“She had problems falling asleep, and she’d wake up in the middle of the night,” he said. “So her daughter brought her some sleep gummies” — edible cannabis candies.

“She tried a gummy after dinner and waited half an hour,” Han said.

Feeling no effects, she took another gummy, then one more — a total of four over several hours.

Han advises patients who are trying cannabis to “start low; go slow,” beginning with products that contain just 1 or 2.5 milligrams of tetrahydrocannabinol, or THC, the psychoactive ingredient that many cannabis products contain. Each of the four gummies this patient took, however, contained 10 milligrams.

The woman started experiencing intense anxiety and heart palpitations. A young person might have shrugged off such symptoms, but this patient had high blood pressure and atrial fibrillation, a heart arrhythmia. Frightened, she went to an emergency room.

Lab tests and a cardiac work-up determined the woman wasn’t having a heart attack, and the staff sent her home. Her only lingering symptom was embarrassment, Han said. But what if she’d grown dizzy or lightheaded and was hurt in a fall? He said he has had patients injured in falls or while driving after using cannabis. What if the cannabis had interacted with the prescription drugs she took?

“As a geriatrician, it gives me pause,” Han said. “Our brains are more sensitive to psychoactive substances as we age.”

Thirty-nine states and the District of Columbia now for medical reasons, and in 24 of those states, as well as the district, is also legal. As older adults’ use climbs, “the benefits are still unclear,” Han said. “But we’re seeing more evidence of potential harms.”

A wave of recent research points to reasons for concern for older users, with cannabis-related emergency room visits and hospitalizations rising, and a Canadian study finding an association between such acute care and subsequent dementia. Older people are more apt than younger ones to try cannabis for therapeutic reasons: to relieve chronic pain, insomnia, or mental health issues, though evidence of its effectiveness in addressing those conditions remains thin, experts said.

In an published June 2 in the medical journal JAMA, Han and his colleagues reported that “current” cannabis use (defined as use within the previous month) had jumped among adults age 65 or older to 7% of respondents in 2023, from 4.8% in 2021. In 2005, he pointed out, fewer than 1% of older adults reported using cannabis in the previous year.

What’s driving the increase? Experts cite the steady march of state legalization — use by older people is highest in those states — while surveys show that the of cannabis use has declined. One national survey found that a growing it safer to smoke cannabis daily than cigarettes. The authors of the study, in JAMA Network Open, noted that “these views do not reflect the existing science on cannabis and tobacco smoke.”

The cannabis industry also markets its products to older adults. The Trulieve chain gives a 10% discount, both in stores and online, to those it calls “wisdom” customers, 55 or older. Rise Dispensaries ran a yearlong cannabis education and empowerment program for two senior centers in Paterson, New Jersey, including field trips to its dispensary.

The industry has many satisfied older customers. Liz Logan, 67, a freelance writer in Bronxville, New York, had grappled with sleep problems and anxiety for years, but the conditions grew particularly debilitating two years ago, as her husband was dying of Parkinson’s disease. “I’d frequently be awake until 5 or 6 in the morning,” she said. “It makes you crazy.”

Looking online for edible cannabis products, Logan found that gummies containing cannabidiol, known as CBD, alone didn’t help, but those with 10 milligrams of THC did the trick without noticeable side effects. “I don’t worry about sleep anymore,” she said. “I’ve solved a lifelong problem.”

But studies in the United States and Canada, which use for adults nationally in 2018, show climbing rates of cannabis-related health care use among older people, both in and in hospitals.

In California, for instance, cannabis-related by those 65 or older rose, to 395 per 100,000 visits in 2019 from about 21 in 2005. In Ontario, acute care (meaning emergency visits or hospital admissions) resulting from cannabis use increased fivefold in middle-aged adults from 2008 to 2021, and more than .

“It’s not reflective of everyone who’s using cannabis,” cautioned Daniel Myran, an investigator at the Bruyère Health Research Institute in Ottawa and lead author of the Ontario study. “It’s capturing people with more severe patterns.”

But since other studies have shown among some cannabis users with heart disease or diabetes, “there’s a number of warning signals,” he said.

For example, a disturbing proportion of older veterans who currently use cannabis , a recent JAMA Network Open study found.

As with other substance use disorders, such patients “can tolerate high amounts,” said the lead author, Vira Pravosud, a cannabis researcher at the Northern California Institute for Research and Education. “They continue using even if it interferes with their social or work or family obligations” and may experience withdrawal if they stop.

Among 4,500 older veterans (with an average age of 73) seeking care at Department of Veterans Affairs health facilities, that more than 10% had reported cannabis use within the previous 30 days. Of those, 36% fit the criteria for mild, moderate, or severe , as established in the Diagnostic and Statistical Manual of Mental Disorders.

VA patients differ from the general population, Pravosud noted. They are much more likely to report substance misuse and have “higher rates of chronic diseases and disabilities, and mental health conditions like PTSD” that could lead to self-medication, she said.

Current VA policies don’t require clinicians to ask patients about cannabis use. Pravosud thinks that they should.

Moreover, “there’s increasing evidence of a potential effect on memory and cognition,” said Myran, citing his team’s study of Ontario patients with cannabis-related conditions going to emergency departments or being admitted to hospitals.

Compared with others of the same age and sex who were seeking care for other reasons, these patients (ages 45 to 105) had 1.5 times the risk of a dementia diagnosis within five years, and 3.9 times the risk of that for the general population.

Even after adjusting for chronic health conditions and sociodemographic factors, those seeking acute care resulting from cannabis use had a 23% than patients with noncannabis-related ailments, and a 72% higher risk than the general population.

None of these studies were randomized clinical trials, the researchers pointed out; they were observational and could not ascertain causality. Some cannabis research doesn’t specify whether users are smoking, vaping, ingesting or rubbing topical cannabis on aching joints; other studies lack relevant demographic information.

“It’s very frustrating that we’re not able to provide more individual guidance on safer modes of consumption, and on amounts of use that seem lower-risk,” Myran said. “It just highlights that the rapid expansion of regular cannabis use in North America is outpacing our knowledge.”

Still, given the health vulnerabilities of older people, and the far greater potency of current cannabis products compared with the weed of their youth, he and other researchers urge caution.

“If you view cannabis as a medicine, you should be open to the idea that there are groups who probably shouldn’t use it and that there are potential adverse effects from it,” he said. “Because that is true of all medicines.”

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But this community of about 315 and its four marijuana dispensaries — one shop for every 79 residents — is a contender for the title of cannabis capital of Colorado.

Dinosaur, nestled in the northwestern corner of the state, is a five-minute drive to the Utah line and a couple of hours away from Wyoming, both states where recreational marijuana use is illegal.

Dinosaur lies at the intersection of U.S. Highway 40 (that’s Brontosaurus Boulevard) and Colorado Highway 64 (Stegosaurus Freeway). The crossroads had long been a stop where truckers filled their fuel tanks and their bellies. But until weed came to town, there was little to sustain the local economy.

It’s a classic story of a border town prospering from differing laws state to state, and how arbitrary lines drawn through a desolate landscape drive economic patterns. Coloradans from Dinosaur cross the border to get groceries and health care. Utahans come to Dinosaur for lottery tickets, liquor, and pot.

The four cannabis stores, which opened after the passage of a 2016 ballot measure, have changed the fortunes of a town that made repeated losing bets on other commodities before finally hitting the jackpot with marijuana.

“You’d be shocked how much money comes through here,” said Jim Evans, the town’s treasurer. “There’s money running out of our ears.”

Lando Blakley, who has lived in Dinosaur most of his life, opened the town’s third retail store, Dino Dispensary, in 2018. He estimates that 95% of his business comes from out-of-state customers, some from as far away as North Dakota.

“Right now, cannabis is Dinosaur’s lifeblood,” he said.

Utah has legalized medical marijuana, but with tight restrictions and few places to buy it. So, patients may have to travel hours to outlets in Salt Lake City or Ogden for an in-state supplier. But for those living in Vernal or other eastern towns, Dinosaur is the closest place to buy cannabis in person.

“If anyone had to travel in the wintertime to go to a dispensary in Salt Lake City, they’re not going to do it,” said Michael, a 37-year-old who, like most pot-shop customers who spoke with ºÚÁϳԹÏÍø News, declined to give his last name after buying marijuana at one of the stores. “Why drive 300 miles and put your life at risk, when you can drive 30?”

It is illegal to bring marijuana over the border to Utah, but multiple customers said they’ve never had a problem. Still, a traffic stop for other reasons could have more serious consequences if police find marijuana in the car.

Utah residents Jackson and Chelsea order their cannabis online from Rocky Mountain Cannabis, located, appropriately, at 420 E. Brontosaurus Blvd. (420 is shorthand for smoking marijuana), and drive across the state line to pick it up.

“Everybody in Utah goes and gets their green card and then comes here and gets their marijuana,” Jackson said.

The cards, carried by people registered with Utah’s medical marijuana program (about 70,000 of the state’s 3.4 million residents), provide cover in case they get pulled over. Other customers say it’s not worth the hassle to apply for a card and pay the $15 annual fee when none of that is required in Colorado.

At least two other Colorado towns rival Dinosaur in per capita retail cannabis outlets. Moffat in south-central Colorado boasts four marijuana stores in a town and surrounding area of just 818 people, due to a massive cannabis .

Sedgwick is another border town that has banked on weed, with three stores and a population of 172. The town sits in the northeastern corner of the state, less than 10 minutes from Nebraska, where marijuana is illegal for both medical and recreational use.

Some border towns opted against allowing marijuana stores, such as Rangely, from which residents now make the 18-mile trip to Dinosaur to buy cannabis.

The four stores in Dinosaur are bunched on the east side of town, just off Highway 40, pretty much the only locations that satisfy the town mandate to be at least 1,000 feet from a school. Most outlets want to be along the highway, to capture customers passing through. Someone could easily walk to all four stores, and some people do just that to dodge the state’s daily 1-ounce purchase limit.

To say that cannabis has transformed the appearance of town would be a stretch. It remains a sleepy little town, with little else to drive its economy. Despite the thriving marijuana trade, there still seem to be more closed businesses than open ones.

In fact, the town isn’t quite sure what to do with all the money it collects. It once limped along with an annual budget of $100,000 or less, but Dinosaur now rakes in that much each month in cannabis revenue alone.

In 2021, the town collected about $1.4 million in cannabis-related taxes and licensing fees.

When it first approved cannabis sales, the town collected a 5% tax that flowed into its general revenue fund. Residents voted to add a second 5% tax earmarked for infrastructure projects. It collects licensing fees from the retail stores and a marijuana grow operation and gets a portion of the cannabis revenue collected by the state.

That money has allowed the town to build new sewage ponds, repaint the inside of its water tank, and add new housing lots with paved roads and sewer and water connections. The town is in the midst of a beautification project, planting trees and flowers, and is refurbishing the former school building into a community recreation center. Where the town previously relied on the county sheriff for law enforcement and suffered through long response times, it has now hired three marshals of its own.

And last year, for the first time in decades, the town revived its annual festival, now called the Dinosaur Stone Age Stampede, with food, games, and music.

But most of the marijuana tax revenue goes into savings. The town expects to have about $3.5 million in its coffers by year-end, and, Evans said, Dinosaur draws some $230,000 a year in interest alone.

Becoming a cannabis hot spot wasn’t a given. Heated debate erupted when the Town Council first considered allowing retail stores. Town leaders ultimately decided to let the residents choose at the polls. An initial ballot measure in 2010 failed.

By 2016, opinions changed as residents saw other border towns in Colorado flourishing while their town was quickly becoming … well, a dinosaur.

“People were seeing that the towns that had [legalized] was prospering,” said Mayor Richard Blakley, 70, who is the father of Dino Dispensary owner Lando Blakley. “And no real bad crime increase or stuff like that.”

The settlement that became Dinosaur was initially called Baxter Flats, but was established as a town in 1947, and named Artesia, a nod to the artesian wells in the surrounding hills. In 1966, the National Park Service told local leaders if they changed the name to Dinosaur, the town would prosper from its connection to the national monument known for its prehistoric fossils and petroglyphs.

Residents agreed and renamed their home and the streets. But prosperity never followed, in part because the Colorado side of the national monument has few dinosaur fossils. It’s mostly a showcase of geology.

“People come in and ask, ‘Where’s the museum? Where’s the skeletons?’” Evans said. Other than a few scientifically questionable dinosaur sculptures, there’s no Tyrannosaurus rex or Stegosaurus, no Velociraptor or Allosaurus.

As the national park rangers say, Utah has the bones, Colorado has the stones — or, as people say on the Utah side of the border, the stoned.

“We have a reputation,” Evans said. “You talk about Dinosaur in Utah, and it’s like, ‘Yeah, they’re all potheads and stuff.’”

The mayor said the town has seen few negative consequences from allowing marijuana, among them some people unprepared for the drug’s potency being sickened by it. The town is growing. The population, which had dropped to 243 residents in the 2020 census, has rebounded to about 315, Blakley said. Many people have also purchased vacant lots to take advantage of the relatively cheap cost of real estate, making it difficult to find land in town.

Blakley hopes the economic growth will bring a grocery store. Residents drive 40 minutes to Vernal, Utah, or two hours to Grand Junction, to stock up on food or to receive medical care. Children go to school in Rangely since Dinosaur’s school closed years ago. An urgent care clinic opened across from the town hall a few years ago, but it couldn’t make a go of it.

Even if Dinosaur continues to grow, it won’t add more cannabis stores. The Town Council capped the available licenses at four. And those four stores are now the essence of Dinosaur.

“Otherwise,” Evans, the treasurer, said, “this is a sad little town.”

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The law, which goes into effect in October, will to take legal action if they believe they didn’t receive proper care due to a conscientious objection by a provider or an institution, such as a hospital.

So-called medical conscience objection laws have existed at the state and federal levels for years, with most protecting providers who refuse to perform an abortion or sterilization procedure. But the new Montana law, and others like it that have passed or been introduced in statehouses across the U.S., goes further, to the point of undermining patient care and threatening the right of people to receive lifesaving and essential care, according to critics.

“I tend to call them ‘medical refusal bills,’” said Liz Reiner Platt, the director of Columbia Law School’s . “Patients are being denied the standard of care, being denied adequate medical care, because objections to certain routine medical practices are being prioritized over patient health.”

This year, 21 bills instituting or expanding conscience clauses have in statehouses, and two have become law, according to the nonprofit Guttmacher Institute. Florida lawmakers passed legislation that allows providers and insurers to refuse any health service that violates ethical beliefs. Montana’s law goes further, prohibiting the assignment of health workers to provide, facilitate, or refer patients for abortions unless the providers have consented in writing. South Carolina, Ohio, and Arkansas previously passed bills.

Supporters of the Montana law, called the Implement Medical Ethics and Diversity Act, say it fills gaps in federal law, empowering more medical professionals to practice medicine based on their conscience in circumstances beyond abortion and sterilization.

The bill applies to a wide range of practitioners, institutions, and insurers, encompassing just about any type of health care and anyone who could be providing it. The exception is emergency rooms, where the federal takes precedence.

“We have technology that is pushing the limits of what is maybe ethical, and that is different in everybody’s minds,” said Republican state Rep. Amy Regier, who sponsored the Montana bill. “Having extra protections for people to practice according to their conscience as we continue down that path of innovation is important.”

Claims the bill discriminates against patients frustrate Regier, who said it’s about protecting health care providers. “Because someone has a conscientious objection to a specific service, they should be able to practice that way,” she said.

In 1973, federal regulations known as the Church Amendments were implemented after the Supreme Court’s Roe v. Wade decision made abortion legal nationwide. Under the Church Amendments, any institution that receives funding from the federal Department of Health and Human Services may not require health care providers to perform abortion or sterilization procedures if doing so would violate their religious or moral principles. Additionally, providers who refuse to perform these services may not be discriminated against for their decision.

Since then, at least 45 states have abortion conscience clauses, according to the Guttmacher Institute. Of those, that patients be notified of the refusal or limit the clause’s use in the case of miscarriage or emergency.

A in the American Medical Association’s Journal of Ethics said, “Clinicians who object to providing care on the basis of ‘conscience’ have never been more robustly protected than today.” Legal remedies for patients who receive inadequate care as a result have shrunk significantly, the article said.

But the wave of medical conscience bills introduced in statehouses since that article was published go beyond abortion to include contraception, sterilization, gender-affirming care, and other services. Opponents such as the American Civil Liberties Union, Planned Parenthood, and the Human Rights Campaign have been vocal opponents of this trend, criticizing it as a backdoor way to restrict the rights of women, LGBTQ+ community members, and other individuals.

Still, lawmakers across the country insist the right of doctors, nurses, pharmacists, and other medical providers to practice medicine in alignment with their beliefs is being infringed.

Some health care practitioners would “just be done” practicing medicine if forced to perform certain procedures such as abortion, Regier said. “That, to me, is what limits patient care.”

Many of the most sweeping bills are backed by organizations that have made it their business to promote this “conscience” agenda nationwide, such as the Christian Medical Association, Catholic Medical Association, and National Association of Pro-Life Nurses. Other groups launched a joint effort in 2020 with the of advancing state legislation that makes it easier for health care providers to refuse to perform a wide range of procedures, including abortion and types of gender-affirming care.

The organizations that started the initiative are the Religious Freedom Institute in Washington D.C., an Arizona-based nonprofit called the , and the Christ Medicus Foundation in Michigan. According to its website, the coalition bolsters efforts to pass more sweeping medical conscience legislation, using methods including print and digital media campaign strategy, grassroots organizing, and advocacy. After successes in Arkansas, Ohio, and South Carolina in 2021 and 2022, it turned to Montana and Florida. Regier said there are a “number of different organizations” pushing this type of legislation, including the Alliance Defending Freedom.

Most of these conscience laws are part of an “arsenal” to further social conservatism, and they are often religiously motivated, said Lori Freedman, a researcher and associate professor at the Bixby Center for Global Reproductive Health at the University of California-San Francisco.

Although federal law is meant to ensure people receive lifesaving care in an emergency, Freedman said, there are cases in which patients don’t receive the care they should simply because they don’t clear the bar of what a facility considers emergent.

While experts warn of the potential patient health consequences of these medical conscience bills, academics say placing a provider’s choice over their patient’s rights is itself a threat.

“These bills do not protect religious liberty because they make it impossible for people to follow their own religious and moral values in making major decisions,” Reiner Platt said.

About 1 in 6 patients in the U.S. are treated in Catholic health care facilities, according to Freedman. Many of those venues strictly regulate or prohibit certain procedures, such as abortion, but do not necessarily disclose that to patients. As of 2016, of hospital beds in Montana were in such facilities, according to the ACLU. Freedman determined through her research that about one-third of people whose primary hospital was Catholic didn’t know of its religious affiliation and therefore were unaware of those limitations on their care.

The problem can extend to secular medical institutions, too. According to the AMA Journal of Ethics article, there are no rules requiring a patient be informed a provider is practicing conscientious objection, which means the patient might “unknowingly receive substandard care” and “even be harmed by” the provider’s refusals.

“As much as we like to think about these providers and their opinions, so much is determined at a larger, structural level,” Freedman said. “Abortion has been stigmatized, marginalized, and constrained,” and plenty of hospitals and physician groups have made great efforts to “make a very safe service somehow illegal to provide within their context.”

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Although decades ago the THC content of weed was commonly less than 1.5%, some products on the market today are more than 90% THC.

The buzz of yesteryear has given way to something more alarming. have landed hundreds of thousands of people in the hospital and millions are dealing with psychological disorders linked to cannabis use, according to federal research.

But regulators have failed to keep up.

Among states that allow the sale and use of marijuana and its derivatives, consumer protections are spotty.

“In many states the products come with a warning label and potentially no other activity by regulators,” said Cassin Coleman, vice chair of the scientific advisory committee of the National Cannabis Industry Association.

The federal government has generally taken a hands-off approach. It still bans marijuana as a Schedule 1 substance — as a drug with no accepted medical use and a high chance of abuse — under the Controlled Substances Act. But when it comes to cannabis sales, which many states have legalized, the federal government does not regulate attributes like purity or potency.

The FDA “has basically sat on its hands and failed to honor its duty to protect the public health,” said Eric Lindblom, a scholar at Georgetown University’s law school who previously worked at the FDA’s Center for Tobacco Products.

Pot has changed profoundly since generations of Americans were first exposed to it.

Cannabis has been cultivated to deliver much higher doses of THC. In 1980, the THC content of confiscated marijuana was . Today many varieties of cannabis flower — plant matter that can be smoked in a joint — are listed as more than 30% THC.

At one California dispensary, the menu recently included a strain posted as 41% THC.

Legalization has also helped open the door to products that are extracted from marijuana but look nothing like it: oily, waxy, or crystalline THC concentrates that are heated and inhaled through vaping or dabbing, which can involve a bong-like device and a blowtorch.

Today’s concentrates can be more than 90% THC. Some are billed as almost pure THC.

Few people personify the mainstreaming of marijuana as vividly as John Boehner, the former U.S. House speaker. The Ohio Republican long opposed marijuana and, in 2011, reportedly declared himself .

Now he’s on the , a producer of marijuana products.

And Acreage Holdings illustrates the evolution of the industry. Its markets a vaping product — “pure live resin in a convenient, instant format” — and concentrates such as “budder,” “sugar,” “shatter,” and “wax.” The company bills its “THCa crystalline” concentrate as the “ultimate in potency.”

Higher concentrations pose greater hazards, according to the National Institute on Drug Abuse. “The risks of physical dependence and addiction increase with exposure to high concentrations of THC, and higher doses of THC are more likely to produce anxiety, agitation, paranoia, and psychosis,” said.

In 2021, 16.3 million people in the United States — 5.8% of people 12 or older — had experienced a marijuana use disorder within the past year, according to a by the federal Department of Health and Human Services.

That was far more than the combined total found to have substance use disorders involving cocaine, heroin, methamphetamine, prescription stimulants such as Adderall, or prescription pain relievers such as fentanyl and OxyContin.

Other drugs are more dangerous than marijuana, and most of the people with a marijuana use disorder had a mild case. But about 1 in 7 — more than 2.6 million people — had a severe case, the federal survey found.

Most clinicians equate the term “severe use disorder” with addiction, said Wilson Compton, deputy director of the National Institute on Drug Abuse.

Cannabis use disorder “can be devastating,” said Smita Das, a Stanford psychiatrist and chair of an American Psychiatric Association council on addiction.

Das said she has seen lives upended by cannabis — very successful people who have lost families and jobs. “They’re in a place where they don’t know how they got there because it was just a joint, it was just cannabis, cannabis wasn’t supposed to be addictive for them,” Das said.

Medical diagnoses attributed to marijuana include “” and , a form of persistent vomiting.

An estimated 800,000 people made marijuana-related emergency department visits in 2021, according to a published in December 2022.

‘Go Directly’ to Detox

A Colorado father thought it was just a matter of time before cannabis killed his son.

In spring 2021, the teen ran a red light, crashed into another car — injuring himself and the other driver — and fled the scene, the father recalled in interviews.

In the wreckage, the father later found joints, empty containers of a high-potency THC concentrate known as wax, and a THC vape pen.

On his son’s cellphone, he found text messages and scores of references to dabbing and weed. The teen said he had been dabbing before the crash and had intended to kill himself.

Weeks later, police arranged for him to be held involuntarily at a hospital for psychiatric evaluation. According to a police report, he thought cartel snipers were after him.

The doctor who evaluated the teen diagnosed “cannabis abuse.”

“Stop doing dabs or wax as they can make you extremely paranoid,” the doctor wrote. “Go directly to the detox program of your choice.”

By the father’s account, over the past two years the teen logged several other involuntary holds, dozens of encounters with police, repeated jailings, and a series of stays in inpatient treatment facilities.

At times out of touch with reality, he texted that God spoke to him and gave him superpowers.

The damage was also financial. Health insurance claims for his treatment totaled nearly $600,000, and the family’s out-of-pocket expenses came to almost $40,000 as of February.

In interviews for this article, the father spoke on the condition of anonymity to avoid undermining the son’s recovery.

The father is convinced that his son’s mental illness was a result and not a cause of the drug use. He said the symptoms receded when his son stopped using THC and returned when he resumed.

His son is now 20, off marijuana, and doing well, the father said, adding, “I have absolutely no doubt in my mind that cannabis use is what caused his psychosis, delusions, and paranoia.”

Uneven State Regulation

Medical use of marijuana is now legal in 40 states and the District of Columbia, and recreational or adult use is legal in 22 states plus D.C., according to .

Early in the covid-19 pandemic, while much of America was in lockdown, marijuana dispensaries delivered. Many states .

But only two adult-use states, Vermont and Connecticut, have placed caps on THC content — 30% for cannabis flower and 60% for THC concentrates — and they exempt pre-filled vape cartridges from the caps, said Gillian Schauer from the Cannabis Regulators Association, a group of state regulators.

Some states cap the number of ounces or grams consumers are allowed to buy. However, even a little marijuana can amount to a lot of THC, said Rosalie Liccardo Pacula, a professor of health policy, economics, and law at the University of Southern California.

Some states allow only medical use of low-THC products — for instance, in Texas, substances that contain . And some states require warning labels. In New Jersey, cannabis products composed of more than 40% THC : “This is a high potency product and may increase your risk for psychosis.”

Colorado’s marijuana rules run . Yet its disclosure underscores the limits of consumer protections: “This product was produced without regulatory oversight for health, safety, or efficacy.”

Figuring out the right rules may not be simple. For example, warning labels could shield the marijuana industry from liability, much as they did for tobacco companies for many years. Capping potency could limit options for people who take high doses for relief from medical problems.

Overall, at the state level, the cannabis industry has blunted regulatory efforts by arguing that onerous rules would make it hard for legitimate cannabis businesses to compete with illicit ones, Pacula said.

Pacula and fellow the federal government to step in.

Months after ending his term as FDA commissioner, Scott Gottlieb issued .

Complaining that states had gotten “far down the field while the feds sat on the sidelines,” Gottlieb called for “a uniform national scheme for THC that protects consumers.”

That was in 2019 and little has changed since then.

Where’s the FDA?

The FDA oversees food, prescription drugs, over-the-counter drugs, and medical devices. It regulates tobacco, nicotine, and nicotine vapes. It oversees tobacco warning labels. In the interest of public health and safety, it also , medical products that can include plant material.

Yet, when it comes to the marijuana that people smoke, the cannabis-derived THC concentrates they vape or dab, and edibles infused with THC, the FDA appears very much on the sidelines.

The medical marijuana sold at dispensaries is not FDA-approved. The agency hasn’t vouched for its safety or efficacy or determined the proper dosage. It doesn’t inspect the facilities where the goods are produced, and it doesn’t assess quality control.

The agency to put cannabis products through clinical trials and its drug approval process.

The FDA’s that THC is the active ingredient in two FDA-approved drugs used in cancer treatment. That alone apparently places the substance under FDA jurisdiction.

The FDA has “all the power it needs to regulate state-legalized cannabis products much more effectively,” said Lindblom, the former FDA official.

At least publicly, the FDA has focused not on THC concentrates derived from cannabis or weed smoked in joints, but rather on other substances: a derived , which the federal government has legalized, and a different cannabis derivative called , which has been marketed as therapeutic.

“The FDA is committed to monitoring the marketplace, identifying cannabis products that pose risks, and acting, within our authorities, to protect the public,” FDA spokesperson Courtney Rhodes said.

“Many/most THC products meet the definition of marijuana, which is a controlled substance. The Drug Enforcement Administration (DEA) regulates marijuana under the Controlled Substances Act. We refer you to the Drug Enforcement Administration for questions about regulation and enforcement under the provisions of the CSA,” Rhodes wrote in an email.

The DEA, part of the Justice Department, did not respond to questions for this article.

As for Congress, perhaps its most consequential step has been limiting enforcement of the federal prohibition.

“Thus far, the federal response to state actions to legalize marijuana has largely been to allow states to implement their own laws on the drug,” a 2022 Congressional Research Service report said.

In October, President Joe Biden directed the secretary of Health and Human Services and the attorney general to toward marijuana — whether it should remain classified among the most dangerous and tightly controlled substances.

In December, Biden expanding research access to marijuana and requiring federal agencies to study its effects. The law gave agencies a year to issue findings.

Some marijuana advocates say the federal government could play a more constructive role.

“NORML does not opine that cannabis is innocuous, but opines that its potential risks are best mitigated via legalization, regulation, and public education,” said Paul Armentano, deputy director of the group formerly known as the National Organization for the Reform of Marijuana Laws.

“Products have to be tested for purity and potency,” he said, and “the federal government could have some oversight in licensing the labs that test those products.”

In the meantime, said Coleman, adviser to the National Cannabis Industry Association, states are left “having to become USDA + FDA + DEA all at the same time.”

And where does that leave consumers? Some, like Wendy E., a retired small-business owner in her 60s, struggle with the effects of today’s marijuana.

Wendy, who spoke on the condition that she not be fully named, started smoking marijuana in high school in the 1970s and made it part of her lifestyle for decades.

Then when her state legalized it, she bought it in dispensaries “and very quickly noticed that the potency was much higher than what I had traditionally used,” she said. “It seemed to have exponentially increased.”

In 2020, she said, the legal marijuana — much stronger than the illicit weed of her youth — left her obsessing about ways to kill herself.

Once, the self-described “earth-mother hippie” found camaraderie passing a joint with friends. Now, she attends Marijuana Anonymous meetings with others recovering from addiction to the stuff.

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The number of reports the Rocky Mountain Poison and Drug Safety office received of kids age 5 or younger exposed to marijuana in 2021. By 2021, this age group made up nearly half of all marijuana exposures — in which the drug is ingested, inhaled, or absorbed through the skin — reported to the office, which is part of the nonprofit Denver Health organization.

In each of those five years, children were most often accidentally exposed by eating edibles — gummies, cookies, drinks, and other products infused with the psychoactive chemical tetrahydrocannabinol, or THC — and not by inhaling smoke or consuming the drug in other forms, like capsules or tinctures. In 2017, 35 children age 5 or younger were unintentionally exposed to marijuana through edibles, compared with 97 in 2021. Exposures don’t necessarily mean the children were poisoned or overdosed, according to the poison and drug safety office.

Marijuana exposures among children are increasing nationwide, with Colorado playing a notable role in this trend. However, the federal government has yet to create uniform protocols, and Colorado health officials haven’t conveyed any plans to revise the regulations meant to prevent children from consuming marijuana.

“Marijuana laws and regulations are regularly evaluated by lawmakers, state agencies, local agencies and the various stakeholders,” Shannon Gray, a spokesperson at the Marijuana Enforcement Division, which regulates the marijuana industry in the state, wrote in an email to KHN. “A top priority is preventing youth access and to the extent we see opportunity in rules to address youth access, we do so.”

Since legalized recreational marijuana sales began in 2014, Colorado has implemented a handful of directives to stop children from mistaking these products for safe, delicious sweets.

Regulations state that:

• No edibles may be manufactured in the shape of a human, an animal, or a fruit.
• All edibles must be sold in child-resistant packaging.
• “Candy” or “candies” isn’t allowed on packaging.
• Advertising must not include cartoon characters, or anything else meant to appeal to children.
• The universal THC symbol (! THC) must be on all packaging and stamped on all edible products.

Data from Rocky Mountain Poison and Drug Safety does not distinguish between incidents involving marijuana sold by licensed retailers and those involving marijuana from sources that don’t follow the state’s packaging rules, state health department spokesperson Gabi Johnston told KHN.

When asked whether the mandates are effective, Gray said the Marijuana Enforcement Division has “observed material compliance with these regulations” among marijuana businesses.

Regulation changes could be considered, including those proposed by state legislators, Gray said. But no forthcoming bills concern edible mandates, according to Jarrett Freedman, spokesperson for the Colorado House of Representatives majority. Democrats control both houses of the state legislature.

One limitation of regulating marijuana packaging is that most children 5 and younger can’t read, said Dr. Marit Tweet, a medical toxicologist at the Southern Illinois University School of Medicine. And, she said, many parents don’t know how to store marijuana safely.

The state health department has worked to address this knowledge gap through its , established in 2014 to teach the public about safe, legal, and responsible cannabis use. One fact sheet advises parents to store marijuana in a locked area, keep products in child-resistant packaging, and avoid using marijuana around children.

Public health officials also launched in 2018 targeting new parents and adults who influence kids’ behavior. Between fiscal years 2015 and 2020, the department spent roughly $22.8 million on those efforts.

It’s hard to say exactly how well marijuana regulations in states like Colorado are working, said Tweet. “It’s possible if those regulations weren’t in place that the numbers would be even higher.”

What’s happening in Colorado is part of a national trend. In a study published in January, researchers looked at the number of children younger than 6 who ingested marijuana edibles nationwide from 2017 to 2021. They found 207 reported cases in 2017. In 2021, , according to data from the National Poison Data System.

The legalization of cannabis has likely played a significant role in the rise of accidental child exposures, said Tweet, a co-author of the study. “It’s more readily available and more of an opportunity for the children to get into.”

Parents may also feel less stigma nowadays in reaching out to poison centers and health clinics, she said.

To understand what factors are driving these numbers, more research is needed into marijuana regulations and the number of child exposures nationwide, said Tweet.

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What was unusual was seeing a bar owner — in this case, Pop’s Blue Moon’s Joshua Grigaitis — grab cans of the drink and give them to customers without looking over his shoulder in a state where , for now. Missouri voters will decide whether to liberalize the law in the Nov. 8 election.

“Contains 10mg of the good stuff, which equals less than .3% by volume. This means it can be sold almost anywhere!” Grigaitis posted on Facebook last month when he announced the new products from his cannabis-infused drink company: hemp-derived delta-9 THC seltzer in “cherry blossom” or “heady lemon” flavors.

Grigaitis thinks he is on solid legal footing in selling the seltzer because it comes from hemp, not marijuana, two plants from the same Cannabis genus. Still, he labels the cans with the percentage of THC by volume, which refers to a federal limit allowed for hemp, anticipating scrutiny of his product.

Rather than offer his drink in the crowded market for medical and adult-use marijuana — which remains illegal at the federal level and faces costly taxes and regulations where legal at the state level — Grigaitis thinks a loophole in a federal law concerning hemp allows him to sell a product that offers the same sort of buzz at his bar, online, and just about everywhere else.

As such, he said, hemp-derived delta-9 tetrahydrocannabinol products have the “potential to flip the entire cannabis industry upside down.”

Grigaitis is not the only one who senses an opportunity. Some 120 brands are selling hemp-derived delta-9 products online, according to an by CBD Oracle, which reports on the industry.

But others in the cannabis industry are concerned about the loophole and are seeking federal legislation to prevent people from selling intoxicating hemp products outside of dispensaries. They say some of the products aren’t safe because minors could access them more easily than products from dispensaries. And they generally aren’t subject to oversight from state regulatory systems. The critics also claim that the products subvert the intent of a 2018 federal law that removed hemp from the federal controlled substances list.

“The medical marijuana and recreational marijuana industries are very regulated to the point where identification, passports, driver’s licenses are all held very tightly at these dispensaries,” said Eric Wang, vice president of sustainability for the , a Kentucky-based trade group.

By contrast, he said, a 12- or 13-year-old child can buy a hemp-derived product legally.

When a bipartisan group of lawmakers passed the 2018 Farm Bill, the advertised aim was to help struggling farmers by allowing them to grow industrial hemp. The law also meant people could sell CBD across state lines. CBD has since become a multibillion-dollar industry.

At the time, then-Senate Majority Leader , a Republican from Kentucky who sponsored the legislation, said of hemp that “everybody has figured it out that this isn’t the other plant.”

The primary difference between marijuana and hemp is that hemp contains very small amounts of THC. The states that it can contain no more than 0.3% delta-9 THC on a dry-weight basis.

Grigaitis argues that his hemp-derived delta-9 beverage is legal because the amount of THC in the beverage is less than 0.3% of the weight of the liquid.

“That is supported by my lawyers, my test labs, my insurance, my bank — everyone,” said Grigaitis, whose Mighty Kind drinks appear in the recent Kevin Smith movie “Clerks III.”

His hemp-derived delta-9 is made from one of two methods: extracting the cannabinoid from the hemp plant itself or through a chemical conversion in which CBD from the hemp is dissolved in a solvent, Grigaitis said. The company is exploring both methods to determine the pros and cons of each, he said.

Because the source is hemp rather than marijuana, he sees a clear path to selling his product beyond dispensaries, which come with extensive regulations and taxes and thus narrow profit margins. Why would he sell in a dispensary, he asked, “when you could go next door into a CBD shop or a vape shop or a grocery store or a bar and sell your stuff?”

But some in the industry disagree with Grigaitis’ interpretation of the federal law. The proportion of the dry weight refers to the amount in the plant, not a beverage, said Jonathan Miller, general counsel for the Hemp Roundtable.

Rep. (D-Maine) has that would amend the 2018 law with additional restrictions on hemp-derived products. Pingree spokesperson Victoria Bonney said the congresswoman was not available for an interview.

In the meantime, at least a dozen states have passed laws limiting sales of another hemp-derived substance, delta-8, which is also intoxicating but not as strong as delta-9. But states have been slow to catch up with these new drug products.

Miller hopes parts of Pingree’s legislation will be included in the 2023 Farm Bill, given the 2018 bill expires next year. The roundtable seeks regulations to limit the amount of THC in finished products rather than in the plant alone and to restrict the sale of intoxicating hemp products to the adult-use marketplace, such as at a pot dispensary, Miller said. Alternatively, the group wants it regulated like alcohol.

The organization includes board members from some of the biggest companies in the adult-use marijuana marketplace, including its president, Pete Meachum. He is a lobbyist employed by , a Canadian cannabis company whose largest shareholder is Altria, maker of Marlboro cigarettes and an investor in Juul. Meachum declined an interview request.

“Anything that threatens the exclusivity of the regulated market is going to be of concern to those that have their time and money invested in it,” Grigaitis said.

But Miller said that with new federal regulations, hemp-derived products “would be available in the same locations where you can buy marijuana products, so there would be an even playing field.”

Other industry groups and the have also called for the FDA to regulate hemp-derived products.

In the meantime, the Pop’s Blue Moon patrons didn’t seem worried about the lack of regulation and were happy to try Grigaitis’ new seltzer. Harper Britz, a 21-year-old who works in the music industry, said she got a pleasant buzz from the seltzer. She liked that she could taste the cannabis.

“It gets that aroma on the nose, just like when you’re smelling wine,” said Britz, who lives in St. Louis and said she regularly uses cannabis. “I’d probably drink this every day if I could.”

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Hours after enjoying the tasty drink and the silliness that reminded Kennedy of a high from weed, she said, she started to feel “really shaky and faint” before collapsing in her friend’s arms. Kennedy regained consciousness and recovered, but her distaste for delta-8 remains, even though the substance is legal at the federal level, unlike marijuana.

“I’m not one to really tell people what to do,” said Kennedy, 35, who lives in Milwaukee and works in software sales. But if a friend tried to order a delta-8 drink, “I would tell them, ‘Absolutely not. You’re not putting that in your body.’”

The FDA and some marijuana industry experts share Kennedy’s concerns. At least a dozen states have banned the hemp-derived drug, including Colorado, Montana, New York, and Oregon, which have legalized marijuana. But delta-8 manufacturers call the concerns unfounded and say they’re driven by marijuana businesses trying to protect their market share.

So what is the difference? The flower of the marijuana plant, oil derived from it, and edibles made from those contain delta-9 tetrahydrocannabinol, the substance that produces the drug’s high, and can be legally sold only at dispensaries in states that have legalized marijuana. Similar products that contain delta-8 THC are sold online and at bars and retailers across much of the U.S., including some places where pot remains illegal. That’s because a 2018 federal law legalized hemp, a variety of the cannabis plant. Hemp isn’t allowed to contain more than 0.3% of the psychotropic delta-9 THC found in marijuana.

The concerns about delta-8 are largely focused on how it’s made. Delta-8 is typically produced by dissolving CBD — a compound found in cannabis plants — in solvents, such as toluene that is often found in paint thinner. Some people in the marijuana industry say that process leaves potentially harmful residue. A in the journal Chemical Research in Toxicology last year found lead, mercury, and silicon in delta-8 electronic cigarettes.

The FDA has about the “serious health risks” of delta-8, citing concerns about the conversion process, and has received more than 100 reports of people hallucinating, vomiting, and losing consciousness, among other issues, after consuming it. From January 2021 through this February, national poison control centers received more than 2,300 delta-8 cases, 70% of which required the users to be evaluated at health care facilities, according to the FDA.

Delta-8 is “just the obvious solution to people who want to have access to cannabis but live in a state where it’s illegal,” said Dr. , a primary care physician at Massachusetts General Hospital and a longtime medical cannabis provider. “You can either get in a lot of trouble buying cannabis, or you can get delta-8.”

Grinspoon described delta-8 as about half as potent as marijuana. But because of the lack of research into delta-8’s possible benefits and the absence of regulation, he would not recommend his patients use it. If it were regulated like Massachusetts’ medical and recreational marijuana programs, he said, harmful contaminants could be flagged or removed.

, chief scientific officer at ProVerde Laboratories, a Massachusetts marijuana and hemp testing company, said he has examined thousands of delta-8 products and all contained contaminants that could be harmful to consumers’ health.

Delta-8 has “incredible potential as a therapeutic” because it has many of the same benefits as marijuana, minus some of the intoxication, said Hudalla. “But delta-8, like unicorns, doesn’t exist. What does exist in the market is synthetic mixtures of unknown garbage.”

Justin Journay, owner of the delta-8 brand 3Chi, is skeptical of the concerns about the products. He started the company in 2018 after hemp oil provided relief for his shoulder pain. He soon started wondering what other cannabinoids in hemp could do. “‘There’s got to be some gold in those hills,’” Journay recalled thinking. He said his Indiana-based company now has more than 300 employees and sponsors a NASCAR team.

When asked about the FDA’s reports of bad reactions, Journay said: “There are risks with THC. There absolutely are. There are risks with cheeseburgers.”

He attributes the side effects to taking too much. “We say, ‘Start low.’ You can always take more,” Journay said.

Journay said that he understands concerns about contaminants in delta-8 products and that his company was conducting tests to identify the tiny portion of substances that remain unknown, which he asserts are cannabinoids from the plant.

An conducted by Hudalla’s firm last year and posted on 3Chi’s website found multiple unidentified compounds that “do not occur naturally” and thus “would not be recommended for human consumption.” Delta-8 oil is still sold on 3Chi’s site.

Journay said the analysis found that only 0.4% of the oil contained unknown compounds. “How can they then definitively say that compound isn’t natural when they don’t even know what it is?” he said in an email.

“The vast majority of negative information out there and the push to make delta-8 illegal is coming from the marijuana industries,” Journay said. “It’s cutting into their profit margins, which is funny that the marijuana guys would all of a sudden be for prohibition.”

Delta-8 products do appear to be significantly cheaper than weed. For example, Curaleaf, one of the world’s , offers packages of gummies that contain 100 milligrams of delta-9 THC for $25, plus sales tax, at a . At 3Chi, , with no tax.

Journay’s criticism of the marijuana industry holds some truth, said Chris Lindsey, government relations director for the , which advocates for legalization of marijuana for adults. “We see this happen in every single adult-use legalization state,” said Lindsey. “Their established medical cannabis industry will sometimes be your loudest opponents, and that’s a business thing. That’s not a marijuana thing.”

Still, the bans might not be working fully. In New York, which banned delta-8 in 2021, Lindsey said, it’s available at any bodega.

In July, Minnesota implemented a law that limits the amount of THC, including delta-8, allowed in hemp products outside of its medical marijuana program. said the law would wipe out delta-8. But the state cannot “control what’s being sold over the internet outside of Minnesota and shipped in,” said Maren Schroeder, policy director for , which aims to legalize recreational cannabis for adults.

Max Barber, a writer and editor in Minneapolis, remains interested in delta-8 despite his state’s restrictions. Even though he could likely obtain a medical marijuana prescription because he has an anxiety disorder and chronic sleep problems, he hasn’t pursued it because pot made his anxiety worse. He used CBD oil but found the effects inconsistent. In March 2021, he tried a 10-milligram delta-8 gummy.

“It got me pretty high, which I don’t enjoy,” he said.

Then he found what he considers the right dosage for him: one-third of a gummy, which he takes in the evening. He said he now gets between six and eight hours of sleep each night, has less anxiety, and is better able to focus. “I have become kind of an evangelist for delta-8 for everyone I know who has sleep problems,” said Barber, who bought enough gummies to last for months after the new law went into effect.

To address concerns about delta-8, the federal government should regulate it and make accessing cannabis easier for consumers, said Paul Armentano, deputy director of the .

He pointed in the International Journal of Drug Policy showing that the number of Google searches for delta-8 in the U.S. soared in 2021 and that interest was especially high in states that restricted cannabis use. “In an environment where whole-plant cannabis is legally available, there would be little to no demand for these alternative products,” said Armentano.

Lindsey, of the Marijuana Policy Project, isn’t so sure that would matter. When he first learned of delta-8’s growing popularity in 2021, he thought it would go the way of drugs like K2 or Spice that he said fall between the regulatory rules long enough to get on shelves before eventually getting shut down.

“That didn’t materialize,” said Lindsey. “The more that we understand about that plant, the more of these different cannabinoids are going to come out.” And that, he said, will in turn spur interest from consumers and businesses.

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Citizens of the Oglala Sioux Tribe overwhelmingly voted in 2020 to legalize recreational and medical marijuana on their sprawling reservation, which has prohibited the sale and consumption of alcohol for more than 100 years.

Customers visiting a dispensary on a recent Friday said they view marijuana as a safe and natural way to obtain relief from mental health disorders and chronic illnesses, which are common among tribal citizens. But they said alcohol has wreaked havoc on the health, safety, and life expectancy of tribal members.

“Cannabis is a natural plant that comes from the Earth — and our people lived off the land, and they got their medicine from the land,” Ann Marie Beane said while shopping at the No Worries dispensary in the small town of Pine Ridge. “Our Indigenous people, they suffer a lot from diabetes and cancer and various other illnesses, but the cannabis really helps them.”

Beane and her 22-year-old daughter said they use marijuana to ease their anxiety.

Marijuana use can lead to physical and mental health problems, but shoppers at the No Worries store said it’s less dangerous than alcohol, meth, and opioids. Those drugs lead to high rates of premature deaths on the reservation through car crashes, violence, and disease.

The Pine Ridge Reservation, established in 1889, is spread across more than 2 million acres of small towns, ranchland, prairies, and otherworldly badland formations. The U.S. Census Bureau says about 20,000 people live there, but community members say that’s a vast undercount and that the population could be as high as 40,000.

Alcohol has been illegal there for most of the reservation’s history, but that hasn’t stopped bootlegging and abuse. “It’s killing our youth — it’s killing our future generation,” Beane said.

The Oglala Sioux Tribe that about 25% of children born on the reservation had health or behavioral problems caused by exposure to alcohol in the womb. The lawsuit was filed against across the border in Nebraska.

The average life expectancy is just 64.5 years in Oglala Lakota County, which includes much of the Pine Ridge Reservation, from the Institute for Health Metrics and Evaluation at the University of Washington. That’s the lowest of any county in the U.S. and about 15 years below the national average.

Native Americans have high rates of health problems, which to poverty and ways their communities have been harmed and fractured by federal policies. Those who live on reservations often have limited access to health care services and healthy food, and their main health care provider is the Indian Health Service, which has been dogged by complaints of and .

On the recent Friday, Beane was among dozens of customers who pulled into the gravel parking lot at the No Worries dispensary. After displaying IDs through a ticket window, customers entered the shop to buy loose marijuana, joints, and edibles prepared in a commercial-grade kitchen.

Only a few customers at No Worries said they use marijuana for purely recreational reasons. More said they use it to relieve anxiety, pain, and other medical conditions.

One customer’s eyes filled with tears as she lifted her shirt to reveal an ostomy bag, which doctors attached to her midsection after removing part of her intestines.

Another customer, Chantilly Little, said she’s recovering from addiction to stronger drugs. The 27-year-old said she has seen drugs kill tribal citizens and wants to be a responsible parent. “I’d rather smoke than do other drugs because I almost gave up on my kids,” Little said.

Stephanie Bolman — a breast cancer patient, former health care worker, and council member for the Lower Brule Sioux Tribe — was traveling through the area and decided to visit the No Worries shop.

Bolman doesn’t use marijuana but wanted to see the dispensary. She’s interested in legalizing medical cannabis on her reservation, situated along the Missouri River in central South Dakota, about four hours east of Pine Ridge.

“Unfortunately, the health care services provided by the Indian Health Service have failed so many in countless ways,” Bolman said. “It has left many to fend for themselves and endure so much pain and suffering that medical marijuana has proven to be lifesaving.”

In 2020, when tribal citizens approved the marijuana initiatives for the Pine Ridge Reservation, they rejected a proposal to legalize alcohol sales and consumption within the two casinos on the reservation.

In 2013, to legalize alcohol reservation-wide by a narrow margin. But the tribal council never implemented the change.

Lakota people did not use marijuana in pre-colonial times, said Craig Howe, a Lakota historian. Lakota and other Great Plains tribes also didn’t use .

Alcohol “was meant to control our people, and eventually it became a weapon of mass destruction,” said Ruth Cedar Face, an addiction treatment counselor and a member of the Oglala Sioux Tribe.

Cedar Face said that medical marijuana can be helpful for certain medical and mental health conditions but that it’s not a cure-all. “When it becomes a problem, when it becomes an addiction, that’s because they’re medicating away the things they need to deal with, like the trauma that is usually the core of any kind of addiction or unhealthy behavior,” she said.

Cedar Face said marijuana can also cause psychosis, lung damage, diminished brain development, and other problems for some users, .

People must be 21 or older to buy or use cannabis, according to Oglala Sioux law. They can face jail time for providing marijuana to minors and fines for using the drug while driving.

Dispensaries can sell only marijuana grown on the reservation, and customers are prohibited from transporting cannabis elsewhere. But about 40% of No Worries customers live outside the reservation, with many traveling from the Black Hills of South Dakota or northwestern Nebraska, said owner Adonis Saltes.

Recreational marijuana is illegal in South Dakota, which means law enforcement officers could charge anyone caught transporting or using cannabis outside reservation boundaries. But the sheriff’s office in Pennington County, which borders the Pine Ridge Reservation, said it hasn’t arrested anyone on such charges.

That contrasts with the experience of the Flandreau Santee Sioux Tribe on the eastern side of the state. State and local law enforcement officers are charging Native Americans and non-Natives who’ve left the reservation with cannabis from the reservation’s medical dispensary, according to Seth Pearman, the tribe’s attorney general.

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And the more serious he got about pot, the more paranoid, even psychotic, he became. He started hearing voices.

“They were going to kill him and there were people coming to eat his brain. Weird, weird stuff,” Kirkaldie said. “I woke up one morning, and no Kory anywhere. Well, it turns out, he’d been running down Villa Lane here totally naked.”

Kory went to live with his grandmother for a couple of years in Napa, California. She thought maybe she could help. Now, she says that was naive.

Kory was diagnosed with schizophrenia. Kirkaldie blames the pot.

“The drug use activated the psychosis, is what I really think,” she said.

Indeed, have linked marijuana use to an increased risk of developing psychiatric disorders, including schizophrenia. The risk is more than for people who use high-potency marijuana daily than for those who have never used, according published in The Lancet Psychiatry in 2019. One study found eliminating marijuana use in adolescents could reduce global rates of schizophrenia .

Doctors and lawmakers in California want cannabis producers to warn consumers of this and other health risks on their packaging labels and in advertising, similar to requirements for cigarettes. They also want sellers to distribute health brochures to first-time customers outlining the risks cannabis poses to youths, drivers, and those who are pregnant, especially for pot that has high concentrations of THC, the chemical primarily responsible for marijuana’s mental effects.

“Today’s turbocharged products are turbocharging the harms associated with cannabis,” said Dr. Lynn Silver with the , a nonprofit sponsoring the proposed labeling legislation, , the Cannabis Right to Know Act.

Californians voted to legalize recreational pot in 2016. Three years later, emergency room visits for cannabis-induced psychosis went up 54% across the state, from 682 to 1,053, according to state hospital data. For people who already have a psychotic disorder, cannabis makes things worse — leading to more ER visits, more hospitalizations, and more legal troubles, said , a psychiatry professor at Yale University School of Medicine who also serves on the for Connecticut’s medical marijuana program.

But D’Souza faces great difficulty convincing his patients of the dangers, especially as have legalized recreational marijuana.

“My patients with schizophrenia and also adolescents hear very conflicting messages that it’s legal; in fact, there may be medical uses for it,” he said. “If there are medical uses, how can we say there’s anything wrong with it?”

Legalization is not the problem, he said; rather, it’s the commercialization of cannabis — the heavy marketing, which can be geared toward attracting young people to become customers for life, and from 4% on average up to between 20% and 35% in today’s varieties.

Limiting the amount of THC in pot products and putting health warnings on labels could help reduce the health harms associated with cannabis use, D’Souza said, the same way those methods worked for cigarettes.

He credits warning labels, education campaigns, and marketing restrictions for the sharp drop in in the past decade.

“We know how to message them,” D’Souza said. “But I don’t think we have the will or the resources, as yet.”

Some states, including Colorado, Oregon, and New York, have dabbled with cannabis warning-label requirements. California’s proposed rules are modeled after comprehensive protocols established in Canada: Rotating health warnings would be set against a bright-yellow background, use black 12-point type, and take up a third of the package front. The bill suggests language for 10 distinct warnings.

Opponents of the proposed labels say the requirements are excessive and expensive, especially since marketing to children is already prohibited in California and people must be 21 to buy.

“This bill is really duplicative and puts unnecessary burdens on the legal cannabis industry, as we already have incredibly restrictive packaging and advertising requirements,” said Lindsay Robinson, executive director of the .

The state should focus more on combating the illicit pot market rather than further regulating the legal one, she said. Legal dispensaries are already struggling to keep up with existing rules and taxes — the state’s 1,500 licensed pot retailers generated last year. Adding more requirements makes it harder for them to compete with the illicit market, she said, and more likely to go out of business.

“The only real option if they fail out of the legal system is to shutter their businesses altogether or to operate underground. And I don’t think the state of California, with the tax revenue, wants either of those to happen,” Robinson said. “The heart of the issue is that there’s a massive, unregulated market in the state.”

Some people are skeptical that the labels will work. Liz Kirkaldie’s grandson, Kory, is stable now, living with his dad. But she’s not sure a yellow warning would’ve stopped him when he was a teen.

“They’re just not going to pay attention,” she said. “But if it helps even one person? Great.”

Scientists still do not know what causes schizophrenia, but they believe multiple factors are at play, including genetics, family history, trauma, and other influences in a person’s environment, like smoking pot. Some scientists believe having schizophrenia in the first place . While it’s difficult to prove a direct causal link between cannabis use and schizophrenia, the associations are strong enough to warrant action, said D’Souza, and, importantly, pot use is one of the few risk factors people can control.

“Not everyone who smoked cigarettes developed lung cancer, and not everyone who has lung cancer smoked cigarettes,” he said. “But I think we would all agree that one of the most preventable causes of lung cancer is cigarette smoking.”

Applying the same health education strategies to cannabis that were used for tobacco, he said, is long overdue.

This story is part of a partnership that includes , , and KHN.

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Wright lives in Prairie County, the state’s fifth-least-populated county, with nearly 1,100 people. She already drives about 35 minutes to get to the marijuana dispensary nearest her home, which is 2½ hours northeast of Billings. And now she wonders how much more difficult it will be to get the cannabis she uses to relieve the chronic pain she developed after a 2017 spinal surgery.

“I’m really worried about supplies and what it’s going to cost,” she said.

For Wright and the approximately 55,000 other Montanans who hold medical marijuana cards and use cannabis for cancer, glaucoma, Crohn’s disease, central nervous system disorders and other ailments, the question is how will recreational marijuana affect their ability to access their medicine.

Other states have had shortages soon after their recreational marijuana markets opened. In January 2020, when recreational marijuana became legal in Illinois, . The same thing happened in and when the recreational market opened in those states.

Pepper Petersen president and CEO of the Montana Cannabis Guild and a medical marijuana provider in Helena, said he’s been telling his patients to stock up because he thinks the state’s dispensaries will run out of pot in the short term.

“We are going to have cannabis shortages. Access will be a problem until supply can catch up with demand,” Petersen said. “How can we produce enough product for thousands of new users in January? The answer is we can’t.”

In Wright’s case, stocking up isn’t an option because of her fixed income, she said. She wonders how high the price of a pre-rolled joint, which now costs nearly $8, will rise and whether she’ll have to drive even farther to get her medicine.

Jared Moffat, a campaign manager for the Marijuana Policy Project, said a state’s market usually takes six to 12 months to stabilize after recreational cannabis becomes legal. One reason marijuana markets are unstable is that possessing and distributing the drug remain illegal under federal law, so moving products across state lines is not an option for dealing with a shortage. Everything that is sold in a state must be grown in that state.

Adding to the potential supply-chain problem is that Montana has restricted who can sell cannabis, at least initially. The legislation that set up the framework for Montana’s recreational marijuana market , meaning newly licensed sellers can’t get into the market until July 2023.

That leaves medical marijuana customers to compete with recreational users for a limited supply of cannabis.

About 80 dispensaries — just 18% of Montana’s 451 licensed dispensaries — plan to exclusively serve holders of medical marijuana cards, according to Czelsi Gómez, spokesperson for the Montana Department of Revenue, which oversees the state’s marijuana programs. The rest plan to cater to both recreational and medical users or to only recreational users.

Some states that have legalized recreational cannabis — including New Jersey and Illinois — have required dispensaries to maintain enough stock to ensure that medical users can get what they need.

Montana has not instituted such a rule. But Gomez said the 80 dispensaries that will serve only medical marijuana users will protect patients. “We believe the medical-only establishments are the safeguard for ensuring medical marijuana is available to registered cardholders,” Gomez said.

Some dispensary owners said they will reserve some of their supplies to ensure medical customers don’t run out. But others said they don’t plan on holding back, arguing that would be bad for business.

Barbie Turner, a co-owner of Alternative ReLeaf, a dispensary with locations in Missoula, Polson and Libby, said she is worried about where medical users will get their cannabis. She said that if serving medical customers requires her to stop selling cannabis to recreational users, she will.

“Not only do our medical patients have a need, they’re the ones who built up these businesses. They’re the ones who built this industry,” she said. “So I think we have an ethical responsibility to take care of them, just like they have taken care of us.”

How big the recreational marijuana market will be is unclear. A cited survey results from 2017 and 2018 that found about 14% of Montana adults said they used cannabis in the previous month, compared with 9% of adults nationally.

Petersen and others said more people might become recreational users once cannabis products that can be smoked or eaten become easier to buy.

Turner said that she and her employees have been working for months to make sure they have enough marijuana but that she’s still worried about the supply. There are limits, both legally and financially, on how much a provider can grow, she said.

Shops will get some help, she said, with the state’s wholesale market opening in January, meaning that dispensaries will be able to sell to one another in bulk.

Although many dispensaries — especially in college towns such as Missoula and Bozeman — are bracing for shortages this month, Erin Bolster said she thinks the real test of marijuana supplies will come in the summer, when millions of tourists visit Yellowstone and Glacier national parks.

Bolster owns Tamarack Cannabis in the Flathead Valley, a popular tourist destination not far from Glacier National Park. In summer 2020, long before dispensaries could sell recreational cannabis, Bolster said, she would get one or two walk-ins and two or three calls a day from tourists who had heard Montana had legalized adult-use marijuana and wanted to see if they could buy.

Come summer, she thinks, the number of customers will skyrocket. That could mean even more competition for Montana’s medical marijuana there and in other popular destinations.

“We’ve been able to expand production,” Bolster said. “But the question is ‘Did we expand enough?’”

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