How big a problem is heavy cannabis use?

Annie Lowrey has a well-thought-out piece about cannabis use disorder in The Atlantic. In my view, this is the most under-covered topic in the debate about whether – and, more importantly how – legalize cannabis.  I’m especially grateful to Lowrey for making me sound coherent; that doesn’t always happen.
Unfortunately, the editor who added the headline and subhead to the story misstated matters fairly significantly. (This happens so often that I now insist on having a voice in the headlines that run over my essays.)

Here’s that text:
America’s Invisible Pot Addicts
More and more Americans are reporting near-constant cannabis use, as legalization forges ahead.
That’s fine clickbait, but it’s not really accurate.
While one of the people described in the story was in fact a near-constant user, the surveys from which the numbers in the story come don’t actually ask about that.  The key question on the surveys is “On how many days last month did you consume cannabis?” The genuinely scary fact is that, among those who report any use in the last month, the fraction reporting 25 or more days – “daily/near-daily” or “DND” use – has gone from 9% a quarter-century ago to about 35% today. (I was inadvertently the source of an error; the number I recalled from my conversations with Jonathan Caulkins and Steven Davenport, and cited to Lowrey, was 40%.)
Someone who takes a single puff of cannabis at bedtime every evening is a daily/near-daily user, but it’s a stretch to call that “near-constant use,” just as it would be a stretch to call someone who has a glass of wine at dinner every day as a “near-constant drinker.”  Now, in fact low-dose use isn’t the most common pattern among DND users; on average, they consume about three times as much per use-day as do less-frequent users. Some of them are, no doubt, “near-constant users” in the sense that they spend most of their waking hours under the influence, but we don’t have an actual estimate of how common that extreme behavior is, or how much it has grown.
What we do know is that only about half of self-reported DND users meet the diagnostic criteria for what is now called “cannabis use disorder” (again, according to their survey answers).  That’s about 4 million people self-reporting a cannabis problem at any time.
But if “addiction” is defined as the chronic, relapsing form of substance use disorder, that’s the rarest form of the disease. Of a population of people with substance use disorder today, only about a third will still meet diagnostic criteria two years from now, and very few of the two-thirds who have “recovered” will have had any formal treatment, even including Twelve-Step participation. There are certainly people with chronic, relapsing cannabis problems, and Lowrey deserves credit for challenging the mythology created by legalization advocates and cannabis marketers that the drug is “non-addictive.” It’s possible that legal availability will make cannabis use disorder more chronic on average by decreasing cost and stigma and increasing ease of access.  But most of the people with cannabis use disorder don’t have, and never will have, “addiction.”
In addition, not all addictions are equally problematic. Again, there’s not good science on this, but it seems very unlikely that the typical person with a cannabis addiction suffers nearly as much as the typical person addicted to the opioids, or for that matter to alcohol. Certainly the acute death toll is much, much smaller: too small to be a real policy concern. The chronic-disease risks aren’t well measured, but cannabis use isn’t associated with liver problems the way alcohol is or with infectious disease the way injected opioids are, and even the cardio-vascular risks are probably modest and will certainly diminish as the market transitions from smoking to vaping.
I’ve been outspoken about my view that legal cannabis is a potential threat to public health, and that legalization advocates and the industry continue to understate that threat. (The best argument for legalizing the drug isn’t that it’s harmless, but that the growing illicit market and diminishing public support for cannabis prohibition specifically and for mass arrest and incarceration more broadly have brought us to the point where continued prohibition isn’t a practical option, and that the public-health consequences of patchwork state-by-state legalization might well be worse than the consequences of a well-designed national legalization.)
Still, having lived through “Your Brain on Drugs” and “Just Say No,” I’m equally aware that risks can be over-hyped as easily as they can be under-played. In drug policy as in drug consumption, moderation is both essential and hard to maintain.

Author: Mark Kleiman

Professor of Public Policy at the NYU Marron Institute for Urban Management and editor of the Journal of Drug Policy Analysis. Teaches about the methods of policy analysis about drug abuse control and crime control policy, working out the implications of two principles: that swift and certain sanctions don't have to be severe to be effective, and that well-designed threats usually don't have to be carried out. Books: Drugs and Drug Policy: What Everyone Needs to Know (with Jonathan Caulkins and Angela Hawken) When Brute Force Fails: How to Have Less Crime and Less Punishment (Princeton, 2009; named one of the "books of the year" by The Economist Against Excess: Drug Policy for Results (Basic, 1993) Marijuana: Costs of Abuse, Costs of Control (Greenwood, 1989) UCLA Homepage Curriculum Vitae Contact: Markarkleiman-at-gmail.com

9 thoughts on “How big a problem is heavy cannabis use?”

  1. The way things are going these days, we are liable to learn that Ms. Lowrey is an alcoholic, or even a marijuana addict herself.

  2. Idle curiosity…which things are going that way that would make you expect those sorts of revelations?

  3. " the debate about whether – and, more importantly how – [to] legalize cannabis. "

    Of course, there never was a debate to make it illegal in the first place. It was done underhandedly, with the aim of disrupting liberal opposition to Nixon's policies. And then the Republicans learned that it could be their most effective voter suppression tactic, as millions of blacks and Latinos have officially or effectively lost their voting rights. Forever, as of now.

    No doubt there will be some people who have overuse or dependency problems with it, although I find it hard to believe that legalization has made any difference whatsoever in availability. The statistical increase reported in the article may simply be that respondents are answering the question more honestly now.

    But there should not be now – and never should have been – a debate about *whether* pot, or other abusable drugs, should be legalized. We will never end alcoholism, but at least we no longer have alcoholism plus Al Capone machine gun violence. With today's issue of gun violence in an America with a 2nd Amendment which has never been stronger in our nation's entire history, could there be any more effective way of reducing the carnage than to eliminate the narco economy?

    1. Are you really unaware that cannabis was criminalized thirty years before Nixon took office?
      Of course "we will never end alcoholism." So what? Reasonable alcohol policies to keep prices up and marketing down, and to compel problem drinkers who make their drinking a problem for others by drunken driving or drunken assault to stop drinking could massively reduce the death toll alcohol exacts from drinkers and their victims: about 88,000 deaths a year, per the CDC. See Philip J. Cook, *Paying the Tab*.

      1. The modern left is leaving us behind Prof. Or maybe I am wrong and it was always like this, but I really doubt it. The average person on my campus thinks that the white supremacists are more numerous and powerful now than they were 40 years ago, that all of the black men in prison are there for smoking weed, and that the feds killed MLK in service of the private prison industry. People are wearing shirts that say "Palestine is a queer / feminism issue" which is a perfectly defensible position, except that they mean it in reverse. Compared to the stuff I am seeing now, "Nixon criminalized weed" doesn't even move the dial. Meanwhile, the "party of sober christian realists" is closing ranks behind the orange troll. It can't always have been like this, something is happening. There is some sort of cultural black hole sucking all of the gravitas and political virtue out of the republic.

          1. What I need is to get out of California. If you want to believe that I am misrepresenting California campus political culture that is your right, but you don't get to exercise that right while being right.

        1. The older I get, the more I think that the "gravitas and political virtue" of the Republic was always more illusion than substance. Reality-based thinking has always had to play a futile game of catch-up with extraordinary(1) popular delusion and crowd madness.

          (1)Popular delusion is in fact perfectly ordinary, and seems otherwise only to the minority who write and read books of the sort that honestly attempt to distinguish facts from opinions.

      2. To be fair, the process that led to the 1937 Tax Act was not exactly a model of disinterested reality-based weighing of pros and cons. And also, the placement of cannabis in Schedule I of the CSA (at a time when the ridiculousness of the 1937 testimony was being looked at for the first time in over 30 years) was explicitly supposed to be an interim measure, until sufficient facts could be gathered to justify a permanent decision. Also also, it is a fact Nixon's refusal to consider the findings of his own commission on what to do about pot that led to the "interim" measure becoming permanent.

        Commentor has details wrong, but has a better grasp of how things actually went than most advocates of continued prohibition. If only there were someone who had some ideas about what "reasonable cannabis policies" would look like.

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