In 2017, clinical social worker Joe Schrank founded an addiction rehab centre with a novel selling point: it encouraged the use of marijuana as a way to quit other drugs and allowed smoking weed and taking edibles during residential treatment. He called it High Sobriety.
Located in California (natch!), it lasted only a few years before disputes between him and other investors – and the fact that insurance companies weren’t eager to cover such care – forced it to close its doors.
But Schrank still sees cannabis use as acceptable during treatment for addictions to other drugs and encourages some of the clients he sees in his private practice counselling people with substance use disorders to utilise it.
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He is far from alone in embracing this idea: in the past few years, the concept of “”, where people in recovery from other addictions continue to use marijuana, has surged in popularity.
As the opioid crisis rages on in the US, variations of this idea are also starting to be embraced by a growing number of mental health professionals. That reflects a broader uptick in support for harm reduction approaches to addiction, where the aim is to minimise negative effects without necessarily requiring abstinence. For too long, the primary approach has been to promote complete abstinence from all drugs. But there is now ample evidence to show that this is not only unnecessary but can be counterproductive. What’s more, there is preliminary data showing that some cannabis compounds – especially cannabidiol (CBD) – may be a useful component of care.
It isn’t yet clear whether cannabis in other forms is helpful, but our evolving understanding of addiction does underscore a startling truth: for many people, recovery doesn’t necessarily mean never using any drugs again.
The decades-long  in the US now claims more than 100,000 lives each year, and this has forced public health officials to reconsider the traditional approach to treatment. That approach, which requires complete abstinence from all psychoactive substances other than caffeine and nicotine, is largely based on principles from Alcoholics Anonymous (AA), which was founded in 1935.
We have learned quite a lot about addiction in the past century, however, and it is clear that traditional treatments aren’t the only effective way to treat substance use disorders. Indeed, most people with substance use disorders severe enough to , typically without attending treatment or even self-help groups like AA. This is true for , cocaine and even (though it is likely that the deadly nature of street fentanyl is reducing recovery rates among opioid users).
Cannabis use after alcohol or drug addiction
Critically, a large proportion of people who end addictions do so without giving up all psychoactive drug use and a significant number recover by moderating rather than quitting their drug of choice. For example, a study published in 2019 surveyed nearly 8000 people in the US with alcohol use disorder and a year later – just over half of them were drinking moderately, while the rest were abstinent.
A 2018 study, relying on a different household survey of more than 43,000 people, found that around said they had or used to have a substance use disorder, and 75 per cent of those said that they were now in recovery. Nearly a third of those who said they were in recovery reported using marijuana in the previous year, however.
The science of cannabis
As the use of marijuana and its compounds rises around the world, żěè¶ĚĘÓƵ explores the latest research on the medical potential of cannabis, how it is grown and its environmental impact, the way cannabis affects our bodies and minds and what the marijuana of the future will look like.
Much of this has been known to addiction experts for decades. But the stark nature of the current overdose crisis is finally underscoring the need to bring harm reduction approaches into the continuum of care.
This shift is driven by a few things. For one, our understanding of addiction has changed. Then, there is a growing body of evidence showing that programmes that offer overdose education, overdose-reversal drugs and needle exchanges save lives. Finally, there’s the acknowledgement that existing policies aren’t working – and may be making matters worse. Last year, the US National Institutes of Health announced plans to invest some $36 million in the recently created 
It is within this broader context that many are starting to consider the role that marijuana might play in addiction treatment.
Abstinence in moderationĚýĚý
Despite cultural myths that say otherwise, we now know that some people can eventually use even their drug of choice in moderation. It is also clear, however, that moderation isn’t possible for everyone. suggests that the more severe an addiction is, the less likely someone is to succeed at controlling drug use. But beyond that, it is difficult to know who is most likely to benefit from a moderation approach.
What about use of less harmful substances while abstaining from the problem drug or drugs? It turns out that people who have an addiction to one drug and recover from it are actually a new problem compared with those who don’t quit their first drug. looked at data from more than 6000 people with substance use disorders and compared those who recovered from their initial drug problem with those who did not. It found that people who recovered from one addiction were half as likely to develop a new drug use problem as those who continued misusing their original problem drug.
The study found an important exception however: those who have multiple addictions are more likely to switch from immoderate use of one substance to excessive use of another. That suggests the level of addiction severity and whether multiple drugs are involved is likely to affect whether marijuana can play a role in someone’s efforts to quit another substance.
Additionally, it is important to recognise the distinction between needing a substance to function well (“dependence”) and being addicted to it. Consider prescription antidepressants. I have been on the antidepressants Prozac and Wellbutrin for decades: I’m not addicted, but I am dependent in the sense that if I quit, I have a serious risk of repeat depression, which I would prefer to avoid. Dependence isn’t necessarily a problem so long as you have safe access and, crucially, the benefits of continuing the medication outweigh its risks.
In contrast, addiction is compulsive use despite negative consequences. When I was in my early 20s, cocaine and heroin use were destroying my life, but I felt like I couldn’t stop taking them even after I got arrested and had to drop out of college. I never, ever forgot to take these drugs because I was always swinging between being high and crashing. I have, however, forgotten my antidepressants from time to time because my life is stable and I don’t obsess about or crave them. By definition, addiction has to do some harm and involve significant craving – otherwise you don’t meet the criteria.
This distinction is why using “one drug to replace another” isn’t necessarily replacing one addiction with another. Taking the prescription opioid substitute methadone instead of street opioids can ameliorate addiction while maintaining dependence, for instance.
A harm reduction strategy
In harm reduction, the goal is to reduce the damage people experience from drugs – not stop the high. So, the idea of using marijuana instead of more risky drugs like methamphetamine or opioids isn’t as bizarre as it might sound. There are few families who, if they had to choose between having a loved one addicted solely to cannabis and having them addicted to crack, alcohol or opioids, would choose anything other than weed.
While research on using marijuana as harm reduction in this way is in its infancy, one small study found that people in treatment for alcohol use disorder were on days when they used cannabis. They also drank 29 per cent fewer drinks on days when they used cannabis.
Another study found that some people who use crack cocaine when they seek to reduce their crack smoking. Similar data also shows that some have used weed to entirely. Further research focused on medical marijuana users finds that many report using it to.
Moreover, while there have been some contradictory findings here, some data suggests that US states with easier access to medical or recreational marijuana have than states with stricter cannabis laws, and some individuals report deliberately . Other studies, however, find .
By itself, marijuana simply cannot match the effects of current medication treatments for opioid use disorder, which is the most deadly condition in psychiatry. Two medications, buprenorphine and methadone, are the to reduce overdose mortality by . But their benefit only lasts as long as people stay on the medications.
With the current opioid supply heavily contaminated by highly potent fentanyl, these medications are vital – treatments such as complete abstinence or substituting marijuana, should not be the first choice. Supplementing these medications with marijuana, however, may help. At minimum, the research we have suggests that programmes that eject or punish patients for smoking weed are .
A found that people on methadone who also smoked cannabis at least daily were 21 per cent more likely to stay on their medication, compared with those who abstained from cannabis or used it less often. Since retaining people in medication treatment is often a challenge, this deserves further research.
Not only is cannabis a potential harm-reduction approach for substance use disorders, it may also yield treatments for addiction. One of the most promising is CBD, which is non-addictive and doesn’t cause a high. In a randomised controlled trial of 42 people with heroin use disorder, and craving when they watched videos of people using drugs, and the reductions lasted at least a week after CBD was taken.
Other, preliminary research suggests that CBD or a derivative of it could also , which is used to reverse opioid overdoses.
As we continue to struggle with high rates of addiction and overdose, health officials cannot afford to ignore new approaches that might help – or to demand that people seeking treatment for deadly addictions quit all drugs before they can get care. Marijuana use certainly carries some risks, but overdose death isn’t one of them. And dead people can’t recover.
Maia Szalavitz is the author of
Looking for help with substance misuse? UK: , 0300 1236600; US: , 1-800-662-HELP (4357)
