Sizing up the risks associated with a commercial marijuana industry
Real talk from Hazelden Betty Ford Foundation youth psychiatrist and addiction expert Dr. Sara Polley
NOTE: This Q&A, facilitated by Jeremiah Gardner of the Hazelden Betty Ford Foundation, was originally published for Hazelden Betty Ford’s monthly Recovery Advocacy Update. If you’d like to receive our advocacy emails, subscribe today.
Over the past couple of decades, people and organizations in favor of legalizing and commercializing cannabis have been successful in getting more Americans comfortable with that agenda — so successful that many people, according to surveys, now believe it’s a harmless drug, or even a healthy one with few to no risks. That’s unfortunate because there are real risks for people — especially young people — vulnerable to addiction. And there are real risks to creating a profit-driven industry that will work every day to downplay potential harms and increase sales (see tobacco, alcohol, opioids). Sara Polley, MD, is a triple-board certified physician and psychiatrist and the medical director at the Hazelden Betty Ford Foundation’s national substance use and mental health treatment center for adolescents and young adults in Plymouth, Minn. Dr. Polley recently submitted a statement and video to legislators who are considering proposals to dramatically expand access to cannabis in Minnesota, and shares more of her thoughts here.
What do you see in your medical practice that the public should know, and that might be surprising to the average person?
I want people to know, and I’m not being dramatic, that we see patients every day who have had their lives destroyed due to marijuana use. It’s true many people use marijuana occasionally and have no problems, something more likely for people who don’t have a family history of addiction, haven’t experienced concerns with other substances, have limited mental health concerns and trauma, and didn’t begin using until they were an adult. But for others, especially those who have some of the risk factors, marijuana use can lead to problems and significant suffering. Contrary to what many people think, marijuana is addictive and can negatively affect our body, brain, relationships and functioning.
All substances and behaviors to which [eople can become addicted do one basic thing in the brain: they increase dopamine. Dopamine is a neurotransmitter that makes us feel good. When we use substances or engage in a behavior repetitively, our brains start to rely on the extra dopamine. The structure and function of our brain changes as a result. Your brain doesn’t care how the extra dopamine got there; it could be from marijuana, gambling, opioids or something else. And, it is these changes in the brain that lead to the changes in behavior that we see when someone has an addiction, or substance use disorder (as it is clinically known).
How have changing perceptions impacted addiction treatment and the ability of professionals and parents to help young people understand the risks of cannabis use and when it is hurting them?
Many young people and their families have mentally moved marijuana into a category of substances they view as being low risk, with a low potential for harm. As a result, we frequently see youth who feel their parents don’t care that they use marijuana so long as they keep up with school and other tasks. We also have patients who commit to stopping other substances, like alcohol or opioids, while indicating plans to continue marijuana use due to feelings that it isn’t contributing to the overall problem.
Unfortunately, marijuana use in my patient population is nearly always causing harm. It can be hard to help patients see this at times due to the culture surrounding marijuana use and the belief that it is natural, harmless, and even a treatment for mental illness. As a result, we rely a lot on therapy techniques like motivational interviewing to help our patients develop a willingness to hear scientific information about the impacts of marijuana on their brain and body and to see how marijuana use is contributing to their situation.
What are the important messages you share about cannabis use that seem to resonate most with young people?
My main message is that, while the risk of harm may be relatively low for older adults who use marijuana occasionally, this is not the case for young people. Marijuana impacts the brains of those under the age of 25 differently. The young brain, and specifically the prefrontal cortex, is still developing until that age. And when the brain is still under construction, it is more vulnerable to being changed and even permanently altered by toxins and stress. Using substances, including marijuana, can cause lasting brain damage when it happens during this sensitive period.
We see an increased risk of developing psychosis and schizophrenia along with worsened and more chronic mental illnesses such as anxiety and depression, which become even more difficult to treat. We see a decrease in intelligence and the ability to concentrate, make decisions, control impulses, and regulate emotions. Lastly, there is an increased risk of developing a severe, chronic addiction — if not in the near term, later in adulthood. These are all possible effects of changes to the brain structure and function of a young person who uses marijuana.
I work with youth and young adults who struggle with legitimate brain injury due to their marijuana use. Some have enough protections, such as a strong intellect or a very healthy environment, to counteract these changes so that we see minimal impact. Others end up needing supports similar to those we offer individuals with post-concussion syndromes, learning disorders, and ADHD. Each one of us has a different sensitivity to the impacts of marijuana. For some, damage will only occur with heavy smoking or use of highly concentrated products. For others, it can happen with less exposure and can be unpredictable.
These days, information presented in opposition to legalization and commercialization, or questioning it, is sometimes disregarded as a War on Drugs trope. But you’re no fan of criminalizing addiction, and you’re also hesitant to fully support legalization and commercialization. What’s the alternative?
I very strongly support efforts to decriminalize marijuana use. I believe it is a fact that criminalization of personal use and possession of small amounts of marijuana was intended as a means to arrest and prosecute people of color. I see this history and its legacy effects play out in my clinical practice every day. The most disadvantaged of my patients are also the ones most likely to have legal charges related to marijuana use. This adds to the trauma they experience and makes it even harder for them to break the cycle of addiction, repression, and injustice.
Decriminalization is not the same as legalization, however. It’s one thing to make sure we don’t incarcerate people for using marijuana and saddle them with legal records. It’s another thing to greenlight a new commercial industry that will be driven by the profit motive and therefore incentivized to get more people to use marijuana and existing users to use more.
I would love to believe in some of the early promises of legalization, but as a medical professional, I follow the research. Now that we have some good data coming out of states that legalized marijuana years ago, it appears the evidence of positive impacts is slim. For example, we are actually seeing an increase in illicit sales of marijuana in states where the drug is legal; that’s likely because interest in the product is increased, and the illegal market can move more quickly and offer more convenient and cheaper products to undercut the legal market. Another concern is that, over time, we see a loss of money in communities where marijuana is legal because of the costs of negative public health effects. And, as you might suspect given my job, most worrisome to me is the research that shows legalizing and commercializing marijuana leads to increased use among youth, even those who are too young to purchase it. That last impact should not be surprising. We see the same with alcohol, which is the most commonly used substance among youth and the one that causes the most harm. We only compound that problem by making marijuana more accessible and socially acceptable, too. In states where marijuana is legal, more homes have products accessible, and use of them is normalized. More kids are using marijuana as a result, sometimes accidentally and sometimes intentionally, and we see more negative outcomes.
You’ve begun experimenting with your own social media posts as a way to reach more people with balanced information about cannabis use and its risks. What sort of responses have you received?
I felt really motivated to start making content on social media after watching other doctors bring awareness to their areas of medicine using platforms like Instagram and TikTok. I watched dermatologists speak about the risks of skin cancer, and an endocrinologist speak about weight management. I thought that my little area of the medical field — adolescent substance use and addiction — could really use more voices, especially because so many young people turn to social media for connection and information. I’ve barely just begun, but I intend to do more, and my goal is to provide easy-to-understand facts about how marijuana impacts the brain and body, and to add visibility to my area of medicine.
Responses seem to be on two opposite ends of the spectrum. I think because there is such a large amount of misinformation and even disinformation surrounding marijuana, I get responses from individuals who subscribe to conspiracy theories about the government or medical science being biased and untrustworthy. For example, I had a response which indicated that none of the scientific literature we currently have about how marijuana impacts the brain can be trusted because it was funded by government grants. I also get responses from young people who seem to reflect on the message and make statements about how they would like to not use marijuana or cut down. I also see messages from members of the recovery community who point out how differently they view their use of marijuana now compared to when they were in active addiction.
What are your top concerns about the potential of legalizing and commercializing cannabis more widely in your home state of Minnesota and elsewhere? What details should policymakers and the public be paying attention to?
I am concerned we are setting our communities up for a public health crisis by increasing the prevalence, normalization and accessibility of marijuana. We seem to be headed straight toward repeating the mistakes that we’ve made in the past with other addictive substances including tobacco and nicotine, alcohol, and even prescription opioids.
For example, we didn’t fully know how harmful tobacco was to health when it began to be sold to the public. And when more evidence did begin to emerge, it was intentionally downplayed, even concealed. With tobacco sales, we allowed the manufacturers, distributors and associated businesses — those who stood to make a lot of money from the product —to create the laws governing marketing, sales and safety. This is exactly what is currently happening in places where marijuana legislation is under consideration. In Minnesota, I have been working to help make sure other voices, like those of medical professionals, are added to the discussion in hopes that we can — at a minimum — put in place guardrails to protect public health.
Tobacco companies understood they would have the most customers if they could make their products seem low risk, fun, normal and even beneficial. They also intentionally targeted marketing to young people, knowing that if people could become psychologically and physically dependent on their products early on, they stood to make a lot of money over the lifetime. I believe we are watching some of the same things, and can expect even more, from those who stand to benefit from marijuana commercialization.
For years, deep-pocketed tobacco companies lobbied against laws that would protect people and be clear about the risks associated with their products. They ignored or obfuscated growing scientific evidence about the negative health impacts of nicotine and how highly addictive it was. As a result, it took far too many years — and cost far too many lives — for public opinion to shift. Today, of course, most people know tobacco use is not healthy, that nicotine in tobacco products is addictive, and that it is not cool or fun to use tobacco products.
Whether you are for or against commercial marijuana, I think we should all acknowledge the risks and — at a minimum — work to keep people safe by asking legislators for strong guardrails to limit the negative impact on public health. For example, we should be looking at limitations on the types of products available, parameters surrounding marketing, rules about where people can use marijuana, and constraints on how potent marijuana products can be. We have the opportunity to learn from mistakes of the past and do better, and I hope that we will for the sake of our communities, public health and our young people.
