Can We Acknowledge What the THC Cap is Really About?

An Open Letter to the West Virginia Department of Medical Cannabis

My first encounter with chronic pain occurred when I was 19. From a few weeks into the fall semester, I’d been experiencing severe pain in my left foot at a particular below the ankle and about an inch or so toward the toes. As I always do, I avoided seeing a doctor and, instead, decided to play a game of chicken with my injury. On the cusp of Christmas break, I buckled.

“It’s a stress fracture,” my podiatrist would tell me, gesturing to a specific point on my x-ray. “Very common in police, waitresses, runners… anyone who spends a lot of time on their feet. But there’s something else I’m noticing,” she said before pausing, perhaps wrestling with the thought.

“It looks like you’ve got a bit of arthritis.”

I left in a fun medical boot for the stress fracture, under advisement to follow-up with my primary doctor who ended up finding more than “a bit of arthritis” as well as… gout.

Since this isn’t a health lesson, I’ll keep this brief: Our bodies produce uric acid, a natural waste product, by breaking down purines in some of the foods we eat. Normally, uric acid is expelled from the body on its own, often via the urine. But if it continues to accumulate in the blood, which can occur for a number of reasons, then it can start building up in crystalline form (monosodium urate) in the soft tissue, but most commonly in the cartilage of the joints. When this occurs, it’s called hyperuricemia.

Left unchecked, hyperuricemia is what leads to gout, “a complex form of arthritis… characterized by sudden, severe attacks of pain, swelling, redness and tenderness in one or more joints.”

It’s horrifically painful. The best I can describe gout is that it feels like you’ve taken your foot off at the ankle, rolled the cartilage of your ankle joint in shards of glass like sprinkles on an ice cream cone, and then popped your foot back on.

I’m going to be randomly and periodically hit with excruciating pain and there’s nothing I can do about it.

My doctor helped me to identify certain dietary and lifestyle changes that curbed the frequency, if not the intensity, of the flares a bit. But no manner of medical care available to me, nor any lifestyle changes I might make, now or then, can stop them completely, which is the part of this that I think I’ve probably struggled with the most. Although I was too young to legally purchase alcohol, I had to make peace with the fact that I’m going to be randomly and periodically hit with excruciating pain for the rest of my life, and there’s nothing I can do about it.

[Prefer to read the shorter version of this letter? Click here.]

~*~

Does anyone else find it amusing that West Virginia, the state probably most known for seceding to the North during the American Civil War, ended up being so utterly conservative? Do we live in the most liberal Southern state or the most conservative Northern state? It’s something I think about from time to time although I’ve not yet found an answer.

Here’s the thing: West Virginians are already using cannabis — and other drugs — en masse. The only distinction to speak of is that most are using it illegally as you would heroin or cocaine by buying it on the street. Despite a state-wide drug problem — Or is it because of it? — there’s not been a serious attempt to legalize like our liberal neighbors, DC and Maryland, where medical cannabis dispensaries were opening as far back as 2013 and 2017, respectively.

As illegal drugs have continued to pour into the state from nearby distribution hubs like Baltimore and Philadelphia, there’s generally this air of resentment among residents that extends even to cannabis. This is based on anecdotal evidence and my own experience, of course, but I get the impression that many West Virginians see the dire economic situation across the entire state as a product of the drug problem.

Surely, there have always been a number of us who would benefit from medical cannabis; however, the reality is that this conversation couldn’t happen due to the ongoing standoff between drug users and those who are vehemently anti-drugs. Both sides had a vocal few who were either too eager to legalize or too eager to dismiss legalization. Those of us who would participate in a medical cannabis program read the room and assumed medical cannabis wasn’t going to be legalized in West Virginia anytime soon.

(I’m thrilled to have been wrong on that front.)

Those who oppose medical cannabis often try to depict it as a guaranteed precursor to hardcore drug use. It’s a very oversimplified way of thinking where you can’t support medical cannabis because cannabis is a drug and drugs are bad; to support medical cannabis is basically to want to legalize heroin; so you’re either be part of the problem or part of the solution.

You’re either part of the problem or part of the solution.

However, the biggest problem I have with this outlook is that it says, “No, I’m not willing to have an open discussion with you about your needs.”

Additionally, those opposed to medical cannabis often cite the gateway hypothesis, also commonly called the gateway drug hypothesis, as “proof” that medical cannabis is more harm than help. However, as widely cited as it may be, the gateway hypothesis is often poorly understood, which is problematic when it’s informing a lot of discussions surrounding medical cannabis.

According to the gateway hypothesis, legal substances like alcohol and tobacco serve as an entry point to more problematic substance abuse, getting the individual acclimated before progressing to increasingly dangerous substances. It relies on the assumption that we tend to minimize as much risk as possible; thus, people tend to start with relatively safe and accessible substances that are available legally. Then he or she can graduate to increasingly dangerous and addictive substances until becoming addicted and, ultimately, dying. Or that’s the theory anyway.

Half of American adults have sampled cannabis at some point or another although it’s possible this number is actually much higher (due to some people not wanting to admit to it). I don’t want to put too much emphasis on this comparison, partly because there’s almost sure to be more to it, but bare with me here: We know the addiction rate in the United States is about 10 percent… so if the gateway hypothesis was factual — meaning many people who try cannabis become addicted to more dangerous drugs down the road — then why isn’t the addiction rate much higher than 1 in 10 adults?

If you ask me, I think the gateway hypothesis feels logical [in spite of its significantly shortcomings] largely because it feels congruent with how we understand the world to work. For example, the gateway hypothesis shares certain similarities to the snowball effect, which is when something small accumulates into a bigger and bigger problem over time, like a snowball rolling down a snowy mountain. However, the gateway effect doesn’t account for causality or context, which is a pretty significant oversight. Shouldn’t we take the context of an individual’s drug use into account when assessing risk for addiction in the future?

In a study from 2017, published in journal Neuropsychopharmacology, a group of researchers put the gateway hypothesis to their test and made a number of interesting discoveries, particularly with the concept of “transgenerational transmission”.

According to the researchers, adolescents exposed to cannabis by their parents are more likely to use heroin in adulthood. Some may see this as proof of the gateway hypothesis, but it’s actually the opposite for me. I see this particular finding as proof that it’s less about the substance than it is about how the individual came to be using the substance in the first place.

This brings to mind another disturbing conversation that’s been taking place recently.

I have made every attempt to see both sides of the argumemnt, but I simply cannot fathom taking away a woman’s ability to have an abortion, especially knowing that terminating unsafe pregnancies has surely been what saved many women’s lives. But our systems seem to crumble whenever confronted by a problem that doesn’t have a quick solution and won’t be easily swept under the rug. Rather than searching for and applying a more appropriate, nuanced solution, legislators have made the decision to take abortion off the table for everyone, including those whose lives — and/or whose quality of life — may depend on it.

I have to assume the reason cannabis is treated differently than something like Advil is due to THC and its psychoactive properties. If you didn’t “get high” on cannabis, then I feel like there probably wouldn’t be a problem.

Here’s probably my biggest hot take in this entire letter: Based on my experiences and everything I’ve read on it, cannabis is safe.

~*~

Did you know it’s basically impossible to overdose on cannabis? It’s true — there’s not been a single death attributed to cannabis. For comparison, over 100,000 lives were lost to drug overdose in 2021 and even aspirin has killed somewhere in the neighborhood of 7,000 to 8,000 people.

Estimates for the amount of cannabis necessary to overdose are often comically, ludicrously large. One source claims it takes “40,000 times the normal amount of cannabis” — which calculates to 1,500 pounds of marijuana — consumed in no more than 15 minutes to overdose, which is no more or less unreasonable than other estimates I’ve seen. Whether or not that’s scientifically accurate is irrelevant; the point is that overdosing is something we essentially don’t need to worry about with cannabis.

The other big issue that people point to when cautioning against medical cannabis or lobbying for cannabis restrictions, which is the plant’s addictive potential.

For decades among canna-connoisseurs, the refrain was the same: “You can’t get addicted to weed, so what is there to worry about?” Although we now know that’s not exactly true, I do fear the pendulum could swing too far in the other direction. From everything I’ve seen, the reality is somewhere in the middle.

In and of itself, cannabis is not an addictive substance, at least not in the way that opioids are addictive. With opioids, you’re taking a drug designed specifically so that it bonds readily with the brain’s opioid receptors, which is how painkillers achieve their pain-relieving effects.

Cannabinoids don’t work in the exact same way as opioids.

We do have receptors in our brains specifically for cannabinoids, but cannabinoids are associated more with psychoactive effects than pain-relieving effects. Further, there are different types of cannabinoids, each found only in specific areas of the brain. Leveraging these characteristics as well as the way our body chemistry ensures that we each respond differently to the psychoactive compounds found in cannabis, geneticists and growers have used selective breeding and cross-breeding to develop hundreds of unique strains of cannabis, each distinct from the next.

Since the body cannot become physiologically dependent on cannabinoids or THC, the assumption for a number of years was that cannabis wasn’t addictive. What we eventually discovered was that it’s simply addictive in a different way.

According to research studies, cannabis is more habit-forming than addictive. Whereas those addicted to opioids will experience unpleasant withdrawals when they’re unable to consume opioids, daily cannabis users won’t experience withdrawal. However, daily cannabis users may exhibit certain symptoms — e.g. irritability and mood swings — when forced to go a period of time without using cannabis. In other words, the effects of cannabis addiction are largely emotional with little to no physical effects, but is cannabis addiction common?

According to WebMD, the answer is no. In fact, it’s believed that only 10 percent of cannabis users even have the potential to become addicted to cannabis while 30 percent of individuals using cannabis currently show signs of marijuana use disorder — which seems high to me although I have no reason to doubt it, especially coming from the CDC.

It seems there are just two ways for cannabis to realistically kill you. Option A is allergic reaction… although there’s no guarantee that an allergic reaction will result in death. In fact, only between 0.07 and 2 percent of allergic reactions result in death, and those cases exclusively from anaphylaxis, which is when the throat closes and restricts the individual’s airway. In other words, someone who’s allergic to cannabis is very likely to survive an encounter with cannabis. In terms of its potential to induce an allergic reaction, cannabis is about as dangerous as any new food you try for the first time.

Currently, there’s no estimate for what percentage of the population is allergic to cannabis although I get the impression it’s a very small percentage, surely small enough that these additional cannabis restrictions are unnecessary. The only risk of a cannabis overdose that I can see would be from cannabis that’s laced with another drug, or Option B.

Anyone buying cannabis on the street simply has no way to know whether the cannabis is laced with other substances. Unfortunately, there’s not currently enough data — a reoccurring theme throughout this letter — with which to determine what percentage of street cannabis is laced with other drugs; however, it’s believed to be a fairly low figure.

But even a low percentage of laced marijuana means tainted product in lots and lots of hands, causing overdoses in people are they unknowingly ingested powerful opioids. It’s a huge risk to buy cannabis — or any other drug for that matter — from a source who isn’t required to follow strict guidelines and regulations when producing cannabis products to ensure consumer safety.

But wouldn’t legalization basically make laced cannabis a non-issue?

~*~

Pushing legislation built on a foundation of ignorance and judgement so you can make sweeping decisions about our medical care is a slippery slope. Regardless of where I fall — or you fall, or anybody falls — politically, there’s simply not a compelling argument in favor of taking away our ability to choose what’s best for us individually.

This whole situation with medical cannabis and the THC cap reminds me of another [much more unsettling] discussion that’s been taking place, which is the topic of women’s right to abortion.

In my mind, taking away a woman’s ability to have an abortion — especially knowing there have been women whose lives were saved only because they were able to terminate unsafe pregnancies — feels like a fundamental violation of one’s civil rights. I won’t go any further than to say the medical cannabis situation echoes what we’ve been seeing with abortion in that it’s something that can either be a very good thing or a very bad thing, depending on how it’s used. But if the pros dramatically outweight the cons, then who am I — Who are you? Who is anyone? — to deprive someone of those benefits, especially when that person is an adult?

Now that the stage has been thoroughly set, let’s get into my biggest issues with putting a 10-percent cap on THC content of cannabis products.

Problem 1: This isn’t really about cannabis, is it?

If the opioid crisis reminded us of anything, it’s that medications prescribed by a doctor are extremely dangerous. In this way, I can sympathize with legislators and policymakers feeling very nervous as they continue to deal with the fallout from prescription painkillers. But as I will continue to reiterate, cannabis and opioids are two separate matters and warrant being approached as such.

The THC cap feels like they’re projecting baggage from the opioid crisis onto medical cannabis.

Research has shown cannabis to be a very safe medication when it’s used responsibly by people of appropriate legal age, so if the medical cannabis system ensures that only people with a demonstrated need have access to cannabis, then what’s the problem? If you ask me, it starts to feel like certain officials are projecting baggage from the opioid crisis onto medical cannabis, which is unwarranted, undeserved, counterproductive, and, frankly, really annoying.

Problem 2: Limiting THC content undercuts the entire THC program.

Every cannabis product naturally has a varying amount of THC in it. It varies from strain to strain, product to product, and even according to the methods use to process the cannabis. Part of the draw, at least for patients, is that you can experiment with different strains, product types (i.e. concentrates versus flower), combinations of products, micro-dosing, and so on, to give you just the right experience and effects in every situation.

If you impose a THC cap, this effectively undercuts much of the medical cannabis program.

For instance, the most potent cannabis products are the concentrates, which include wax, rosin, resin, and oil cartridges. As you might guess, these products contain concentrated amounts of THC. However, even if you consumed copious amounts of concentrates at once, there would be no danger of overdosing. At worst, the individual would experience a more intense high than he or she is comfortable with (I’ll touch on this again in Problem 5).

Problem 3: Not everyone wants high-THC cannabis products.

It seems that Dr. Berry — or anyone else pushing for the THC cap — assumes we walk into a dispensary and default to buying whichever product has the highest THC content when everything I’ve heard from people who actually participate in the medical cannabis program indicates that this couldn’t be further than the truth.

In fact, I’ve heard a number of cannabis users say THC content isn’t a good indicator of the experience you’ll have with a particular strain or on a particular product. If nothing else, this tells me there’s a fundamental lack of understanding of medical cannabis and among many on the board.

The thing that I really want to get across, especially to any decisionmakers who might be reading this, is that cannabis products have a wide variety of THC percentages naturally. This often becomes a fundamental part of medical cannabis programs and key to the flexibility and versatility of medical cannabis; patients have the freedom to explore different strains and product types at different times to find the right effects.

Problem 4: It will make things harder for growers (and potentially more expensive for patients).

If cannabis products cannot contain more than 10 percent THC, grow operations will going to have to implement [what are sure to be substantial and expensive] changes, likely including but not limited to new equipment, personnel, and systems. Considering how young the West Virginia medical cannabis industry is at this point, this could be a huge problem for smaller growers in particular.

As someone who doesn’t grow cannabis, I can’t speak too much on this perspective, but I wanted to at least mentioned it. As someone who buys medical cannabis, I would expect that any expenses associated with implementing new equipment and processes at these grow facilities will translate to price increases for patients, which is unnerving since pricing is currently relatively high due to this still being so new in West Virginia compared to other states.

Problem 5: We’re adults. We can make adult decisions for ourselves.

When you take too much cannabis, you end up getting a bit too high. The worst case scenario would be for the experience to be unpleasant and, sure, you might lose your lunch, so to speak. In terms of actual risk of death, we’re talking about chances so infinitesimal as to be virtually impossible. Yet some look at the THC limit as a way to ensure that individuals can’t become more high from cannabis than they’re comfortable with or intended.

It’s nobody’s job but my own to police how much cannabis I use, just as it’s nobody’s business how much wine I drink at dinner. Given how safe cannabis has proven to be and how flexible it is as a substance, there’s nobody more knowledgeable about my body than me, which makes me the best person to decide how I medicate with cannabis.

Here’s the thing: When a behavior has a negative consequence, a logical person learns not to repeat that behavior again. So if someone consumes too much cannabis and gets too high, then that person learns from the experience and takes it into consideration the next time he or she doses. No harm, no foul.

Problem 6: The people deterred by the THC cap aren’t participating in the medical cannabis program.

I’ve touched on this a couple of times throughout this letter, but I want to give special mention to it here because it’s important. Look at it this way: When someone wants to get drunk yet only has beer available, that person has two options: drink more beer to achieve the desired effects or don’t drink at all. While there’s no way to know for sure, I would expect the THC cap to result in a similar situation; although it’s meant to restrict the amount of THC a person can consume, it really just forces people to consume larger quantities to achieve the same effects, which is similar to what you see as individuals start to build a tolerance over time.

Those pushing for the THC limit seem unable to recognize that those of us who use medical cannabis aren’t drug-seekers looking to party [unless we also happen to have one of a list of approved medical conditions] as each patient is approved using medical records and real diagnoses. At least with how things are set up now, there’s no walking into a dispensary on a whim to buy a product and get high. (For me, the whole process — i.e. getting my medical documents, making an appointment with a medical cannabis specialist for a referral, and then finally getting my approval — took about six weeks from start to finish. Needless to say, you don’t decide to start using medical cannabis products on a whim.)

Imposing a THC cap only punishes patients since anyone who might be deterred by the THC cap aren’t even able to get into medical cannabis dispensaries… unless they have a documented diagnosis of one of a limited number of health issues, of course.

Problem 7: The gateway hypothesis is not a valid argument. Period.

The gateway hypothesis is incomplete at best and invalid at worst. Based on the evidence we have currently, it’s not cannabis use but, rather, the use of any substances during early adolescence that is a better indicator of drug use during adulthood.

But until there’s been more research in this space to move the needle one way or the other, the gateway hypothesis is a non-issue.

Problem 8: The THC cap won’t make cannabis more or less accessible to adolescents.

For anyone who’s unfamiliar, diversion is a term that refers to when substances obtained through legal channels end up in the hands of recreational drug users. It’s one of the only arguments against medical cannabis that I actually agree, specifically as it relates to accessibility to adolescents.

I’d assume that many who want to impose a 10-percent THC limit are coming at this in the same way: Once a medical cannabis program makes cannabis accessible to people of legal age, more and more people are going to be using medical cannabis while living with people who are underage and who could potentially get their hands on medical cannabis products with no more difficulty than sneaking alcohol from a parent’s liquor cabinet.

In my circles, people are generally aware that I’m supportive of medical cannabis yet they’re often surprised that I’m so staunchly against adolescent cannabis use. They’ll ask, “Isn’t that kind of hippocritical?”

But it makes perfect sense to me.

The adolescent brain is still actively developing, both psychologically and physically. Although a personal legally reaches adulthood in the United States at age 18, the brain doesn’t reach full maturity until somewhere around age 25. This is important because adolescents who get into substance abuse are at risk of chemically interfering or inhibiting their own neurological growth and development.

So when I look at it from this perspective, I can almost begin to understand how a THC cap could seem like a failsafe, effectively ensuring that adolescents don’t get their hands on high-THC products by ensuring that high-THC products can’t be produced and sold.

Although this feels like treating a hangnail with amputation, it’s the best argument I can see in favor of the THC cap. Even so, imposing a THC cap isn’t the correct response.

Even the strongest cannabis doesn’t compare to some of the other substances that adolescents may find in their own homes. I would go so far as to say that adolescents living with adults who use medical cannabis but do not drink or use other substance are far safer than adolescents living with adults who drink alcohol frequently but vehemently oppose medical cannabis.

Problem 9: Anyone set on high-THC product can still buy it on the street.

Imposing a 10-percent THC limit on medical cannabis products only affects state-sanctioned products. What about all the cannabis still being grown, distributed, and sold on the street?

When you think about it in this way, the THC cap almost becomes comical because anyone who’s intent on using cannabis products that aren’t capped at 10 percent THC content will just look elsewhere. It wouldn’t surprise me if a number of patients responded to the THC cap by canceling their medical cannabis licenses in protest.

It could also force growers to close their doors due to so few medical cannabis patients being willing to buy products limited to 10 percent THC.

~*~

As of this writing, I have been using medical cannabis for about two months. In that time, I’ve have the opportunity to try more than 20 different indica, sativa, and hybrid strains, each offering a unique experience and effects.

Because of how medical cannabis programs have worked, I had the freedom and flexibility to experiment. I learned to figure out exactly the right dose for me, not just day-to-day but moment-to-moment. Compared to pharmaceutical medications, cannabis has an almost dizzying amount of dosing flexibility; it’s been a godsend in situations when I’m experiencing breakthrough pain between full-on flares.

I’ve made a lot of interesting discoveries over the past eight weeks, and I’ll share a handful of them with you here.

• Because sativa-dominant strains are energizing, I’ve been able to reduce my coffee intake by half and my sugar intake by almost as much.
• If the muscles around my skull start to tighten, I know a severe headache or migraine is coming. But after just a small dose of an indica strain, those muscles loosen and the impending headache quickly fades away.
• Some situations call for bigger (or smaller) doses of cannabis while others call for specific strains. For instance, indicas are my go-to for pain relief, but I’m probably not going to medicate with an indica just before a job interview. If anything, I might micro-dose with a hybrid strain, just to take the edge off.
• Micro-dosing tends to give me the most flexibility during the daytime; it allows me to maintain the therapeutic benefits while minimizing euphoria.
• Although there are a number of strains with a high THC percentage, strain type — i.e. indica, sativa, hybrid — tells me the most about a particular strain. With some of those high-THC strains, I benefit from having the full spectrum of dosing options; I can either micro-dose with small hits to manage my arthritic pain or bigger hits to manage gout pain.

Many of these discoveries wouldn’t have been possible if the products that I’ve been using couldn’t contain more than 10 percent THC.

So why am I writing this letter? And what am I hoping to accomplish?

For a number of years, Dr. James Berry, associate professor and medical director at the West Virginia University School of Medicine, has been seemingly on an anti-cannabis crusade. During a presentation in 2019, Berry drew a parallel between alcohol and cannabis with a reference to Prohibition, implying that when alcohol was made illegal in the United States in the 1920s, alcohol-related injuries and illnesses decreased. (Is he oblivious to the horror stories of people dying or getting sick from the bootleg alcohol that circulated during Prohibition? It ended up being far more dangerous than legal alcohol and is why Prohibition ended after a decade.)

Berry’s perspective seems to be informed largely by experiences with patients of his who used cannabis and, according to Dr. Berry, exhibited signs of depression and psychosis. But I would caution Dr. Berry against making generalizations based on his experience with some of his patients.

For every broken bone in a hospital emergency department, there are probably hundreds of sprained ankles being nursed from home. In my experience, people tend to put off medical care as long as possible. Incidentally, this means doctors primarily treat patients whose symptoms are more extreme. This tells me that the “psychosis” and other afflictions he believes he observed were probably outliers who don’t represent the typical effects of cannabis.

To my knowledge, the only point on which Dr. Berry and I agree is that we need more research into the effects of cannabis. Although I already feel confident in medical cannabis based solely on my own experiences, more information is never a bad thing. Additionally, I’m confident that more research will show just how far from reality Dr. Berry’s perspective is.

Short of changing the contents of products, I’m sure I would support any precautions that Dr. Berry or anyone else may want to put in place to ensure that cannabis doesn’t fall ino the hands of children. The only [negative] effects to result from restricting THC content in cannabis products would be to those using cannabis for legitimate medical purposes. Anyone who might be deterred or discouraged by a THC cap are supposed to be weeded out by the patient licensing process. So then we’re looking at a THC limit that’s just going to make things worse for medical cannabis patients.

Here’s a fun experiment: Put a representative outside every dispensary currently open in West Virginia to poll each person as he or she leaves. I’d bet an ounce of top-shelf mecical cannabis that you’d get a similar response from everyone in the program: The THC cap is the last thing any medical cannabis patient wants… but it’s not about having stronger product to get a stronger buzz.

If Berry’s THC limit gets approved and I’d never done what I could to stop it, I would kick myself. Honestly, I’m not sure how much any single person can move the needle, but I had to try.

In the words of Charles R. Swindoll, “Life is 10 percent what happens to you and 90 percent how you react to it.”