Opioids aren’t the only drugs killing Americans. A disturbing study published last week in JAMA Network Open revealed that alcohol-induced deaths in the US spiked alarmingly between 2000 and 2016—and are now climbing faster than ever.
Annual alcohol-caused deaths among American men rose 78% in that span, from 14,979 in 2000 to 25,213 in 2016. Deaths among women more than doubled, from 4,648 to 9,644.
Those aren’t deaths merely correlated with alcohol, like drunk driving fatalities. They’re deaths caused directly by the ravages of drink: alcohol-induced pancreatitis, liver disease, cardiomyopathy, and alcohol poisoning.
Some heavy drinkers recover their health through the Alcoholic Anonymous method—12 steps and complete sobriety. But the AA way isn’t for everyone. As more research, data, and personal experience come to light, we’re seeing many adults improve their health through alternative paths of harm reduction.
What’s harm reduction?
It’s a set of ideas and interventions that reduce the harms of problematic substance use. It often involves stepping down from a more harmful drug to a less harmful one—and not necessarily an embrace of complete abstinence. In its mildest form it may involve moving from coffee to tea. At the other extreme: moving from heroin to methadone.
Opponents often mock this as simply swapping one addiction for another. It’s not. And as cannabis legalization continues to expand, it’s playing a growing role in harm reduction strategies—especially when it comes to alcohol.
A mystery tipster
I was reminded of that fact a couple weeks ago at a cannabis conference in San Francisco. During a presentation at the International Cannabis Business Conference (ICBC) gathering, I mentioned the surprising popularity of Leafly’s guide to going ‘Cali sober.’ That’s when people don’t drink alcohol but do enjoy cannabis.
A white-haired gentleman approached me after I left the stage. “You shouldn’t be surprised that so many people are interested,” he said. “It’s not a new concept. In fact, Tod Mikuriya did some of the earliest work on that here in California in the 1970s.”
I didn’t realize until the next day that the tipster was the legendary Fred Gardner, editor of the cannabis website O’Shaughnessy’s. Part underground zine, part medical journal, and part historical archive, O’Shaughnessy’s has served as the OG voice of the medical marijuana movement since its first issue in 2003.
Yes, ‘Cali sober’ started in California
About the trend of Cali sober, Gardner spoke the truth. Back in 1970 Dr. Tod Mikuriya, a Northern California physician, published an article titled Cannabis Substitution: An Adjunctive Therapeutic Tool in the Treatment of Alcoholism. A 49-year-old patient of his, whom he called Mrs. A., came to him with a long history of alcohol abuse. She happened to mention her use of marijuana as well, and the fact that she decreased her booze intake when she smoked.
So Mikuriya gave her advice that in 1970 was truly radical: “I instructed her to substitute cannabis daily—any time she felt the urge to partake in alcohol,” he wrote.
Guess what: It worked. Five months later, Mrs. A’s health was on the upswing. “Her appearance, complexion, posture and energy level have gradually improved,” Mikuriya noted. “She is afforded a new awareness and control over her life, instead of being continually sick and intoxicated and acting out in a maladaptive fashion.”
“I can in no way claim a total cure,” Mikuriya cautioned. But “for selected alcoholics the substitution of smoked cannabis for alcohol may be of marked rehabilitative value.”
That was 1970. Years later Mikuriya would become one of the most courageous—and persecuted—leaders of California’s medical marijuana movement. But he never forgot the curious case of Mrs. A.
Abstinence isn’t the only way
In 2003, he published a follow-up paper, Cannabis as a Substitute for Alcohol. In a harm reduction regimen adopted by 92 alcoholic patients, Mikuriya found that all 92 reported some benefit. “Even if [cannabis] use is daily,” he wrote, replacing alcohol with cannabis “reduces harm because of its relatively benign side-effect profile.” Cannabis doesn’t damage the liver, spleen, esophagus, or digestive tract, as alcohol does. “Sleep and appetite are restored, ability to focus and concentrate is enhanced, energy and activity levels are improved, pain and muscle spasms are relieved.”
Abstinence-only advocates can be zealous and confrontational. A recent tweet by Leo Beletsky, a leading drug policy expert and a professor of both law and public health, pointed out that alcohol harm reduction exists and works. An abstinence advocate responded by mocking the idea as “cuckoo” and heralding full sobriety as “the only way!” In recovery culture this is not an atypical response.
The vast majority of the institutional medical world agrees with him. Most public health agencies still view any cannabis use as problematic cannabis use. Sobriety is counseled as the one true path.
Here and there, though, new thinking around harm reduction is taking hold.
Official recognition slow in coming
Public health officials now recognize that medication assisted treatment (MAT) offers great hope to people struggling with opioid use disorder. Methadone maintenance programs, born in the late 1970s, have long reduced heroin-related deaths. Now the next generation of opioid MAT, extended-release naltrexone, is allowing patients to use a single monthly injection to block the body’s opioid receptors, reduce cravings, and prevent relapse.
Some opioid treatment programs are also using cannabis as an exit drug, with research-proven success. The controlled use of marijuana eases a patient’s withdrawal from opioids while providing relief from the conditions that led to opioid use in the first place, like chronic pain. Researchers have found that opioid prescription rates are 6% lower in medical and rec-legal states. Leafly began covering this phenomenon in 2017. In just three years the concept has moved from an idea mocked as “stupid” to an increasingly accepted recovery strategy.
Consumers in legal states already embracing it
‘Cali sober’ is the next step in mainstream harm reduction. There are data sets hinting that some consumers are already going Cali, perhaps without even realizing it. A 2017 University of Connecticut study found a 12% decline in alcohol sales in states that legalized medical marijuana between 2006 and 2015. A 2018 report by Cowen & Company found that legal adult-use states saw a 13% lower rate of binge drinking than states that prohibit all cannabis.
Going Cali sober isn’t a panacea. In the words of the late Dr. Mikuriya, the method may be “of marked rehabilitative value” for some people, but not everybody. And that’s okay. In medicine as in life we too often demand one approved drug for all patients, one approved path to health and happiness. Human bodies don’t work like that, and neither do human lives.
There’s one thing I know absolutely doesn’t work: Belittling and punishing a person for taking a first step. A few months ago I heard a harm reduction worker explain their work at a street outreach clinic in Washington, DC. “The most important thing is to meet people where they are,” they said, “and help them reduce harm from there. In whatever form that takes.”
That stuck with me, because it reminded me of the insight I’ve gained over the years about how people change their minds about cannabis legalization. Meet people where they are. Don’t mock them. Encourage them to ask around, do some research, keep an open mind. Three of the most powerful phrases I’ve learned are these: “I hear you”;“Seven years ago I thought the same thing”;“Then I started looking into it, and…”
Small steps lead to great change. In 2020, moving from alcohol to cannabis could literally save thousands of lives. Spread the word.