful medicine and starts to address the problem that doctors urgently need to get up to speed on this issue to be helpful to their patients.

My late father had been working on this issue for fifty years, since 1973, when his masterpiece “Marihuana Reconsidered” was published. We are not there yet, in terms of full legalization (so we stop arresting brown and Black people for nonviolent possession of cannabis). We are not there yet in terms of universal access to medical cannabis (so that patients don’t needlessly suffer). We are getting there. Education and accurate information are cornerstones of this process. Of all people, our addiction specialists should lead the way, instead of muddying the waters.

Because our healthcare system is failing on so many simultaneous levels, it is difficult for a veteran primary care doctor to know where to begin. I work at an inner-city clinic located in an exceptionally poor part of Boston. For one week during Covid, our town had the highest infection rate in the entire country due to the sheer poverty of the inhabitants, many of whom live in cramped, communal spaces, and who simply didn’t have the luxury or ability to “social distance”. Because this neighborhood is home to many immigrants, we frequently have ICE agents roaming the streets, attempting to torture and humiliate anyone who has dark skin. The highly pro-social, if beleaguered, doctors and nurses that I work with do their best to provide good care to these downtrodden residents. This is increasingly difficult to accomplish in an age of extreme corporatization of medicine, where the hospitals and the insurance companies compete to see who can place more burden on doctors and who can reduce the care provided to patients. Both doctors and patients are suffering.

When I was invited to the “concierge” practice at my hospital to give a collegial lunchtime talk on the practicalities of medicinal cannabis, I was excited to see what a different practice environment might look like. Most of you already know that a concierge practice is one in which you pay a certain annual membership fee to have direct, continuous, and personalized access to your doctor.

How attentive and friendly this doctor is, and how much attention they pay to your specific needs and whims depends on how much moolah you pay the practice, out of pocket, year after year. The costs of this specialized access tend to range from hundreds to thousands of dollars per year.

At the practice I went to, the cost of belonging to the concierge practice is a whopping ten thousand dollars per patient per year. If you are a couple, that is $20,000/year. Who has that kind of money? This would be as if I charged each of my patients, over the 17 years I have been in my clinic, $170,000.00 for being their doctor. Multiply that times thousands of patients and the numbers add up to very happy (and well-paid) hospital executives.

Treatises could be written about the hypocrisy of certain hospital systems, which spend abundant advertising money on virtue signaling, bemoaning deficits in “equity”, and complaining about health disparities. As they increasingly cater to the top 1%, this all starts to border on the ludicrous - but this is a topic for another day.

My cramped office is adjacent to 2 banks, a Burger King, some nearby industrial wasteland, train tracks, and a regional FBI headquarters where, unfortunately, one might see ICE agents processing their recent arrests. The concierge practice I was visiting, by contrast, is in a gleaming building, in Boston’s snazzy West End neighborhood. Up on the tenth floor, it boasts a resplendent view of the Boston skyline. Just arriving there, I started to feel my health improve.

The waiting room was so spacious, I got in about half of my daily step count walking to the front desk to ask for directions to the conference room. In passing, I noted the high-end coffee maker they had in the patient waiting room and lamented that all we can afford to offer our patients is water. My curiosity was kindled by this opulence, and I started exploring. I discovered that their exam rooms were each about four times larger than the cramped exam rooms I use at my inner-city practice. They were filled with natural light, and they were jam-packed with state-of-the-art equipment. No worn-out blood pressure cuffs that leak air or exam room tables that shed their skin, and which look like dying animals. The catered lunch for my talk was delicious, and I mourned the long-past days when our clinic, and our academic medical system at large, had more dedicated time for learning and other initiatives that would help us care for our patients. Most of these niceties have gone by the wayside as we scurry around, trying to keep up with an ever-increasing workload.

The 10K bucks a year buys you much more than nice exam rooms. At a time when 41% of Massachusetts residents are having difficulty accessing primary care, members of the concierge practice benefit from same day visits with their own personal physician. My patients wait weeks to months to see me.

All of this was epitomized when, during my talk, one of the doctors bolted out because a patient was in a car accident and was calling him from the side of the road. What access. Immediate phone calls! Before AAA, or even the police, come to your roadside aid, you get to run your symptoms by your doctor. The practice also offers an on-site nutritionist and a health coach.

It is also rumored that patients receive expedited access to specialists, which is the Holy Grail of effective medical care. One of my patients recently had to wait thirteen months for an appointment with Dermatology for a lesion that I was concerned about. It is hard to imagine that someone paying $10K a year would have to wait this long.

It is an open secret that very high net worth individuals get priority access to specialty care. This has always been the case. I saw this, and was strongly pressured to participate in it, when I worked at an affluent practice right out of residency, at a different hospital. I would get reprimanded: “Ms. X is a V.I.P., why did you let her wait ten hours in the Emergency Department before getting admitted?”

This is one of the reasons I quit this practice. If the precedent and pathway for preferential access already exists, then why wouldn’t people who pay a hefty premium for medical care also get prioritized access? Of note, this service is not officially offered or advertised by the concierge practice as a perk of signing up.

A final perk from the concierge practice is that, as you join up, they invite you for a “non-clinical visit” to meet and schmooze with your new primary care doctor to see if you are a good fit. Imagine this, in a time when access to primary care is so restricted, rather than grasping at whatever primary care crumbs fall your way, you get to pick and choose the personality of your doctor.

Astoundingly, there is currently a one-year wait list for this concierge practice. Again, I can’t help but wonder, how do so many people have so much money? Few primary care doctors - the people that care for these patients - could even dream of affording this membership, unless we were to win Powerball or the like.

The doctors and nurses at the concierge practice were caring and professional. They too are just trying to make their way through a broken medical system. We had a great chat about medical marijuana, and I appreciated their curiosity on this issue which doctors so often ignore. These providers certainly didn’t create the system where the care given to the rich so far surpasses that doled out to the poor, all within the same hospital systems. But it raises the question: is any of this ethical? Do the top 1% really deserve to live longer, to suffer less? Do they deserve to get their needs addressed, so much more immediately and comprehensively than the poor do? In what world, in what universe, is this even remotely fair?

This visit also made me sad because it reminded me of how much better the medical care was that we all provided when I first started primary care, twenty-five years ago. That was in the days before most of the hospitals began their corporate transformation and started morphing into amalgams of Amazon/CVS/Optum/Meta. This was back in the days where more than just the bottom line mattered, and the hospitals didn’t use the profits they suck out to pay their executives seven-digit salaries.

Back then, regular physicians had much more time to listen to patients, to connect with them, to get to know them, to review their charts and to figure out how to humanely address their problems. Patients felt heard and cared for. All patients were concierge patients. Back then, we had far more support, time, and bandwidth for educational ventures. These days, the only way for me to get to a medical conference is to use up my scarce vacation days. Critically, we had more ready access to specialists. No one would ever have to wait 13 months for a Dermatology appointment.

It is profoundly demoralizing for all the healthcare providers to try one’s hardest and to see the care you provide get steadily worse, year after year, due to shifts in a larger corporate environment you can’t control. There is a name for this: moral injury.

I did return to my practice with one morbid idea, expressed in the satirical spirit of Jonathan Swift’s “A Modest Proposal”. I thought – why don’t we ask each of our patients for a one-dollar donation and then, when we get up to $10,000 dollars, we could sponsor one lucky soul to go to the concierge practice for a year’s time. Sort of like a Willy Wonka Golden Ticket for your health and longevity. Then, at least one of our patients can enjoy, for at least one year, the healthcare of the top 1%. They could enjoy immediate and 24/7 contact with their doctors, ready access to nutritionists and coaches, and the ability to relax over gourmet coffee in the Taj Mahal of doctor’s offices while waiting for their physical exams. They would be at least a tiny bit healthier and might live a bit longer. A win-win for everyone.

What is the solution to all of this? Lord knows. The heart of the problem is the vast and worsening wealth inequality in our society where the top 1% hold 1/3 of the country’s wealth, and the top 5% hold 2/3 of our wealth. There is no doubt that the rich live longer than the poor. Check out this graph from a recent Boston Globe article about a study, “Low-Income Older Adults Die 9 Years Earlier than Those with Greatest Wealth”:

The hospitals are only going to continue to make this problem worse as they have become solely about maximizing revenue and certainly don’t mind this model of extremely profitable care. At this point, I’m not even sure that good patient care is still on their radar screens, even as a distant blip. The parasitic health insurance companies have always made everything worse, so don’t turn to them for assistance. I doubt that what’s left of our government, in an environment of insane funding cuts to Medicaid and the demolition of other healthcare subsidies that the Republicans are pushing, is going to be able to step in and fix this. The current crop of Republicans is nihilistic, with its fervor to dismantle everything they can except, of course the privileges of the top 1%, which enable them to get even richer (and thus to live longer).

Whatever the solution to this ethical and practical minefield turns out to be, it is going to involve doctors and patients banding together against the Corporate Overlords. We need to demand a more equitable healthcare system – some sort of socialized medicine - that works for everyone. The pathway to retake our healthcare system seems increasingly unclear as it is intimately entwined with larger problems. Critically, we need to reverse the vast and growing wealth inequalities. We need to do this before we are permanently stuck in an undemocratic system in which the Oligarchs control everything. One must hope that we haven’t reached that point yet.

Today is the two-year anniversary of my getting hit by a car and fracturing my right leg. I want to rerun the blog I wrote at the time, detailing what it is like both to be hit and to recover from such an accident.

I am happy to report that I am walking normally, save for a little arthritis in my right knee from the three surgeries I had.

The third surgery was for an infection in my knee - they had to redo the entire operation three months after the accident and then they put me on intravenous antibiotics for three months, all of which totally sucked. After this final operation, I had to start learning how to walk from scratch, a second time.

It was by no means a predetermined outcome that I would end up able to walk again.

The surgeon said that people with one or more of the "four D's" are far more likely to get amputations. The four D's are:

1) Depressed (ie., unable to care for self or to maintain a positive attitude)

2) Drug addicted (unable to care for self due to compulsion to use and other health issues)

3) Destitute (can't afford medical care; no stable place to recover)

4) Divorced (don't have anyone to help with intravenous antibiotics or dressing changes, or to help fend off depression)

Fortunately, I have an incredibly loving spouse who helped me, I was able to care for myself, had good health insurance, a safe and quiet place to recuperate, and am not addicted to anything in particular (besides coffee). Because of this good fortune, I can walk.

I'm incredibly grateful to be walking yet it makes me sad to think of the thousands who went through a similar type of injury and are now relegated to wheelchairs because they don't have all of the right pieces in place. Our healthcare and social safety net should be such that all people, regardless of finances, other health issues, or social status, receive the same health outcomes. We have a long way to go towards creating a more equitable society and, currently, seem to be rapidly heading in the opposite direction.

Please enjoy "Notes From the Mowed Down" (below) and look both ways before you cross the street!

-Dr. G.

I'm sitting here with a broken leg, and with nothing but time on my hands. It was little more than six weeks ago that a seventy-six-year-old psychiatrist from my hometown decided to drive home from work after dark, seemingly forgot to turn her lights on, pretended she was in a NASCAR race, and mowed me down as I was crossing a street on foot. She said she never saw me. It was mutual. I had been trying to get ice cream at a popular, local ice cream store, and had been crossing the street with my extended family in tow. Any one of us could have been hit, ranging from my 16-year-old niece to my ninety-three-year-old mom.

One moment I’m crossing the street and the next moment – after an ugly, surreal thud - I am sitting down in the road, holding my floppy right foot onto my leg so that the blood vessels would remain intact – some atavistic doctor instinct. This instinct just might have ended up saving my foot, by preserving the blood flow to already quite damaged tissues.  I stayed preternaturally calm throughout, and remember saying to my wife, “Tell the kids I’m alive and it’s just my foot.”  In the ambulance, they gave me two hundred micrograms of Fentanyl – enough for eight colonoscopies. It didn’t have the slightest effect on my pain. “Can I please have some more?” “Sorry – that’s the maximum.” They couldn’t give me anymore for fear I’d stop breathing.

I wasn’t aware that it was possible to feel this much pain. When pain is severe enough, it predominates over all other thoughts and feelings you may be having. I remember thinking, a little later, “Maybe I shouldn’t volunteer for Doctors Without Borders when I get older” – something I’ve always fantasized about. As someone once said, “Getting shot at wasn’t a big deal, it was actually getting shot that sucked.” I do not want to feel this level of pain ever again, no matter what.

                                                                        ***

Rushed to the hospital where I work,  Man’s Greatest Hospital (M.G.H.), I suddenly found myself to be a center of attention. A flurry of activity was occurring that I can barely remember. I had entire conversations with doctors and nurses that were complete blanks as if I were an alcoholic in the midst of a blackout. In truth, they were giving me copious quantities of sedatives and opioids, which, along with the infinite level of pain, might have affected my memory. I don’t think I would have survived if they didn’t give me these meds.

During my evaluation, the trauma nurses unceremoniously snipped off my bathing suit while I had the incongruous and decontextualized thought, “Hey, that’s my favorite bathing suit”.  No worry – I wouldn’t be swimming for a while. Maybe never at that point. I wouldn’t be walking or driving either for that matter. Earlier in the day, this bathing suit’s owner enjoyed a glorious day on the beach with my three adult children. This magical day was supposed to end with ice cream, not with them all witnessing me getting flattened by a distracted or impaired driver.

Having been through this ordeal, I feel as if I have special insight into what medieval tortures felt like for the people on the receiving end, or for what soldiers must go through when they step on a landmine.

                                                                        ***

Next, they geared up the complex and uncertain process of fixing my right leg. In medical terms, what I had was a comminuted (e.g., bone broken into pieces), open (i.e., bones poking out into the world where they certainly don’t belong – presenting a huge risk for infection), fracture of both my tibia and fibula - or an ‘open tib-fib fracture’. I have a blurry memory of signing a ‘consent’ for the first surgery, though what I was about to go through seemed like a foregone conclusion.

A standard surgical approach to address an open tib-fib fracture is the sequence of surgeries known as ORIF, or ‘Open Reduction, Internal Fixation’. During the first surgery, they anchored my bones and other tissues back into their proper location. To hold them in place, they attached a sort of external scaffolding to my leg by drilling screws into the bones of my heel and my shin. A picture is worth a thousand words.

Yes, it was just as painful as it looks! Even more so. The tiniest of movements resulted in an immediate, burning reminder that I had metal pins screwed into my bones in several different locations. Between the original injury and the surgery, I felt as if my leg had been dipped into a vat of hydrochloric acid. The pain went to eleven. Only opioids made this the least bit tolerable.

The words of the song, ‘Sister Morphine’ by the Rolling Stones, written about addiction, fully capture my growing desperation, as I was in excruciating pain, waiting each time for the nurse to come with the pain meds,

Not only was I waiting for Sister Morphine (or, technically, Uncle Oxy?), around the clock, I was awaiting my next surgery with trepidation.

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                                                                        ***

Several days later, after a thermonuclear attack with very strong antibiotics on any potential residual microbes, to cleanse the tissue that should never have been open and exposed, I was due for the second surgery. This part is called “internal fixation”, the IF in ORIF, and it was hopefully the final, definitive surgery. Luckily, I was on a huge dose of ketamine, an interesting drug that I’ve written about for Harvard Health. I sorely needed the ketamine because, during this seemingly barbaric procedure, they injected a nail behind my right kneecap…ouch!... and thus inserted a rod into my leg, extending from my knee to my ankle, to hold my bones in close proximity. Once held together, the bones, especially the weight-bearing tibia, can ideally grow and heal together.

Here is a ‘before and after’ radiograph. On the right frame (before), just off the street, the bones are severely fractured, both the thicker tibia and the thinner fibula. You can see why my foot was flopping to the side.  On the left of this X-ray, if you look, you can just see where the skin was punctured. On the left frame (after), several weeks out, I have the rod in place and my bones are starting to unite together. The most important bone is the thick one, a.k.a. the tibia, which bears most of the weight. This is just to the right of the rod and you can see it looking well-aligned.

Pain control: Cannabinoids and opioids

When in severe pain, such as after a traumatic accident like mine, or immediately after major surgery, opioids are required, period. Nothing else is strong enough, including cannabis, Tylenol or non-steroidals. It is inhumane and unethical to undertreat pain, even if you are worried that a certain percentage of people will ultimately get stuck on opioids (though, there are sensible ways to minimize the likelihood of this).

Unfortunately, as part of a highly misguided attempt to stem fentanyl overdosages, our government has been pressurizing doctors to not prescribe enough opioids. This is backfiring, as opioid overdoses haven’t dropped in response to this policy, but suicides have risen due to undertreated chronic pain. I discuss this in a piece in TIME Magazine. In short, as they deny people who are addicted, or people who are in chronic pain, sufficient access to opioids, patients buy these medicines on their own, and it is the illegal sale that results in so many people perishing from products tainted with fentanyl. If opioids were legal, available, and sensibly regulated, few would be dying from fentanyl.

On a visceral level, I wasn’t that excited to be taking opioids after my accident and my surgeries. This was due to my past addiction and the horrible associations I have with that miserable time in my life. This entire uphill battle against a near-lethal opioid addiction is recounted in my memoir, ‘Free Refills: A Doctor Confronts His Addiction.” Though, after this type of accident, and these painful surgeries, the pain was SO severe, I gladly accepted whatever opioids they would throw my way, much as a drowning person would accept a floatation device thrown to them in the water.

As a cannabis specialist, I was aware of research that cannabinoids can reduce the dose of opioids needed by co-working on overlapping receptors. For example, if you use 2.5 milligrams of oxycodone in an experimental situation, it doesn’t noticeably help with pain. If you use 2.5 milligrams of THC, the same thing: no pain relief. Yet, it has been shown that the 2.5 milligrams of oxycodone given with the 2.5 milligrams of THC can help control pain. There is a nonlinear, 1+1=3 phenomenon going on. I was able to leverage this knowledge to minimize both my pain and my opioid exposure. (People aren’t officially allowed to use cannabinoids in the hospital due the Federal illegality; this needs to change!)

I found that for every 2.5 milligrams of THC I was using I could go down on the opioids by about five milligrams. This made for much more coherent texts to friends and family and for a much more comfortable early recovery. Also, even though I’d been on opioids before, during prior surgeries, since my addiction, I know enough to attempt to minimize the dosage as able so as to not tempt fate. (I discuss pain control and the role cannabis plays in my new book, “Seeing Through the Smoke.”)

                                                                        ***

Wound care

A note on one of the underbellies of getting better: wound care. Wound care is a critical part of healing. I broke my leg, but the flesh wound was equally as complex to heal, requiring ongoing, sophisticated input from the experts in Plastic Surgery. In fact, they thought I didn’t have enough remaining healthy skin to cover up the wound and were strongly considering a skin flap – which is an utter nightmare involving a much more prolonged hospital stay, that I was able to avoid.

Wound care often requires dressing changes several times a day. It is not practical for the visiting nurses to come to your home anywhere near this frequently. So, ideally, a family member steps up and takes over the wound care. The two problems of this are one, it's gross, and two it can be quite complicated. One needs a family member or a friend who doesn't mind the grossness and can handle the complexity. Many families simply don't have this. As a consequence, they have much worse outcomes with their wounds.

Fortunately for me, my wife Liz, who is not medically trained (she is, however, a brilliant Data Engineer at one of the other Harvard Hospitals, though I’m not entirely sure what she actually does…) embraced my wound care and did an absolutely spectacular job. As I witnessed her meticulously addressing my complex wound, sometimes to the tune of several hours a day, I remembered that her father was a general surgeon. I could see the general surgeon genes operating within her – she would have been a phenomenal surgeon. Thanks to her competent and tender ministrations I was able to overcome two serious wound infections, avoid the dreaded skin flap surgery, and thus focus on healing my bones - which is the critical formula for success in an injury like this. 

Conclusion

This entire accident has been an utter nightmare – literally the most difficult experience I have ever had to walk through (or, actually, limp through with a walker or, now, on crutches). For one, I thrive on exercise, and having to essentially sit still for several months has been utter torture. I feel like a puppy that has terrible owners and who, instead of getting tons of puppy-level exercise five times a day, is simply locked in its crate. It would take an entire other essay to list the things I had to cancel, the things I’ve missed out on, and how difficult it has been, at times, to maintain my mood above Dostoyevskian levels.

But there has been a massive bright side. The outpouring of love and support from friends, family members, and colleagues, is something I will remember and cherish for the rest of my life. It brought my family closer – nothing like all of us almost getting mowed down by a careless driver who was driving without looking at the road to bring you all together! I feel like I’ve grown, and many of my relationships have grown deeper.

I also have a more profound, if possible, love and respect for my partner Liz who has been with me every broken step of the way. Finally, I am grateful to still be alive – one step further and it would have been all over, as the driver would have mowed me down full-on, hitting much more than just my leg. I am not done yet.

P.S. This is me speaking, broken leg and all, at the recent Cannabis Science Conference in Rhode Island, with Cherissa Jackson and Brian Essenter, five weeks after the accident.

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As cannabis legalization has been sweeping across the country, the opioid epidemic continues to rage and to take lives. If we are serious about ending this crisis, it’s time to apply the lessons from the legalization of cannabis to our current mess with opioids. This may seem counter-intuitive, because cannabis is a comparatively safer substance. Opioids are more significantly more addictive, and the addiction is often deadly. Yet, despite their many potential harms, criminalization has not been at all successful for the opioid epidemic. Criminalization of any drug is a formidable barrier to treatment and enhances risks on a number of fronts.

I know about these risks because of my work as a physician and because of my own brutal struggle with opioid addiction, which nearly destroyed my life. I’m one of many who struggle, or who have struggled. We lose tens of thousands of people per year to opioid overdoses. Millions of others shuffle through their miserable addicted lives. The courts and law enforcement have become the de facto first responders to a public health scourge, when it ought to be doctors, addiction specialists, and other healthcare professionals on the front lines.

I am twenty years into recovery. I have helped dozens of other doctors who were addicted. I have treated thousands with addiction over the last quarter century as a primary care doctor and as an addiction specialist. Over the years, I’ve come to realize that it is the criminalization of drugs as much as the drugs themselves, that causes many of our problems.

It is the illegal nature of street opioids, as much as the opioids themselves, that is killing people. Millions of people with untreated addiction or undertreated chronic pain—who don’t have a safe medical supply of opioids— are forced to purchase their opioids on the street to obtain relief from their pain or their soul-crushing withdrawal symptoms.

The street supply of almost all drugs is now heavily contaminated with fentanyl, as well as other adulterants such as xylazine. A small fraction of our overdose deaths stem from the use of legally prescribed opioids. The vast majority arise from illegally bought, contaminated drugs.

We’ve known that decriminalized or legal drugs are less dangerous than those bought in the underground market. We’ve known this at least since the early 20^th century, when we launched our disastrous experiment with alcohol Prohibition. Those years—from 1920 to 1933—saw a proliferation of severe, often fatal poisonings from a tainted supply.

In much the same way, the illegality of opioids has fatally tainted the street supply. In sharp contrast, cannabis is now legally bought from dispensaries and is screened for heavy metals, molds and pesticides. It is labeled and it is safer. People generally know what they are getting (even if the regulation of cannabis, at this point, is less than perfect).

When one buys any drug from a street dealer there are no controls, regulations, checks, or recalls. For the cannabis buyer this process was once a roll of the dice. Now, with the risk of fentanyl laced drugs, for people who purchase street opioids, it is more a game of Russian roulette. It is my conviction that if opioids were decriminalized and accessible, a vastly lower number of people would be dying from fentanyl, and from opioid overdoses at all.

A recent study in The American Journal of Public Health lends evidence to the idea that law enforcement is contributing to the damage from opioids. The authors were able to prove the following hypothesis,

We tested the hypothesis that law enforcement efforts to disrupt local drug markets through routine supply-side interdictions—as measured by police seizures of opioid- and stimulant-related substances—are associated with increased spatiotemporal clustering of fatal and nonfatal overdoses, as well as increases in EMS naloxone administration, in the area surrounding the seizure.

The disproportionate involvement of law enforcement in the drug realm harms patients in other ways as well. Millions of dollars are being wasted on militarized police units that could be far better spent on addiction treatment. With this money, we also could be offering patients a realistic pathway out of their addicted lives. We should be providing housing, healthcare and jobs training to people suffering from addiction. This is what they have been doing in Portugal since they decriminalized drugs, with overall success. Many people wish to transition out of addiction but simply don’t have the tools that they need.

If we were to decriminalize opioids, it can’t be done in the ‘free for all’ manner of cannabis dispensaries because opioids have much more potential for harm and need to be more strictly regulated. The dispensing of opioids could be connected to treatment programs and educational resources. The dispensing of opioids could take the form of government-controlled stores. For example, people could present a card from their doctors stating their need for opioids, due to addiction or to chronic pain. The access would need to be very low threshold for patients, in order to circumvent the illicit market. There certainly wouldn’t be “recreational opioids” as there is now “recreational cannabis.” It would be limited, as much as possible, to medical uses.

According to a study by the Rand Corporation, there is good evidence for heroin assisted treatment (HAT) from Europe and Canada,

Evidence from randomized controlled trials of HAT in Canada and Europe indicates that supervised injectable HAT—with optional oral methadone—can offer benefits over oral methadone alone for treating OUD among individuals who have tried traditional treatment modalities, including methadone, multiple times but are still injecting heroin.

These patients, if not provided this treatment, or a comparable treatment, would likely be buying their drugs on the street, risking a tainted, deadly supply.

An often-overlooked benefit of the legalization of cannabis is that it has allowed for more truthful and open communication between patients and doctors. Patients can now freely discuss their use with doctors, with less fear of judgment and stigma. This results in greater safety and open discussions about potential misuse. Opioid users would stand a better chance of getting potentially life-saving help if they could candidly discuss their concerns and struggles with doctors and other healthcare providers. If people are afraid of getting into trouble, they clam up - this is another harm of criminalization.

We now have effective tools, including medications that can help treat people addicted to opioids. This is known as Medications for Opioid Use Disorder (MOUD) and includes buprenorphine (Suboxone) and methadone. These medications are associated with a fifty percent or greater reduction in overdose deaths. Sadly, we don’t have the medical infrastructure or social safety nets to provide this care to more than approximately one-fifth of addicted patients who need it.

We are nibbling at the edges of the opioid crisis, first with the provision clean needles to prevent HIV and Hepatitis C, and now (hopefully – if not blocked by the Federal government) with ‘safe injection facilities’—where people suffering from opioid addiction can use opioids in a medically monitored setting. Recently, over-the-counter Narcan has been approved which is a drug that can transiently reverse an opioid overdose. These measures are big steps in the right direction, but they are not nearly enough. It is time to go much further and to decriminalize opioids. By doing so, we can finally reroute resources from prosecution and punishment to support services and treatment.

The War on Drugs, which we’ve been suffering under for more than a half century, was never entirely about the drugs themselves. It can be looked at as a fabricated moral panic to help control and subjugate certain sectors of our population, mostly people with brown and Black skin. The numbers of arrests, in the tens of millions, are truly staggering. It has been quite effective for this unfortunate purpose of social control, but it also has resulted, among other harms, in our current opioid crisis.

We do not need to continue fighting this war that has already been lost. Law enforcement are exactly the wrong people to be involved with drug issues, except perhaps in cases of impaired driving or violent behavior. We would be much better off if we extrapolated our ongoing success with legal cannabis into the opioid realm. Let’s focus our attention on providing resources and on providing treatment, not on punishing and saddling people with needless criminal records. Let’s decriminalize, opioids, and let’s start saving lives.

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Many of you may have encountered "kratom" at gas stations, convenience stores, smoke shops, and even at natural health or vitamin shops. It comes packaged as capsules, powders, drinks, or energy shots. It is touted to help many conditions ranging from pain relief to elevation of mood and focus. Legions of people rely upon it for opioid withdrawal symptoms. Its growing prominence and visibility in these retail spaces has sparked both curiosity and excitement as well as concern among healthcare providers.

Depending on what you read, who you listen to, and which experts you defer to, you can get a remarkably different idea about the benefits or potential harmfulness of kratom. Millions of people believe that kratom is an accessible pathway out of undertreated chronic pain and opiate withdrawal, which can safely improve mood and focus. Many experts believe that kratom is a dangerous, unregulated, addictive drug with little medical utility and potentially severe side effects, including addiction and overdose. How can millions of regular kratom users, the US Drug Enforcement Agency (DEA) and medical professionals have such divergent views of the same plant? Is either vantage point fully accurate? How do we factor in that it is difficult to come up with a sensible opinion on any drug in a culture that’s been assaulted by a half century’s War on Drugs, which tends to shift the dialogue toward distorting facts and exaggerating harms?

What is kratom?

Kratom (Mitragyna Speciosa) is a tropical tree related to the coffee family native to Southeast Asia, with properties that range from stimulant-like, energizing and uplifting, to opioid-like, causing drowsiness, constipation, and euphoria. Kratom has dozens of active components and stimulates numerous different receptor systems in our brain. All of this makes kratom difficult to characterize as one particular type of drug such as a "stimulant" or an "opiate."

The two main chemicals, mitragynine and 7-hydroxymitragynine, have strong activity at the main opioid receptor, the "mu" receptor, which is the same one stimulated by narcotics such as heroin and oxycodone. Kratom is commonly consumed orally, such as made into a tea, with added sweetener to overcome its utterly disgusting bitterness (in my opinion…) or swallowed as a pill. There are now available extremely potent concentrates such as 7-hydroxymitragynine which appear to be even more addictive and toxic. The variety of kratom related products are proliferating.

Side effects of kratom that have been cited include agitation, tachycardia, drowsiness, vomiting, and confusion. There are also said to be grave side effects such as seizures, as well as respiratory and cardiac arrest. Deaths have been reported from kratom though, as discussed below, this has not truly been established.

Kratom can be found in gas stations, smoke shops, natural medicine and botanical shops, and paraphernalia shops in most parts of the US, except in the handful of states and cities that have banned it. Many people purchase kratom over the Internet, where it typically is sold "for soap-making and aromatherapy" to avoid the fact that in 2014 the FDA made it illegal to import or manufacture kratom as a dietary supplement. The sites essentially say, ‘not for human consumption, wink wink, nod nod.’

What are some of the problems with kratom?

There is little to no reliable information on the growth, processing, importing, packaging, or labeling of the kratom sold in the US, which adds to the already considerable uncertainty of its health risks. No adults are regulating this industry. This means that there is no guarantee that any kratom that you buy will be safe and unadulterated. In 2018 the FDA instituted a mandatory recall over concerns about Salmonella contamination of kratom-containing products. The DEA has recently placed kratom on its Drugs and Chemicals of Concern list but has not yet labeled it as a controlled substance.

Kratom can be addictive due to its opioid-like qualities, and a small minority of users end up requiring addiction treatment. This is called Kratom Use Disorder, and is often characterized by tolerance, withdrawal, and cravings. There are case reports of doctors needing to use Suboxone (buprenorphine), a treatment for fentanyl and oxycodone addiction, to get people off of kratom. The CDC claims that between 2016 and 2017, there were 91 deaths due to kratom, but this claim must be greeted with skepticism, as all but seven of these casualties had other drugs in their system at the time of death, making it impossible to uniquely implicate kratom.

Why do people use kratom?

The DEA, who tend to be one of the least reliable resource on any drugs in my humble opinion, maintains that kratom has no medical uses or benefits. However, in Asia kratom has been used for hundreds of years to treat cough, diarrhea, opiate withdrawal, depression, and chronic pain, and to boost energy and sexual desire.

More recently, in the US there has been an uptick in the use of kratom by people who are self-treating chronic pain and acute withdrawal from opiates. People are desperately seeking alternatives to prescription medications as pressure is put onto doctors not to prescribe these pills. This pressure, as well as a lack of available providers, results in an increase in overdoses, as people are thus forced to buy street drugs tainted with fentanyl, and suicides.

There is very limited research suggesting that kratom is effective and safe. A 2024 study, ‘Ecological Momentary Assessment of Self-Reported Kratom Use, Effects, and Motivations Among U.S. Adults’, which assessed 357 current kratom users, found that,

Kratom has an extremely vocal community of supporters, and, while there are countless anecdotal testimonials of effectiveness, these treatment practices and outcomes using kratom have not been as rigorously studied as they need to be. I look forward to seeing more studies, hopefully in the near future, so we can confirm kratom’s safety and efficacy.

A patient wishing to use kratom for pain or to mitigate withdrawal symptoms would encounter several problems, not all of which have to do with the intrinsic properties of kratom itself.

• First of all, the DEA has threatened to make it a Schedule 1 controlled substance (i..e., no medical utility, high misuse liability), which is in the same category as heroin or psilocybin. Paradoxically, both of these drugs have robust medical usefulness – did I mention that the DEA doesn’t know what it is doing?. This would make it difficult for desperate patients to access and would likely make the supply, as a whole, even more dangerous. It is always the case that making drugs illegal makes them more hazardous for everyone.

• Secondly, the complete lack of oversight or quality control in the production and sale of kratom makes its use potentially dangerous. There is no ‘adult in the room’ regulating kratom and naked capitalism, on its own, can make for extremely unsafe products.

• Thirdly, kratom has not been well studied for any of the uses its proponents claim, though as the saying goes, "absence of evidence of benefit isn't evidence of absence of benefit." The harms haven’t been adequately studied either.

• A final problem is that kratom doesn't show up on drug screens. One can argue that the wider adaptation of another potentially addictive opioid-like substance in the midst of an opioid epidemic, which has killed more than one hundred thousand people per year over the last several years, is the last thing we need.

Is there a sensible path forward with kratom?

I'm not sure that anyone has the answer to this question. At bare minimum, safety could be improved with:

• Regulation: it would be safer if people knew the exact dosages they were consuming and that it was free of contamination from things such as pesticides and heavy metals.

• Education: educated consumers, who know the dangers and potential benefits, are far less vulnerable to misleading claims and able to pick safer products.

• Research: if it does have benefits for either addiction or chronic pain, as its advocates claim, we need to know. It is also critical that we better define the risks of using kratom, so that people are more accurately informed, and can practice harm reduction. Kudos to Kirsten Smith at John Hopkins who is studying all this stuff.

• Keep from criminalizing kratom. As with all other drugs throughout history, this would make everything about its use more dangerous.

If the above suggestions could somehow be accomplished, by scientists and public health specialists, without overdue distortion from corporate interests, antidrug ideology, and romanticism by kratom enthusiasts, we could then have enough clarity to answer the question: is kratom harmful or helpful?

My guess: more helpful than harmful, but…coherent regulation is essential.

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Cannabis is indispensable for millions of patients to help alleviate a variety of gastrointestinal symptoms including colitis symptoms, gastroparesis, irritable bowel syndrome and, particularly, chemotherapy induced nausea and vomiting. It is used with great success for migraines and is also used to treat a miserable, related syndrome called cyclic vomiting syndrome. Cannabis is not recommended for use during pregnancy, despite the fact that it is highly effective for the nausea and vomiting associated with morning sickness, which makes it a popular option.

So, how can cannabis cause vomiting? What is this increasingly diagnosed condition called cannabis hyperemesis syndrome (CHS)?

Paradoxical and biphasic reactions

Some drugs have paradoxical reactions, meaning that a small percentage of patients experience effects that are opposite from the usual and intended effects. For example, Benadryl (diphenhydramine) makes most people sleepy, which is why it the active ingredient in Tylenol PM (which is a crappy sleeping medication - but that is for another day). However, a small percentage of patients become wired and physiologically excited after consuming Benadryl. Another example: barbiturates are usually extremely sedating but, a subset of people become highly activated after taking them.

Moreover, some drugs are “biphasic” meaning that in low doses they have one effect and in higher doses they have a different effect. Using cannabis to treat anxiety is the perfect example of this. When used at a low dose it helps alleviate anxiety for most people. At high doses cannabis can cause severe anxiety and may even lead to a full-blown panic attack. Any of us who have accidently consumed too large of a dose, such as too much brownie batter or an unmarked edible, can attest to this fact.

Given this framework, it is not difficult to understand that cannabis might alleviate nausea at low doses and might exacerbate it at high doses. The most dramatic example of this is when people “green out” meaning that they acutely consume much too high a dose of cannabis. They can spend the rest of the evening barfing uncontrollably – it is ugly to witness. This particular reaction is best considered a toxic overdose, and it demonstrates that cannabis can cause nausea and vomiting. Cannabis hyperemesis is a chronic cannabis induced vomiting syndrome among heavy, regular cannabis users that is being increasingly recognized.

Cannabis Hyperemesis Syndrome (CHS)

CHS largely afflicts a minority of longstanding, heavy users of cannabis. It is characterized by severe, episodic nausea and vomiting, often accompanied by abdominal pain and weight loss. Curiously, people report taking hot showers to alleviate the symptoms, which can be a clue to the diagnosis.

This syndrome does not occur with people taking an occasional, sociable puff of cannabis at a party. This syndrome does not often occur with medical patients taking a modest dose of cannabis every day, such as a small, regular dose of an edible or a puff or two for chronic pain. It almost predominantly occurs in heavy cannabis users and most typically occurs in young men aged 16-34.

People with CHS often end up in the emergency room, possibly several times a month, with electrolyte abnormalities, severe dehydration and, occasionally, more ominous symptoms, such as muscle breakdown or, uncommonly, seizures. There can also be acute kidney failure, esophageal injuries from intensive vomiting, and pneumomediastinum, which is when you throw up so intensely that you tear a hole inside of your chest.

Is it accurately diagnosed?

Cannabis hyperemesis has gone from being underdiagnosed to being over diagnosed. We didn’t have a definition of it until 2004 so, before then, it was never diagnosed. Even after it was clearly defined as a syndrome, emergency room department doctors didn’t associate cannabis – a drug known for helping nausea and vomiting in cancer patients – as the cause of these wretched symptoms. Also, patients were not particularly forthcoming about their cannabis use due to the war on drugs which made an accurate diagnosis less likely. Who wants to risk getting into trouble by admitting to cannabis use? You can’t have a diagnosis of CHS without the cannabis part.

Today, with more scientific understanding, more clinical experience, more accepting attitudes toward cannabis use, and more general recognition, it is very frequently diagnosed in the emergency department.

The increased incidence of CHS likely has to do with the fact that cannabis is much stronger that it used to be and because there are now more people are using it heavily – both risk factors for CHS.

At the same time, given that it is now a fashionable diagnosis that doctors frequently read about in the press, many patients who present with vomiting, and who have ever admitted to cannabis use, at any point, can be given this diagnosis, without much deeper thought. This leads to overdiagnosis.

The problem with this automatic, default diagnosis of CHS is that it might not be accurate. It is unhelpful to give someone the wrong diagnosis. For example, there is a syndrome called “Cyclic Vomiting Syndrome” (CVS) which presents in almost the exact same manner that CHS does. One main difference is that with CVS there is less of a history of trying to self-treat with hot showers. Otherwise, they can appear in an identical manner.

CVS is a complex syndrome of nausea and vomiting, that is physiologically related to migraines. Migraines are one of the conditions that medical cannabis works particularly well to alleviate. In fact, many people use cannabis to treat CVS with good benefit.

This means that a patient can often present with a) cannabis use and b) nausea and vomiting and therefore will almost automatically be given a diagnosis of CHS. Yet, the diagnosis won’t actually be CHS. It will be CVS, which is being treated with medical cannabis. This is a perfect example of how CHS can be misdiagnosed. The treatments for these two conditions are overlapping, so misdiagnosing isn’t the end of the world.

How to treat CHS

The only way to differentiate between CHS and CVS is to stop using cannabis for 3-6 months. If the problem resolves, it was CHS. If the problem continues, without any cannabis use, it is CVS. As such, the only true diagnostic tool for and treatment of CHS is complete cessation of cannabis use.

Unfortunately, very few heavy cannabis users manage to remain abstinent even for the 3-6 months it takes to develop an accurate diagnosis. In my book, this can be considered an example of cannabis addiction. My best definition of addiction is, “continued use despite negative consequences”. Not being able to stop a drug that is likely responsible for landing you in the E.D. several times a month, with great misery and expense, certainly falls into the category of “continued use despite negative consequences”. I have had several patients go through this exact scenario and it is awful to witness.

Short of cannabis cessation, there are standard treatments for CHS. We often start with aggressive hydration, which helps restore kidney function, and with repletion of electrolytes which can be dangerously depleted, such as magnesium, phosphorous, and potassium. Imaging is done to make sure there isn’t anything else going on such as pancreatitis or cholecystitis (i.e., gallbladder inflammation).

In CHS, traditional medications for nausea tend to be less effective, but we still rely on the usual meds: Compazine (prochlorperazine) and Zofran (ondansetron). When these don’t work, we often must escalate to more heavy-duty medications such as intravenous Haldol (haloperidol) which is an anti-psychotic drug, and intravenous Ativan (lorazepam) which is a strong sedative benzodiazepine. Interestingly, the nausea can often respond to capsaicin cream rubbed onto the belly, due to the specific types of receptors thought to be involved in CHS (i.e., the TRPV1 receptors, otherwise known as the capsaicin receptors). As mentioned, hot baths or showers can provide relief as well.

How do you get people to stop using cannabis when they really need to, such as in cases of CHS or other clinical conditions such as cannabis addiction or psychosis? We are not good at it. There are no FDA approved medications for this. It is often difficult to convince a patient that their use is a problem. Even if blatantly misused, they can convince themselves that their use is still “medical”.

Cannabis cessation among heavy, daily users can result in significant withdrawal symptoms such as irritability, insomnia, anxiety, and lack of appetite (which, significantly, are the opposite of what people use cannabis to treat in the first place). Just as with opioids or alcohol, the unpleasantness of the withdrawal symptoms can promptly lead people back to use.

The current behavioral treatments for cannabis misuse are not particularly effective. They include psychotherapy such as CBT (“cognitive behavioral therapy”), support groups (such as the cult-like Marijuana Anonymous or groups such as Smart Recovery), and the utilization of other medications such as gabapentin or anticonvulsants, all of aren’t particularly effective and which have serious side effects.

Future directions

How can we lessen the harms and suffering associated with CHS? I suggest a harm reduction framework. We can encourage cannabis users to tone down the volume and frequency of their use so as to keep the consumption at a sustainable level. Lots of people puff away all day with decreasing benefit and accumulating harm. We can stop, as a society, fetishizing high THC above all else. If we bred cannabis to be comprised of somewhat less THC and, instead, to include more of the other, healthful cannabinoids, such as CBD, CBC, and CBN, then there might be fewer problems such as CHS. We should encourage people to avoid concentrates as these are extremely potent, often up to 95% THC. This seems like a perfect set up for CHS, as well as for cannabis addiction and, potentially, psychosis.

We should encourage patients to solely procure their cannabis through the legal market so that we know it has been tested. We can thus be reasonably assured that this cannabis is free of heavy metals, lead, pesticides and fungus, none of which can possibly be helpful in cases of CHS.

Doctors can do a better job of not jumping to the conclusion, in the Emergency Departments, that any syndrome of vomiting in a cannabis user is CHS, so we don’t continue to misdiagnose it. If someone looks like they have CHS but can’t stop using cannabis for long enough to make an accurate diagnosis, we need to devote the necessary resources to treating this problem, as we should with any other addiction.

We must continue to work to lessen the stigma surrounding cannabis use so that people can readily admit to their consumption to their doctors. This way they can ask for help if they need it. The more our society can come to common ground around cannabis, about the harms as well as the benefits, the more we can have helpful communication instead of discord. There will be much less confusion and disagreement around cannabis related problems, including cannabis hyperemesis syndrome.

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