In defense of being ‘Cali sober’

The phenomenon of being “Cali sober” is taking the recovery world by storm. It is defined as dedicating oneself to a life free of drugs and alcohol — except for cannabis and other psychedelics. (Though many consumers don’t think of cannabis as a psychedelic, policy experts often consider it one because of its effects.)

Hardcore proponents of abstinence-based recovery, such as Alcoholics Anonymous, dismiss the Cali sober approach as dangerous and “not really recovery.” Those who make their livings by treating addiction the traditional ways, such as addiction specialists and representatives of our country’s sprawling rehab industry, also dismiss the idea. For example, the Cleveland Clinic maintains a blanket ban on physicians certifying patients for medical cannabis for any condition (even though medical cannabis is legal in Ohio). One of their addiction psychiatrists told the clinic’s website, “After all, you’re not sober if you’re still using mind-altering substances. You’re replacing one addictive substance with another. It’s a slippery slope.”

But the slippery slope holds no water. I am 15 years into recovery from a vicious addiction to prescription opioids. I’m also a physician and have had the privilege of treating thousands of patients for substance use disorders, ranging from doctors surreptitiously snorting oxycodone to people living on the streets. Through these experiences, I’ve given a great deal of thought to the issues surrounding what predisposes one to addiction, what constitutes an addiction, how we get addicted, and how we recover. The best definition of addiction that I’ve heard, to date, is a simple one, “continued use, despite negative consequences.”

Yet this definition raises some crucial questions: Continued use of what? All drugs, or just the one(s) that derailed your life? For how long? For life?

For nearly a century, the recovery community has largely followed a line from Alcoholics Anonymous: that recovery means abstinence from all drugs and alcohol, completely and forever (except, of course, for tobacco and caffeine, which are considered “good drugs” and are freely allowed at 12-step meetings).

Unfortunately, this binary and ideological approach has an extremely low success rate — by one estimate, 5%-10% for AA. Its rigidity alienates many and is mainly based on historical tradition rather than science. It has very little to do with our modern understanding of addiction, the new treatments we are developing, or the realities that our understandings and treatments of addiction have greatly evolved since the “Big Book” of Alcoholics Anonymous was written in 1939.

It’s time to update that thinking. It isn’t cheating to use medicines or other substances to maintain recovery. In fact, anyone who wants to enter and stay in recovery mainly must find a way to eschew the continued use of the specific drug that derailed your life in a way that is causing ongoing distress.

My definition is more consistent with current scientific thinking about recovery, which includes the use of modern, lifesaving medications that help people overcome the biological components of their addictions. My definition is also more inclusive, and humane. Offering a bigger recovery tent allows more people to feel welcome and safe. This can save lives.

There is no firm scientific basis for the “abstinence only” models of recovery, which have engendered generations of slogans and platitudes that people like me have had to repeat over and over, when forced into rehab, as I was for 90 days. We sat in a group and chanted, “one is too many and a thousand is never enough” as a totem against future drug and alcohol use. This experience, to me, was so boring and mindless; it was enough to make you want to use drugs again.

Moreover, this approach is about as far away from science as one can get on planet Earth. The most convincing study I found, published in JAMA in 2014 showed the opposite:

“As compared with those who do not recover from an SUD [substance use disorder], people who recover have less than half the risk of developing a new SUD. Contrary to clinical lore, achieving remission does not typically lead to drug substitution, but rather is associated with a lower risk of new SUD onset.”

In other words, the tools, insight, and experiences you gain from the process of getting into recovery from one addiction can be protective against other addictions, so one may be at less risk with a different drug than an addiction naive person might be. None of this is definitively settled, but it is intriguing and certainly is consistent with the use of alternative treatments — such as cannabis and psychedelics — to maintain and support one’s recovery.

It is important to state that 12-step programs are quite effective for a self-selected group of people who enjoy these meetings, who relate to them culturally, and who find them invaluable to sustain their recoveries. If someone chooses abstinence, and it works for them, that is something to be supported and celebrated. Yet, there is no rationale or evidence to impose this model on all people seeking recovery.

The first public challenge to abstinence-only recovery paradigms came with widespread adoption of methadone and Suboxone (buprenorphine) to treat opioid use disorder. In short order, stories started filtering out about people being hassled at 12-step meetings for using Suboxone or methadone. People were told at recovery meetings, “you aren’t really in recovery if you are taking methadone/Suboxone – you’re just swapping one drug for another.” I’ve seen people say things along these lines at Narcotics Anonymous meetings. Yet the clinical utilization of Suboxone and methadone results in a 50% reduction in both overdosages and death from overdose. Recovery has to be about the outcomes and about saving and improving lives.

What happens when you go a step further, beyond Suboxone and methadone, and not only challenge the abstinence-only model, but challenge it with medicines/drugs that have been deliberately stigmatized by the war on drugs, such as cannabis and other psychedelics? To many 12-steppers and addiction psychiatrists, the inclusion of cannabis — a “bad” drug — in any talk of “recovery” from addiction is heresy. It bucks against the decades of inaccurate messaging we’ve been given that cannabis is highly addictive and extremely dangerous. It can be difficult for them to understand the idea of Cali sober because many don’t have lived or clinical experience treating people with cannabis, and don’t have a realistic, nuanced view of the relative benefits and harms of cannabis use. They have only been exposed to magnified versions of the harm and have been shielded from discussions of benefits.

We are in the process of a vast societal reevaluation of the relative benefits and harms of cannabis, with public acceptance of both medical and recreational use growing yearly. Using medicinal cannabis to transition away from more dangerous drugs, such as alcohol or heroin, is an increasingly popular and accepted form of harm reduction. I have had tremendous success in my clinical practice transitioning people from both medicinal opioids and alcohol to cannabis. I find cannabis to be particularly efficacious, because it can help treat or palliate many of the symptoms that may have helped incite and fuel the addiction to these other drugs in the first place, such as anxiety, insomnia, chronic pain, and trauma.

It is important to note that cannabis certainly is not without its own set of harms. Cannabis use is best avoided by teenagers (due to the concern about the health of their developing brains), by women who are pregnant or breastfeeding (due to concerns about effects on the fetus/newborn), before driving, or in patients with a personal or family history of psychosis (as cannabis can destabilize these patients). But the best way to prevent use by people who are at risk is careful regulation and education rather than through criminalization, which drives drug use underground and makes it, on the whole, vastly more dangerous.

In no particular order, the critical components of a healthy, stable recovery from addiction are insight, humility, connection, mindfulness, and gratitude. As we focus on the present, connect with others, and approach the world with kindness and humility, we are happier and stronger, and this leaves much less room for the drugs to settle back in.

These are exactly the traits within us that cannabis helps foster, which is why it so powerfully aligns with the personal recovery plans of so many recovering people. To quote the astronomer Carl Sagan, the smartest person I’ve ever met to date (and longtime friend of my father, an academic who was early to challenge popular myths about cannabis):

“The illegality of cannabis is outrageous, an impediment to full utilization of a drug which helps produce the serenity and insight, sensitivity and fellowship so desperately needed in this increasingly mad and dangerous world.”

It’s notable this language so thoroughly overlaps the language in the 12-step programs, which are fundamentally based on “serenity and insight, sensitivity and fellowship.”

If people have surmounted their addictions and are back to work, healthy, and living fulfilling, meaningful lives, what does it matter if they are abstinent, on cannabis, using Suboxone, or microdosing with psychedelics? One may yearn for a perfect world in which we would all do yoga, eat tofu, and meditate, where no one feels the need to rely on a drug or a substance to help get us through the day. Yet, there are very few, if any, societies that have existed without the use of one psychoactive drug or another.

Addiction is a deadly consequence of an ugly confluence of distress and drug use that needs to be addressed with empathy, compassion, and evidence, not with judgment, stigma, and adherence to old beliefs that aren’t borne out by research. Every path out of addition and into safe, stable recovery is unique to the person walking it. But all of us who are recovering from addiction nourish and support one another, not to be divided along lines of rigid approaches and inflexible ideologies.