Cannabis was legal in America well into the 20th century and medical cannabis products were manufactured by pharmaceutical companies and widely prescribed and used. Of course, it’s important to keep in mind that this was before modern medicine: before aspirin even.
Thirty years after medical cannabis was first re-legalized in California in 1996, what is the role of medical cannabis today?
The flip side of cannabis as a medical or mental health treatment is when cannabis use is disruptive, harmful, and risky. What is cannabis use disorder, and is today’s increase in cannabis use disorder related to the potency of cannabis now? Related to this, which is greater: the number of people who drink alcohol almost daily or the number of people who use cannabis almost daily?
Cannabis became common in American medicine beginning in 1840 when knowledge of medical uses was brought from India, but medical beliefs and practice around cannabis began to turn in the 20th century. In 1915 California became the first state to make cannabis illegal. Of course, always the eager trendsetter, California was also first to reverse course and re-legalize cannabis for medical purposes in 1996.
Medical re-legalization pulled some people away from black market cannabis, allowed professional medical supervision of cannabis treatment, and added to the number of products tailored or specified for treatment of conditions including cancer, chronic pain, multiple sclerosis, nausea, vomiting, epilepsy, PTSD, and arthritis.
Now, patients seeking cannabis help in the 40 states with comprehensive medical cannabis programs, along with the District of Columbia and Puerto Rico, can have their need certified by a doctor and then usually pay a fee for a state medical card. Today, around 3 million patients are certified for medical cannabis purchases or home-cultivation.
Medical cannabis programs have requirements for lab testing, which increases safety and standardization of doses for patients and lets patients avoid the unknowns of black market cannabis. However, widely varying methodology between labs and cherry-picking of samples submitted to labs have sometimes made test results unreliable and variable according to the lab, putting patients at risk of misdosing. State regulatory oversight has increased over time, but it remains uncertain whether medical cannabis is well-tested for impurities and the cannabinoid content well-quantified at all times in every jurisdiction.
Nonetheless, medical dispensaries provide relative safety assurance compared to the black market, where pesticide, heavy metal, and fungal contamination is untested and deliberate adulteration of cannabis with dangerous substances such as fentanyl sometimes occurs.
Yet cannabis in a medical dispensary is lightly regulated compared to federally regulated pharmaceuticals. For example, all non-prescription over-the-counter drugs, such as pain relievers and cold medicine, must conform to strict standards published by the FDA. We are far from that with medical cannabis.
THE ECONOMICS OF MEDICAL CANNABIS
Most medical cannabis is not taxed, while recreational cannabis is heavily taxed in some states. However, most patients seeking cannabis face fees for a doctor’s certification and for the state medical card.
Medical cannabis patients are more frequently low-income and tend to be older and in worse health compared to recreational users. Perhaps this has to do partly with the more limited access these groups have to traditional medical care.
Medical dispensaries risk losing customers to recreational dispensaries in states with both, while paying higher operating costs. While some states with recreational cannabis continue to see increases in the number of medical patients, it may be that more dual-licensing states have a decreasing number of medical patients. However, patients typically don’t find specialized cannabis formulations to treat their chronic conditions in recreational dispensaries, which tend to focus on products with high levels of the psychoactive ingredient, THC, the part that makes users high. Products for medical purposes usually have lower THC doses and, often, high ratios of CBD, a non-psychoactive ingredient, to THC.
CANNABIS USE DISORDER
This substance use disorder is defined with 11 criteria that include craving, unsuccessful effort to cut down, and interference with work or relationships. Meeting two or three of these 11 criteria constitutes a mild case of cannabis use disorder and having six or more is a severe case. In 2024, 7% of Americans 12 and up, that is 21 million people, had cannabis use disorder of some severity. Within those numbers, 5% of adolescents and 16% of young adults had cannabis use disorder. That’s 1.2 million kids age 12 to 17 and 5.5 million adults age 18 to 25.
Related to cannabis use disorder, the number of people who use cannabis on a daily or near daily basis has been climbing rapidly over the last 20 years, and in 2022 the number of frequent users of cannabis surpassed the number of frequent users of alcohol in America. In the same way that near daily use of alcohol has a statistical association with alcohol use disorder, so does near daily use of cannabis have a statistical association with cannabis use disorder. I find the rapid increase in near daily use of cannabis worrying.
The reason that there are now more people who use cannabis near daily compared to those who drink near daily is unknown. I have seen that the 2024 study that reported the increased near daily use did not take into account that medical use of cannabis is frequently on a daily or near daily basis (42% in one study), which would tend to increase the reported overall number of daily or near daily cannabis consumers.
Decriminalization of cannabis is, of course, likely the biggest contributor to the increase of near daily use, but it’s concerning that frequent use has been found to be associated with the use of stronger cannabis at the individual level.
Both frequent use and stronger cannabis are related to Cannabis Hyperemesis Syndrome, or CHS. Emergency room visits for CHS have risen in the last 10 years. CHS presents in the emergency department as severe nausea, cyclic vomiting, and very bad stomach pain, conditions that can continue up to a week.
Some people might have heard a frequently cited estimate of how common CHS is. That estimate is a large number, but, to me, the methodology for making the estimate is very suspect, so I won’t quote it. But, even if on further research the risk turns out to be relatively small, for those who get it, CHS is very, very not fun.
Despite cannabis still being listed as a Federal Schedule 1 drug with no accepted medical use, like heroin and LSD, the FDA has approved four THC- or CBD-based drugs. These are for the treatment of nausea from chemotherapy, anorexia, and seizures from two rare forms of epilepsy. The FDA seems to have an encouraging posture towards applications for additional cannabis-based medicines.
Alcohol and cannabis are both used by many people to self-medicate. That is unlikely to ever stop. While there is often a difference between what makes people feel better and what science says is the most effective treatment to make them better, there is a validity to both perspectives. After all, even placebos without any biologically active ingredient can be effective. If a benefit is perceived, a benefit is received.
Thank you for reading. In Part Three of “Ultraprocessed Cannabis: Potency, Policy, And Public Health In America,” we do a health reality check for and against cannabis; discuss cannabis in relation to America’s other favorite recreational substance, alcohol; and follow the path of ultra-potent to ultra-high to ultraprocessed.
If you haven’t already, be sure to check out the first part of our series, where we look at how cannabis got so strong and how the U.S. got a hodge-podge of cannabis regulation. You can find that at EatingInAmerica.co.
Your support of Eating in America is so helpful to this Substack’s growth. Please let me know your thoughts about cannabis in the comments. Thank you!
