Cannabis for Treating Psychiatric Problems? A Clear Yes, Maybe.

Marijuana is now legal in two states, and legal for medical use in 23 states and the District of Columbia. Polls show the majority of Americans support cannabis legalization, and more and more of the country is joining the legalization trend. As a counselor working with people diagnosed with psychosis and mental illness I am often asked about my opinion and clinical experience — as well as my personal experience — with medical cannabis.

The issue is not clear-cut either way, but I think it is time for everyone, especially if you are concerned with the risks of pharmaceutical drugs, to set aside what we think we may know and take a serious look at cannabis as an option for people with serious mental health challenges. Medical use of marijuana has clear potential for reducing psychiatric drug use, drugs that are notorious for their devastating adverse effects. The decision to use cannabis is not simple, and along with the War on Drugs anti-pot propaganda there is also a lot of pro-marijuana fanaticism to wade through, but this is the reality: many people can forgo pharmaceutical drugs and use cannabis instead.

I don’t need to reiterate the extensive research on medical use of cannabis available on the internet, and I have already written about cannabis and substance use in counseling practice in a previous post on Mad In America (“The Substance of Substance Use”). But here are some more thoughts about cannabis specifically.

There is now widespread evidence people are already successfully using cannabis to treat psychiatric conditions. Cannabis has long been used as medicine and spiritual tool throughout human history, for for far longer than the brief period of prohibition when it’s been criminalized. Criminalization didn’t come from medical assessment of cannabis’ usefulness, but was instead a political decision motivated by racism and suppression of the insurgent youth culture. Extensive studies showing medical benefits — for cancer, Alzheimers, multiple sclerosis, hepatitis C, irritable bowel, Parkinsons, pain management, and other conditions — have driven ballot initiative success around the country. This has begun to convince even longtime opponents, with US President Obama formally acknowledging cannabis as no more dangerous than alcohol, and CNN’s chief medical correspondent Dr. Sanjay Gupta, one of the world’s most influential opinion leaders on medicine, recently reversing his opposition to medical marijuana. Dr. Gupta even apologized for his previous anti-legalization stance and “not looking hard enough” at the issue.

But what about mental health conditions?

Around the country, medical marijuana cards are routinely given to people suffering anxiety, depression, insomnia, ADHD, trauma, and mental health issues. The internet is replete with a growing number of testimonies of successful symptom alleviation through cannabis, including people diagnosed with psychotic disorders such as bipolar and schizophrenia, These are not just a few anecdotes, these are thousands of people giving firsthand accounts of benefitting from cannabis for mental health conditions. And with the growing number of dispensaries, review websites, and legal cannabis consumers, these testimonies are growing in number.

And at the same time, it is not uncommon for me to receive emails like this:

“Our son was doing so well in school, and then he started smoking marijuana and went psychotic and went into the hospital, where he was diagnosed with schizophrenia.”

“Before her delusions began I learned she was experimenting with marijuana…”

So what is going on?

Our culture has been saturated for years with a simplistic prohibition mentality around marijuana. Media reports demonize cannabis, with many scientific studies were twisted and manipulated to support a political agenda. Just one notorious example was the Heath/Tulane study in 1974. which claimed to show marijuana “kills brain cells.” These findings, reported by a mainstream research institution with impeccable scientific credentials, were considered gold standard evidence and quickly became part of the mainstream attitudes. “Marijuana kills brain cells” was paraded by President Reagan in his anti-drug propaganda and brought out by frightened parents everywhere when they discovered a joint in their teenager’s bedroom. The study even supported extremist media campaigns like the “This is your brain on drugs” television commercial, where a broken egg on a hot griddle became the last word on marijuana dangers.

The Heath/Tulane study was later exposed as pure scientific fraud: researchers were able to show brain cell death only by pumping so much marijuana smoke into the laboratory animals that the animals couldn’t breathe. It was asphyxiation from lack of oxygen, not ingesting marijuana, that caused the brain damage. The poltiicization of science continues, and Dr. Gupta writes that of current US marijuana studies, 94% are designed to investigate harm, not potential benefits.  Despite countless other studies showing marijuana’s benefits and extremely low risk profile compared to either tobacco or alcohol – two very legal and very deadly drugs — we have let prohibition politics, not solid science, shape and continue to determine US drug policy and leadership worldwide.

This corruption is even more true in mental health, where substance use has become synonymous with substance abuse, and the mental health system oversees abstinence-based treatments that are often the criminal punishment for users arrested for possession alone. No leading mental health organization has publicly expressed opposition to the War on Drugs or presented an honest discussion of the potential value of legalization. Mainstream mental health websites such as National Alliance for the Mentally Ill and the Schizophrenia Society of Canada continue to echo this demonization. Any potentially valuable caution about the role of cannabis use in psychosis – of which I will discuss more in a moment – gets lost and discredited in the general “just say no” message. There is no balanced discussion, not of how cannabis might help some people forgo the risks of psychiatric drugs relative to the possible risks to adolescent brain development. Mainstream opinion makers, driven in part by pharmaceutical and American Medical Association opposition to legalization, have instead elected to emphasize the psychosis-marijuana link research and ignore everything else.

NAMI medical director Dr. Ken Duckworth sums it up on the NAMI website “The overwhelming consensus from mental health professionals is that marijuana is not helpful—and potentially dangerous—for people with mental illness.” He doesn’t point out that this consensus is a result of politics, not medical science. The rest of the policy document has War on Drugs propaganda on full display. Dr. Duckworth writes, “Approximately one-third of people in America with schizophrenia regularly abuse marijuana.” Really? Can we see a study citation for that statement? The answer is no, there is no citation because NAMI made this claim up, there is no research behind it.

Dr. Duckworth also rings the alarm bell of addiction, counting the mental health industry’s conflation of use and abuse. He states that “a significant percentage of individuals who use marijuana will become physically dependent on the drug. This means that stopping their marijuana abuse will cause these people to experience a withdrawal syndrome.” Dr. Gupta, however, disagrees. Dr. Gupta writes on CNN that “In 1944, New York Mayor Fiorello LaGuardia commissioned research to be performed by the New York Academy of Science. Among their conclusions: they found marijuana did not lead to significant addiction in the medical sense of the word…” He adds, “The physical symptoms of marijuana addiction are nothing like those of the other drugs I’ve mentioned.”

My bet is with Dr. Gupta on this one. As Dr. Gupta’s reversal indicates, there is a clear case for legalization of cannabis because there is an undeniable scientific research base — and common sense base – for cannabis’ benefits relative to its risks. As a recreational drug there is just no comparing cannabis risks to other drugs such as alcohol and tobacco. But in the context of the War on Drugs’ demonization, proponents of marijuana have reacted with a defensive romanticization, adding to the confusion. Left in a vacuum by mental health and medical organizations that should have been providing sound and honest discussion on the issue, the many mainstream research studies on medical benefits of cannabis are often touted and available on aggressively pro-marijuana sites. You feel that you are pulled to one side of the other in this political – and economic – tug of war. (The pro-marijuana sites are after all, now burgeoning with advertising revenue from the surfacing marijuana industry. The message today is “cannabis is good for you,” and of course the next message will be “buy some today” and then “from us.”)

As a society we are thankfully stepping away from both demonization and romanticization. And this means looking at two important facts about cannabis: dosage and strain. 

The cannabis of today isn’t the cannabis of yesterday. But the commonplace claim that “marijuana today is stronger than it was in the past” is far from the whole picture. Yes there is a lot more strong marijuana out there, but that also has positive implications for medical use. There is a an increased complexity and sophistication of how cannabis is being used, in many different ways by many different people, that has to be understood.

As far as dosage goes, the importance of understanding this complexity is well illustrated by the experience of New York Times Pulitzer Prize winning columnist Maureen Dowd. In a high-visibility, and influential, act that formed part of Times reporting on growing legalization efforts in Colorado and elsewhere, Dowd got high on pot in Denver. And promptly had a psychotic episode. She presumably didn’t go on to be diagnosed bipolar, and did not need to be hospitalized, but her bad trip, replete with delusions of being dead and paranoid fears of the police, for some might be considered proof positive that cannabis is a bad idea for anyone “at risk for psychosis.”

Dowd, however, was in effect writing a denunciation of wine by binge drinking on tequila. “Alcohol makes you sick and pass out” says more about how, how much, and what we drink, than it does that we drink alcohol. Simple enough common sense, but that is exactly what has been lost with prohibition propaganda. Without adequate understanding, Dowd apparently downed an entire cannabis infused edible candy. Edibles are notorious for their potency. Then she did what anyone following sensible marijuana use knows not to do – she gobbled up even more of the edible when she didn’t feel any effects after a few minutes. She doubled the eventual impact of the drug, and delivered a massive dose to her marijuana-naive self after the slow-onset that is standard for eating marijuana (smoking effects are much faster; eating means the cannabis has to be digested before experiencing amplified effects.). It could be humorous – Dowd was lambasted in the internet for her irresponsibility – if it wasn’t so emblematic of the impact of prohibition. Rational discussion by a presumably thoughtful professional journalist turns into nonsense, fuel for more simplistic demonization.

Dosage, including the delivery method (and now there are tinctures, vaporizers and other methods beyond smoking or eating), is an important reality to cannabis consumption. If a drug leads to psychosis at a higher dose, but doesn’t at a lower dose, is the problem the drug or its use? If a drug at one dose is useful and at a higher dose is harmful, does that mean the drug is “useful” or “harmful?” So we begin to see one explanation for how a drug that many people find useful for psychosis can be the very drug that causes psychosis for many others. It becomes more understandable that my email inbox has emails from people blaming marijuana for mental illness alongside emails from people who’ve been helped.

Dowd also didn’t chose her strain with any care, and strains can make a huge difference in cannabis use. There are hundreds of strains of crossbred hybrid cannabis, with colorful names like Blue Dream, Girl Scout Cookies, AC/DC, and Lemon Alien Dawg. This diversity isn’t just fanciful or aesthetic: strains differ by aroma and flavor, Much more importantly, different strains have drastically different psychoactive effects. Alcohol intoxication might feel a bit different between beer, wine, and spirits, but not by much The different effects between different cannabis strains are like taking completely different substances.

There are 483 currently known compounds in marijuana, and at least 84 different psychoactive cannabinoids. THC is just one. This may explain why some people are using marijuana to alleviate psychosis while others find it makes psychosis worse. Medical marijuana users routinely share information about the qualities of different strains – some good for sleep, some for anxiety, some for depression, etc – to help each user find out what works for them. Of the many alkaloids, cannabidiol (CBD) is associated with anti-anxiety response, while THC causes more mind-altering, and is potentially paranoia and anxiety inducing. Similarly, marijuana users have long known that the sativa varieties are different than the indica; sativa is associated with a more energetic high, prone to produce anxiety and paranoid in some people. while indica is more sedating. There is strong evidence that high CBD cannabis can alleviate psychosis for the simple reason that it is anti-anxiety, in the same way that anti-psychotics are for many people helpful because they are tranquilizing. CBD, however, clearly lacks the devastating side effects of antipsychotic drugs.

(The cannabis industry is still only now emerging from the underground, and with lack of the regulation and quality control of other industries users still have to rely on trial and error. It’s not a guarantee that what the dispensary labeled as Blue Dream isn’t actually Kali Mist, or there isn’t sativa in that tincture marked indica. Medical users will be better served by legalization, which will allow greater testing and reliability of supply, as in the wine industry. The best role of regulation in the legalization process is fiercely debated by growers concerned about issues such as ecological sustainability, labor conditions, and the specter of Big Tobacco-style profiteering. In Sonoma County where I live, there is a huge marijuana industry and vast sums of money moving into the state in anticipation of California following the trend towards full legalization. The legal wine industry in the area is very shady, and has a deserved reputation for greedy disregard for the environmental and local community in its rapid expansion. That might be a cautionary tale: the gentle peace-ecology-love aura of marijuana may, some fear, quickly give way to the cutthroat realities of just another boom industry and agribusiness product.)

Word about CBD is getting out. Along with the emails from people tracing psychosis back to marijuana use, I now routinely encounter people in my work, lucky to be in a legal state or country or able to risk acquiring pot through the underground, who are using cannabis to help with distressing experiences associated with psychosis and mental illness diagnosis. Some have switched strains to high CBD and found different effects, some are using cannabis to help come off psych drugs, some are using cannabis instead of psych drugs, and some – very interestingly – have gotten benefits from cannabis and never gotten on psychiatric medications to begin with. Scientific studies on CBD support what I am seeing: a University of Cologne study from Germany, in a four week trial, found CBD as effective as an anti-psychotic in calming psychotic symptoms. A co-author of the study wrote “Not only was [CBD] as effective as standard antipsychotics, but it was also essentially free of the typical side effects seen with antipsychotic drugs.”

A glance through research results on CBD from studies around the world shows evidence to support what we know already: CBD marijuana can help mental health conditions. These users are often careful in dosage, some even using just a few drops or “homeopathic” doses to get the desired effects.

(Other research is also intriguing. Numerous studies show anxiety alleviation, and, consistent with studies on Alzheimers and Parkinsons, one University of Montreal study published in Psychiatry Research even showed cannabis users diagnosed with schizophrenia to have better memory and prefrontal lobe functioning than those not using cannabis. Could cannabis be not only a substitute for psychiatric medications, but a treatment for the harm they caused? And other studies that are more troubling, such as those showing memory impairment and youth development harm, are essential to come to terms with in any benefit/risk assessment, but what do dosage and strain have to do with the results these studies found?)

So the kind of cannabis used, as well as the dosage, may explain part of the puzzle of different reports around cannabis and psychosis. This is in addition to a general principle with all psychoactive substances, a principle that applies to cannabis as well:

Response to cannabis use is widely diverse and individual. The medical marijuana dispensary community is thoroughly familiar with the fact that as a “medicine” cannabis does not provide uniform “treatment.” Instead, just as each individual experiences “illness” differently, each individual has their own response, and what is right for one person might not be right for another – including the need to forgo cannabis altogether. Some people find the “high” contributes positively their medical condition and life circumstnaces, others seek out strains that have helpful effects without the high. Dispensary staff I’ve met are skilled at helping individuals navigate different strains and dosages for individual needs.

Substance abuse is a serious and devastating problem. Some people find that abstinence is the best strategy, such as following an AA 12 step program. Taking any drug – alcohol, tobacco, or cannabis — involves risks. Cannabis needs to be subjected to the same caution, but overall cannabis is undoubtedly much safer on the body than alcohol or tobacco (zero marijuana caused deaths compared to many millions of alcohol and tobacco deaths) and much safer than any psychiatric medication. The growing legalization and medicalization of cannabis will no doubt be used by some to rationalize their addiction or avoid facing the fact that the drug is not helping them – but this is true of any substance, including alcohol and psychiatric meds. Once we step outside the demonization/romanticization polarity of the War On Drugs mentality we can engage this complicated reality more clearly. Saying cannabis might be helpful for some people is not to deny it might make others worse.

What about me personally? I found years ago that marijuana only worsens my own anxiety and further disconnects me from reality. I was smoking around the time I was first hospitalized, and though I quit marijuana I still had another psychotic break many years later when I wasn’t using and hadn’t used marijuana for 8 years. I do believe that pot was a contributing – but in no way a causal – factor in my first crisis, however, and that smoking played a role in the several years onf decline that led to that crisis. But tellingly this was all wildly overstated by the hospital doctors who interviewed me. When I moved to Conard House, an outpatient facility in San Francisco, I was sent to a mandatory anti-drug meeting along with every marijuana user at the house, regardless of the frequency of use or whether or not it was abused or a problem. When I challenge the meeting leader by saying that marijuana was much safer than alcohol, I was kicked out of the program. (I was sent to a homeless shelter at 14th and Mission, right next to a thriving street crack market where I passed dealers every day on my way to and from my room. A good friend of mine from a previous program, who had been abstaining from cocaine for several years, was sent to the same shelter, I watched as he gradually lost control of his addiction with the temptation of those dealers; he left the shelter and I never heard from him again.)

I think that CBD strains are promising, and I personally would not hesitate to try a small dose of CBD marijuana in a time of emotional distress where I felt I had run out of other options. I would watch carefully my response, and proceed only if I felt confident I wasn’t going to get paraoind or become anxious. Friends, clients, and colleagues who use cannabis have educated me about its potential if I did ever find myself in need, and have introduced me to the California dispensary system. I’m grateful I live in a state where I can learn about these issues and can first try a CBD brownie (gluten free of course) instead of a dose of Seroquel if I ever get out of hand with sleep deprivation or go off the deep end in a psychosis. And when I’ve seen friends go down to the psychotic vortex and head for the hospital, I wish there was some CBD weed around to try first to help them break the crisis cycle, rather than relying on a psych med as a last resort.

With clients I work with I now feel it is unethical as a therapist to not include cannabis in the list of possible wellness tools for those in legal states. I am pro-choice regarding psych drugs, and if I acknowledge that anti-psychotics, even with the risks, might be a wise choice for some people, I would be completely, well, crazy not to acknowledge that cannabis might be a wise choice for some people as well. I’ve always welcomed herbal medicine and traditional chinese and other treatments into the range of possible wellness choices, because they have such a demonstrated history of helping so many people. Cannabis also has such a history, and I believe everyone working in the field as a therapist or psychiatrist needs to consider taking the same stance I have.

From a mental health advocacy standpoint, marijuana legalization also has many other implications that we as mental health professionals should look at. The AMA, APA, NAMI and other groups have failed to meet this issue responsibly. An American Journal of Public Health study by a team of economists, for example, examined states that had legalized marijuana for medical use. The study found there was a 10.8 percent reduction in the suicide rate of men in their 20s and a 9.4 percent reduction in men in their 30s. That is extraordinary – we know that psychiatric drug use can exacerbate suicidality (the drug warning is right there on the label), and alcohol of course can contribute to suicidality. It’s not clear exactly why greater availability of medical cannabis might lower suicide rates, but this is a very, very significant finding to study further for anyone who takes suicide prevention seriously. (I recently lost a dear friend to suicide, and I am convinced benzodiazepines and alcohol played a role in killing her. I wish her therapist and doctors had explored cannabis as an alternative – she needed any alternative – and her death is one of the things motivating me to write this blog post and “come out” with my clinical practice decisions around cannabis.)

Studies also show reduction in alcohol use results from legalization, which, again, has enormous implications. Alcohol is an extremely dangerous and socially destructive drug with notorious mental health harms. The National Council on Alcoholism and Drug Dependence reports that alcohol use is a factor in 40 percent of all violent crimes in the United States, including 37 percent of rapes and 27 percent of aggravated assaults. In 1995 alone, college students reported more than 460,000 alcohol-related incidents of violence in the US. A 2011 prospective study found that dating abuse was associated with drinking among college students. A 2014 study found marijuana had clearly lower rates of associated domestic and partner violence. As pro-legalization comedian Bill Hicks remarked, imagine you are at a sporting event and some guy in front of you is screaming and picking a fight: is he high on marijuana or is he drunk on alcohol?

Reducing alcohol use in society will likely reduce violence; reducing violence means reducing trauma in society as a whole. When did we lose sight of ending violence as a way of preventing the cause of so many mental health problems? And legalization has already reduced traffic fatalities associated with drunk driving in states where it is legal – each traffic death sends out shockwaves of trauma and grief, and turns many people to alcohol or psychiatric drugs. (Hicks also said the biggest traffic danger from driving high is hitting the garage door because you forgot to open it.) Marijuana legalization is an upstream solution with huge implications. From a public health standpoint there is really no argument: if we can bring alcohol use down in society, then marijuana legalization is clearly worth it. According to the Centers for Disease Control, abuse of prescription opioids such as Oxy-Contin and Vicodin is a national epidemic that kill 16,000 people annually and devastate lives and families. Cannabis legalization could also reduce the market and illegal demand for opiods, easing this epidemic.

Legalization of cannabis also has important implications for young people and families – once we understand the complexity of substance use. The War on Drugs has devastated the US black community, and it is shameful that white-dominated mental health organizations have not spoken up against prohibition. Prison and the police are a traumatizing factor that directly interfere with mental health recovery. While legalization, according to the Journal of Adolescent Health, has not led to an increase in teen marijuana use, it does give families and youth more flexibility. For young people using cannabis, it might be more realistic to switch the kind of cannabis they are using as a harm reduction approach, rather than giving cannabis up completely. Many young people are committed to cannabis as a lifestyle, a form of religious expression, and a pathway to independence. Under prohibition it is impossible to talk openly about their cannabis experiences, and difficult to differentiate cannabis strains they are consuming. It may be easier for a teen to hear “use CBD strains, not the THC strains” than for them to hear “you have to stop smoking entirely;” “You can smoke pot, but in moderation” might work better than “you can’t get high at all.”

A harm reduction perspective is best served by legalization. Collaborative relationships require honesty: young people today know that different strains do different things, and they know the hypocrisy of a War On Drugs that sends people to jail for smoking a joint and then sells their lawyer whiskey at the bar next to the courthouse. Overgeneralized associations between marijuana and mental health problems, including psychosis, ignore a complex reality.

Adolescents using marijuana who get into emotional and psychological difficulties are like any adolescents who get into emotional and psychological difficulties, for whatever reason. They need help and support. The family needs help and support. The problem is never “marijuana plus genetics equals psychotic disorder.” The marijuana may, or may not, be part of the problem. When families — and doctors —are blaming the marijuana it is usually a sign of a deeper problem being avoided. Prohibition is based on fear, the same fear behind the search for a simplistic answer, something to grab ahold of as the solution in a situation that feels out of control.

Cannabis use then often becomes a power struggle in families. As a therapist I have seen time and time again families where a son or daughter has been psychotic after using marijuana, and the family’s response is to ban their son or daughter from using. So what does the young person do? They keep smoking, of course, except now they have a new problem: hiding from the parents, a power struggle with their parents, and the beginning of a cycle of isolation if the power struggle continues. I have to work hard to stay in a trusting relationship with both sides, and that job gets harder the more prohibition fear entrenches intolerance. The solution is to create conversations about the substance; even if the parents are strongly against any marijuana use, it’s important to respect all sides, but on an equal playing fiend where the young person can be validated for a choice that has some science on its side. Dismissing one side doesn’t help. Doesn’t it make more sense to say Let’s talk? than to Just Say No?

I have no doubt that marijuana use has played a role in many people’s problems with psychosis. I routinely work with people to encourage them to stop smoking when they know it can lead to crisis. I’ve seen people off marijuana start using again and end up hospitalized. And marijuana can certainly lead to habituation for some people and play a role in substance problems. Educating society about these risks makes the same sense that educating society about alcohol risks makes sense – as long as the risks are not exaggerated. Personally I would like to see cannabis avoid the commercialization of alcohol and be a more accepted – but not promoted or advertised – personal option. We really don’t need any more consumerism than we already have. Instead, we need an honesty and smart use that we really don’t even have with alcohol, with all the alcohol advertising and the culture of happy hour and spring break.

And of the risks, what about the correlation between first break psychosis with a higher rate of marijuana use? There is in my view validity to that concern — and it also be at least in part misleading. What if the causality is sometimes in the other direction? What if people who end up psychotic are drawn to altered states of consciousness in general, what if they first seek out in marijuana what they eventually end up later seeking in their break to a psychotic reality? Working with young people over many years, I see the need to get “high” comes first, not after, the substance. Few families have honest discussions about the need to get high and get away – how it is a human need that everyone has. And getting high repeatedly may be an escape hatch out of untenable life circumstances and confusing options. Maybe a young person is drawn to cannabis by the same inner need that will eventually draw them to psychosis, correlating the two – but not indicating causality.

As we come to terms with the devastating impact that psychiatric drugs have on society, we face a compelling question: What if there was a substitute? Someone considering a benzo, or an anti-psychotic, or an anti-depressant, is about to embark on a risky treatment option that might work out fine, or might end up destroying their life. That is the reality of the risks of psychiatric drugs. The Soteria House alternative and the Open Dialogue approach, it should be remembered, do rely on psychiatric drugs as a last resort. What if everyone had, on a wide scale, the option of choosing something with a lower side effect profile, and perhaps thereby could be diverted from a risky pathway? That may be what the US is on the brink of with legalization. And what exactly do we know of Pharma’s influence in opposing marijuana legalization? The American Medical Association and APA have long opposed legalization; does medical cannabis represent a threat to Pharma markets?

These social implications have not gone unnoticed by the web of financial interests benefitting from cannabis prohibition. The same public policy corruption driving psychiatric drug use is also evident in efforts to block legalization. Dr. Herbert Kleber of Columbia University, an impeccably credentialed academic, is widely quoted in the press warning against marijuana – and also serves as a paid consultant to leading prescription drug companies. Oxy-Contin manufacturer Purdue Pharma and Vicodin manufacturer Abbott Laboratories are among the leading funders of the Community Anti-Drug Coalition of America and Partnership for Drug Free Kids – both  fierce prohibition advocates. (Other funders include Janssen and Pfizer.) When Patrick Kennedy’s so-called Project SAM (Smart Approaches to Marijuana) worked against Alaska’s legalization initiative, activists counterattacked by pointing out the organizations extensive  financial ties to the liquor and beer lobby. Dr. Stuart Gitlow, President of the American Society Of Addiction Medicine, another legalization opponent, went on the media circuit disputing President Obama’s statement that marijuana is no more dangerous than alcohol: Gitlow serves as medical director for pharma company Orexo, an opioid manufacturer. Former Drug Enforcement Administration head Peter Bensinger and former White House drug czar Robert DuPont (yes that was his title) now run a commercial firm that specializes in the market for workplace drug testing.

While some police have come out against the War on Drugs, many police are lobbying in favor of it. Is it because they receive millions in funds to use under drug money seizure and assets forfeiture laws? One Florida sheriff who led opposition to legalization went so far as to state openly that drug asset forfeitures were important for county law enforcement resources. California legalization was opposed by another police lobbyist who made a career of funneling federal War on Drugs grants to state law enforcement. This is corruption in the crudest form : a mandate for serving public good diverted to individual gain.

As Los Angeles Police Department Deputy Chief Stephen Downing told The Nation, “The only difference now compared to the times of alcohol prohibition is that, in the times of alcohol prohibition, law enforcement—the police and judges—got their money in brown paper bags. Today, they get their money through legitimate, systematic programs run by the federal government. That’s why they’re using their lobbying organizations to fight every reform.” Legalization means challenging economies of influence and politics of corruption that have made drug policy and criminalization big business. Importantly, ending alcohol Prohibition in 1933 involved a vast clearing out of this corruption from the federal to the local level; hopefully the grassroots drive for cannabis policy reform will likewise have wide anti-corruption implications.

Even when we support cautious consideration and avoid making any blanket endorsement, cannabis is a powerful psychoactive plant that involves risks. Small controlled doses – a few drops of tincture, a small puff from a cigarette, a single edible candy – are still unpredictable, and might launch someone onto an unpleasant altered state, make working or relating in public difficult, trigger insomnia, interfere with driving, set someone down a path to addiction, or worse. Harms to memory and cognition development among adolescents might reveal themselves after long term heavy use. There are risks: it’s not a one size fits all solution. It will take some time to sort out studies and research honestly and get a realistic sense of the social impact in the wake of a politicized and corrupted research legacy.

And this underscores one of the central problems with the cannabis policy discussion. Legalization activists wisely chose to emphasize medical uses on a pathway towards greater marijuana acceptance. But in practice, as a plant medicine, cannabis has never been and probably never will be a targeted medical treatment. It is a plant, not a pill. Cannabis is a choice to introduce a substance into one’s body that will have unique and unpredictable effects on consciousness. It’s a life decision. It changes you, in subtle ways or dramatic ways, to ingest a substance.

Like regularly taking alcohol, drinking coffee daily, smoking cigarettes, and the use of food and herbal medicines in traditional cultures, marijuana is really best understood as a relationship. The human body and mind have receptors uniquely designed to interact with cannabis, which helps explain the broad range of consciousness and physical health effects now bing studied and experienced. Specific uses and strains might target symptoms associated with a diagnosis, but cannabis is not like penicillin. Only the individual knows how perception and consciousness are altered, and whether that is experienced as a plus or a minus in life. Some people will choose to be high if it goes along with reduction of some other discomfort; others will prefer to avoid getting high in any form. From food to movies to wine to sexuality, “self-medicating” is after all a widespread social practice and should be acknowledged: we all, to some degree, medicate ourselves just as we all, to some degree, get high. And this is what we have overlooked in our understanding of psychiatric drugs – they too are very powerful mind altering substances that get us “high.” It’s not what we think of as a high, we are still altered when we take our Zyprexa or our Prozac, and some psychiatric drugs, such as the benzodiazepines and the stimulants, are widely used recreationally. The psychiatric drugs have clear toxicities to the body; cannabis has extremely few, and a wide profile of benefits. That’s why it’s been used around the world as medicine since prehistoric times. It is also mind altering, despite the emphasis on “medical” use, and we need to recognize that altering our minds is part of what we do as humans.

We need the freedom, especially when we are facing extreme distress and crisis, to choose what risks we want to take and what substances we want to introduce, or not introduce, into our bodies and minds. We are bombarded by physical and psychological stresses in virtually every aspect of our lives today. Some of us choose alcohol, Some of us choose yoga, running, and organic food. Some us will choose cannabis. We need to take a principled and ethical look at that choice, and we need to ensure that people exploring this option aren’t put in jail for it.