Humanity has always had a complicated, often contradictory relationship with psychoactive substances. Across cultures and centuries, people have turned to intoxicants for healing, ritual, socialization, recreation, and escape—while societies have alternately embraced, feared, outlawed, and medicalized them. Our collective experience is marked throughout history by recurring cycles of enthusiasm followed by backlash, with each phase leaving its own lessons etched into public policy and cultural memory.
Many ancient civilizations used psychoactive plants in religious ceremonies. Indigenous cultures in the Americas ingested peyote, ayahuasca, and psilocybin-containing mushrooms as a rite of passage and to facilitate spiritual communion, while in ancient Greece the psychoactive brew kykeon was central to the Eleusinian Mysteries religious festival. Society has embraced fermented beverages as social lubricants and ceremonial staples, even as moral and religious leaders have condemned their excesses.
From Moral Panic to Medical Promise
The United States, in particular, has a long tradition of allowing public sentiment rather than scientific evidence determine policy around controlled substances. In the early 20th century, public alarm over narcotics prompted federal authorities to regulate substances found in everyday consumer products. Coca-Cola originally contained cocaine extract from the coca leaf—hence its name—and opiates were routinely included in children’s medications. As public concerns grew, the government responded by expanding FDA oversight and removing addictive narcotics from popular products.
Prohibition followed, driven more by moral zeal than medical necessity. The Volstead Act of 1919 attempted to eliminate alcohol through constitutional fiat. Fourteen years later, amid widespread noncompliance, black-market explosion, and popular disillusionment, it became the only constitutional amendment ever repealed.
Opium and its derivatives illustrate the same pattern within medicine. In the 19th century, opium tinctures such as laudanum were ubiquitous remedies for insomnia, pain, and “nervous complaints”—and were even administered to children. But when addiction and misuse became impossible to ignore, opiates transformed from household staples into tightly controlled substances. A century later, the pendulum swung yet again with the aggressive promotion of prescription opioids as safe analgesics—an era whose catastrophic consequences we are still confronting.
Tobacco presents a final, sobering example: celebrated for centuries as both pleasure and medicine, woven into global commerce and daily ritual, only to be revealed in the 20th century as a leading cause of preventable death. The ensuing regulatory response—warning labels, advertising bans, taxation—shows how societies can pivot sharply when confronted with incontrovertible evidence of harm.
Against this historical backdrop, we are currently experiencing another such moment of reversal. Substances once condemned as dangerous and criminal—sometimes punishable by lengthy prison sentences—are now being reconsidered as legitimate medical treatments. As a psychiatrist whose 40-year career has focused on the development and clinical use of psychotropic drugs, I have watched this pendulum swing with both familiarity and concern. The era of “Reefer Madness” alarmism, PCP-dusted youth overwhelming emergency rooms, and lurid accounts of LSD-induced psychosis has largely faded. In its place, we find a cultural landscape that resembles a new “Wild West” of tolerance—even celebration—of substances that only recently were synonymous with deviance and danger.
Cannabis: the Modern Turning Point
The contemporary movement to decriminalize and legalize recreational drugs began with cannabis. Advocates strategically emphasized its therapeutic potential, drawing attention to the severe and often disproportionate penalties imposed on cannabis users. This argument served as a political Trojan horse: although scientific research eventually produced only one FDA-approved cannabis-derived therapy—for rare childhood epilepsies such as Lennox-Gastaut syndrome—it catalyzed a sweeping shift in public opinion. State legislatures soon faced intense pressure to decriminalize, then legalize cannabis, culminating in broad access for both medical and recreational use. In less than two decades, marijuana moved from demonized contraband to mainstream consumer product, driven not by scientific breakthroughs but by a cultural tsunami demanding unrestricted access. Today, cannabis has been rehabilitated in the public imagination, legalized for medical use in 40 states and for recreational use in 24.
We have witnessed a similar phenomenon with phencyclidine’s (PCP, also known as “angel dust”) younger congener, a PCP-light marketed as ketamine. This powerful drug, which was approved by the FDA for medical use as a dissociative anesthetic for children, subsequently spread to the public sector for recreational purposes as a club drug called “special K.” More recently, when ketamine was found to have dramatic therapeutic effects on severe depression, which in turn prompted opportunistic clinicians to extend its use in ketamine clinics across the country like wild-fire, and its use for a variety of additional purposes rapidly expanded—even in the absence of scientific evidence.
We are now in the midst of the next iteration of this “reformist” trend with psychedelic drugs. As psychedelic startup companies spring up and seek FDA approval for use of these agents in myriad indications, a parallel process calling for the legalization of psychedelics is gaining momentum. Legislation approving their sale to the public in supervised settings has already occurred in Oregon and Colorado. Given the history of drug legalization in the U.S., the changes in how these recreational intoxicants are more or less regulated are neither unprecedented nor surprising. In this latest iteration, however, the changes are more consequential, given the nature of the substances, their potential adverse as well as therapeutic effects, and the ease with which the public can access them in our current society. The question is, how will federal and state governments respond to this latest challenge? Will they ensure that any relaxation of laws around formerly illicit drugs is accompanied by appropriate cautions? Referencing their psychoactive predecessor, cannabis, may be informative and provide some plausible answers.
Cannabis sativa is a naturally occurring plant composed of over a hundred biochemical constituents. Only one, however, is psychoactive (i.e., induces mind-altering effects) – THC. Cannabis has been used historically in various forms by different cultures but has long been considered illegal in the U.S. The fearmongering of the evils and perils of pot reflected in the 1936 film “Reefer Madness” and criminal punishments for its use and distribution are now widely recognized as vastly disproportionate to the risks inherent in the substance. Yet cannabis is currently still considered illegal under the federal Controlled Substances Act (CSA) of 1970. It is said to have “no accepted medical use” and a high potential for abuse and physical or psychological dependence.
This conflict between federal and state legislation may soon be reconciled, however. While the scientific information necessary to officially endorse cannabis products as having therapeutic benefits (beyond the one indication for Lennox-Gastaut epilepsy) is lacking, the American public does not seem to care: a recent Pew Research Center Survey found that 88 percent of Americans felt that marijuana should be legal for medical use, with 57 percent also saying it should be legal for recreational use. Enthusiasm for maintaining the status quo at the federal level also appears to be waning. In a dramatic example of government yielding to public opinion, the U.S. Senate introduced legislation to legalize cannabis on the federal level on May 1, 2024. Although the drive to relax federal cannabis laws has lessened somewhat since the start of the Trump administration in 2025, the U.S. House of Representatives introduced a bipartisan bill on April 17, 2025 to lay the groundwork for federal cannabis legalization by studying and recommending a framework based on analyzing alcohol regulation models.
Some may see the rise of marijuana as an impressive demonstration of social progress; others will consider it the result of reckless and ill-conceived policies that have created a tangled matrix of laws and conflicting incentives based on confused logic and incomplete facts.
On the positive side, Americans now have easy access to a recreational intoxicant that is arguably no more dangerous than alcohol or tobacco, and they no longer need fear the disproportionately severe punishments previously meted out to those apprehended for possession and use. Yet there remain numerous inconsistencies and cross-purposes integral to the legalization and commercialization of cannabis products. The most obvious of these is the fact that federal law still considers the use, sale, and possession of cannabis illegal.
When Legalization Collides With Public Health
The legislative conflict between federal and state laws is not ideal, but it avoids becoming a grievous problem in large part because it is tolerated, and the federal law is not enforced. More onerous is the conflict that has emerged between legislative reform and public health. By acceding to public opinion and false claims of salutary effects, state governments are unwittingly exposing their constituents to serious health hazards. Compounding this misguided policy is financial incentive: state governments that relax cannabis laws are faced with the prospect of increased tax revenues.
In a glaring recent example of governmental misstep, Gov. Kathy Hochul declared New York State’s commercialized cannabis licensing and distribution system “a disaster” and announced on March 17, 2024 “a top-to-bottom review of the NYS Cannabis Control Board and its system for regulating legalized cannabis products.” The main purpose of the review, rather than an increase in oversight, was to process applications faster and enable more cannabis vendors to open quickly. Yet just weeks before Hochul’s executive order, which would give New Yorkers greater access to cannabis, the American Heart Association (AHA) had issued a warning on the higher risks of cardiovascular events associated with heavy cannabis use. This warning was based on a National Institutes of Health (NIH)-funded study of nearly 435,000 American adults, which found that “Daily use of cannabis . . . was associated with a 25% increased likelihood of heart attack and a 42% increased likelihood of stroke when compared to non-use of the drug.”
Prior to the American Heart Association’s statement, the NIH had issued a warning that “young men with cannabis (marijuana) use disorder have an increased risk of developing schizophrenia.” Similar studies found that regular recreational users of high-potency marijuana were at nearly five times the risk of developing a psychotic disorder as non-users, and the risk of marijuana-driven psychosis was far greater than that of psychosis brought on by amphetamines or alcohol. High potency refers to the fact that the commercialized pot sold legally today is not the same naturally grown weed smoked by constituents of the counterculture.
Such health hazards are not some abstract possibility or unconfirmed scientific speculation, but a growing current reality. As a practicing psychiatrist, I have witnessed these effects first-hand as a burgeoning number of cannabis-induced medical and mental disturbances—particularly in young people—show up in our hospital emergency rooms and are referred to me for consultation. And while the rising numbers of adverse effects occurring in the wake of legislative reform are disturbing, they are not surprising. Rather, they were anticipated.
At the start of the movement to liberalize access to cannabis, Roger Dupont, the founding director of the National Institute of Drug Abuse, Nora Volkow the current director of NIDA, and I foresaw this problem looming large in 2014 and published an article in the medical journal Science that predicted such adverse effects. “The debates over legalization, decriminalization, and medical uses of marijuana in the United States are missing an essential piece of information: scientific evidence about the effects of marijuana on the adolescent brain,” we wrote. “Much is known about the effects of recreational drugs on the mature adult brain, but there has been no serious investigation of the risks of marijuana use in younger users.”
While the rising numbers of adverse effects occurring in the wake of legislative reform are disturbing, they are not surprising. Rather, they were anticipated.
Part of the argument for legalizing cannabis was that it was no more dangerous than other legal recreational intoxicants like alcohol and tobacco. Kevin Sabet, National Drug Control Policy Advisor in the Bush and Obama administrations, however, pointed out the flaw in that assumption in his book, SmokeScreen: What the marijuana industry doesn’t want you to know. Legislators, he wrote, didn’t reckon on the possibility that commercialization of cannabis would lead to inconceivably high potencies—with THC concentrations in some products approaching levels up to 99.9%, as compared to less than 10% in naturally grown pot sold on the black market.
This revelation was disclosed in an NBC News report on states enacting legislation to legalize cannabis in April 2022: “We were not aware when we were voting [in 2012] that we were voting on anything but the plant,” said Dr. Beatriz Carlini, a research scientist at the University of Washington’s Addictions, Drug & Alcohol Institute. She has led the effort in Washington state to research high-potency pot and is now exploring policy options to limit access. Her team concluded in 2020 that “high-potency cannabis can have lifelong mental health consequences.”
So while possible therapeutic value has been the lever, tax revenue for states and profits for new industries—resulting from broad access—have clearly become the goal, with unsuspecting users as the potential victims. And the template used for the legalization of marijuana is now driving rapid legalization of a host of previously prohibited recreational drugs including MDMA (ecstasy) and psychedelics.
Evidence Must Lead Policy—Not Profit or Popularity
There are reasons to believe in, and support, the therapeutic potential and safe recreational use of cannabis, and there are compelling arguments for the pharmaceutical use of psychedelics. It is imperative, however, that accurate knowledge derived from research carried out with scientific rigor, objectivity, and dispassion informs the legislation and policy around these drugs—policy that will affect the lives of millions of Americans and particularly youth. Until we have this knowledge, we must be prepared to temper the irrational exuberance of advocates for unrestricted recreational use of illicit drugs and restrain commercial interests from expanding the user base and potency of available products. This responsibility resides with government: as calls for legalization from medical startups and public opinion increase in tandem, governors and legislators must hold the line and not succumb to the pressure of public opinion and the temptation of additional tax revenues.
Would not legalize this stuff until we all have driverless cars.