What is “Cali Sober”?

Using cannabis and psychedelics to conquer addiction.

The concept of being “Cali sober” is taking the recovery world by storm. It is defined as dedicating oneself to a life free of drugs and alcohol — except for cannabis and psychedelic drugs, which are thought to facilitate one’s recovery. Hardcore proponents of abstinence-based recovery, such as Alcoholics Anonymous, dismiss the Cali sober approach as dangerous and “not really recovery.” Many who make their livings by treating addiction in the traditional ways, such as addiction specialists and representatives of our country’s sprawling rehab industry, also dismiss the idea. For example, the Cleveland Clinic maintains a blanket ban on physicians certifying patients for medical cannabis for any condition, even though medical cannabis is legal in Ohio. One of their addiction psychiatrists told the clinic’s website, “After all, you’re not sober if you’re still using mind-altering substances. You’re replacing one addictive substance with another. It’s a slippery slope.”

This particular slippery slope has dried up. I am 17 years into recovery from a vicious addiction to prescription opioids. I’m also a physician and have had the privilege of treating thousands of patients for substance use disorders, ranging from doctors surreptitiously snorting oxycodone to people living on the streets. Through these experiences, I’ve given a great deal of thought to the issues surrounding what predisposes one to addiction, what constitutes an addiction, how we get addicted, and how we recover. The best definition of addiction that I’ve heard, to date, is a simple one, “continued use, despite negative consequences.”

Yet this definition raises some crucial questions: Continued use of what? All drugs, or just the one(s) that derailed your life? For how long? For life?

For nearly a century, the recovery community has blindly followed the concept, from Alcoholics Anonymous, that recovery means abstinence from all drugs and alcohol, completely and forever. That is, except, of course, for tobacco and caffeine, which are considered “good drugs” and are freely allowed at 12-step meetings. The founder of A.A., Bill Wilson, was quite open about how the psychedelic LSD provided him with the spiritual awakening that directly led to his lifelong recovery from alcohol addiction. It is impossible to overstate the irony involved with his creating, and the rest of us following, such an ideologically rigid abstinence-based system, which doesn’t allow for the use of psychedelics.

This binary and ideological approach has an extremely low success rate — by one estimate, AA has a 5%-10% rate of long-term sobriety. Other estimates are somewhat higher. The rigidity and cult-like properties of AA alienate many from the entire recovery endeavor. AA, and its close cousin NA, or “Narcotics Anonymous”, are mainly based on historical tradition rather than science. They have very little to do with our modern understanding of addiction. They are oblivious to the new treatments for addiction we are developing or the realities that our understandings and treatments of addiction have greatly evolved since the “Big Book” of Alcoholics Anonymous was written in 1939.

It’s time to update that thinking. It absolutely isn’t cheating to use medicines or other substances to enter into or to maintain recovery. We treat opioid addiction, alcohol addiction, and other addictions with traditional pharmaceuticals with good benefit. For opioids, we use methadone, burprenophrene (Suboxone), and naltrexone. For alcohol we use naltrexone, disulfiram (Antabuse), and acamprosate. This is mainstream, accepted medical practice.

There is no firm scientific basis for the “abstinence only” models of recovery. These programs have engendered generations of slogans and platitudes, that people like me have had to repeat over and over, when forced into rehab by the courts. (The excruciating nature of this is documented in my memoir, “Free Refills”.) We sat in a basement of a church and chanted, “one is too many and a thousand is never enough” as a totem against future drug and alcohol use. We chanted, “let go and let God.” To this day, I have no idea whatsoever what this means. This experience, to me, was so boring and mindless; it was enough to make you want to use drugs again.

Moreover, this rigidly abstinence-based approach is about as far away from science as one can get on planet Earth. The most convincing study I found, published in JAMA in 2014 showed a different picture:

Compared with those who do not recover from an SUD [substance use disorder], people who recover have less than half the risk of developing a new SUD. Contrary to clinical lore, achieving remission does not typically lead to drug substitution, but rather is associated with a lower risk of new SUD onset.

In other words, the tools, insight, and experiences you gain from the process of getting into recovery from one addiction can be protective against other addictions, so one may be at less risk with a different drug than an addiction naive person might be. None of this is definitively settled. We do know that addiction has a genetic component. But, it is intriguing and certainly is consistent with the use of alternative treatments — such as cannabis and psychedelics — to maintain and support one’s recovery.

It is important to state that 12-step programs are effective for a self-selected group of people who enjoy these meetings, who relate to them culturally, and who find them invaluable to sustain their recoveries. If someone chooses abstinence and the 12-Steps, and it works for them, that is something to be supported and celebrated. Yet, there is no rationale or evidence to impose this model on all people seeking recovery.

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The first public challenge to abstinence-only recovery paradigms came with widespread adoption of methadone and Suboxone (buprenorphine) to treat opioid use disorder. In short order, stories started filtering out about people being hassled at 12-step meetings for using Suboxone or methadone. People were told at recovery meetings, “you aren’t really in recovery if you are taking methadone/Suboxone – you’re just swapping one drug for another.” I’ve seen people say things along these lines at Narcotics Anonymous meetings. Yet the clinical utilization of Suboxone and methadone results in a 50% reduction in both overdosages and death from overdose. Recovery has to be about the outcomes and about saving and improving lives.

What happens when you go a step further, beyond Suboxone and methadone, and not only challenge the abstinence-only model, but challenge it with medicines/drugs that have been deliberately stigmatized by the war on drugs, such as cannabis and other psychedelics? To many 12-steppers and addiction psychiatrists, the inclusion of cannabis — a “bad” drug — in any talk of “recovery” from addiction is heresy. It bucks against the decades of (inaccurate) messaging we’ve been given that cannabis is highly addictive and extremely dangerous. It can be difficult for them to understand the idea of Cali sober because many don’t have lived or clinical experience treating people with cannabis, and don’t have a realistic, nuanced view of the relative benefits and harms of cannabis use. They have only been exposed to magnified versions of the harm and have been shielded from discussions of benefits.

During the War on Drugs, cannabis was derided as a “gateway” into addiction. Start experimenting with weed as a teen and within no time you’ll be on the streets, strung out on heroin. With time, this concept has been debunked. In fact, many people, myself included, believe that cannabis helped them get off of more dangerous drugs, and is more correctly considered a gateway out of addiction. Study after study shows people using fewer highly addictive substances like opioids or benzodiazepines as they institute medical cannabis. The research supporting the use of psychedelics in treating addition, including psilocybin, ibogaine, and ketamine, seems to be growing daily.

We are in the process of a vast societal reevaluation of the relative benefits and harms of cannabis, with public acceptance of both medical and recreational use growing yearly. Using medicinal cannabis to transition away from more dangerous drugs, such as alcohol or heroin, is an increasingly popular and accepted form of harm reduction. I have had tremendous success in my clinical practice transitioning people from both medicinal opioids and alcohol to cannabis. I find cannabis to be particularly efficacious, because it can help treat or palliate many of the symptoms that may have helped incite and fuel the addiction to these other drugs in the first place, such as anxiety, insomnia, chronic pain, and trauma.

It is important to note that cannabis certainly is not without its own set of harms. A subset of people get addicted to cannabis. Cannabis use is best avoided by teenagers (due to the concern about the health of their developing brains), by women who are pregnant or breastfeeding (due to concerns about effects on the fetus/newborn), before driving, in patients with a personal or family history of psychosis (as cannabis can destabilize these patients), and in patients with cardiac risk factors. Smoking cannabis is much more dangerous than using an edible or a tincture due to the toxic combustion products in cannabis smoke. The best way to prevent use by people who are at risk is careful regulation and education rather than through criminalization, which drives drug use underground and makes it vastly more dangerous.

The critical components of a healthy, stable recovery from addiction include insight, humility, connection, mindfulness, and gratitude. As we focus on the present, connect with others, and approach the world with kindness and humility, we are happier and stronger, and this leaves much less room for the drugs to settle back in. We need to get our needs met in a healthy manner so there is less room for the drugs to creep back in.

These are the traits within us that cannabis helps foster, which is why it so powerfully aligns with the personal recovery plans of so many recovering people. To quote the astronomer Carl Sagan, the smartest person I’ve ever met to date (and longtime friend of my father, an academic who was early to challenge popular myths about cannabis):

The illegality of cannabis is outrageous, an impediment to full utilization of a drug which helps produce the serenity and insight, sensitivity and fellowship so desperately needed in this increasingly mad and dangerous world.

It’s notable this language thoroughly overlaps the language in the 12-step programs, which are fundamentally based on “serenity and insight, sensitivity and fellowship.”

If people have surmounted their addictions and are back to work, healthy, and living fulfilling, meaningful lives, what does it matter if they are abstinent, using cannabis, using Suboxone or methadone, or microdosing with psychedelics? One may yearn for a perfect world in which we would all do yoga, eat tofu, and meditate, where no one feels the need to rely on a drug or a substance to help get us through the day. Yet, there are very few, if any, societies that have existed without the use of one psychoactive drug or another. Most people need something at the end of a rough day.

Addiction is a deadly consequence of an ugly confluence of distress and drug exposure. It needs to be addressed with empathy, compassion, and evidence, not with judgment, stigma, and adherence to old beliefs that aren’t borne out by research. Every path out of addition and into safe, stable recovery is unique to the person walking it. We must meet people where they are. All of us who are recovering from addiction must nourish and support one another. We must not be divided along lines of rigid approaches and inflexible ideologies. If you are “Cali Sober” you are fully in recovery and that is to be celebrated.