Can We Acknowledge What the THC Cap is Really About? (TLDR Edition)

An Open Letter to the West Virginia Department of Medical Cannabis

My first experience with chronic pain was when I was 19.

I’d had throbbing pain deep inside of my left foot for several weeks and finally reached my breaking point. It was time to see a doctor.

“It’s a stress fracture,” the podiatrist told me at my first appointment, pointing to a specific spot on the x-ray image she had displayed on the computer screen. “Very common, I see it all the time. But it looks to me like you’ve also got a bit of arthritis.”

She’d advised me to follow up with my primary doctor so she can give me a referral to a rheumatologist, which is a doctor specializing in the treatment of arthritis. But before making it to my follow-up appointment, I was struck by another bout of severe pain.

It afflicted a similar area on the same foot although the pain was different this time. Whenever I stayed completely stationary, the pain was almost zero, but any sort of movement of the joint — not even from standing or walking but even just flexing my ankle in any way — triggered piercing pain. Ultimately, in addition to “a bit of arthritis,” I received a new diagnosis: gout.

In case you’re not familiar, gout is “a complex form of arthritis… characterized by sudden, severe attacks of pain, swelling, redness, and tenderness in one or more joints.” And it’s horrifically painful. Whenever I’m asked to describe the pain, I explain that it feels like you’ve taken your foot off at the ankle, rolled your cartilage in shards of glass like putting sprinkles on an ice cream cone, and then popped your foot back on.

No manner of medical care available to me, either now or then, nor the recommended dietary changes could curb my arthritic pain completely, which was the hardest part of the situation; at 19 years old, I had to make peace with periodic bouts of excruciating pain for the rest of my life, and there was nothing I could do about it.

[Want to read the extended version of this letter? Click here.]

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Did you know it’s basically impossible to overdose on cannabis? It’s true — there’s not been a single death attributed to cannabis. (By 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 that’s necessary to overdose are often measured in quantities so large as to be legitimately hilarious. According to one source, it takes “40,000 times the normal amount of cannabis” — which calculates to 1,500 pounds of marijuana. But equally importantly, all that marijuana must be consumed in 15 minutes or less to trigger an overdose. 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.

Cannabis isn’t a physiologically addictive substance in the way that opioids are. With opioids, you’re taking a drug designed specifically to attach to the brain’s opioid receptors, which is how painkillers achieve their pain-relieving effects.

We do have receptors in our brains specifically for cannabinoids, but cannabinoids are associated with psychoactive effects rather 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.

For decades, canna-connoisseurs repeated the same refrain: “If you can’t get addicted to weed, and if you can’t overdose on it, then what is there to worry about?” Years of research have shown that to not quite be the case, but the pendulum seems to be swinging too far in the other direction as is the case with the 10-percent THC cap.

Although the body cannot become physiologically dependent on cannabinoids or THC, cannabis is addictive in a different way. Recent research seems to indicate that cannabis is more habit-forming than addictive with withdrawal symptoms that rarely exceed irritability and mood swings. But according to WebMD, only 10 percent of cannabis users even have the potential to become addicted to cannabis.

From what I can see, there are just two ways for cannabis to realistically kill you. Option A is allergic reaction although only between 0.07 and 2 percent of all allergic reactions result in death due to anaphylaxis, which is when the throat closes and restricts the individual’s airway. This means if someone who’s using cannabis has an allergic reaction, then that individual is very likely to survive the encounter. (In terms of its potential to induce an allergic reaction, you’re about as likely to experience an allergic reaction from cannabis as you are to a food item that you’re trying for the first time.)

Currently, there’s no estimate for what percentage of the population is allergic to cannabis although common sense might suggest it’s a very small percentage. That brings us to Option B, which is a cannabis overdose. But as we’ve already discussed, it’s virtually impossible to overdose on cannabis. Instead, it’s more likely for an overdose to result from cannabis that’s laced with another drug.

The obvious question is: Do we know how much of the cannabis in circulation on the street is laced with other drugs? 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 although most believe it to be a fairly low figure.

But even a low percentage of laced marijuana puts tainted product in a lot of hands and could mean a lot of overdoses from people unknowingly ingesting fentanyl or other deadly drugs. This makes it a huge risk to buy cannabis — or any other drug for that matter — from a source who isn’t required to adhere to strict guidelines and regulations to ensure consumer safety.

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

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Regardless of where I fall — or you fall, or where anybody falls really — politically when you consider how safe cannabis is relative to other therapeutic substances, there’s not a compelling argument for taking away our ability to choose what’s best for us individually. It actually reminds me of another [much more unsettling] discussion that’s been taking place, which is abortion rights.

In my mind, the ability to have an abortion is essential, especially when you consider situations like when women need to terminate unsafe pregnancies. Obviously, the prospect of leveraging abortion as a form of birth control is problematic, but to take away women’s ability to choose feels like a fundamental violation of their 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. When the pros dramatically outweigh the cons, who am I — who are you? who is anyone? — to deprive someone of those benefits, especially when that person is an adult and the risks are so much lower than almost any other form of medicinal care?

Problem 1: This is about the opioid crisis, isn’t it?

If the opioid crisis showed us anything, medications prescribed by a doctor can be extremely dangerous. Although I can sympathize with legislators and policymakers who are nervous about cannabis due to the continued fallout from prescription painkillers, the thing to remember is that cannabis and opioids are two separate matters and should be approached as such.

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

Cannabis has been shown to be a very safe medication, particularly when it’s used responsibly by people of appropriate legal age. When the medical cannabis system is designed so that only those with a demonstrated need can access cannabis, what’s the problem?

If you ask me, it feels like they’re projecting their 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 that when someone walks into a dispensary, they default to buying whichever product has the highest THC content. In my humble opinion, this perspective is derived from the expectation that opioid users seek the most potent product available to them, which couldn’t be further from the truth when it comes to cannabis.

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 decision-makers 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 is 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 mention 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 higher 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 rational person recognizes that he or she shouldn’t repeat that behavior again. But the unique thing about cannabis is that, for the most part, the only risk of misuse is that you might experience stronger psychoactive effects than you’d intended.

Problem 6: Those deterred by the THC cap probably aren’t in the program at all.

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 — meaning they’d have to spend even more money — to achieve the desired therapeutic effects.

Those pushing for the THC limit aren’t recognizing that those of us who use medical cannabis have real diagnoses with medical records backing them up. And for drug-seekers, there’s no walking into a dispensary on a whim to buy a product for the express purpose of getting high due to the licensing process, which, from start to finish, took about six weeks for me. In short, you can’t start using medical cannabis products on a whim.

Imposing a THC cap only punishes the patients whose needs wouldn’t be met by products with low THC content.

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

The gateway hypothesis is incomplete at best and perpetuates dangerous misconceptions 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, I count the gateway hypothesis as a non-issue.

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

For the uninitiated, diversion refers to when substances obtained through legal channels — i.e. with a prescription — are sold or traded to recreational drug users. It’s one of the only arguments against medical cannabis that I actually agree with, specifically as it relates to accessibility to adolescents.

If you’re in favor of a 10-percent THC limit, then I assume you’re coming at it this way: A medical cannabis program makes cannabis accessible to people of legal age who have legitimate medical conditions. However, as more and more people use medical cannabis, it stands to reason that more adolescents will be living in close proximity to a loved one’s medical cannabis supply.

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 hypocritical?” But it makes perfect sense to me.

The adolescent brain is still actively developing, both psychologically and physically. Although a person is technically an adult at age 18 in many countries, the brain doesn’t reach full maturity until somewhere around age 25. This means adolescents who get into substance abuse are chemically interfering and even inhibiting their 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 substances are far safer than adolescents living with adults who drink alcohol frequently but vehemently oppose medical cannabis.

Problem 9: Anyone set on high-THC products can still buy them on the street.

Imposing a 10-percent THC limit on medical cannabis products only affects state-sanctioned products and the people who are licensed to buy them. 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 simply turn to illegal channels. In fact, I wouldn’t be surprised if a number of patients canceled 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.

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As of this writing, I have been using medical cannabis for about two months. In that time, I’ve had 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 related to my medical cannavis use 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, which, because I’m not using as much creamer and other add-ins, has also reduced my sugar intake.
• If the muscles around my skull start to tighten, I know a severe headache or migraine is coming. But if I microdose with an indica strain, I can get those muscles to loosen, which often stops the migraine from happening.
• There are situations that 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 microdose a hybrid strain to curb my pre-interview jitters.
• Microdosing tends to give me the most flexibility during the daytime; it allows me to maintain the therapeutic benefits while minimizing euphoria.
• The temperature at which you vaporize, or “vape,” cannabis often determines which effects you experience and to which degree you experience them. For example, vaping a lower temperatures — i.e. at or below 330 degrees Celcius — gives me more of the physical, or pain-relieving, effects while vaping at higher temperatures tends to bring out more of the psychoactive effects.
• 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 vocal about his opposition to medicinal cannabis. During a presentation in 2019, Berry drew an interesting, if not quite apt, parallel between alcohol and cannabis with reference to Prohibition, implying that when alcohol was made illegal in the United States in the 1920s, alcohol-related injuries and illnesses decreased. (Although I’d counter with the countless tales of people dying or getting sick from the bootleg alcohol that circulated during Prohibition, which was why it ended after only 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 experiences with those specific patients.

For every broken bone in a hospital emergency department, there are surely hundreds of cuts, scrapes, and sprains nursed from home. People tend to put off medical care as long as possible, only caving when they can’t deal with the pain any longer. For this reason, it’s commonly presumed that doctors primarily treat patients whose symptoms are most acute or severe. If this is, in fact, the case, then the “psychosis” and other afflictions that Dr. Berry observed were likely outliers that don’t represent the consensus, or else other variables could not or were not able to be detected.

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 based on my own anecdotal evidence, more information is never a bad thing. Additionally, I’m confident enough to wait for more research before we make any rash decisions. (And I expect more research will show just how far from reality Dr. Berry’s perspective is.)

Outside of manipulating or restricting the actual products, I would probably be open to any precautions that Dr. Berry recommends to ensure that cannabis doesn’t fall into the hands of children. But restricting the THC content in cannabis products would simply hurt those who are using cannabis legitimately and safely. Again, anyone who might be deterred or discouraged by a THC cap is 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 more difficult 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 medicinal 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.”