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Brian Lehrer: Brian Lehrer on WNYC. Now, we'll complete a three-part series for the first week of legal recreational cannabis sales in New Jersey. Last Thursday, day one, we talked about how people in or applying for certain kinds of jobs might still have their employment be dependent on negative cannabis tests, even though using is legal under state law now. On Monday after the first weekend that the dispensaries were open, we opened the phones on the experience of shopping for cannabis legally for the first time.

Today, anticipating new cases of cannabis use disorder in New York and New Jersey and how to treat and minimize them. Maybe you've seen on TV that New York State launched a series of ads, promoting a website called Cannabis Conversations around some of the issues with legalization. One of the sections on that site is about health effects. One of the sections in that is about what's called "cannabis use disorder."

Like with lots of things that are legal, it can be used or abused, used in a pretty safe and healthy way, or lead to problems. With me now is Dr. Chinazo Cunningham, MD, commissioner of the New York State Office of Addiction Services and Supports and professor of Medicine, Family and Social Medicine, and Psychiatry and Behavioral Sciences at the Montefiore Health System and the Albert Einstein College of Medicine. Dr. Cunningham, thanks for joining us for this. Welcome back to WNYC.

Dr. Chinazo Cunningham: Thank you, Brian. I'm so happy to be here.

Brian: When is someone just a cannabis user and when do you say in your field that they have cannabis use disorder?

Dr. Cunningham: Really, the hallmark of having any substance use disorder is really about loss of control of that substance and continued use of the substance despite negative consequences. Cannabis use disorder is a clinical diagnosis made by clinicians. There's a list of 11 criteria that exist and then depending on the number of criteria people meet, they either have mild, moderate, or severe cannabis use disorder.

Just some examples of when we talk about loss of control, that includes things like craving cannabis or trying to cut down or stop cannabis but been unsuccessful in doing so, or using cannabis in larger amounts or for longer periods of time than intended. Then in terms of negative consequences, it's that cannabis use interferes with jobs or parenting. It impacts relationships negatively that people continue to use in hazardous conditions like driving under the influence, or that it has negative physical or psychological consequences and then people continue to use despite this.

Brian: Listeners, we can take some calls on cannabis use disorder for the New York State Commissioner of Addiction Services and Support, Dr. Cunningham, 212-433-WNYC. If you have experienced cannabis use disorder, you can tell a little of your story and maybe even give advice to, potentially, new users under legalization how to avoid it, or ask about your own situation or of someone you know if you're unsure, if you have a problem, or anything you want to ask at 212-433-WNYC, 212-433-9692, or a tweet @BrianLehrer.

Just one thing, listeners. Remember, this is not to debate legalization. The states have had that debate. Legislators and voters have decided for New York and New Jersey and Connecticut, all three states in our core listening area, this is about managing risk for some people in the legal environment. 212-433-9692 or tweet @BrianLehrer. Dr. Cunningham, as you know, we have such a big problem in the US these days with opioid addiction, which leads to many, many opioid-related deaths even. I think cannabis is not classified as addictive in that same sense, but how do you categorize or distinguish between how people can become dependent on various substances?

Dr. Cunningham: I would say just to start that cannabis is addictive and can be addictive just like nicotine, just like opioids, just like alcohol. I think one of the things when we talk about opioids and really any substance is that there is physiologic dependence. What that means is that in some situations, the body gets used to that substance. Then if the substance is not taken, there can be a withdrawal syndrome. We see that with opioids, we see that with alcohol, and we can see that with cannabis as well.

That is also one of the criteria for the diagnosis of a substance use disorder, but it's only one. I think sometimes particularly, we've seen this with the prescription opioids, that there's a conflation between what it is to have an opioid use disorder and what it is to take prescription opioids and for the body to become physically dependent on it. Again, that can be one of the criteria for a substance use disorder, but that in itself does not equal addiction.

Brian: What kinds of withdrawal symptoms do people experience with cannabis use disorder?

Dr. Cunningham: There's a range of symptoms. They can include things like becoming more irritable, losing sleep, having some tremors. Certainly, cravings is part of it. Typically, what we also see too with this is that tolerance can develop so that people need to take more of the substance in order to get the same effect.

Brian: Let's take a phone call. Ben in Manhattan, you're on WNYC. Hi, Ben.

Ben: Hello, Brian. My name is Ben. I'm a longtime listener, a first-time caller. I was just absolutely stunned and so grateful to hear that this topic was being discussed today. I'm a person in recovery from cannabis use disorder. I've been away from my drug of choice for four and a half years. I could actually give you the day count if I looked at my phone. This is a topic that so few people are talking about, especially as legalization becomes more prevalent.

I don't have any opinions on that that I want to share right now, but I think that growing up as a child in the '80s, this was always something that was looked at as a warm and fuzzy, harmless sort of a thing. For me, it led to nearly two decades of really out-of-control use where I knew that I had a problem, but I couldn't find a way to stop it. While there are many ways, the way that worked for me was I found a 12-step organization called Marijuana Anonymous that a lot of people don't know exists.

Basically, it's an outgrowth of the 12-step community that started with Alcoholics Anonymous back in the '30s and '40s. There is a very robust community of people who are peer-to-peer support with our own methodology. I just wanted to plug it because if you're listening to this segment, chances are, you know somebody who maybe can't control their use. Marijuana Anonymous is the resource that gave me four and a half years of freedom and a life beyond my wildest imagining. Thank you for taking on this topic and thank you for taking my call.

Brian: Thank you for making it, Ben. We really appreciate it. Well, Dr. Cunningham, what has the experience from earlier legal states taught you about how patterns of cannabis use disorder change after legalization? First, do the sheer numbers of people with the disorder tend to go up?

Dr. Cunningham: Yes, so I would start by saying that, over time, what we've seen is that the amount of use has gone up. That's been, really, a pattern that we've seen over the last 20 years or so. Then that use has been increased more in states that have legal cannabis and then, not surprisingly, that we would expect that cannabis use disorder would also go up if use goes up. Right now in the United States, among Americans, cannabis use disorder is seen in about 5% of the population, so it's hard to know--

Brian: 5% of the total US population has cannabis use disorder? That's a huge percentage really, 5%, isn't it?

Dr. Cunningham: Well, it is, but if you look at, for example, alcohol use disorder, that's 10%.

Brian: 10 out of every 100 Americans has alcohol use disorder?

Dr. Cunningham: Sorry, wait. Yes, that does sound [chuckles] a lot. I have to double-check my statistics, but I think maybe that's among people who use regularly.

Brian: Yes, that sounds probably more right.

Dr. Cunningham: Yes.

Brian: I guess we're guessing here at what that number means, but maybe 5% of people who use cannabis at all might develop a cannabis use disorder. You're saying that percentage stays the same in legal states roughly. Because more people use once it becomes legal and you could just go into a store and get it, then the number of people with the disorder goes up?

Dr. Cunningham: Yes, that's what we would expect that as the number of people who use the substance goes up that we would expect that the number of people then who develop a use disorder also goes up.

Brian: Do different kinds of people statistically develop cannabis use disorder than in illegal environments?

Dr. Cunningham: We know that cannabis use is, for example, about the same in Black individuals as in white individuals. We know there are some differences by race and ethnicity, for example, that Asian individuals have less cannabis use than white or Black individuals. The development of a use disorder is complicated as you might expect, right? A lot of it has to do with genetics. It has to do with environment. It has to do with availability of the substance. If you put that all together, then we would expect that there would be differences based on those factors.

Brian: Let's take another call. Ben in Crown Heights, you're on WNYC. Hi, Ben.

Ben: Hi, I had a lot of trouble with cannabis use in high school. I used it way too much in an unfathomable amount every time. I'm really appreciative that this is being talked about. I do think there is some level of addiction involved in it, but I find the characterization of comparing it to opioids or nicotine is irresponsible in just a yes or no sense. Sure, there are some addictive qualities to it, but I was able to stop once I wanted to. It was really about getting my head around that and making it feel valuable to do so. Decades later, I'm able to go back to it on a very much more regulated way. It's not really a problem for me. That's dramatically different from the stories you hear about heroin and cigarettes and alcohol.

Brian: Dr. Cunningham?

Dr. Cunningham: Yes, I think that's an interesting perspective. What I would say is that all these substances, nicotine, alcohol, opioids, cannabis, really change the-- When people have developed a substance use disorder, it really changes the chemistry of the brain. It's not really just the choice once it becomes a use disorder that it really requires treatment. The body really becomes physiologically dependent on it.

I think it's a medical condition. Really, what we want to get away from in the society is thinking that it's about somebody who's strong or weak or it's about a moral shortcoming because it's really a medical condition that requires treatment. Now, does that mean that people need to go to complete abstinence? I would say in order to regain their life and their function, I would say most of the time probably, but not necessarily all of the time. It's great to hear the story here, but I don't know that everybody can do that.

Brian: This might be instructive for other listeners. Since you said you are able to just decide to stop using cannabis or stop using it in a problem way once you realize you had a problem, I guess Dr. Cunningham was saying, if you were able to do that, then you may not have had the disorder as they tend to define it. What was the trouble if you want to talk about it again, just for the edification of other listeners who may find themselves in a similar circumstance, that you're describing as trouble with it, short of not being able to stop?

Ben: Sure. Well, I'll just say, getting to stop it, it wasn't just a, "Oh, okay," deciding to, "Okay, now, I'm going to do it." It took a long time. In fact, I've always thought that the psychological addiction of it was what kept me from realizing that stopping was what I needed to do or the things that I was displeased with in my life or related to my use. That's essentially what was going on. I think I was unable to have personal relationships with people the way I wanted to. I was unable to act in a really genuine manner without it and then eventually with it. It just seemed like I had to stop. I didn't stop immediately. It took years.

Brian: Ben, thank you for your story. That's probably helpful to some of the listeners out there. Do you want to make a distinction, Dr. Cunningham, that he made between psychologically dependent and physically dependent?

Dr. Cunningham: Yes, I think that they're intertwined, right? There's certainly an anticipation that people feel with substances that if they don't have it, if they don't use it, they're going to feel bad. If they are physiologically dependent on it, they will develop withdrawal symptoms without use. Again, with cannabis, that can be feeling anxious, irritable, angry. Part of that is maybe the anticipation that that's going to happen or part of it may be the realization that that happens. They're certainly intertwined here. Again, that is one of the elements, the criteria that is part of the diagnosis of a use disorder.

Brian: We're talking about cannabis use disorder with Dr. Cunningham, who is the commissioner of the New York State Department of Addiction Services and Supports, part of our first-week rollout series with legal cannabis sales for the first time in our immediate area. Our previous segment was much more fun, you might say, on Monday. People talking about the experiences that they had shopping for legal cannabis for the first time over the weekend in New Jersey.

Our earlier segment was about just the awareness that people might need to have in some job categories that you still might get tested for cannabis to get or to keep a job even though it's legal to use in the state right now. That was Segment 2. That was Segment 1 actually. The call-in on dispensaries was Segment 2. This is Segment 3 on the one-week mark or at the one-week mark of legalization in New Jersey. Babar in Norwalk, you're on WNYC. Hello, Babar.

Babar: Hi, Brian. A few years ago, I might have agreed with your previous caller, don't throw in cannabis, marijuana with some of these other drugs. I didn't realize this when the market was being legalized that there was so much of it [inaudible 00:17:54]. The flower, I agree. It's not as addictive even though I think there are people who have issues with it.

You have to be outside to smoke it in certain situations. The environment does control your addiction maybe to some degree. Now, they have drops for drinks. They have tablets you can pop like aspirin, vaping, dabbing, the waxes, the hash. This stuff was never available to most of us up until a few years ago at best. Some of these things, I'm seeing for the first time in the last year or two.

These are hardcore concentrates. If you saw someone smoking some of this and you didn't know better, you might think they are smoking heroin. They use the butane lighters to heat up glass or metal until it's bright red and then you take a quick puff or whatever it is. I do see an addiction problem coming in the next few years, not soon. Since the market is just being legalized, it's just opening up, these concentrates, I think, are going to be a massive issue in the long run.

90% concentrate. For the people in the know, some of us are baffled by what the hell is going on. From TV shows, it looks like crystal meth in some forms if you see the pictures of it, the little jars that comes in. That's what I would say. I don't think marijuana has been a big problem for a long time, definitely wouldn't have thrown it in with opioids, heroin, cocaine, this, and that.

Brian: Maybe coming with some of these new forms, these concentrates. Is that something you're familiar with, Dr. Cunningham? The wax and dabs as he calls them and highly-concentrated marijuana products that people use in different ways and whether experience from other states where these are sold indicates that they may produce cannabis use disorder more easily or differently?

Dr. Cunningham: Yes, this is a really important point here that when we talk about cannabis, it's not one thing. From a clinical standpoint, I think we're really focusing on the THC content and the CBD content. What we do know is that over time in this country, really over the last few decades, the amount of THC that is seen in cannabis has increased. That's even regardless of legalization. These products that are very, very high in THC are ones that, really, we see the most negative consequences from. Those are where we see people can develop psychotic-like symptoms.

Certainly, it can be at risk for developing a cannabis use disorder. I think this is where it's important in terms of thinking about policies in the legalized market is that we have the ability to know what's in the product, to test the product, know what's in them, and then to be able to manage how much THC is in the products. I know that in Colorado, there have been efforts to reduce what the potency level can be for cannabis products. That is absolutely something that we're following and is really about the THC content with the really high levels leading to some negative consequences.

Brian: Babar, thank you very much for your call. Do you know, Dr. Cunningham, if some of the new tax revenue from legal cannabis sales is going to be dedicated to treatment services? I know you can always speak for New York State because that's where you're the commissioner, but also you're on the medical side, you're not on the revenue side, and things like that. I don't know if you know the answer. Is there some of the revenue that's going to be dedicated from these tax receipts?

Dr. Cunningham: Yes, we do know that, that there is some money that will be coming to the Office of Addiction Services and Supports from the taxation of legalized cannabis in order to address both prevention and treatment of cannabis use disorder. Brian, I also just want to mention. I know we had talked earlier about the numbers in terms of cannabis use disorder. In fact, those numbers are correct. This is from a publication from the National Survey on Drug Use and Health, showing that 14 million Americans have cannabis use disorder, which is 5%, and that 28 million Americans have alcohol use disorder, which is about 10%.

Brian: That is a lot of Americans with substance dependency disorder, isn't it?

Dr. Cunningham: Yes.

Brian: Well, I see the commercials for all these online gambling sites now, now that that's been legalized in New York and New Jersey. They often tout how much fun it is and how you can make money. They give you credit to make some debts when you first sign up to get you in the habit, I guess. Then there's almost a throwaway line at the end that says, "Gambling problem? Call this hotline number." Like, "Don't call us. We're roping you into this world that can cause addiction, but go see some agency if you get too hooked." Again, this is not to argue against legalization of online gambling or cannabis, but who deals with cannabis use disorder when it occurs in a legal environment?

Dr. Cunningham: In terms of thinking about public health, we have our agency, the New York State Office of Addiction Services and Supports, which deals with and oversees, regulates, funds, and supports addiction services across New York. We really oversee all addiction and so that's gambling. That's also substances, so alcohol, cannabis, cocaine, opioids. We have systems in place. We're monitoring data.

When we implemented the online sports betting, we definitely worked with our partner state agencies to make sure that people knew that there was access to gambling treatment if they had a problem gambling. We've been monitoring our HOPEline, which people can call if they have any problems with any addiction or any questions about it to be well-positioned to address any potential increase in problems.

This is something that we're doing with cannabis as well. We're working with other state agencies as a partnership. We're going to be closely monitoring calls, so our HOPEline. We're preparing our providers, making sure that they understand what legalization of adult-use cannabis is and that they're ready to provide treatment as needed. This really is a partnership. We want to make sure that if there are problems with these changes in the policies that we're certainly ready and able to address them.

Brian: Listener asks following up on the previous caller about dabs and wax and what you said about concentrated. Let's see. Yes, listener asks skeptically, "We will limit alcohol concentration in liquor too?" Of course, not limited in the cannabis, but you're talking about that being a danger. A number of people are tweeting, "Hey, what about alcohol? Isn't alcohol so much worse in one way or another?" Certainly, the statistics that you cited show, there are a lot more people with alcohol problems than can cannabis problems, but what about that comparison in general that people may want to make on one side or another?

Dr. Cunningham: Yes, so we have a lot of legalized substances that can be harmful. Let's put nicotine in that batch too, right? We know a ton of the harms that happen with smoking cigarettes. Alcohol is in there too. We have tons of data that show the potential harms of alcohol, including on the body medically, the liver cancers. There are just a number of conditions that alcohol is associated with, not to mention driving and effect on relationships and jobs, et cetera. This is also true for prescription medication. We've seen this with prescription opioids, prescription benzodiazepines like Valium and Xanax.

We have a lot of things that are legal that can lead to potential harms, but they can also be beneficial. I think that really what we have to do is take a look at the risk and benefits and make sure that from a public health standpoint, we're collecting the data so that we can see if problems increase. We can be able to address them. We can put preventative efforts into place and then we can change our policies accordingly. This is really not unique to cannabis that there are other substances, nicotine, alcohol prescription, opioids, or benzodiazepine that are really very similar.

Brian: Before we run out of time since your office also deals with gambling addiction and that's recently legalized in New York, few years earlier in New Jersey. I don't know if you look across the state lines at them, but have you seen an increase in problem gambling in New York since that legalization? It's really recent, so maybe it's too early. What are you seeing?

Dr. Cunningham: We are not seeing an increase in numbers really. I think, initially, we've been very closely monitoring our calls, for example, to our HOPEline. What we've seen is that the number of calls per month range in the 200 to 300 calls, so really not a large number of calls. When we look back over the past three or four years, those numbers are really no different than two or three years ago. It's still early as you said, Brian. This was implemented in January. We're now in April. We'll see, but we are closely monitoring this. We are working with, again, other state agencies on this to make sure that if people do develop problems, they know how to access services.

Brian: Dr. Chinazo Cunningham, MD, commissioner of the New York State Office of Addiction Services and Supports and professor of medicine, family, and social medicine and psychiatry and behavioral sciences at Montefiore Health System and the Albert Einstein College of Medicine. Thank you so much for joining us today. We really, really appreciate it.

Dr. Cunningham: Thank you so much, Brian.

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