In the Weeds

As a therapist, I’m usually talking to people one-on-one, but today I’m standing in the middle of a large high-school gymnasium, looking out at a sea of 2,000 juniors and seniors seated in the bleachers.

I’ve just spent the past 45 minutes delivering an impassioned argument for why it’s important they have a clear picture of the concerning mental health impacts of marijuana and THC (marijuana’s primary psychoactive ingredient) on the developing brain. I’m a big proponent of the ethical principles of autonomy and informed consent, and when teens believe the common myth that marijuana is largely safe—that it’s “just a plant” or “not addictive”—it robs them of their ability to make an informed choice.

As we start the Q&A, a teacher passes the microphone to a teenage girl with her hand raised. “I heard your talk,” she says. “But I don’t understand. How can weed possibly be bad for us if it cures cancer? Isn’t that a really good thing?”

A murmur travels through the gym. Some of the students snicker, others sit back, waiting to see how I’ll respond. I’m just thankful she asked the question. Implausible as it may seem, I’m sure she really does believe that marijuana cures cancer—and she likely isn’t the only one in attendance who does.

Misinformation about drugs and addiction runs rampant in our culture—not just with teenagers who get their health information from Instagram, Snapchat, or the TV show Euphoria—and it can take many forms. It can be false, negative assumptions about people who use drugs, fueling stigma and leading those suffering from addiction to hide their use while their problems continue to grow. It can be willful ignorance, because many people just don’t like to think about how drugs and addiction might negatively affect themselves or others. But perhaps the most insidious form of misinformation is the kind that’s intentionally spread for financial gain, at a huge cost to the public. Just look at Big Tobacco’s history of claiming that cigarettes aren’t addictive and don’t cause cancer. Or consider the way Purdue pharmaceutical company aggressively marketed OxyContin to physicians by telling them it wasn’t addictive, thereby launching the opioid epidemic.

When it comes to cannabis, the spread of misinformation doesn’t look all that different. Marijuana—cannabis with THC levels of greater that 0.3 percent—is the second-most consumed recreational drug in the U.S. behind alcohol. According to the Substance Abuse and Mental Health Services Administration, 70 million Americans ages 12 and over have used a THC product at least once in the past year: that’s 22 percent of the U.S. population. Perhaps it’s indicative of the stress Americans are feeling right now. THC, now legal in many states, is often marketed as a way to relax or escape from reality. The Centers for Disease Control and Prevention report that adult and young-adult use of THC is at “historic highs.”

I’ve worked with clients of all ages who’ve used THC in an attempt to self-medicate for conditions like anxiety, traumatic stress, and insomnia. Unfortunately, THC usually doesn’t solve any of these problems. In many cases, it actually makes them worse.

Hard Truths

Despite how common THC use is, a shocking number of my clients are unaware of basic facts about the drug. For instance, the average THC potency of the marijuana flower (used for smoking) has dramatically increased—from four percent in the mid-1990s to 21 percent in today’s recreational markets. This means that one joint today is roughly equivalent to smoking several 90s-era joints at the same time. Other THC products, like concentrates and vapes, are on an entirely different level: they often contain 70 to 90 percent pure THC, 20 to 25 times as strong as a 90s joint.

According to the European Archives of Psychiatry and Clinical Neuroscience, a peer-reviewed medical journal, THC use is consistently associated with worsening depression, anxiety, psychosis, and suicidal behaviors. Frequent THC use by teens has been associated with depression, anxiety, dropping out of school, unemployment, and future addiction, according to a recent study published in Drug and Alcohol Dependence. Although some people have claimed that THC can be successfully used as a harm-reduction tool for opioid addiction, there’s no consistent evidence to support this. And despite rumors to the contrary, research indicates that THC is physiologically addictive: according to a recent study published in JAMA Network Open, roughly 21 percent of marijuana users struggle with dependency. About six percent of those users are moderately to severely addicted to it.

Importantly, there’s no substantive difference between so-called “medical marijuana” and “recreational marijuana,” just as there’s no difference between “medical OxyContin” and “recreational OxyContin.” It’s the same product, in this case just taxed differently. So why hasn’t the public heard much from the scientific and medical communities about this issue? Tens of millions of dollars are spent on advertising and branding that paint cannabis and cannabinoids as a therapeutic supplement or a healthy, alternative high. It’s hard to disseminate information from medical and academic journals that would compete on that scale.

Initiatives that seek to inform and protect consumers, like accurate warning labels about mental health risks and capping maximum THC content, have faced swift backlash from government officials, cannabis advocates, and influential trade groups. The cannabis industry has worked hard to persuade the public that THC is completely safe—and in many ways, they’ve succeeded. We often hear misleading or inaccurate tropes like “it’s not as bad as alcohol,” “it’s natural,” “it’s just a plant,” and “marijuana never killed anybody.”

The proliferation of these ideas has been entirely intentional: these companies understand that the less risky someone deems a drug, the likelier they are to buy it. That’s why the perceived risk of using THC products has steadily decreased since the mid 90s, even though the products have become objectively riskier and more dangerous to use as potency has increased. It’s clearly in the financial interest of the cannabis industry for their products to be considered safe, healthy, and medicinal. There’s a reason nearly every state with a recreational marijuana program had a medical marijuana program that came before it: it shapes public perception, lowers estimates of risk, and increases the chance that a recreational market will take off. And it’s worked: the U.S. cannabis market is currently worth between 25 and 35 billion dollars, and it’s expected to be worth more than 50 billion dollars over the next few years.

But there are hidden costs, notably the harm caused to people struggling with mental health issues who are vulnerable and desperately seeking relief. What happens when they’re told—and believe—that THC is “medicine,” and that they can use it to treat their condition? Recently, a new client struggling with anxiety-related insomnia told me he’d been using THC gummies for the last two years to knock himself out quickly before bed, but still felt incredibly fatigued every morning. Even though I mentioned to him that THC interferes with the brain’s ability to enter REM sleep, which can affect how restorative his sleep feels, he didn’t stop using the gummies until he took a trip to a state where marijuana wasn’t legal and had to leave them behind. The result? Having successfully addressed his anxiety in therapy, he quickly fell asleep and achieved the proper amount of REM sleep. He told me that afterward, he’d felt refreshed for the first time in years.

What Do We Tell Our Clients?

Cannabis and cannabinoids sold by dispensaries aren’t FDA-approved for any medical or psychiatric condition. It’s not because the FDA is targeting cannabinoids: in fact, three FDA-approved cannabinoid medications are currently on the market: Marinol (dronabinol) and Cesamet (nabilone), synthetic, THC-like cannabinoids primarily used to treat nausea and vomiting from chemotherapy, and Epidiolex (cannabidiol, a plant-derived CBD medication used to treat epileptic disorders). Simply put, “medical marijuana” is a misnomer used to work around the FDA-approval process and insinuate, largely without evidence, that cannabis and cannabinoids have broad medical and health benefits. A recent review in Current Addiction Reports concluded that “CBD and other cannabinoids are not ready for formal indications as medicines to treat a wide range of clinical conditions as reported.” Another example: CBD is often touted as a treatment for pain, but a recent systematic review in the Journal on Pain concluded that CBD is “expensive, ineffective, and possibly harmful.”

What about the fact that doctors prescribe medical marijuana? Doesn’t that mean it’s safe? Well, in most states, medical marijuana isn’t explicitly prescribed because it opens physicians up to liability if something goes wrong—say, if the patient becomes addicted. Instead, physicians who approve medical marijuana use are only certifying that the patient has a “qualifying condition”—a list of conditions is generally approved by state legislatures, not by a recognized medical authority. Plus, when it comes to cannabis, the physician’s dosage recommendation (if they make one) is only a suggestion. Once the patient has their medical marijuana card, they can buy whatever product they’d like: it could be a vape pen with 85 percent pure THC concentrate, or a joint with 28 percent THC flower. The physician has no control over the cannabis type, potency, quantity, or delivery system, all of which impact possible risks and benefits of use.

Ultimately, I try to convey to clients that while “medical” marijuana may be therapeutic in some cases—for example, there is some evidence that THC can provide relief from nausea, vomiting, short-term insomnia, and certain types of pain—but just as with any chemical you put in your body, you need to understand the risks, benefits, research, and alternative treatments.

Proponents will often cite cannabis’s purported benefits in alleviating PTSD symptoms: being high allows some users to relax in the short term, and THC, like alcohol, can prevent PTSD-nightmares by reducing activity in the prefrontal cortex. But in reality, using cannabis to treat PTSD is counterproductive. According to the journal Psychological Medicine, while it numbs symptoms temporarily, it exacerbates them over the long term. When used to treat PTSD in veterans, cannabis has been associated with poor outcomes, worsening addiction, and suicidal behaviors. It’s such a problem, in fact, that the Department of Veterans Affairs recommends against using cannabis to treat PTSD. Nonetheless, in almost every state with a medical marijuana program, PTSD is listed as a qualifying condition to receive the drug. Many dispensaries even offer discounts to veterans.

It’s critical that our clients understand the risks associated with use, along with possible benefits. A large-scale review recently published in the Journal of the American Heart Association found that regular cannabis use was associated with a 42 percent increase in risk of strokes and a 25 percent increase in risk of heart attacks. Another study, published in the journal Psychiatry Research, found almost 129,000 cases of cannabinoid-induced psychosis occurred in 2017 alone, or an average of one psychotic break every four minutes. There are behavioral risks as well: a study in Drug and Alcohol Dependence found that over a six-month period, 50 percent of medical cannabis patients acknowledged driving while “a little high,” and 20 percent acknowledged driving while “very high.” We should be open about these statistics with clients who may be curious about trying marijuana or other cannabis products for their purported mental health benefits.

Our role as therapists is to support our clients as well as we can, without assuming we know what’s best for them. That said, everyone deserves the right to make an informed choice about the drugs they put in their body, and I’ve found there’s a consistent gap between what my clients think they know about cannabis and the truth.

At the end of the day, some clients may still choose to use marijuana to manage their mental health needs; that’s ultimately their choice to make. At least by providing them with accurate information, we’re empowering them to make their own decisions for their own reasons, not because they were duped by our newest addiction-for-profit industry.

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