Can We Use Alcohol or Marijuana Safely? How About Responsibly?
Can We Drink and/or Use Marijuana Safely? How About Responsibly?
Gene Gilchrist
Louisville, Kentucky
We have published several articles about alcohol and other drug use, abuse and addiction that were designed to change the understanding of these issues. We attempted to demonstrate that the common image of alcohol and other drug abuse and addiction as that of a destitute, often homeless individual is terribly skewed. Rather, the 40 million Americans with a substance use disorder (chronic abuse and addiction) walk among us every day. These folks have a diagnosable, behavioral health condition and they are in our social clubs, houses of worship, workplace and in our homes. You knew that; hopefully, it has crystallized for you.
Early in drafting we consulted respected colleagues for comment on several of the articles. One of the suggestions was that in order to be comprehensive we should discuss the issues around safe or responsible alcohol use. Given the rate at which legalization of marijuana is occurring, it seems reasonable to assume that this, too, is fair for the sake of being comprehensive. There are those who are arguing for safe use of schedule 1 and schedule 2 narcotics other than marijuana and “as prescribed” in the case of schedule 2. We shall touch on that briefly.
Given the record established over several of these articles the reader might suspect bias by the writer. Honest self-examination suggests that the writer take care about bias. Too, the moralistic lens through which portions of the public still view these issues colors how the handling of this issue of responsible alcohol and marijuana use might be approached. H.L. Mencken’s definition of a puritan comes to mind (“A Puritan is someone afraid that someone, somewhere may be enjoying themselves”). This seems tame compared to sayings that those of us of a certain age may recall from not so long ago. “There’s nothing worse than a reformed bum,” is among the gentler. Certainly the views of the general public have softened, the moralistic tones have given way to biomedical science views in some part, but these moralistic tones persist. The comment from the reviewer about being comprehensive stands nonetheless and merits attention.
Among a few serious trepidations about risk in this writing is the litigious nature of America today. We live in a society where someone who spills coffee in their own lap can successfully sue the maker of the coffee. One fears that regardless of the position one might take about alcohol or marijuana use, an individual or a loved one of an individual will later claim that it was this article that caused them to use and caused the subsequent harm. Paranoia you say? Ask the company that made the coffee and later paid an undisclosed but presumably large sum of money to settle.
Let’s take that risk off the table and preview the conclusions herein. Medically speaking, there is no amount of alcohol or marijuana that is safe to use. Alcohol is a toxic, psychoactive, and dependence-producing substance and was classified decades ago as a Group 1 carcinogen by the International Agency for Research on Cancer. There are other medical concerns such as weight gain, renal, neurologic and cardiovascular risks and those increase as the amount of alcohol consumed per sitting and per week increases and over time. If the question is about medically safe use, then alcohol is a drug that begins to impact the body negatively starting with the first and smallest amount ingested. Marijuana, or more specifically tetrahydrocannabinol, is a psychoactive drug that impacts perception, motor skills and reasoning from the very first ingestion in most people (there are, of course, a very tiny number of people who process these substances differently). Medically speaking, again, there is no safe use of marijuana. That is not to say that taking these medical risks with alcohol and marijuana and acting responsibly thereafter is not possible. In fact, both happen millions of times every day. However, the writer is regularly asked how to avoid the downside risks from alcohol and more often marijuana where today street marijuana can be deadly. The answer is rather obvious; don’t use it.
Why Do Americans Use Alcohol and Marijuana?
If one concurs, then it is reasonable to ask why one should use alcohol or marijuana at all. Our history as humans has involved alcohol for a very long time. In Alcohol and Humans, A long and social affair (Hockings and Dunbar, Oxford University Press, 2020), the editors cite archeologic findings of fermented alcohol from 900,000 years ago. They note the use of forms of cannabis and psilocybin in ritual nearly as far back. In the United States and Europe moralistic views of alcohol flourished for centuries (where do you think the term “demon rum” originated?) and resulted in national acts generally known as “prohibition” that was repealed in short order in those countries that enacted such laws. Remember that in America it was not law passed by a handful of moralistic elected officials, but a constitutional amendment passed by the majority of voters in three-quarters of the States. Prohibition failed miserably. By some estimates the height or alcohol consumption in the U.S. on a per capita basis occurred during prohibition. As a species, a people, a nation, we want to drink.
Concerning marijuana, opinions are similar to alcohol. According to Pew Research 88% of Americans believe that marijuana should be legal in some circumstances, 57% believe it should be legal for recreational use, and only 11% think marijuana should be illegal in all circumstances. Contrary to widespread belief, USA Today surveys found that slightly less than half of Americans have tried marijuana and about 17% use marijuana regularly. Given the rapid adoption of marijuana legalization, one might assume that both the 50% and the 17% would increase.
It does appear that either through public attitudes or prohibition or both we are dampening the use of schedule 1 narcotics (street drugs) other than marijuana and the abuse of schedule 2 narcotics (prescription drugs) or at least when compared to alcohol or marijuana. The National Institutes for Health estimates that about 7% of Americans use those drugs irresponsibly (allowing the responsible use of prescription drugs as prescribed). To be certain, 100,000+ deaths annually in America from overdose is unacceptable. The point here is about factors tempering use of these drugs.
In discussions about why we use alcohol the National Academies (“Review of Evidence on Alcohol and Health, National Academies Press, 2005) notes that many alcohol-containing beverages provide flavors and sensations that people enjoy—fine wine, craft beer, or distinct distilled spirits, which may be mixed with other flavored, often sweet ingredients. Alcohol has other characteristics that likely impact the decision to consume it, specifically the effect on how we act and respond in social situations based on how alcohol may affect self-confidence, inhibition, stress/anxiety, mood, pleasure and enjoyment. Furthermore, there is a cultural sense of alcohol consumption as a rite of passage or a sign of adulthood that likely influences the decision to drink alcoholic beverages. In America there are long and lasting relationships between alcohol and social situations (National Academies). Pairing of wine with food, lowering social inhibition in group settings, recreation such as a drink at the golf course, and even business situations such as a cocktail “after work” have all persisted for a very long time. The point here is that there are 80-100 million Americans (the math follows below) who use alcohol for personal, social, and business reasons and can and most often do use alcohol responsibly and in moderation. They likely do not know the details of the medical harm, but they respect alcohol as a drug and treat it responsibly. It is also true that 40 million Americans should never use alcohol, and 50 million Americans should use it more responsibly than they do currently.
Studies and discussions of why we use marijuana are less advanced. Given the evolving nature of legalization it has been the case that most marijuana use has occurred in private and most marijuana has been purchased illegally. The situation in Europe such as the “tea shops” in Amsterdam is much less common in America. Again one might assume that as legalization progresses this situation will evolve. Until then, credible research on the use of marijuana is and will be somewhat more limited than in the case of alcohol. Perhaps we may assume that the reasons for the use of marijuana are, in the main, similar to those for alcohol.
What About the Health Benefits of Alcohol?
The reader may be thinking about reports in recent years about the health benefits of alcohol. Those reports often discussed cardiovascular benefits, usually involving wine, and were always certain to discuss moderate use. The rejoinder above about alcohol being unsafe in any amount is from the World Health Organization in 2022 (“No level of alcohol consumption is safe for our health”, World Health Organization, December 2022):
“We cannot talk about a so-called safe level of alcohol use. It doesn’t matter how much you drink – the risk to the drinker’s health starts from the first drop of any alcoholic beverage. The only thing that we can say for sure is that the more you drink, the more harmful it is – or, in other words, the less you drink, the safer it is,” (Dr. Carina Ferreira-Borges, acting Unit Lead for Noncommunicable Disease Management and Regional Advisor for Alcohol and Illicit Drugs in the WHO Regional Office for Europe). “
How do we explain these different reports? There are several studies that typically involve a J-shaped or U-shaped curve. If consumption of alcohol is plotted from abstinence to heavy drinking on the X axis these studies often report that moderate users of alcohol are less likely to suffer from a wide array of health issues than abstainers. Of course, the health issues for alcohol use beyond moderate use increase quickly and that association has been well and long established. The report from the National Academies found such J and U plotted curves for all-cause mortality (the top causes of death in American including heart disease, stroke, cancer and accidents), weight and by extension morbid obesity, cancer, heart disease and stroke. Evidence was never strongly correlated and occasionally weakly correlated. Evidence on dementia was inconclusive.
Reconciling these two views about alcohol use as a medical negative or positive revolves around accepted science used for evidenced based treatments. Specifically, the studies reviewed by the National Academies and many other studies were observational versus approved and monitored clinical trials, the latter being the accepted method in the biomedical sciences (it should be noted that the serious health impacts from heavy and binge drinking also arise from observational studies although the correlation is must stronger).
A report published in the Journal of the American Medical Association (JAMA) (“Association of Habitual Alcohol Intake With Risk of Cardiovascular Disease; Biddinger et al, March 2022”) discusses the issue:
“Observational studies have repeatedly demonstrated a lower risk of CVD (cardiovascular disease) with light to moderate alcohol intake compared with either abstinence or heavy consumption, suggesting J- or U-shaped epidemiologic associations. However, the observed cardiac benefits of alcohol have been hypothesized to be the product of residual confounding (variables) because of favorable lifestyle, socioeconomic, and behavioral factors that tend to coincide with modest alcohol intake. Efforts to address this complex association through a randomized clinical trial have been met with logistical and ethical challenges, culminating in the discontinuation of a trial of modest alcohol consumption led by the National Institutes of Health.”
In simpler terms, ethical challenges in clinical trials have retarded if not eliminated the opportunity for this standard of study in the biomedical sciences. Further, given the biologic evidence of the harmful effects of alcohol in the body biomedical science looks for other, possible explanations for the apparent “benefit” of moderate alcohol use. Current thinking is that there are factors other than the abstinence or moderate use of alcohol that explain the outcome in the observational studies. Essentially, intervening variables not studied such as lifestyle choices other than alcohol use are producing skewed results not a protective result from the known carcinogen alcohol. The JAMA publication in fact found correlation between moderate use and other healthy lifestyle choices. The moderate drinkers make other, similar lifestyle decisions that provide healthier outcomes. Plainly, there do not appear to be protective or prophylactic benefits from alcohol use.
Who Drinks and What Is Moderate Use?
We should take a moment for two, definitional items. First, how is moderate alcohol use defined? Any number of sources will define moderate use similarly. The Centers for Disease Control (CDC) defines moderate drinking as two drinks per day and seven per week for men and one drink per day and four for a week for women (alcohol is metabolized differently by gender). A standard drink is 12 ounces of beer at 5% alcohol by volume (ABV), 5 ounces of wine at 12% ABV, or 1.5 ounces of spirits at 40% ABV.
Secondly, how many Americans are we discussing here? The United States Census Bureau estimates that there are 258.3 million adult Americans. The National Institutes for Health estimates that 70% use alcohol at least on occasion leaving us 180.8 million Americans. Among these the Centers for Disease Control estimates that there are 43 million binge drinkers who consume toxic amounts in one sitting and do so four times a month. The CDC also estimates that there are, separately, 13 million heavy drinkers who drink beyond moderation every week. The NIH estimates that there are 40 million Americans with a substance use disorder. If we remove these three groups, then we are talking about 84 million Americans who might use alcohol in moderation. Certainly, there is overlap in the three categories calculated by two different agencies that may not coordinate their studies. Regardless, let’s make it 100 million adult Americans who drink and do not binge drink, heavy drink or suffer the disease SUD.
Then, Is Alcohol Safe?
Then, to the question, is there such a thing as safe alcohol use? Certainly, the science is clear that for women who are or anticipate being pregnant alcohol should be avoided. Also, the evidence is clear that adolescent alcohol use (the numbers above define American adults, but this is worth mentioning for the 18-20 year old cohort) is brain shaping during a time of brain growth and should not be used. Further, the evidence is incontrovertible that drinking beyond moderate use such as binge drinking, heavy drinking or those with substance use disorder is harmful.
What of the 100 million? If the evidence is that any amount of alcohol is harmful, and previous reports of the health “benefits” of moderate consumption are under question at best if not being debunked, then the benefits of alcohol consumption previously described occur with risk taking. It is also very common. Perhaps the majority of the 100 million Americans we are discussing do so consuming less than two standard drinks per day and less than seven per week. They do so for camaraderie, business, recreation. These risks can be managed, and many do so. They are, nonetheless, risks.
On the other hand, Americans take similar and more severe risks on a regular basis. The automobile is one example. Driving Test America estimates that in 2021 Americans drove cars and light trucks 3 trillion miles, averaging 2.4 trips per day. These drivers are guided by rules of the road and formal laws that guide their driving behavior. Nonetheless, there were 6.1 million vehicular crashes, resulting in 1.7 million injuries and 39.3 thousand deaths all in 2021. This analogy falls apart at some point, as all do, but hopefully the point is made that alcohol use is not the only widely popular, risk taking behavior in America. For instance, mortality per driven mile in 2021 was .000013. How does that risk compare to the cancer risk from alcohol where in some cancers the known risk from alcohol increases from a 10.4% risk to an 11% risk or .038? Whether or not one is willing to take either risk is an individual decision in America.
Then, is there a safe level of alcohol consumption? No. Alcohol is a toxic, psychoactive, and dependence-producing substance that begins to have negative impact on the human body from the first drop. Binge drinking, heavy drinking, adolescent drinking, drinking while pregnant or lactating, driving after drinking are highly risky and irresponsible behaviors. 40 million people or 1 in 8 Americans are in danger of developing an alcohol use disorder. Purported health benefits of alcohol have been largely debunked. On the other hand, many Americans can and do practice responsible drinking
What About Responsible Use?
Assuming that one decides that the benefits outweigh the risks, then there are many sites and publications that provide recommendations for responsible drinking. The recommendations are generally the same. Susan Reed, Ph.D. suggests (“How To Drink Responsibly”, Sober.com):
· Follow guidelines for drinking in moderation (defined above)
· Monitor serving size (also above)
· Track alcohol use for a couple of weeks or month to see your actual patterns and adjust accordingly
· Set limits or goals per session, per day, per week meeting guidelines or better
· Never drive, operate machinery, or go to work after drinking
· Practice saying no or not drinking in circumstances when you normally drink
· Do not always associate drinking with one or another behavior (i.e., sporting event)
Two additional items are listed on Health Direct (Australian Ministry of Health), “Tips for Safe and Responsible Drinking”:
· Always note recommendations about alcohol use with prescription drugs
· Never drink without food (note that other sources recommend staying hydrated as well)
If one decides to drink and follow these guidelines, then one other note. Alcohol impacts reasoning. It is dangerous to decide to act responsibly then use a substance that reduces our ability to think logically about those immediate future behaviors. Be careful.
Is Marijuana Use Safe?
The research on cannabis (marijuana) is becoming nearly as well developed as that for alcohol and is rapidly increasing with the current interest in marijuana legalization. The research clearly indicates that cannabis use is as deleterious to health as alcohol if not more so. Further, given that it is estimated that 1 in 6 Americans use marijuana recreationally, the associated cultural uses are fewer or at least less frequent but are likely similar to the case for alcohol use.
We want to be clear that the medical uses of cannabis are researched, proven and developing. Pain management in particular is a very difficult topic in America and the increasing use of cannabis as prescribed is a welcome development. Recreationally, however, it is difficult to make a strong case for the use of marijuana
The National Institutes for Drug Abuse (NIDA, “Cannabis”, February 2024) report several issues resulting from marijuana use. To start, the widely held belief that marijuana is not addictive is false. NIDA reports that 22-30% of regular users over time will develop cannabis use disorder – emotional and/or physical dependence.
In addition, NIDA cites the following issues with short term use:
· Intoxication and associated perception, motor skill and reasoning effects which occur for most users rapidly
· Psychotic experiences including anxiety, fear, distrust, panic, or hallucinations more often occurring with excessive amounts or excessive dosages and/or for inexperienced users
· Cardiovascular issues due to elevated heart rate
· Respiratory issues from rapid and irregular breathing
Speaking to long term use NIDA notes:
· Lung Damage when the method of delivery is smoking
· Heart disease with long-term cannabis use and an increased risk of stroke, heart attack, and arrythmias
· Gastrointestinal problems including acid reflux, pancreatitis, and peptic ulcer disease
· Increased cancer risk with an increased likelihood of developing head, neck, or throat cancer particularly in people who smoke cannabis.
NIDA also noted behavioral health issues. These issues include problems in cognitive functions like learning and memory, attention, processing speed, perceptual motor function, and language. Some evidence has linked cannabis use to earlier onset of psychosis in people with genetic risk factors including schizophrenia, as well as worse symptoms in people who already have these conditions. Some research has also shown an increased risk of depression in people who use cannabis during adolescence.
Given this research, the biomedical case against marijuana use appears stronger than that for alcohol. Nevertheless, like alcohol, there seems to be social benefits as there are 43 million adults (17% of adults) using marijuana.
What About Responsible Use of Marijuana?
Similar to the case for ameliorating risk with alcohol, there are recommendations for marijuana. Writing in the Harvard Journal of Medicine Peter Grinspoon, MD (“If you use cannabis, do it safely”, Harvard Medical Review, Peter Grinspoon, January 2023) offers the following advice:
Buy it legally. If you live in a state with legal cannabis — whether medical or recreational — go through the legal market rather than the illicit market, despite the temptation of lower prices. While many State programs are less than perfect, buying cannabis through the legal market generally offers some advantages and protections
Pay attention to potency: The most straightforward way to get into trouble with cannabis is by consuming too high a dosage of the main active ingredient, THC. Cannabis flower is far more potent than it was in the 1970s. Taking too much cannabis, or using cannabis that is too strong for you, can cause a severe anxiety attack, possibly landing you in the emergency department. Too high a dosage can also potentially trigger other medical conditions, such as cardiac arrhythmias and syncope
Go Slow. Some people develop cannabis hyperemesis syndrome — uncontrolled vomiting in response to cannabis use — which can only be treated by ceasing use. Start low, go slow, and stay low is good advice
Avoid cannabis if … teens should absolutely avoid using cannabis due to concerns about the effects it can have on brain development, women who are pregnant or breastfeeding should abstain from cannabis, people with certain psychiatric conditions, such as any type of psychosis, or those with a family history of schizophrenia, should avoid using cannabis, as this can worsen their condition
Be careful about how. Don't smoke cannabis, which can inflame your lungs. Use an under-the-tongue tincture, an edible, a topical product, or a dry herb vaporizer. If you do smoke cannabis, don't hold it in your lungs for more than a second or two; holding it in longer doesn't give you more effect, it just irritates your lungs
Be careful about when. Don't drive for at least four hours even if you feel you are able to drive safely sooner than that. After an edible, wait 8 to 12 hours before driving. Avoid using cannabis for 24 hours before your shift if you work in a safety-sensitive job. Never go to work under the influence
Tell certain people. Communicate with all of your health care providers about your cannabis use. Open dialogue helps coordinate care and avoids drug interactions.
The biomedical case against the recreational use of marijuana seems very strong. Nonetheless, 43 million Americans do so and there are recommendations for managing responsible use as there are for alcohol. Again, there are behaviors in America that are just as risky if not more so such as the automobile. This does not justify taking risks with alcohol or marijuana but does suggest that risk taking is not an uncommon part of life in America.
What About Schedule 1 Narcotics or “Street Drugs”?
There are reports of individuals using schedule 1 narcotics recreationally and safely, but there is limited research to justify such use.
Schedule I drugs are those that have the following characteristic according to the United States Drug Enforcement Agency (DEA):
The drug or other substance has a high potential for abuse
The drug or other substance has no currently accepted medical treatment use in the U.S.
It has a lack of accepted safety for use under medical supervision.
Drugs or Substances listed in DEA Schedule 1 (other than cannabis) may include:
· Heroin
· LSD (acid)
· Mescaline
· MDMA (ecstasy)
· Psilocybin
· Methaqualone (quaaludes)
· Bath salts
According to the National Association for Mental Illness (NAMI, www.nami.org), federal law prohibits the manufacture, distribution, dispensation and possession of Schedule I substances except for federal government-approved research studies. As a result, U.S. researchers face regulatory hurdles to studying any Schedule 1 drugs. While still evolving, research on the effects of Schedule 1 drugs is currently insufficient, particularly as it relates to people with mental illness. To be clear, NAMI argues for research given that there is a substantial amount of self-medication among people with severe mental health issues and observational reports that certain schedule 1 narcotics may have benefit in treatment of that mental illness.
Given the DEA review, the potential for abuse and addiction, and lacking any proven efficacy, it is highly recommended that no one use schedule 1 narcotics.
In sum,
Alcohol, marijuana and especially schedule 1 narcotics all have negative medical consequences that impact the body even in small amounts and immediately upon ingestion. Further, there are entire categories of Americans who should abstain including people with substance use disorder, pregnant and lactating women, people with comorbidities in behavioral health, adolescents. There are also times when use of these drugs is dangerous including operating an automobile or working.
However, the use of alcohol is well engrained in American culture and marijuana use seems to be gaining similar popularity. The reasons are many and long standing. While the risk is real, some of these risks are marginal and similar to or less than other risks such as automobile transportation. Perhaps as many as 100 million American adults can and often do use alcohol and marijuana responsibly and there is ample advice about how to do so.
January 2025
