“Human beings have a strong dramatic instinct toward binary thinking, a basic urge to divide things into two distinct groups, with nothing but an empty gap in between. We love to dichotomize. Good versus bad. Heroes versus villains. My country versus the rest. Dividing the world into two distinct sides is simple and intuitive, and also dramatic because it implies conflict, and we do it without thinking, all the time.” ― Hans Rosling
People really do tend to see things all one way or all another way. In psychology, this is also known as splitting – a defensive mechanism in which we tend to see things in all or nothing terms, often in contradictory ways. This includes how we conceptualize substance use and addiction. It has huge policy implications in the realm of drug policy. We adopt strategies that move us in different directions for different communities, sometimes at the same time. We flip between patterns of more permissive use and then back to punitive approaches. We view addiction as entirely related to trauma and social or economic disparities, or simply a result of bad decisions made by people making a conscious decision to purse self-destructive choices. Yet, we know that substance use, and addiction is a far more complex topic with a broad range of variables.
Substance use leading to addiction has complex psychosocial and genetic facets and occurs across all socioeconomic classes. Kids decide to use drugs with brains not able to make fully formed decisions for a variety of reasons, including trauma and even simple experimentation. Kids who experiment and have the wrong genetic loading can rapidly become addicted. Some people can use with little consequence, others can experience problems, and some become addicted, and use leads to death. Use rests on a continuum with a myriad of variables. No simple answers here.
We have no panacea to addiction, yet we want single focus solutions for an incredibly complex condition that defies easy resolution across that continuum of use and risk of consequence. This is perhaps the truest in respect to cannabis, which is portrayed as either a panacea or the devils lettuce depending on the era and who you ask.
Oversimplifying of Cannabis policy has huge consequences. Historically, we created moral panic, and these efforts backfired. Consider the 1936 movie Refer Madness, an anti-drug propaganda film intended to scare the hell out of kids so that they would never use. The film depicts kids lured into using cannabis, rapidly turned into depraved lunatics who engaged in rape, murder and suicide. Like many white kids in my era, I used to watch the movie as entertainment while getting high. I saw the overstatement of risk as cause to discount any and all such claims by adults. Drug experimentation for many white kids in my era was something of a right of passage with little consequence. But we also put in place mandatory sentencing guidelines applied in a disparate fashion. We locked up our black and brown brothers and sisters and caused intergenerational consequences that remain daunting to overcome in these communities.
We see these same dynamics work in the other direction. Cannabis as a cure all. It has recently been touted as a treatment for PTSD, although the research does not support this, and even suggests it to potentially harm PTSD healing efforts. Cannabis is being falsely claimed as a cure for cancer. We even moved to use cannabis as a treatment for opioid use disorder in a few states, including in my home state of Pennsylvania despite the lack of evidence for its use even in this way and with growing evidence that such polices have fueled addiction.
Overstate the benefits and understate the risks, it is age old play book used by the makers of addictive drugs. For companies and cartels alike selling drugs, these strategies make sense. Exploit every opportunity to sell your drug and make money. In contrast, prohibitionists overstate the risks to create fear and that fear is used to target marginalized communities for increased sanctions. The consequences of binary thinking. We need a more balanced approach. We need to address the risks, reduce addiction, and get people help without resorting to punitive measures or simply locking people up. A nuanced approach, not a binary “all one thing or the other” policy applied in a disparate fashion.
The current administration had moved to pardon the 6,500 people who have been incarcerated for simple possession of marijuana. It was a mark on their record for life. It was the right thing to do. We have learned through the opioid epidemic that the war on drugs is a war on American families. We saw this when addiction started impacting white rural America, and it makes sense to change our polices in ways that support all families, not just white ones. We need to work to undo harms like this even as we work to protect the next generation from developing substance use problems.
One of the truths is that there is a significant increase in societal harms as a result of more permissive, high potency cannabis. In the same breath, it is a drug that many people can use in moderation without significant consequences. We are seeing this even as we come to terms on how drug war polices around cannabis have harmed entre communities.
Consider that there is a growing association between heavy cannabis use and being a victim or perpetrator of intimate partner violence. We are seeing a one in five increase in the odds of hospitalization among recreational cannabis users and even deaths from cannabinoid hyperemesis syndrome (CHS), aka scromiting among other growing risks. Which brings me back to the title of this article. How do we address, or even talk about these things rationally and find the right balance to address harms yet not move back to blanket prohibitions and overly punitive strategies applied disparately?
One of the models that gets held up is the Portugal model. Portugal is a European nation of 10 million people that has moved to address addiction as a public health issue. Drug use has been decriminalized, yet drugs are still confiscated, and possession may result in administrative penalties such as fines or community service. Having larger amounts of drugs can and does lead to incarceration, with one factor in the sentencing consideration being if people are selling the drugs to support their own use. Mandatory help can be required for drug users as evaluated by the local Commission for Dissuasion of Drug Addiction, which can fine or even take people’s property when they continue using drugs harmfully. Unlike the United States, where a handful of people who need help can access treatment often after long waiting periods, treatment is available on demand in Portugal. Most stories of what Portugal has done lack these details on measures of control and highlight the decriminalization elements. Our oversimplified view of Portugal is problamatic.
Here in America, we face dynamics of commercialization of drugs that is not present to the same degree as in European nations like Portugal. We only need to look as far as the opioid epidemic, fueled by bogus research like the infamous pseudo-addiction study led by Purdue Pharma Vice President of Health Policy Dr David Haddox and marketing strategies that took advantage of concepts like pain is the fifth vital sign to expand drug sales. They even weaponized stigma and blamed people who became addicted in order to bank their massive profits off the suffering of American families. These are patterns in our own history to pay attention to at this juncture as we consider cannabis use policy.
In a world that sees things in binary terms, we need nuanced policy around cannabis use, cannabis control, cannabis treatment and cannabis recovery strategies. Cannabis is not harmless, it is not a panacea for a myriad of ailments, but nor is it a drug that turns people into depraved lunatics, although we are seeing increased levels of psychosis for heavy users of high potency strains. We need policies that keep cannabis out of the hands of kids who are at greater risk to become addicted to it, strategies to reduce risks of it being a factor in cannabis related highway deaths and awareness in our communities that this is a drug that is not without significant risks to our society.
The danger of saying these things or suggesting rational policy is to risk getting marked as a prohibitionist. This is also a strategy fueled by big cannabis and other addictive drug merchants to dissuade policy development that reduce sales. Heavy users are their best customers. The dynamic in industries working in the addictive drug space is to maximize and capitalize profits while hiding and socializing the consequences. We end up blaming those who get addicted as a result.
So, what should we do? A partial list of areas of focus for nuanced, non-binary thinking policy development:
- Addressing problematic use from a medical lens rather than a criminal justice lens across all communities
- Restricting access and marketing of cannabis to young people as they are more vulnerable to addiction
- Truth in marketing about the risks of cannabis use across our society
- Objective research on risks of cannabis for people in recovery from other substance use disorders
- Objective, longitudinal studies on the long-term consequences of more potent cannabis that is present today
If we want something different, we need to do things differently. Over the course of American history, we have tended to flip into overly punitive drug use policies in response to substance use related consequences as harms become more prevalent. Our capacity to have nuanced policies are made more challenging as a result of industry related influence on how we think about, and address substance use in our society.
We face of growing evidence that we are under emphasizing the consequences of more potent and accessible forms of cannabis. Unless we address these developments, we will flip once again into a “lock them up” mentality in respect to persons who find themselves experiencing consequences. Particularly in marginalized communities. If we are to avoid that, we need to figure out ways to shift away from binary thinking in respect to drug policy and develop far more nuanced solutions accepted across the political spectrum of thought, and even greater challenge in our polarized era.
Substance use and addiction are highly complex issues requiring a wide range of responses. Are we capable of doing something different than what we have in the past? The only way to know is to try. Good things have always been hard.