As a global society, we are living in reliably unreliable times, bathed in the dubious glow of a bonfire of certainties. Please allow me to add another set of conventions to the pyre: our most maligned and restricted drugs might heal us.
Consumers, the medical community and regulators are beginning to re-examine a range of previously taboo substances through the fresh light of evidence and experience. The rehabilitation of these substances – cannabis, nicotine and psychedelics amongst them – will create a new transgressive wellness and form part of our collective health and wellbeing in the years to come.
The drivers of this shift are multitudinous and varied in their recency. On the consumer side, we have become more nuanced in our use of substances, increasingly disenchanted with legacy solutions and, as a result of man-made catastrophes such as the US’s opioid crisis, increasingly less inclined to blindly outsource our health to the pharmaceutical industry. (In the 2021 Edelman Trust Barometer only 57% of the global public reported trust in pharmaceutical companies, falling to less than half in the US and Japan specifically).
From the perspective of the medical and regulatory community, dimensions of these same considerations exist. Amongst some clinicians there is an increasing awareness of the limits of existing ‘official’ treatment paths for a host of conditions as diverse as chronic pain relief (including end of life palliative care), epilepsy, depression and sleep disorders. There is a building appetite for optionality in approaches.
Redefining public health domains
Equally, many global governments are defining public health more broadly (including in ways which annex policy territory from criminal justice) and are counting the cost not just of public health issues in and of themselves but of misaligned and ineffective responses to crises in individual and population health. All of this is seeding an openness amongst several (although by no means all) administrations to explore the role that erstwhile demonised substances could play.
The nature of the compounds themselves is also supportive of this process. Cannabis, nicotine and psilocybin, for example, are all naturally occurring organisms with millenniums of holistic human use whose prohibition, in contrast, is a relatively recent ‘aberration’. In the context of the reification of and return to nature ongoing as a consumer trend, this amounts to a powerful narrative. On the other hand, man-made substances such as LSD and MDMA have a technical origin, produced under the auspices of pharmaceutical or military research which (in some senses at least) confers a kind of native legitimacy.
Of course, none of this is to say that these substances are risk-free, nor that all are or will be proven to be equivalently beneficial, nor that regulators will provide the same levels of access to each. A varied mix of depressants, psychedelics and stimulants, these are compounds with unique properties and evidence bases which mandate being treated with a combination of caution and respect. What is clear however, is that their rehabilitation from a mono-dimensional framing as agents of chaos into the facilitators of transgressive wellness is underway.
The slow-burn rehabilitation of cannabis
In fact, in the case of cannabis, the rehabilitation process is already maturing. Cannabis is a plant with a well-established history of thousands of years of human use in industrial, therapeutic and recreational contexts and is currently known and consumed (no matter what governments say) in every corner of the world. Euromonitor International data show that the average prevalence of illicit cannabis use in our 20 research markets is 5% and the global value of the illicit market is around USD150 billion.
Beyond the hazy hype, there is a broad-based growth narrative for legal cannabis. More and more geographies are amending their legal structures to move from prohibiting to controlling and taxing cannabinoid products. Consumers are turning to cannabis use in increasingly diverse parts of their lives – therapeutically, for relaxation, mood management and more. According to Euromonitor International, these dynamics will drive growth from under USD30 billion in 2020 to over USD90 billion in 2026.
The heritage of cannabis use and its association with indigenous, ethnic and counter cultures over time enriches the emerging legal industry and will inform its sense of social equity and branding semiotics. However, the modern cannabis consumer is diversifying away from the traditional image of ritual recreational flower consumption. There will still be ritual, as well as recreation, alongside a range of fresh usage occasions involving innovative delivery mechanisms.
A multi-valent substance
It is this multi-valency of cannabis, its capacity to be simultaneously oriented backwards and forwards, acknowledging its history and embedded perceptions without being defined by them, that provides a template for the broader evolution of transgressive wellness. Since the beginning of its modern day reliberalisation in the 1970s, the credibility of cannabis as a medical treatment – assisted by high-profile use with vulnerable patient groups and by the development of pharmaceutical propositions such as Epidiolex – has grown to a point where the public believes in its therapeutic potential. (Around half of respondents to our global cannabis survey support the legalisation of medical cannabis for any condition). Once this Rubicon is crossed, wider legalisation virtually inevitably follows – for many, it becomes hard to justify ongoing prohibition of a substance that we sense could one day help us, or a member of our families.
The future of cannabis wellness divides between on the one hand, pharmaceutical drug development utilising cannabinoids (increasingly synthesised and manipulated) to target specific clinical conditions, and on the other, hyper-personalisation of generally available cannabinoid formulations tailoring offerings to our individual endocannabinoid systems, metabolisms and wellbeing goals.
Psychedelics as breakthrough therapies
Notwithstanding the inherent differences between the various substances, a raft of entheogens and empathogens such as psilocybin, LSD and MDMA are following a similar therapeutic recognition-liberalisation-acceptability pathway as cannabis has already trod. Indeed, the therapeutic value of some of these compounds is already more readily accepted than that of cannabinoids, with a number of organisations developing business models around the clinical application of psychedelics, MDMA and ketamine. The US FDA has designated psilocybin as a breakthrough therapy for major depressive disorder and MDMA for post traumatic stress disorder, indicating widespread conviction that clinical trials may ultimately prove these substance assisted-therapies superior to existing treatments for the conditions in question.
Interestingly, it is perhaps precisely the clarity and potency of the clinical application of these substances at high doses and in specific treatment settings which makes it more challenging to envisage them forming part of our day to day wellbeing routines. While there is a significant and growing trend towards microdosing of psychedelics amongst particular cohorts in a handful of markets, wider mainstream use implies commercialism, which in turn relies on more than the current wave of decriminalisation seen largely in the US.
Put simply, these are powerful substances which in the words of leading researchers in the area ‘increase entropy in spontaneous neural activity’ and in so doing can create permanent or semi-permanent changes in mindsets and patterns of thinking. It does not yet appear certain that they can be effective at low enough doses that they can be taken out of the clinical setting and into our broader wellness arsenal. However, even if psychedelics were to be confined to the treatment room, their wider use looks set to be revolutionary.
Nicotine wellness: None more transgressive
Turning last to the least taboo but arguably most transgressive of our substances, what of nicotine? Despite it being the most widely available of the compounds I have discussed, its path to rehabilitation is arguably the longest and steepest. Public misunderstanding of the properties and impact of nicotine consumption is significant and potentially stubborn, as it is condemned in the public mind by the substantial sins of its predominant delivery system, the combustible cigarette.
It is of course the combustion that causes the harm in this equation, and according to my own (inexpert) understanding of the existing evidence base, nicotine in and of itself is a relatively benign proposition. Awareness of nicotine as a possible cognitive function enhancer, of a potential role in the treatment of conditions such as Parkinson’s, has been present in the background for some time. More recently, a putative link between consumption of nicotine and resistance to transmission of COVID-19 has surfaced in datasets across multiple populations. It is also likely to be less addictive when consumed in formats other than the traditional cigarette.
Combined, these point to the perhaps counter-intuitive potential future scenario of nicotine being delivered as one, or one of a number of, ingredients in an infused oral mechanism such as a tablet, shot or gel in the service of enhanced immunity, focus and cognitive function. Not quite ‘Tobacco saves’ perhaps, but certainly ‘Nicotine improves’.
From transgression to wellness
Ultimately, this journey of rehabilitation has some substantial road to run and a number of additional substances to embrace. Not all will reach the end. Yet a combination of our disenchantment as a consumer base, our collective curiosity, and the thirst of our experts and governments for us to do more good and less harm at lower cost will ensure without doubt that one era’s transgression, is another’s wellness.
A version of this piece first appeared as part of EuroNews.next’s Rethink series