Analysis of HHS Cannabis Rescheduling Rationale

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On August 30th, 2023, the Department of Health and Human Services (HHS) announced it recommended the reclassification of marijuana to Schedule III to the Drug Enforcement Administration (DEA). Four months later, HHS released an unredacted version of its recommendation to reclassify the drug. The 252-page review had been hidden from the public and was only released after legal action was threatened against HHS.  

This HHS recommendation is based on cherry-picked data and represents a weak and intellectually dishonest argument to reschedule marijuana. This summary describes just a few of the many flaws in the HHS methodology and conclusions. SAM’s full report provides an in-depth analysis of what the HHS got wrong and how the process could have been strengthened.  

1. In years past, the FDA, an agency of the HHS in charge of approving medicinal drugs, used an established five-factor analysis in determining whether Schedule I drugs have “currently accepted medical use.” In the current report supporting the recommendation to reschedule marijuana, the FDA changed these criteria to get its desired answer.  

 If marijuana had been held to the same standards as other drugs, it would not be deemed to have “currently accepted medical use,” due to the infeasibility of measuring all strains and the insufficient amount of existing research into its safety and efficacy. In fact, the FDA’s new two-factor test explicitly states that studies used to support marijuana’s accepted medical use do not need to be controlled, a standard that was required in the five-factor test (save an evaluation done by a consensus of experts). 

2. It is not clear why the FDA moved away from the five-factor test, unless the agency approached the rescheduling review with a pre-determined conclusion.  

The five-factor test has been used for decades by Republican and Democratic Administrations. Additionally, the United States Court of Appeals for the District of Columbia Circuit examined and validated the test in Alliance for Cannabis Therapeutics v. Drug Enforcement Administration. The marijuana industry petitioners in that case even conceded that the five-factor test had no flaws, as explained in the opinion for the court. 

3. The FDA now considers the existence of state medical marijuana programs as evidence that marijuana has currently accepted medical use.  

A drug’s popularity among the public has never been used as a standard to determine medicine. Supreme Court Justice Steven Breyer in Gonzalez v Raich (545 U.S. 1 (2005), a case involving a medical necessity for the use of marijuana, opined during oral arguments that “medicine by regulation is better than medicine by referendum.” The Court’s 6-3 decision, which Justice Breyer joined, upheld the prohibition of marijuana for medical use under the Controlled Substances Act (CSA). The FDA’s novel standard in recommending marijuana’s rescheduling is rooted in a logical fallacy: some people say that marijuana is medicine, so marijuana must be medicine. The FDA is delegating its authority to determine that medications are safe and effective to popular opinion, a practice that not only exceeds the statutory authority of the agency but makes a mockery of the congressional intent of the Food, Drug, and Cosmetic Act to protect the public health. Following the FDA’s logic, psychedelic drugs, which are seeing a popular push for medical legalization, could also be considered medicine and be rescheduled due to shifting public opinion. 

4. The FDA compares marijuana to a limited, hand-picked list of other controlled and noncontrolled substances (e.g., heroin, alcohol, cocaine), not all Schedule I drugs. 

In the recommendation, the FDA measured marijuana’s potential for abuse by comparing it to a hand-picked selection of Schedule I, II, and III drugs. For example, the FDA compared marijuana to heroin, another Schedule I drug. The recommendation claims that because marijuana has a lower abuse potential than heroin, it shouldn’t be in the same category. Yet the FDA failed to compare marijuana to other Schedule I drugs, such as LSD. Comparing marijuana’s abuse potential against all Schedule I drugs would have allowed for a more rigorous analysis, but it would not have allowed the FDA to conclude that marijuana belongs in Schedule III. To qualify for Schedule III, a drug or other substance must have “potential for abuse less than the drugs or other substances in Schedules I and II” (21 USC 812(b)). Fifty years of data published by HHS show that marijuana does not meet this standard. 

5. None of the studies used by the FDA to justify its claim that marijuana is medicine support that conclusion. 

The FDA determined that marijuana is acceptable for medical use for pain, nausea and vomiting, and anorexia. Only three studies were used to justify this claim. The first (University of Florida), concluded that results were “inconclusive or mixed.” The second (National Academies of Sciences & Medicine) relied primarily on a study for which the results were not statistically significant. For the third (Agency for Healthcare Research and Quality), the FDA concluded that the positive effects of marijuana in the study were small and that “the increased risk of dizziness, nausea, and sedation [from marijuana use] may limit the benefit” (page 27 of 252). Furthermore, some of these studies were with inhalable marijuana; prior FDA evaluations have excluded inhalable marijuana studies because of their unreliability and questionable practices. 

Why Legal Pot Makes This Physician Sick→

Last year, my husband and I took a 16-day road trip from Kentucky through Massachusetts to Maine. On our first morning in Boston, we exited the Park Street Station en route to Boston Common but instead of being greeted by the aroma of molasses, we were hit full-on with a pungent repulsive odor. "That's skunk weed," my husband chuckled as we stepped right into the middle of The Boston Freedom Rally, a celebration of all things cannabis.

As we boarded a hop-on-hop-off bus, we learned that this was the one week of the year that the city skips testing tour bus drivers for tetrahydrocannabinol (THC), "because we all test positive," the driver quipped. As our open-air bus circled the Common, a crowd of pot enthusiasts displayed signs in support of relaxed regulation for public consumption.

The 34-year-old Boston Freedom Rally is a sign that US culture has transformed forever. Mary Jane is no friend of emergency physicians nor of staff on hospital wards and offices. Healthcare workers should brace for the true impact of THC as its adoption by all ages rises.

Toking Boomers and Millennials

Researchers at University of California, San Diego looked at cannabis-related emergency department visits from all acute-care hospitals in the state from 2005 to 2019 and found an 1808% increase in patients aged 65 or older (that is not a typo) who were there for complications from cannabis use.

The lead author said in an interview that, "Older patients taking marijuana or related products may have dizziness and falls, heart palpitations, panic attacks, confusion, anxiety or worsening of underlying lung diseases, such as asthma or [chronic obstructive pulmonary disease]."

A recent study from Canada suggests that commercialization has been associated with an increase in related hospitalizations, including cannabis-induced psychosis.

According to a National Study of Drug Use and Health, marijuana use in young adults reached an all-time high (pun intended) in 2021. Nearly 10% of eighth graders and 20% of 10th graders reported using marijuana this past year.

The full downside of any drug legal or illegal is largely unknown until it infiltrates the mainstream market, but these are the typical cases* we see:

Let's start with the demotivated high school honors student who dropped out of college to work at the local cinema. He stumbled and broke his clavicle outside a bar at 2 AM, but wasn't sure if he passed out so a cardiology consult was requested to "rule out" arrhythmia associated with syncope. He related that his plan to become a railway conductor had been upended because he knew he would be drug tested and just couldn't give up pot. After a normal cardiac exam, ECG, labs, a Holter, and an echocardiogram were also requested and normal at a significant cost.

Cannabinoid Hyperemesis Syndrome

One of my Midwest colleagues related her encounter with two middle-aged pot users with ventricular tachycardia (VT). These episodes coincided with potassium levels < 3.0 mEq/L in the setting of repetitive vomiting. The QTc interval didn't normalize despite a corrected potassium level in one patient. They were both informed that they should never smoke pot because vomiting would predictably drop their K+ levels again and prolong their QTc intervals. Then began "the circular argument" as my friend described it. The patient claims, "I smoke pot to relieve my nausea," to which she explains that "In many folks, pot use induces nausea." Of course, the classic reply is, "Not me." Predictably one of these stoners soon returned with more VT, more puking, and more hypokalemia. "Consider yourself 'allergic' to pot smoke," my friend advised, but, "Was met with no meaningful hint of understanding or hope for transformative change," she told me.

I've seen cannabinoid hyperemesis syndrome several times in the past few years. It occurs in daily to weekly pot users. Very rarely, it can cause cerebral edema, but it is also associated with seizures and dehydration that can lead to hypovolemic shock and kidney failure.

Heart and Brain Harm

Then there are the young patients who for various reasons have developed congestive heart failure. Unfortunately, some are repetitively tox screen positive with varying trifectas of methamphetamine (meth), cocaine, and THC; opiates, meth, and THC; alcohol, meth, and THC; or heroin, meth, and THC. THC, the ever present and essential third leg of the stool of stupor. These unfortunate patients often need heart failure medications that they can't afford or won't take because illicit drug use is expensive and dulls their ability to prioritize their health. Some desperately need a heart transplant but the necessary negative drug screen is a pipe dream.

And it's not just the heart that is affected. There are data linking cannabis use to a higher risk for both ischemic and hemorrhagic stroke. A retrospective study published in Stroke of more than 1000 people diagnosed with an aneurysmal subarachnoid hemorrhage found that more than half of the 46 who tested positive for THC at admission developed delayed cerebral ischemia (DCI), which increases the risk for disability or early death. This was after adjusting for several patient characteristics as well as recent exposure to other illicit substances: cocaine, meth, and tobacco use were not associated with DCI.

Natural My…

I'm certain my anti-cannabis stance will strike a nerve with those who love their recreational THC and push for its legal sale, after all, "It's perfectly natural." But I counter with the fact that tornadoes, earthquakes, cyanide, and appendicitis are all natural but certainly not optimal. And what we are seeing in the vascular specialties is completely unnatural. We are treating a different mix of complications than before pot was readily accessible across several states.

Our most effective action is to educate our patients. We should encourage those who don't currently smoke cannabis to never start and those who do to quit. People who require marijuana for improved quality of life for terminal care or true (not supposed) disorders that mainstream medicine fails should be approached with empathy and caution.

A good rule of thumb is to never breathe anything you can see. Never put anything in your body that comes off the street: Drug dealers who sell cannabis cut with fentanyl will be ecstatic to take someone's money then merely keep scrolling when their obituary comes up.

Let's try to reverse the rise of vascular complications, orthopedic injuries, and vomiting across America. We can start by encouraging our patients to avoid "skunk weed" and get back to the sweet smells of nature in our cities and parks.

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*Some details have been changed to protect the patients' identities, but the essence of their diagnoses has been preserved.

Melissa Walton-Shirley, MD, is a native Kentuckian who retired from full-time invasive cardiology. She enjoys locums work in Montana and is a champion of physician rights and patient safety. In addition to opinion writing, she enjoys spending time with her husband and daughters, and sidelines as a backing vocalist for local rock bands. Her Heartfelt column was the 2022 northeast regional gold and national silver Azbee award winner. 

Brutal Marijuana Studies Now Emerging - It Should Never Have Been Fully Legalized

For years, marijuana advocates claimed that if only America would loosen restrictions, we'd all see how beneficial the drug is. But now, more than 10 years after the first efforts to do just that, we are seeing that the critics were right. Liberal pot laws and increased usage are far from the panacea pot-lovers claimed. Starting back in 2012, Colorado passed a law to allow private use of marijuana. Soon the state of Washington joined the Centennial State in loosening its pot laws. And many more came in the following years, especially when the states began to realize it could tax "legal" marijuana and bring millions into their state treasuries. Now even the federal government is looking to loosen the reins and is preparing to take pot off its Schedule One prohibitions, a move said to be the first step in decriminalizing marijuana. But now these states are finding that it is time to pay the piper, as a raft of ill-effects are spreading like wildfire all across the country. From mental illness to addiction and impaired driving, the effects on many are not as beneficial as advocates claimed. There do seem to be a very few beneficial uses for pot for a small number of people. It does help in pain relief for the chronically afflicted, it can help with nausea from chemotherapies and it is sometimes effective for those with anxiety. But all those benefits are limited and are far outweighed by the deleterious effects seen when widespread use is factored in, according to a raft of new studies reported by the Daily Mail. With a pool of more than 40 million pot users to look at, researchers are finding that recreational use of the drug is becoming an increasing problem everywhere it is being tried. As the Mail noted, researchers from the Aarhus University Hospital in Denmark have found that despite claims by pot advocates, the drug is just as addictive as any other drug. And 41 percent of users have developed major problems with depression. The research found that chronic marijuana use quadrupled risk of developing a bipolar disorder and added to a rise in psychotic breaks, including thoughts of, and deaths by, suicide, with pot linked to 30 percent of cases of schizophrenia. The researchers added that people who already have a propensity for these mental disorders often find that pot makes them worse, not better. That is nothing like the benign effects pot advocates claimed we'd be seeing. Pot advocates also claimed that one can't really become addicted to the drug. This has also been revealed as false. "New research from University of Washington and Kaiser Permanente Washington Health Research Institute estimates 21 percent of marijuana users had become addicted," the Mail reported, adding that at least four million Americans have developed "marijuana use disorder" since pot became so much easier to get. Another claim that many advocates have made is that pot will calm you and make sleep come easier. This is also not true, studies have found. "A 2021 study in the journal BMJ reported adults who used cannabis 20 or more times in the previous month were more likely than non-users to get six or fewer hours of sleep per night," the Mail reported. In addition, 39 percent of daily pot users developed clinical insomnia. An even more alarming study says that pregnant women will put themselves at a 70 percent higher risk of birth defects if they regularly use pot during pregnancy, and they will be 2.3 times more susceptible to a stillbirth. Also, "A 2022 study published in JAMA Pediatrics found prenatal cannabis exposure after five to six weeks of pregnancy is associated with attention, social and behavioral problems that persist into early adolescence," the Mail reported. Finally, the evidence seems irrefutable that heavy pot smoking is just as bad on your body as heavy tobacco smoking. Smoking anything -- pot or tobacco -- increases the risk of coronary artery disease and also puts users at an increased risk of lung disease. A study from Canada found that "three-quarters of marijuana users had emphysema - a lung disease which leaves sufferers struggling to breathe -- compared to two-thirds of tobacco users," the Mail wrote. While it might be a better idea to go to a prescription model, where only seriously ill people are able to gain access to pot, it seems clear that recreational and non-medicinal use has had detrimental effects on Americans.

Legalizing Marijuana Is a Big Mistake

Of all the ways to win a culture war, the smoothest is to just make the other side seem hopelessly uncool. So it’s been with the march of marijuana legalization: There have been moral arguments about the excesses of the drug war and medical arguments about the potential benefits of pot, but the vibe of the whole debate has pitted the chill against the uptight, the cool against the square, the relaxed future against the Principal Skinners of the past.

As support for legalization has climbed, commanding a two-thirds majority in recent polling, any contrary argument has come to feel a bit futile, and even modest cavils are couched in an apologetic and defensive style. Of course I don’t question the right to get high, but perhaps the pervasive smell of weed in our cities is a bit unfortunate …? I’m not a narc or anything, but maybe New York City doesn’t need quite so many unlicensed pot dealers …?

All of this means that it will take a long time for conventional wisdom to acknowledge the truth that seems readily apparent to squares like me: Marijuana legalization as we’ve done it so far has been a policy failure, a potential social disaster, a clear and evident mistake.

The best version of the square’s case is an essay by Charles Fain Lehman of the Manhattan Institute explaining his evolution from youthful libertarian to grown-up prohibitionist. It will not convince readers who come in with stringently libertarian presuppositions — who believe on high principle that consenting adults should be able to purchase, sell and enjoy almost any substance short of fentanyl and that no second-order social consequence can justify infringing on this right.

But Lehman explains in detail why the second-order effects of marijuana legalization have mostly vindicated the pessimists and skeptics. First, on the criminal justice front, the expectation that legalizing pot would help reduce America’s prison population by clearing out nonviolent offenders was always overdrawn, since marijuana convictions made up a small share of the incarceration rate even at its height. But Lehman argues that there is also no good evidence so far that legalization reduces racially discriminatory patterns of policing and arrests. In his view, cops often use marijuana as a pretext to search someone they suspect of a more serious crime, and they simply substitute some other pretext when the law changes, leaving arrest rates basically unchanged.

So legalization isn’t necessarily striking a great blow against mass incarceration or for racial justice. Nor is it doing great things for public health. There was hope, and some early evidence, that legal pot might substitute for opioid use, but some of the more recent data cuts the other way: A new paper published in The Journal of Health Economics found that “legal medical marijuana, particularly when available through retail dispensaries, is associated with higher opioid mortality.” There are therapeutic benefits to cannabis that justify its availability for prescription, but the evidence of its risks keeps increasing: This month brought a new paper strengthening the link between heavy pot use and the onset of schizophrenia in young men.

And the broad downside risks of marijuana, beyond extreme dangers like schizophrenia, remain as evident as ever: a form of personal degradation, of lost attention and performance and motivation, that isn’t mortally dangerous in the way of heroin but that can damage or derail an awful lot of human lives. Most casual pot smokers won’t have this experience, but the legalization era has seen a sharp increase in the number of noncasual users. Occasional use has risen substantially since 2008, but daily or near-daily use is up much more, with around 1‌‌6 million Americans, out of ‌more than 50 million users, now suffering from what ‌‌is termed marijuana use disorder.

In theory, there are technocratic responses to these unfortunate trends. In its ideal form, legalization would be accompanied by effective regulation and taxation, and as Lehman notes, on paper it should be possible to discourage addiction by raising taxes in the legal market, effectively nudging users toward more casual consumption.

In practice, it hasn’t worked that way. Because of all the years of prohibition, a mature and supple illegal marketplace already exists, ready to undercut whatever prices the legal market charges. So to make the legal marketplace successful and amenable to regulation, you would probably need much more enforcement against the illegal marketplace — which is difficult and expensive and, again, obviously uncool, in conflict with the good-vibrations spirit of the legalizers.

Then you have the extreme case of New York, where legal permitting has lagged while untold numbers of illegal shops are doing business unmolested by the police. But even in less-incompetent-seeming states and localities, a similar pattern persists. Lehman cites (and has reviewed) the recent book “Can Legal Weed Win? The Blunt Realities of Cannabis Economics,” by Robin Goldstein and Daniel Sumner, which shows that unlicensed weed can cost as much as 50 percent less than the licensed variety. So the more you tax and regulate legal pot sales, the more you run the risk of having users just switch to the black market — and if you want the licensed market to crowd out the black market instead, you probably need to make legal pot as cheap as possible, which in turn undermines any effort to discourage chronic, life-altering abuse.

Thus policymakers who don’t want so much chronic use and personal degradation have two options. They can set out to design a much more effective (but necessarily expensive, complex and sometimes punitive) system of regulation and enforcement than what exists so far. Or they can reach for the blunt instrument of recriminalization, which Lehman prefers for its simplicity — with medical exceptions still carved out and with the possibility that possession could remain legal and that only production and distribution be prohibited.

I expect legalization to advance much further before either of these alternatives builds significant support. But eventually the culture will recognize that under the banner of personal choice, we’re running a general experiment in exploitation — addicting our more vulnerable neighbors to myriad pleasant-seeming vices, handing our children over to the social media dopamine machine and spreading degradation wherever casinos spring up and weed shops flourish.

With that realization, and only with that realization, will the squares get the hearing they deserve.

Parents are not ready for the new reality of teen cannabis use →

The voice mail was waiting on Amy’s phone one morning in February 2019, a missed call from her 18-year-old son the night before. When Amy, a mom from Connecticut who is being identified by first name only to protect her family’s privacy, played the message, she heard the panicked voice of her child.

Mom, he said, my face won’t stop twitching. I feel like I’m going to die. I’m trapped in another dimension and I can’t get out.

Terrified, Amy called the campus police at the University of Delaware. They found him asleep in his dorm room. Just a panic attack, they told her.

But she knew better. When she spoke to her son William, who is being identified by his middle name to protect his privacy, he told her: “I’m sorry. I think I just smoked way too much pot.”

Her son — an incredibly bright boy, a rule-abiding kid, a doting big brother — had started experimenting with marijuana as a junior in high school, Amy says. He told her it helped with his social anxiety, which intensified when he went to college, where he started smoking marijuana nearly every day. But the voice mail was the first time William had ever exhibited psychotic symptoms. About two months later, he called again with the same plea for help: He was trapped in another dimension, afraid he was about to die.

“My husband was like, ‘This isn’t from pot, no way, pot wouldn’t do this,’” Amy says. “But I’d started researching cannabis-induced psychosis, and I was like, ‘This is what’s happening.’”

That sense of disbelief — pot wouldn’t do this — is prevalent among parents who have watched their teenagers become gripped by addiction. But the landscape of teen marijuana use has radically transformed in the decades since today’s parents were teens themselves, and many Gen X’ers and millennials might not be attuned to what that means. A typical joint smoked decades ago contained less than 4 percent THC, the psychoactive compound in marijuana that causes the sensation of a high. Dried cannabis flower now averages closer to 15 to 20 percent THC, while the high-potency products most popular with teens — including THC-concentrated oils, edibles, waxes and crystals — often contain anywhere from about 40 percent to upward of 95 percent THC, an astronomical increase in potency that can have a significant impact on a developing adolescent brain.

Meanwhile, the number of American teens using these products has soared in recent years. Research published in 2022 by Oregon Health & Science University found that adolescent cannabis abuse in the United States has increased by about 245 percent since 2000; a 2022 study by the Columbia University Mailman School of Public Health found that, in 2020, 35 percent of high school seniors and 44 percent of college students reported using marijuana within the past year. That study also found that vaping was increasing as the most popular method of cannabis use.

Even as more families find themselves navigating the complex new reality of teen cannabis use, an antiquated cultural perception of the drug persists: Marijuana is medicinal, it’s natural, it’s not dangerous.

That’s what Laura Stack thought when her then-14-year-old son, Johnny, told her that he’d tried marijuana at a friend’s party near their home in Colorado in 2014, the same year that marijuana dispensaries first opened in their state. “I said to myself, ‘It’s just weed,’” she says.

She remembers what she told her child at the time: “‘Thank you for telling the truth, but please don’t ever do that again; you’ll ruin your brilliant mind.’” Privately, though, she wasn’t very concerned. “I’d used it when I was in high school, so I said to myself, ‘I used it, I’m fine, it clearly didn’t hurt me,’” she says. “I didn’t have any urgency around it. I was just so ignorant.”

[Potent pot, vulnerable teens trigger concerns in first states to legalize marijuana]

Johnny was a gifted, well-adjusted kid, Stack says, an excellent student with a perfect SAT score in math and a scholarship to Colorado State University. But by the time he was a senior in high school, he’d started vaping and “dabbing” — inhaling high-concentrate THC oil — multiple times per day, and his life unraveled. He developed paranoia, which progressed to psychosis, and he cycled through different treatment programs and hospitalizations as his family frantically tried to help him find a way back to himself. He was ultimately diagnosed with cannabis use disorder and cannabis-induced psychosis; he never tested positive for any other drug. He was put on antipsychotic medication, which helped, until he stopped taking it. In November 2019, Johnny leaped to his death from the top of a parking garage.

Stack has shared her son’s story with high school students and their parents countless times as the founder of Johnny’s Ambassadors, a nonprofit organization that seeks to educate parents and teens about the danger of youth marijuana use. “When we do a parent night or a community event, and I ask a crowd: How many of you know what ‘dabbing’ is? You’ll get just a few hands. And then the ones who raise their hands will say ‘Oh, I thought you meant the dance move,’” she says. “These parents just don’t know. They are just as unaware as I was.”

As an addiction develops, parents often describe a common pattern of decline and disengagement, the distortion of a teenager’s sense of self and personality as they grow removed from things they once cared about. M., a parent in California who is being identified by his middle initial to protect his family’s privacy, watched this happen to his youngest child, S., who is also being identified by his middle initial. S. was a good-natured and affectionate son, his father says, a diligent student and a star athlete who was on track to get a scholarship to a top-tier school; he dreamed of someday going pro.

S. started experimenting with marijuana as a high school sophomore. “He knew his big brother smoked, he knew his big sister did,” M. says. “He was curious. And it’s everywhere. It’s legal, right? It’s natural, right? It’s not meth or heroin.” M. felt he had a handle on what his children were using: “I grew up in the marijuana scene and I smoked weed, I smoked a lot of weed.”

But his son’s product of choice wasn’t the same plant buds that M. once knew; S. gravitated toward cannabis vape cartridges, flavored oils that left no scent in the air, so his parents wouldn’t detect when he was smoking. As his use progressed, fueled in part by his distress over athletic injuries, his behavior began to deteriorate. He grew increasingly hostile when his parents expressed concern. Then, one night in February 2022, S. didn’t show up to a school event, and the police later called to say they’d found him wandering a nearby neighborhood, shirtless in near-freezing weather, consumed by paranoid delusions.

Over the months that followed, M. says, the family endured a succession of traumatic episodes that have left lasting scars: There was the day S. was first hospitalized, when he FaceTimed his older sister in tears and told her that their parents wanted to call the police to take him to the emergency room; M.’s daughter cried as she tried to calm her little brother down, telling him, you need help. There was the second time S. experienced psychotic symptoms, when M. says his son appeared “demonic,” explaining with calm, chilling certainty that his mother had been partially possessed by an evil spirit, and he needed to “kill off” that part of her. There was the time M. was driving his son home, and S. kept begging his father to change lanes repeatedly, because he was convinced that driving behind certain cars would stop his body from itching.

This kind of account represents an extreme outcome — many teens, including S.’s two older siblings, might use marijuana without experiencing anything so severe — but psychotic symptoms themselves are hardly a rarity among adolescents and teens who use marijuana, says Sharon Levy, director of the Adolescent Substance Use and Addiction Program at Boston Children’s Hospital and associate professor of pediatrics at Harvard Medical School.

“I see kids with psychotic symptoms all the time,” she says. “It doesn’t mean they all have psychotic disorders, but it is scary.” In 2018, her team published a letter in the medical journal JAMA Pediatrics after surveying more than 500 children during their annual physical exams. Seventy teens who indicated that they had used marijuana “monthly or more” within the past year were asked a follow-up question: Had they experienced a hallucination or paranoia? “These symptoms are really psychotic symptoms,” Levy says, “and 60 percent of these kids said yes, they had experienced one or both of those.”

The impact occurs on a spectrum, Levy says: There are children who might experience hallucinations, delusions or paranoia as an acute symptom that resolves as soon as they’re no longer under the influence. There are teens who experience lingering psychotic symptoms, but can identify them as such — like one of Levy’s recent patients, a teen girl who thought that household objects were talking to her but recognized that this could not be real. And then there are the children like S., who develop psychosis that persists, and who no longer recognize that they are dissociated from reality.

“That’s the most severe form, and that’s the form that happens least commonly,” Levy says, “but I think as you move to lesser degrees of this, it’s actually fairly common.”

Teens are more vulnerable than adults to the impact of THC, Levy says, because the compound affects parts of the brain — the hippocampus, the prefrontal cortex — that are still undergoing structural development during adolescence. THC mimics a class of chemicals that the body naturally produces, Levy says, chemicals that guide the development of neurons in an adolescent brain. “Brain development is a very, very complicated process that we don’t fully understand, but we do know which areas of the brain are really rich in these receptors,” she says. When THC binds to those sites, “it interferes, it messes with the system.”

The lasting impact of this interference has been well documented, Levy says. “We’ve known for a very, very long time that the children who use cannabis products during their adolescence have worse outcomes across the board: They’re less likely to finish school, they’re less likely to get married and start a family of their own, they don’t do as well in the workplace.”

Any psychoactive compound has the potential to be addictive, Levy says, and while it’s true that some people can drink alcohol or use marijuana without developing a substance use disorder, the age of the user and the potency of the product matters: “When it comes to addictive substances, dose matters, and how quickly a dose gets to a brain really matters,” she says. “These highly potent products are much more addictive.”

Recreational cannabis use is illegal for those under age 21 in the U.S., but some studies indicate that children can more easily access the drug in states where it has been legalized. Some parents note that their children first accessed the drug through older friends or siblings who had obtained a medical cannabis card when they turned 18.

“The dramatic rise in adolescent cannabis use in 2017 really does coincide with the wave of decriminalization in the country,” says Adrienne Hughes, lead author of the OHSU study and assistant professor of emergency medicine in the OHSU School of Medicine. Beyond rendering the drug more accessible, she says, legalization has also “contributed to the perception that it’s safe.”

Levy believes the problem isn’t legalization itself, but rather a lack of sufficient regulation (Vermont and Connecticut are the only states to limit the potency of cannabis concentrate products). In certain states, she says, “the industry is very involved in regulating itself … which means that more and more products are available, and there is more confusing messaging to the population.” The result, she says, is that “marijuana is becoming more accepted by parents and kids, and it’s also more dangerous.”

But even for children who have been diagnosed with cannabis-induced psychosis, Levy says, there is hope of recovery; if they stay sober, their brains have the potential to heal.

That is what M. and his family are fiercely hoping for. M. estimates that he’s spent well over $100,000 on hospital and ambulance bills and rehab to try to save his son, who was diagnosed with cannabis use disorder and cannabis-induced psychosis. S. has been in an inpatient recovery center in California for about two months, and he’s doing better, M. says, but he still has months of treatment ahead of him.

There are moments when M. can envision a future for his son again: Maybe S. will attend community college, when he’s ready. Maybe he’ll study a foreign language — S. has sometimes said he’d like to live overseas, to get away from marijuana. “I’ve accepted the fact that he may never play [sports] again,” M. says, “but I really hope he does, because it really anchors him. It centers him. But I don’t know what’s going to happen.”

The rest of the family is still recovering, too. “It’s all so traumatic. We all have PTSD, we all have guilt, we’re all in counseling,” M. says. “This is what this does to a family.”

Amy, the mother from Connecticut, said she watched her son “slowly unravel” during his college years as his marijuana use continued to accelerate, leading to a psychotic break in November 2021. For the next year, William was in and out of emergency rooms, psychiatric wards and treatment centers, she says, a time she describes as all-consuming darkness.

“I was talking to all these doctors all around the state and around the country, all these residential treatment centers,” Amy says. “My purpose in life was to keep him alive until we could get him treatment that stuck.” He was diagnosed with severe cannabis use disorder, and doctors told Amy that his psychotic symptoms could be due either to bipolar disorder or cannabis-induced psychosis — the only way to be certain, they said, was to see if the symptoms abated once he was sober for a prolonged period of time.

Finally, in October, Amy and her husband brought their now 22-year-old son to Florida, where he is receiving treatment at an inpatient rehabilitation facility. Amy and her husband are staying with relatives nearby; Amy promised her son she’d stay close, that she’d wait for him to get better.

“They say that for the brain to heal, it literally could take a full year,” she says. “His improvement is vast, but he has a long way to go still.”

In the three years since Johnny Stack died, Laura Stack has seen the demand for her presentations grow. There are now more than 10,000 parent ambassadors affiliated with her nonprofit, she says, and a support group for parents of teens with cannabis-induced psychosis has grown to more than 500 members. She has become adept at reciting the latest research and the most startling statistics. She has learned what to share and what to say to help steer young lives in a safer direction.

But when she reflects on her own story, there are still questions she isn’t sure how to answer. Would it have mattered if they hadn’t lived in a place where it was so easy for her son to access these products? “But it’s everywhere,” she says, “so it really doesn’t matter where you live.” Then she wavers: “I don’t know, though. I wish I had moved.” She is quiet for a moment. “What I know,” she says, “is I would have done anything.”

The legalized drug crisis is harming young people far more than most realize→

The data is in and it’s becoming increasingly clear that the impacts of commercial marijuana industry are even worse than we thought, particularly for America’s young people. A new report released by Smart Approaches to Marijuana shows the reality in "pot-legal states" paints a vastly different picture than the common sales pitch of the industry and supporters of legalization. 

The marijuana industry, which spent billions to lobby elected officials and bankroll legalization referendum campaigns, is following the playbook pioneered by Big Tobacco. They recognize that the road to big profits runs through the heaviest users. As such, they have increased potency of the drug by more than four times since 1998, hoping to hook kids while they are young and vulnerable. The numbers show that it’s working. 

Usage rates have reached record highs among those who are most vulnerable to marijuana’s long-term health effects. The National Institute on Drug Abuse warned, "Past-year, past-month, and daily marijuana use (use on 20 or more occasions in the past 30 days) reached the highest levels ever recorded" among those aged 19 to 30. The percentage of 8th, 10th and 12th graders who used marijuana daily has more than tripled between 1991 and 2020. 

Daily marijuana use is indicative of a marijuana use disorder, also known as addiction to marijuana. For all the talk about how pot is not addictive, in 2021, 1.3 million individuals between the ages of 12 and 17 had a marijuana use disorder, accounting for more than 46% of users in that age group. Legalization is also associated with a 25% increase in marijuana use disorder among them as well. 

Jeremy Baldwin tags young cannabis plants at a marijuana farm operated by Greenlight, Oct. 31, 2022, in Grandview, Mo. Voters in North Dakota and Arkansas have rejected measures to legalize marijuana, while those in Maryland have approved legalization. Similar measures also were on the ballot in Missouri and South Dakota. (AP Photo/Charlie Riedel, File)

As usage rates, potency and addiction have increased, the adverse effects have also increased. Though supporters of legalization like to downplay the risks of marijuana, the drug caused more than 70,000 individuals younger than 18 to have marijuana-related emergency department visits in 2021. 

The industry told parents and politicians that they would not target kids. That’s turned out to be false. From "Pot Tarts" to "Stoney Patch Kids," the packaging of edibles laced with high-potency THC often looks like traditional snacks. Not surprisingly, between 2017 and 2021, there was a 1,375% increase in at-home exposures to marijuana edibles involving children younger than 6.  

More minors are driving under the influence of marijuana too. In 2021, 10.67 million people admitted to driving under the influence of marijuana, including 1.36 million who were between the ages of 16 and 20. There were 2.41 times more minors on the road under the influence of marijuana than were under the influence of alcohol. 

Minors have also gravitated toward marijuana vapes, products engineered to include a near-pure form of THC. Between 2017 and 2020, the percentage of 12th graders who vaped marijuana increased from 9.5% to 22.1%. Among 10th graders, it increased from 8.1% to 19.1%, and among 8th graders, it increased from 3.0% to 8.1%. A 2022 study found, "cannabis vaping is increasing as the most popular method of cannabis delivery among adolescents in the United States." and frequent use is increasing faster than occasional use. 

The marketing scheme of the industry has been to engineer a more potent drug, in forms easier to consume and while stoking the perception that it’s harmless. In 1991, 78.6% of 12th graders believed that using marijuana regularly puts one’s health at great risk. But in 2021, only 21.6% held this viewpoint. Those who hold that point of view are six times more likely to use it than individuals who perceive it as being high risk. 

By 2021 nearly seven in 10 12th graders seemingly approve of marijuana use. 

We all want the best future for our children. Yet, the growth of the pot industry has provided kids with greater access to a drug that medical science links to psychosis, depression, suicidality, and lower IQ at a time when the brain is still developing. Regular users are nearly five times more likely to develop a psychotic disorder and users of high-potency marijuana are four times more likely than users of low-potency products to become addicted. 

More young people are becoming addicted to marijuana, and it is sending more of them to the hospital. More of them are using a more potent form of the drug. It is past time for our nation to reverse course and advance drug policies that protect our children, rather than allow them to be collateral damage for another Big Tobacco.