November 2023 AOM: Seeing Through the Smoke: A Cannabis Expert Untangles the Truth About Marijuana

It is our pleasure to welcome Dr Peter Grinspoon, author of Seeing Through the Smoke, as our featured author for November. Peter, a Cannabis specialist and Instructor in Medicine at Harvard Medical School, investigates and untangles the reality behind Cannabis. His book cuts through the confusing and mixed public messaging around this grossly misunderstood drug. It uses data-driven medical science and a critical historical perspective to reveal the truth and the middle ground hidden behind the layers of disinformation. In his article, Peter explores the way forward to finding a pragmatic and healthy relationship with Cannabis on a societal and personal level.

Interact with Peter on our AoM forum here.

As we reconsider what is and isn’t true about cannabis, hopefully we can bridge, or at least narrow, the divide between those who continue to remain skeptical about cannabis, the ‘Reefer Pessimists’ and the cannabis enthusiasts, or the ‘Cannatopians’. One of the most powerful actions of cannabis, both helpful and inconvenient, is that it helps us to forget. Forgetting is going to constitute a large piece of this reconciliation between the dueling parties about the nature of cannabis. Both sides have to do their share, with or without the use of the temporary, short-term fuzzifying effects of cannabis.

Now that cannabis is being relegalized after almost a century, and is increasingly being normalized, the Cannatopians need to let go of their anger and distrust of both the U.S. government and, at times, science in general. Yes, science was distorted by the Drug War. To date, the U.S. government—as a whole—has almost certainly told many more lies than truths about cannabis. However, times are changing, policies are lightening up, and, increasingly, better people are in charge. Cannatopians need to trust the scientific process and to look at each study on its own merits, no matter whether it claims harm or benefit. It is just as important for all of us to know about harms as it is to understand benefits so that cannabis can be used safely and effectively, and so that cannabis users can make a truly informed decision. Any cannabis user should want to know about harms as well as benefits, including the concerning environmental effects of cannabis production, with its massive usage of energy and water.

The Reefer Pessimists must forget, or at least contextualize, much of what they have learned because so much of this knowledge was manufactured with an agenda (if not flat-out fabricated) by the dictates of the War on Drugs. This led to unrealistically negative beliefs and a lot of unhelpful mythology (e.g., breasts, sperm, I.Q.). The cynicism regarding cannabis from the War on Drugs, along with vastly lopsided funding into purported harms (but not into potential benefits), created an echo chamber of presumed negativity and flat-out dismissiveness, which continues to artifactually distort and obscure continuing explorations into the true nature of cannabis.

Ideally, skeptics can work with true believers to advocate for safe practices, many of which most of us can agree upon, such as avoiding cannabis during pregnancy and breastfeeding (except under certain very narrow circumstances), before driving, and during adolescence. There are certainly benefits that we can all agree upon, such as using cannabis to treat chronic pain and insomnia. We do better when we work together.

It is time to support balanced research and to forgo all the agendas and superstitions of the past. For the Cannatopians, no more reflexive belief in cannabis as a miracle cure, such as for cancer (until it is actually proven). For the Reefer Pessimists, no more adding derogatory air quotes when you mention the words “medical marijuana.”

What we must not forget is the cruel, pointless, and destructive criminalization—over the last eight decades—that forced tens of millions, in the United States alone, to suffer, to resist, to struggle, and, ultimately, to carry us to where we are today with a burgeoning legalization movement. We are just beginning to discuss rebuilding the communities that have been harmed by the War on Cannabis. The battles over legalization, pardons, expungements, reparations, and the future direction of the cannabis industry are far from over.

Cannabis is being destigmatized and reintegrated into human society at a rapid but uneven pace across the globe. This is long overdue, as its criminalization and demonization has caused infinitely more suffering and demonstrable harm than benefit. Cannabis is a complex drug, which we are, in some senses, extremely familiar with from thousands of years of use as well as thousands of studies. At the same time, there seem to be a growing number of unanswered questions as we learn more about the intricacy and complexity of the endocannabinoid system as well as about new medicinal benefits. The more we learn, the less we seem to know. Certainly, in researching and writing this book, after reading everything I could find, I feel on less solid ground than I did when I started. It’s a lesson in humility.

Cannabis is becoming renormalized in our society, and it is long past time that we renormalize our thinking about it, as well as our policies. The more we can work together collegially, compromise on the issues we disagree on, respectfully listen to each other, and, if necessary, respectfully agree to disagree — the better these policies will be. We should neither idealize nor needlessly restrict its use.

What lessons have we learned from our eight-decade-battle over cannabis? How can we apply this to the future so that our society can derive maximum gain and minimum harm from cannabis, and so that this issue ceases to provide further fodder for the culture wars?

Finding a Way Forward

To start, we need to get doctors and patients on the same page about cannabis. Physicians don’t need to be in absolute agreement, or to encourage its use by patients, but there needs to be open, nonjudgmental, two-way communication. No more dismissiveness, criticism or cowardly avoidance of the topic altogether. In this way, well-accepted risks, such as drug interactions or changes in anesthesia requirements, can be communicated and minimized. Doctors can help emphasize “harm reduction” practices like incorporating CBD to mitigate cognitive effects of THC and using a dry herb vaporizer instead of smoking, to spare the lungs. This will create an opportunity to emphasize basic safety issues like safe storage (so kids, teens, and pets don’t get into it), avoiding driving after use, safe dosage (“start low and go slow”), and sensibly integrating cannabis with the rest of the patient’s care. Patients will feel heard, can express thoughts and ideas, can get help if needed, and – at this point — can help educate their doctors about the rudiments of cannabis medicine.

A critical component of this is educating doctors on the endocannabinoid system – our ancient, innate system of neurotransmitters and receptors which cannabis bootstraps on to in order to work its effects. Doctors also urgently need to be informed about the practical basics of cannabis medicine, which is not rocket science compared to a lot of the other stuff we do. Physicians from a century ago knew much more about the use of cannabis than do contemporary physicians—it is unfortunate that this part of the art of medicine, utilized by great physicians throughout history, such as Sir William Osler, has been lost to all but the minority who take an active interest in cannabis medicine.

From what I’ve witnessed, cannabis is rarely, sparsely, and very misleadingly covered in the continuing medical education in my field, internal medicine, even at the most “prestigious” conferences associated with top medical schools. We aren’t going to get anywhere if we keep going at this pace – the gap between doctors and patients will remain unbridged. Mainstream medical conferences either ignore it, pay lip service to it, or echo cherry-picked nonsense from the past. The evolution of physician knowledge has been glacial; the best you can say is that at least now they occasionally mention the words “medical marijuana” instead of fully ignoring it.

At the same time, there are separate medical cannabis conferences, for cannabis supporters, that, to a certain extent, “preach to the converted,” because if you are there, you have an interest, belief in the benefits of, and probably some facility with medical cannabis. This subject needs to be taken seriously, by our entire profession, as seriously as patients take it, if doctors wish to be viewed as legitimate, trusted partners and reliable sources of information.

Legalizing sensibly

As we legalize, we need to regulate in a sensible way. Legal cannabis doesn’t have to be a commercialized free-for-all, devoid of any limits or restrictions. There are practical, painless ways to simultaneously increase knowledge, permit usage, and reduce harm, such as:

1. Limiting or banning advertising for cannabis, at the same time as we ban it for tobacco, alcohol, and Big Pharma too. None of these ads are helpful to society
2. Educating people about the higher risks that likely pertain to specific populations, such as teens; those with, or predisposed to, certain psychiatric conditions; and pregnant/breastfeeding women.
3. Not taxing cannabis at such a high rate, which only fosters the less regulated, and less safe, illicit market.
4. Figure out, once and for all, how to detect (if possible) and discourage stoned driving (without getting people who aren’t impaired in trouble).
5. Stop making cannabis into tasty edibles, chocolates, or candies that any small child (or pet) would happily overconsume.
6. Provide neutral education on harms that are credible and believable, given without judgment, exaggeration, or stigma.
7. Pursue research that isn’t based on any corporate or political agenda and which isn’t biased in either direction.
8. Address whether any limits on potency of flower or concentrates make sense—and how to do this without either inadvertently pushing consumers into the illicit market (if even possible) or making medical cannabis even more expensive for patients on fixed incomes.
9. Regulate CBD and other minor/new cannabinoids (e.g., CBN, THCV, delta 8 THC) in a coherent and helpful way, not like we are currently doing. We need to regulate the production of these products, not permit them as “supplements” without any control over their manufacturing or safety/benefit claims.
10. Destigmatize all aspects of cannabis usage so that people who need it medically don’t feel bad about using it and so that people who do start using it problematically can get empathic, non-judgmental help.
11. Legalize federally so that regulation, safety standards, labeling, and commerce can be coherent and consistent, throughout the United States and, ideally, the entire world.
12. Come up with standardized dosages to help make research and clinical care more consistent, for each type of consumpion method.
13. Better define “cannabis addiction” beyond the deeply flawed concept of “cannabis use disorder,” which ropes in many of the medical marijuana patients
14. Allow hospitals to allow inpatients to use medical cannabis so they don’t have to either withdraw from cannabis in the hospital, use it surreptitiously, or interrupt their care regimens. (This doesn’t mean smoking or vaping in a hospital.)
15. Use legalization as an opportunity to redress as many harms of the War on Cannabis as possible. Let nonviolent cannabis prisoners out, expunge all records for nonviolent cannabis offenses, and find a way to fund profits from the nascent industry to the families and communities that have been harmed heal their traumas and regain financial stability.

Some of these are being addressed, but we have a massive amount of work to do.

As cannabis increasingly becomes mainstream for medicinal uses, or for whichever wellness and lifestyle enhancement people augment with cannabis – mindfulness, social connection, creativity, spirituality, enjoyment of sex, art and music — it is critical to educate cannabis users about how to use cannabis safely. Understanding that everyone’s needs and habits are different, here are some general principles:

1. Keep dosages of THC as low as possible. As with all drugs and medicines, the lower the (effective) dose, the less harmful. We fetishize high THC in the United States at the expense of other potentially more medicinal components. Periodic tolerance breaks (e.g., taking two weeks off to let your receptors reset and your tolerance dissipate) helps keep the dosage down.
2. Use CBD along with your THC. Get cannabis that has both CBD and THC in it or take the CBD separately—current research suggests this can help protect your brain.
3. Don’t smoke! (Unless you are a very occasional user). There’s no reason to expose yourself to combustion products, such as tar, benzene, polycyclic aromatic hydrocarbons, etc. (Even though cannabis has never been shown to cause lung cancer or COPD, there’s no reason to inhale all of this crap.) If you prefer to use cannabis inhalationally, use a dry herb vapor- izer, which doesn’t combust the cannabis, but instead heats it to a lower temperature (which is enough to extract the cannabinoids) and which produces a less irritating vapor. Or explore edibles, tinctures, inhalers, oils, suppositories, patches, and lotions—there are lots of options these days.
4. Don’t use cannabis, even medicinally, if you might have to drive. Not only is this dangerous and irresponsible; it is also extremely stressful and unpleasant, as well as unethical, as it puts others at risk.
5. Watch the dosage on edibles. It is very easy to take too much. Don’t make the classic mistake of “Hey, nothing is happening” after twenty minutes and then take five more gummies, as they can take up to ninety minutes to kick in. Don’t be like my friends who visited Amsterdam during college, did exactly this with Space Cakes, and then were so scared they hid in the closet of their hotel room for an entire day.
6. If you have a particularly good or bad reaction to a particular strain or chemovar, write it down. Journaling is good practice in any case—dosage, benefits, side effects, formulations, and delivery mechanism.
7. If you are smoking (or vaping), you don’t have to hold your breath for more than a few seconds—it is a misconception that holding the smoke in longer gets you higher. It just irritates your lungs.
8. Use caution if you have any history of addiction or any history or family history of mental illness, particularly psychosis or schizophrenia. Speak with your doctor (or a doctor that is able to be helpful, if your doctor isn’t) and exercise caution before starting cannabis. The use of cannabis, or any drug, can also make mental illnesses more difficult to diagnose and treat.
9. Use with great caution as well if you have a history of coronary disease or an arrhythmia; involve your medical providers and keep the dosages very low (and avoid smoking).
10. If your use is escalating and you find yourself craving cannabis frequently, or if you have trouble cutting down, ask for help. Addiction is a disease of isolation; be open and honest— especially with yourself. If people don’t take you seriously because it’s “just a weed addiction,” seek help elsewhere. Any addiction—and people do get addicted to cannabis—should be responded to with empathy and competent treatment.
11. Ask your doctor, or a cannabis specialist, about any potential reactions there may be between THC, CBD, and any medications you are taking. This is particularly true if you are on blood thinners or other medications that need to be kept within a narrow range (e.g., antiepileptics, immunosuppressants, chemotherapeutic agents). Also, if you use cannabis frequently, make sure the anesthesiologist knows, before surgery, as you might have higher anesthesia requirements.
12. Know the relevant laws in your area, and don’t get tangled up with law enforcement. You can’t (yet) legally fly with cannabis. Other states where the legality is different might not accept your medical cannabis card and could even arrest you if they don’t (yet) have legal medical cannabis.
13. Make sure that the product you are using is safe. This is best accomplished by going through the legal market if available (as these products are carefully monitored for pesticides and molds, and are regulated), growing your own, or knowing your grower.
14. Do not use during pregnancy or breastfeeding, if feasible, until we understand this area much better. If you are using, please let your care teams know. Care teams, on their end, must respond with compassion, not stigma and punitiveness.
15. Avoid using cannabis with other sedating drugs, particularly alcohol, or medications such as opioids or benzodiazepines, as the impairment can be additive.
16. Be careful with concentrates (wax, shatter, crumble, bubble hash, rosin, etc.), as we haven’t really studied these for safety, and also it’s easy to accidentally get way too high when using them, which is not pleasant and can be dangerous.
17. Learn how to read the labels on the cannabis so you know exactly what you are consuming and can better decide what works for you.
18. Learn enough about cannabis so that you can be your own advocate; this will help you speak with doctors and budtenders alike.

We must acknowledge all who needlessly suffered under the criminalization of cannabis, and those who fought to change this. It is an extraordinary tale of how ordinary people stood up, over several generations, to stigma and repression and faced down the combined forces of the government, corporations, and, unfortunately, much of the medical profession. Many paid a steep price, including arrests, loss of assets, jail time, and criminal records.

Lessons Learned

What lessons can we learn from the eighty-year fiasco of cannabis prohibition that might be applied to other societal issues?

To start, as Dr. Andrew Weil points out in the foreward of this book, the ways that both sides strayed from objectivity about cannabis are instructive. Some major flaws of the medical establishment were exposed. They were too often narrow-minded, disrespectful of patients’ stories and experiences, and closed off to new information that went against mainstream opinion. To an uncomfortable degree, many of the medical societies have been unduly influenced by the economic interests of Big Pharma and the political interests of NIDA and various other organs of the War on Drugs, such as the rehab industry and law enforcement. By being on the wrong side of the War on Drugs, our profession violated the dictate to “do no harm” and demonstrated a remarkable willingness to be accessories to the stigmatizing “your brain on drugs” culture war, rather than to think for ourselves, learn the nuances of the cannabis issue, and advocate on behalf of patients.

As for the cannabis activists, I’m reminded of an aphorism from Nietzsche, which I can only paraphrase: “If you automatically react against something, you are just as controlled by it as if you comply.” Confronted with relentless negative, and at times dubious, information about cannabis from the U.S. government and from anti-cannabis researchers, cannabis advocates have counterreacted and reflexively dismissed concerns about potential harms. Many of these studies are valid and important, or at least hypothesis generating, with major implications for health and harm reduction.

Cannabis Unites

Opinion on cannabis, particularly medical cannabis, is broadly positive. Ninety-four percent of Americans are in favor of legal access to medical marijuana. Can you name any other issue about which 94 percent of Americans agree? Can you even imagine it? I’m not sure that 94 percent of Americans believe the earth is round, that we actually landed on the moon, or that the sky is blue.

The reality of the situation is that people across the globe, including most Americans, are waking up to the fact that they have been sold a bill of goods on cannabis. Many people want “something” after a long day at work, to soothe sore muscles and frayed nerves, and now that cannabis is increasingly a legal, available option, I predict that many will start choosing cannabis over alcohol. While not harm free, it is healthier, safer, less fattening (provided you don’t eat your way through the kitchen nightly after consuming), and, for many, more interesting and more productive. It is more conducive, in my opinion, to genuinely connecting to other people, which is particularly important given how isolated and lonely a great number of people are feeling these days.

Cannabis unites people in so many ways. It unites them when they use it together, it unites as a shared cultural practice and belief system, and it unites them politically over concerns about social justice. We are seeing examples of former influential Republicans, like John Boehner, and mem- bers of law enforcement “switching sides” and joining the cannabis train. The days of illegality of cannabis are numbered as, defying the organs of power, Americans are saying “just say legalize” to cannabis. This movement is spreading around the world too, with many countries liberating cannabis laws. Perhaps the United States, which has for so long been internationally influential in a corrosive way, by demanding that other countries march in step with our War on Drugs, could even help lead the world into a new, more enlightened phase in this area of policy. Currently, Canada, Uruguay, and Israel are the ones leading the way.

Are there any lessons from the cannabis story that might apply to the broader War on Drugs? If the illegality of cannabis was such a social and financial disaster for millions of people—with absolutely nothing of benefit to show for it—why prohibit the use of other drugs? Is the criminalization of meth, opioids, and cocaine any more sensible or productive than that of cannabis? Is prohibition really the best way to protect people from the harms of these drugs? Or is it time for this policy to be broadly reconsidered as well? On the one hand, cannabis is less dangerous, and less rewarding, than these other drugs, so it is easier to contemplate legalization. On the other hand, many of the dangers of criminalization— tainted supply, needless arrests for nonviolent crimes, wasted resources, racially biased arrests—apply just as much to these more dangerous drugs. The “tainted supply” problem, in particular, relates to opioids more than any other drug right now, with 108,000 overdose deaths in the last twelve months of this writing, mostly from fentanyl and other adulterants.

In my opinion, the issue of drugs lands somewhere between a medical issue, an economic issue, an ethical issue, and a social justice issue. People should be freely allowed to change their consciousness, as long as it doesn’t harm or inconvenience other people. If people get addicted or have any medical consequences of their drug use, they ought to have unfettered access to medical attention, and to compassion. When people become addicted, it is often due to unresolved trauma, a medical issue, or socioeconomic problems such as homelessness or poverty—addiction a “disease of despair.” The last people who should be involved are law enforcement. Why are we punishing people for being addicted, or for just wanting something to help them get by? Again, as long as it doesn’t hurt other people, it should be legal. And by legalizing, we make the supply chain safer, with no adulterants, and more ethical as well—no more cartels.

If people drive when impaired or act in a violent or antisocial way, such as they might do under the influence of alcohol, that reasonably becomes a law enforcement issue. One could argue that treatment is always more productive than punishment (which doesn’t at all help people with the disease of addiction), although intoxicated drivers do need to be taken off the roads. Otherwise, the harms of being involved with law enforcement and the court system, including the carceral system, are often worse than the harms of the drug use itself, to individuals, their families, and their communities. The very involvement of law enforcement deters people from admitting they are struggling and from seeking help. Ideally, we could make our criminal justice system more rehabilitative and less needlessly punitive, like it is in many European countries.

I am convinced that if opioids were legal, no one would be dying of fentanyl overdoses. The supply would be regulated, monitored, and safe; the drug use wouldn’t be underground; and we’d have safe injection sites everywhere they are needed. There wouldn’t be legal and social barriers to asking for help. We’d also have billions of dollars freed up from law enforcement to use for addiction treatment, jobs training, and the basics that humans deserve and require, such as food, health care, and housing. I’m not saying “defund the police,” just “defund the War on Drugs.”

Portugal is an example of a country that has decriminalized drugs. They also redirected a large portion of their funding away from law enforcement to housing, job training, and addiction treatment. Their rates of addiction, HIV, and hep C plummeted. The only casualty was the bloated budgets of the different law enforcement agencies. Portugal defunded the War on Drugs, and the results have been spectacular.

We can, and must, do the same thing here. The only way to win the War on Drugs is to surrender, retreat, apologize, expunge, make reparations, and reframe our entire attitude about drug use and addiction. The main obstacle to doing so in the United States is that we have a much more entrenched, enriched, and entitled law enforcement bureaucracy, which is used to funding itself with “asset forfeiture” and unlimited Drug War dollars. The War on Drugs is also a mechanism of racial oppression, which is destructive beyond words. We need to empty out our prisons of nonviolent drug offenders and get them the help they need to get back on their feet. I predict that some combination of decriminalization and legalization will be a major component of how we will solve the addiction crisis in this country. Legalization is a glowing success for cannabis, and I predict it will be so for most of the other drugs, within the decade.

Peter Grinspoon, M.D.
Primary care doctor and cannabis specialist at Massachusetts General Hospital
Instructor in Medicine, Harvard Medical School
Author of ‘Seeing Through the Smoke: A Cannabis Expert Untangles the Truth About Marijuana’