A little harmless pot


I understand addiction.  After “retiring” from a 35 year career in emergency medicine several years ago, it was only a few months before I was back picking up random shifts with my old group.  I don’t know if the best term for my behavior was relapse or recidivism. The point is I know what it is to want to “get that feeling back.”  Even though I was frequently exhausted walking out of the ER after a long night shift, there was a deep sense of well being that would come over me.  It was a feeling I didn’t get from many other activities.

That’s why I was intrigued when I was approached a few years ago to think about changing gears and working with opioid addicted patients.  I had seen the illnesses, the injuries and the social devastation caused by the opioid epidemic for all those years.  But it all seemed to whiz by me so fast that I didn’t have time to really get at, much less understand, its cause.


When I finally got into it, I came to recognize two fundamental truisms.  First, they were the same patients I had been treating for the last several decades.  Second, they all had the same desires and hurdles that I did.  In other words, we were all addicted to something in some way.  Something gave us that “feeling” of well being.  Whatever its origin, the final mediator of that great feeling of well being was dopamine bathing the frontal cortex.  And once you got it, you wanted to keep it as long as you could. The big difference was that these patients got that feeling of well being from something that was destroying them, their families and their communities.

What does that have to do with “a little harmless pot?”  My OUD patients are not addicted to pot.  They have much bigger fish to fry.  But about every other patient I see has a urine drug screen that is positive for THC.  It’s called a “dirty urine” in street vernacular.   For many of them, a joint is seen as no more harmful than the evening cocktail that I enjoy almost every night.  “It helps me sleep,” many say.  And then they wait cautiously for my response.

I want them to trust me.  I don’t want to be seen as a naive prude who can’t relate to their lives.  I want them to stay focused on the job of recovery from opiates.  Some will tell me that it helps them with their anxiety.  And since I really don’t want them taking benzodiazepines and opioids I just shrug and let them know that basically I’m not going to get excited about it.  I want my reaction to be nonjudgmental, but I really do have opinions about the safety of marijuana use.


The first concern — and one that has been voiced many times over the years — is that marijuana is a “gateway drug.”  This always made intuitive sense to me, even if I didn’t have statistics to prove it.  Now, I’m hearing patient after patient tell me that their opioid use started with marijuana.  During a recent intake interview I asked, “How did you start taking opiates?  Were they prescribed to you or did your opioid use start recreationally?”

One thing did surprise me. Due to a naive sense of denial, I used to think that most opioid users did not start with prescription opioids. Or if they did start with prescription drugs, it was someone else’s prescription that they got a hold of for recreational use.  I’m disappointed to report that my belief in the integrity of the medical system was misplaced.  Over 80% of my patients report that their addiction started with a real injury or surgery that was followed by prescribed opioids for pain relief.  Some will admit that they got more than just pain relief and that was what hooked them.  But they wouldn’t have taken the opioid without a doctor’s prescription in the first place.  And what’s worse, when their doctor realized that their patient was addicted, they simply cut them off or punted them over to pain specialists whose hands were largely tied at that point.

Returning to the intake questions, my patient detailed deep dive into heroin that seemed to come out of nowhere.  But when I questioned him further, he responded that “of course” this was all preceded by a long history of marijuana and then cocaine use.  This doesn’t prove anything except that it is common knowledge among OUD patients that marijuana is how they got started.  They just don’t want to throw away this crutch.

My next warning is about the use of marijuana in a household containing children. Colorado has seen a fivefold increase in pediatric marijuana poisoning in recent years.  My real concern, however, is the emergence of marijuana paranoia or marijuana psychosis that has been noted on the rise in Colorado.  I’ve even read reports of increases in violent behavior that stemmed from the marijuana using patient believing that they were at risk from the person that they were attacking.


How does this happen?  I’m no neurologist or psychiatrist, but I have some ideas that I would like to throw out for discussion.  It has to do with “reality testing.”  Generally speaking, if a person thinks something is real that is not true, we conclude that they are failing at reality testing.  My psychiatrist mentor used to tell the story of the schizophrenic going down the road who started to hit the green lights with perfect timing.  At the first light he was delighted.  At the second, he was beginning to think that someone was changing the lights to please him.  And by the third light, he was convinced he was the king and the lights were being changed by the central government.

Normal thinking people encounter thousands of mental inputs each day that must be interpreted by the inhibitory and modulating effect of thoughts and experiences contained in other areas of our brain.  It is this analysis that allows us to determine what is “real.”  What if the neurons connecting the parts of the brain doing this analysis are impaired or destroyed?  In some situations one might feel that all is well, when it is not.  One might also conclude that he or she is in danger because the inhibitory thought is suppressed.  I’ve asked some of my patients who actually enjoy using marijuana daily if they have ever seen this effect.  And even those who enjoy daily use will admit that they have seen paranoia in others.

When I bring this up with my friends who want to promote recreational and medicinal marijuana we often times slide into a needlessly antagonistic discussion.  They remind me of the dangers of alcohol abuse.  And they are absolutely correct.  We warn people of the dangers of alcohol abuse.  We punish those who abuse the privilege and step over the line to the detriment of others.  Can’t we do the same with recreational use of cannabis?  Probably so.  But I wonder if, like my opioid dependent patients who don’t want to give up their nightly joint, we want this to be more benign than evidence suggests.

I was fooled once about the potential for harm in prescription pain relievers.  A decade from now I would hate to see the medical community look back and say that they were fooled into complacency a second time.


FOUNDER/EXECUTIVE EDITOR Dr. Plaster has been an emergency physician for more than 30 years, working exclusively night shifts for the past 20 years in emergency departments across the country. During that period, he joined the U.S. Navy and served two tours in Iraq. Dr. Plaster is the founder and executive editor of Emergency Physicians Monthly and the founder of Plaster Publishing.


  1. Ian Mitchell on

    The gateway theory is pseudoscience that originated in stigma and ignorance. This piece of dogma originated in the 1950’s under Harry Anslinger, a racist hate-monger who is responsible for much of the stigma and reefer madness of the 20th century. Anslinger was not originally a believer in the gateway theory, preferring to focus on spreading propaganda such as marijuana causing Mexicans to become violently insane and that marijuana encouraged black men to want to have sex with white women.1
    “The primary reason to outlaw marijuana is its effect on the degenerate races.” – Harry Anslinger
    “There are 100,000 total marijuana smokers in the US, and most are Negroes, Hispanics, Filipinos and entertainers. Their Satanic music, jazz and swing, result from marijuana usage. This marijuana causes white women to seek sexual relations with Negroes, entertainers and any others.” – Harry Anslinger
    Anslinger was also a proponent of the word “marijuana” or “marihuana”, a linguistic switch to appeal to xenophobia. Americans were more familiar with the word “cannabis”, as grown by Eli Lilly on its farms and sold to physicians like Sir William Osler.
    The gateway theory later became a useful tool for drug warriors and has persisted in the law enforcement community despite being scientifically discredited.2 (Notably, AG Jeff Sessions, a man who believed the Ku Klux Klan weren’t too bad until he found out they used cannabis, repeated this outdated claim in 2018.)

    “Bottom Line…The argument that wider access to marijuana could be fueling the opioid crisis has not been supported by science, and in fact a growing number of voices have been recently casting marijuana as more of a potential solution than a problem.”3

    Physicians are now finding it more difficult to continue with expressing this outdated idea. In the lead up to the legalization of cannabis in Canada, the president of the Ontario Medical Association was forced to apologize after bringing up the gateway theory in an interview.4

    “I apologize. I misspoke. Recreational cannabis is NOT a gateway drug. I thank my colleagues for correcting me. Decriminalization & harm reduction create safer, healthier communities. Illness should be treated without stigma…Making mistakes is human, but as soon as you make a mistake you have to correct it no matter your position. Whether you’re the president of the Ontario Medical Association or a small-town doc.” – Dr. Nadia Alam4


    Lastly, while “dirty urine” may be street vernacular, so is “crackhead”, but both are laden with stigma; the only appropriate use of these in an article would be to explain how these terms are no longer acceptable in clinical use.
    ‘reducing stigma is vital for enhancing public health. One inexpensive way we could begin to do this would be to remove the terms “abuse” and “abuser,” “dirty” and “clean” from our vocabulary and commit to a medically appropriate lexicon that conveys the same dignity and respect we offer to other patients. We should stop talking dirty.’5
    1. Sullum J. Bill Bennett’s Marijuana Gateway Theory (And Harry Anslinger’s). Forbes. https://www.forbes.com/sites/jacobsullum/2015/02/10/bill-bennetts-marijuana-gateway-theory-and-harry-anslingers/. Accessed May 11, 2019.
    2. Marijuana as a Gateway Drug: The Myth That Will Not Die | TIME.com. http://healthland.time.com/2010/10/29/marijuna-as-a-gateway-drug-the-myth-that-will-not-die/. Accessed May 11, 2019.
    3. Enos G. Marijuana as gateway to opioid use has scant support, but notion persists. Alcohol Drug Abuse Wkly. 2017;29(10):1-7. doi:10.1002/adaw.30873
    4. Oct 08 MA· CN· P, October 8 2018 4:00 AM ET | Last Updated:, 2018. Dr. Nadia Alam’s apology raises questions about the medical community’s stance on marijuana | CBC News. CBC. https://www.cbc.ca/news/canada/toronto/medical-community-marijuana-divide-1.4853639. Published October 8, 2018. Accessed May 11, 2019.
    5. Kelly JF, Wakeman SE, Saitz R. Stop Talking ‘Dirty’: Clinicians, Language, and Quality of Care for the Leading Cause of Preventable Death in the United States. Am J Med. 2015;128(1):8-9. doi:10.1016/j.amjmed.2014.07.043

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