Kai Raydon was a neuropharmacology major at the University of Colorado, Boulder, the kind of person who studied how drugs act on the brain because he wanted to understand exactly what they did. In the summer of 2023, he ordered what he believed to be a Quaalude from a dark-web vendor. For people his age, Quaaludes exist almost entirely as mythology, the drug your parents’ generation glamorized and then outlawed: the legendary high from movies and songs that hasn’t been legally produced in the United States since 1983. What arrived in Kai’s package, forty years after the last legal Quaalude was manufactured, wasn’t a Quaalude. It was something newer and far more dangerous than anything he knew to test for.

Kai knew that any dark-web purchase came with risks, so he did his best to prepare for them. He tested a sample of the powder with a fentanyl test strip. It came back negative. He weighed out a gram on a digital scale and snorted it.

He never woke up.

The coroner couldn’t say what killed him. Standard toxicology found nothing that explained the death. It took months for a specialized forensic lab to produce an answer: N-desethyl etonitazene, a nitazene analog ten times more potent than fentanyl. It was not on any scheduling list. It was not in any test strip’s detection library. Two years earlier, it had been described in a pharmacology paper as a hypothetical compound, one that scientists thought chemists might eventually synthesize. By the time it killed Kai Raydon, it had existed as a real drug for less than a year.

He did everything harm reduction asks of a person, and it killed him anyway. Not because the strip failed, but because it worked. It was built to catch fentanyl, and what he took wasn’t fentanyl. It was something the strip was never designed to look for, because it barely existed when the strip was made.

In a system shaped by prohibition, safety will always be one step behind the chemistry. And as the chemistry gets faster, that delay costs more lives.

What’s strange about Kai’s death is that it happened in the middle of the first real win American drug policy has had in a generation.

For the first time in a decade, overdose deaths in the United States are falling, and they’re falling fast. CDC data show the overdose death rate dropped 26.2% between 2023 and 2024. The death rate from synthetic opioids, which are mostly fentanyl, fell 35.6% over the same period. Tens of thousands of people are alive today who would not have been under the trajectory we were on in 2022.

It happened because people built something. Harm reduction workers spent a decade fighting to get naloxone out of pharmacy-only restrictions and into gas stations, vending machines, school nurses’ offices, and the pockets of people who use drugs. Drug user unions pushed states to legalize fentanyl test strips one legislature at a time, against paraphernalia laws written in the 1970s. Public health departments built fentanyl-specific overdose response protocols from scratch. Clinicians fought their own systems to offer low-barrier buprenorphine to people walking into emergency rooms in withdrawal. Mothers who lost children became advocates, and then became the reason other mothers didn’t.

None of this came from the top. It came from people who understood earlier than anyone in power did that drug users were not the problem, the supply was, and that keeping people alive was the prerequisite to everything else.

What they were fighting wasn’t regulation. It was prohibition. And what they built in its place was the first draft of a public health system, forced up from the bottom because no one at the top would.

The tools they built are specific to the drug that killed the most people for most of that decade. The infrastructure that saved tens of thousands of lives in 2024 could not have saved Kai in 2023, and it will not save the next person, because the supply has moved.

The changing supply is already showing up in the data, and the data is ugly.

We just figured out how to treat fentanyl. The drug now being cut into it is called medetomidine, a veterinary sedative approved for dogs and cats. In April 2026, the White House Office of National Drug Control Policy and the CDC issued a joint health alert about its rise in the fentanyl supply. Seizures went from 247 in 2023 to 2,616 in 2024 to 8,233 in 2025.

Yet seizure data is a blunt instrument. It tells you what’s being found, not what’s being used. For that you need drug checking programs, and that data is worse.

In Philadelphia, the public health department started testing for medetomidine in May 2024. It was in 29% of fentanyl samples. Six months later, by November, it was in 87%.

Medetomidine is an alpha-2 adrenergic agonist, not an opioid, which is why naloxone reverses the fentanyl beside it but not the medetomidine. People are arriving in emergency departments with heart rates as low as 32 and sedation that doesn’t respond to the standard protocol. In one 209-patient study, 77.5% of medetomidine cases needed the ICU and 20% were intubated. After the drug entered Philadelphia’s supply, ICU admissions doubled.

The tests can’t reliably find it, either. In that same 209-patient cohort, a third of the patients who came in with every sign of medetomidine tested negative for it. The drug was what made them sick, and the hospital lab still missed it. Every prevalence number is an undercount, and there isn’t a test strip on the market that catches it.

This is what it looks like when a supply outpaces a response. The naloxone works on the opioid. The withdrawal protocol works on the opioid. The strip catches the opioid. None of it catches the thing the opioid is now mixed with, and the thing the opioid is now mixed with is sending people to the ICU at a rate public health wasn’t ready to absorb. The drug that made the biggest drop in overdose deaths in a generation possible is being diluted, chemically, into something the response wasn’t built to meet.

The drug that killed Kai was a nitazene. Nitazenes were the first act of this pattern, and medetomidine is the second. Together, they tell you everything about how prohibition shapes a supply.

Nitazenes are synthetic opioids developed in the 1950s by a Swiss pharmaceutical company looking for a non-addictive painkiller. They failed clinical trials because they suppressed breathing too severely, and they sat in old German patents for sixty years. Then, in 2019, as China scheduled fentanyl analogs and Mexican cartels scrambled for new precursors, chemists went back to those patents. Isotonitazene appeared in the North American supply that year, and the analogs kept coming. By the end of 2024, forensic labs had identified at least twenty-two distinct nitazenes in the supply. The UN Commission on Narcotic Drugs has now scheduled twelve of them.

The pattern is simple enough that the DEA described it back in 2019, about a different drug, the stimulants sold as bath salts: “as one synthetic cathinone is controlled, another unscheduled synthetic cathinone appears.” Nitazenes are doing the same thing now with opioids, only faster. Each scheduling action closes one molecule and opens a race to the next one. While the illicit chemists are working from published literature, the regulators are working from case reports that take months to produce. In that gap, the new drug always wins.

There’s an obvious way out of a race like this: stop banning one molecule at a time and ban the whole class at once. In July 2025, China did exactly that, the thing prohibition advocates in the United States had spent years demanding. It scheduled the entire nitazene class, every compound built on the benzimidazole core, in a single action. And it worked. Nitazene detections in US drug markets began falling in late 2025.

The market didn’t slow down. It switched. By January 2026, the Center for Forensic Science Research and Education, which runs the country’s most comprehensive surveillance program for novel opioids, reported that as the nitazenes receded, a new class was moving into the space they left: the benzimidazol-2-ones, known as orphines, structurally different enough that the nitazene scheduling doesn’t reach them. CFSRE is already tracking at least six, chlorphine, N-propionitrile chlorphine, spirochlorphine, spirobrorphine, 5,6-dichloro brorphine, and 5,6-dichloro desmethylchlorphine. The first fatal overdose alert is already out, for cychlorphine.

And the orphines were not new. Brorphine, the first of them, surfaced in 2019 and was rapidly banned in multiple countries. Here is what CFSRE says those bans did: they “appear to have accelerated structural diversification.” Ban the first compound, and the class fractures into a spread of new analogs, the halogenated and cyclized variants now filling the space the nitazenes left behind.

So it happened twice, in a single alert. Ban the nitazenes, and the market moves to the orphines. Ban brorphine, and the orphines multiply. This was the best case, the coordinated, class-wide enforcement that was supposed to finally work, executed exactly as designed. It closed one door, and within months the supply was through the next.

Every drug policy we might adopt sits somewhere on a parabolic curve, with prohibition at one end and unregulated commercial markets at the other.

We know what prohibition produces, because we’re living in it. It produces fentanyl, then nitazenes, then medetomidine, then orphines in the wings. It produces a chemistry that moves faster than the response. It produces the conditions under which a college student can do exactly what harm reduction tells him to do and die anyway. And it produces nothing new. It selects, from a back catalog of compounds that failed clinical trials for being too dangerous to sell, for whichever one is unscheduled, cheap to make, and potent enough to ship.

We know what the other end produces too, because we already live in it for other drugs. Tobacco is legal, commercialized, and lightly regulated, and it kills roughly 480,000 Americans a year. Alcohol is legal, commercialized, and lightly regulated, and it kills another 178,000. Both ends of this curve are lethal.

The middle, where harm is lowest, isn’t a utopia and doesn’t pretend to be. It’s regulated access, with the constraints the market wouldn’t put on itself. It’s where public health lives.

The response we’ve already built is a step in that direction. Naloxone, drug checking, low-barrier treatment, all of it moves toward that middle and away from prohibition. It worked. But it was only the first step, and the supply has already moved past it.

So the real question isn’t whether to regulate drug markets. It’s which end of the curve we keep choosing. Right now we choose prohibition, and prohibition keeps producing the next drug. The answer isn’t the far end either, the legal, commercialized market that kills hundreds of thousands a year. It’s the middle.

The work now is to move toward it, toward a supply people don’t have to test in the dark and hope. We know what that looks like. We’re already doing pieces of it. What’s left is the will to finish.

The next person will do what Kai did. They'll test what they bought, watch the strip come back clean, and take it. And if they die, it won't be because the strip failed. It will be because the chemistry was already one step ahead, the way prohibition guarantees it always will be.

For as long as I can remember, I have been in some kind of pain. My knees hurt so badly in middle school that I saw specialist after specialist, before chalking it up to growing pains that never went away. In college, I’d stand up after practice, and my hips would just get stuck, my pelvis frozen out of place, leaving me unable to stand up straight for the rest of the night. To this day, if the weather shifts too quickly, my whole body feels as if it’s being stretched and kneaded, like a piece of dough. For most of my life, nobody could tell me why.

The answer, when it finally came, was hypermobile Ehlers-Danlos syndrome. It’s a connective tissue disorder, which really just means the collagen that’s supposed to hold my body together doesn’t do its job. Collagen is the scaffolding the whole body is built on, so when it’s faulty, the trouble doesn’t stay in one place. For me, that’s joints that slip and give out, skin that bruises and tears too easily, and a long string of other problems that took years, and a lot of doctors, to finally connect. What it means day-to-day is simpler than all of that. I live in chronic pain.

I came to cannabis the way a lot of people do. I was twenty-one, in college, and I wanted to know what being high felt like. There was nothing medical about it. I’d absorbed the same reefer-madness warnings as everyone else, and I was curious what the fuss was actually about.

By my senior year, though, I was using it consistently, and somewhere in there it quietly stopped being a weekend thing and became part of how I got through the day. I know some would flag that as the start of a substance problem. But in reality, cannabis took the edge off the pain, loosened the tightness and the muscle spasms I had daily, and cut the nausea and near-daily vomiting that had somehow become normal for me. At the same time, I was earning the highest grades of my life, and I had the energy to take on a job to support myself through my final year. I never sat down and decided to turn it into medicine. I just kept noticing, over and over, that it was doing things for me that my actual medical care wasn’t.

And yet, the more medical my use became, the more firmly I was stuck buying it on a purely recreational market.

I went to college in Pennsylvania, a medical-only state, but my driver’s license was still from New York, so I couldn’t get a medical card where I actually lived. That turned out not to matter, because the recreational market in New Jersey wasn’t hard to reach, and by the spring of my senior year, I was working as a budtender at the nearest dispensary, selling the exact thing I used to treat my pain, labeled as recreational. I did eventually get a New York medical card, but it was only good for the weeks I spent back home, and those were few and far between. The card came with me to Connecticut for grad school, where my proof that I was a patient stopped at the state line. A New York medical card doesn’t work in Connecticut, and I couldn’t get a Connecticut one as long as my license said New York. The one stretch it actually earned its keep was once a week, when I traveled back to New York for work and got to be, briefly, a medical patient.

Add it up, and I’ve been a cannabis consumer in five states: Connecticut, Massachusetts, New Jersey, New York, and Pennsylvania, that last one only by proxy, through my partner’s medical card experience. In every one of them, the thing that decided whether I counted as a patient or a customer wasn’t my body, or my diagnosis, or what I was using it for. It was my address. Which is why I can’t stop asking. What is medical cannabis, anyway?

It’s a question that became much less abstract this spring. This past April, the Trump administration moved medical cannabis from Schedule I, where it had sat next to heroin for decades, down to Schedule III, the tier that holds things like ketamine and Tylenol with codeine. But it only moved the medical kind. Recreational cannabis stayed exactly where it was, a Schedule I drug with, on paper, no accepted medical use at all. So the country now runs a federal system with two tiers for the same plant, three if you count hemp, and an entire industry trying to work out what that actually means for taxes, research, and everything else.

The federal government just drew a bright legal line between medical and recreational cannabis, and hung a whole tax structure and research agenda on it, at the exact moment I can tell you from lived experience that the line barely exists. The plant doesn’t know whether it’s medical or recreational. Half the time, neither do I.

I learned how arbitrary that line was from the inside. In the early days of recreational legalization in New Jersey, I worked at a dispensary that ran both medical and recreational operations under the same roof. Same plant, same shelves, often the same brands, the only difference being the color of the label: orange for medical, white for recreational.

And at the time I worked there, that label mattered. There were things I could sell a recreational customer that a medical patient couldn’t buy, and things set aside for patients that no recreational consumer could touch. Often, the only thing that determined which side of that line a person landed on was whether they had a qualifying condition and the time and money to get certified. I watched people get confused by it constantly, because it made no intuitive sense. It was bureaucratic.

The blurred line between medical and recreational cannabis wasn’t just a quirk of my store or of New Jersey. It shows up across the country. A study in the Annals of Internal Medicine found that as states legalized recreational cannabis, medical enrollment fell in thirteen of the fifteen that did so. New Jersey is the starkest version. Its medical program peaked at just over 129,000 patients in May 2022, the same spring recreational sales began. Four years later, it’s down to about 47,000, a drop of nearly two-thirds, and still falling. New Jersey even tried to slow the bleed by dropping the ID card fee, rolling out free digital cards, and running enrollment clinics. People left anyway.

It’s clear to me that these patients didn’t suddenly get well; they converted into recreational purchasers. The same person, with the same body and the same reasons, simply buys the recreational version, because the medical pathway isn’t offering them better medicine. It’s offering them a doctor’s visit, a registry entry, a renewal fee, and a qualifying condition off a state-approved list. Take away the legal need for all that, and most people are happy to be customers rather than patients. Their intentions don’t change. Only the paperwork does.

If the medical label disappears the moment it’s no longer legally required, it was only ever a filter for who could spend the time and money to become a patient.

None of this is to say the science is settled, because it isn’t, and I won’t pretend otherwise. We still don’t have solid dosing guidance for most conditions, and the lists of qualifying conditions states use have always run ahead of the evidence behind them. The National Academies’ 2017 review found conclusive or substantial evidence for only three uses: chronic pain in adults, the nausea and vomiting caused by chemotherapy, and the muscle spasticity of multiple sclerosis. But most patients are certified for those better-documented conditions anyway, with roughly two-thirds using cannabis for chronic pain alone. For the conditions further down the list, thin evidence isn’t the same as no benefit. The trials were never run, because Schedule I made them almost impossible for half a century.

That’s the quietly hopeful part of rescheduling. Pulling cannabis off Schedule I is meant to open the door to the large-scale research that could finally tell us what works, for whom, and at what dose. But the people using it now aren’t waiting for that consensus to arrive, and I think their experience has to count for more than it does. In survey after survey, patients report real relief, and many say they’ve cut back on opioids and other prescription painkillers since they started. The thinness of the formal evidence was never proof that cannabis doesn’t work. It’s proof that we spent decades refusing to study a medicine millions of people were already relying on, all while criminalizing them for it. When a skeptic says the science is broken and we need better criteria, they have a point; the science does need to catch up. But we shouldn’t punish patients for an evidence gap we created by making the research almost impossible to do.

But imagine we had all of the evidence tomorrow: perfect dosing, airtight criteria, a clean account of exactly who benefits and how. None of that would have gotten me a card in the state where I actually lived. It wouldn’t have made my New York card work in Connecticut. It wouldn’t have changed the fact that the thing deciding whether I was a patient or a customer was my driver’s license, not my diagnosis. The system we built around medical cannabis was never organized around the patient’s body. It was organized around residency, registries, certification fees, and lines on a map. You can sharpen the science all you want. It won’t touch the part that’s actually broken.

What would it look like to build this around patients instead? Some of it is obvious. A medical card from one state should, in theory, work in another, the way a prescription does. Getting certified shouldn’t cost more than the medicine it unlocks. And a spot on a government registry, with the justified fear that comes with it, shouldn’t be the price of relief. The harder fix underneath all of that means admitting the line we keep drawing between the patient and the customer mostly isn’t real in practice, and then being honest enough to stop building systems that pretend it is. Rescheduling won’t do that on its own, and neither will a better-evidenced list of conditions. It takes designing for the actual person at the counter, whichever door they came through, and building a medical system worth opting into, rather than one that people abandon the moment the law stops requiring it.

As for me, I’m still in pain most days, and I still treat it with cannabis I buy on the recreational market, now in a state where my license finally matches my address. The plant hasn’t changed since I was twenty-one. Neither have my reasons. The only thing that has ever really moved is the paperwork: which state I’m standing in, what color the label is, whether an official list has decided my body counts. I came looking for a fun high in college and found a medicine, one that helps me function well enough to do the things I love. While the federal government reshuffled its schedules and drew a brighter line than ever between the medical and the recreational, it still can’t tell me which one I am. I stopped needing it to. I know what my cannabis use is for. The system is the only one still confused.

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Over the past two fiscal years, Massachusetts has distributed roughly $55 million in grants to cannabis social equity businesses through the Cannabis Social Equity Trust Fund. Individual awards have ranged from $25,000 to $500,000, covering rent, payroll, debt service, and capital costs to get a licensed operation off the ground. In FY25, 181 businesses received funding, and in FY26, another 194. The money comes from cannabis sales tax revenue, administered by the state’s Executive Office of Economic Development, and it goes exclusively to entrepreneurs from communities disproportionately harmed by cannabis prohibition. It is, by design, a state government patching a federal policy gap. Every dollar in that fund exists because the federal government refused to treat cannabis businesses like any other legal industry.

A federal Schedule I classification has meant that cannabis businesses can’t access federal banking services, federal small-business loans, or take standard federal tax deductions. Specifically, under Section 280E of the Internal Revenue Code, businesses that deal in Schedule I or II controlled substances can’t deduct ordinary operating expenses like rent, payroll, utilities, and insurance from their federal tax burden. Where a restaurant or a hardware store pays federal taxes on profit alone, a cannabis business pays on gross revenue. Whitney Economics has estimated that effective federal tax rates for cannabis operators range from 70 to 80 percent, compared to the standard 21 percent corporate rate.

That tax burden sits atop startup costs that already dwarf those of most small businesses. Depending on the state, opening a single dispensary can require anywhere from $250,000 to over $2 million in upfront capital, and many states require applicants to prove $150,000 to $250,000 in liquid assets just to qualify for a license. Without access to federal lending or tax relief, states have tried to reduce those barriers on their own. Massachusetts, Maryland, Illinois, New York, Connecticut, Minnesota, Washington, and California have all built equity-specific grant or loan programs to help undercapitalized operators cover costs the federal government won’t. Last week, the federal government took a step toward changing that. But not for everyone.

On April 23, the Acting Attorney General signed a final order rescheduling certain cannabis products from Schedule I to Schedule III. Schedule III now covers two categories: FDA-approved drug products containing cannabis, and cannabis held under a state medical license. The entire adult-use market, every recreational dispensary in every legal state, remains Schedule I.

For the operators the order does cover, the most immediate change is 280E relief. State medical licensees can now deduct ordinary business expenses from their federal taxes, the same thing every other legal business in the country already does. But medical licensing predates adult-use in every state that has both, and medical licenses have historically been held by larger, better-capitalized operators, many of them multi-state companies that established themselves in medical markets years before adult-use programs launched.

When states built adult-use markets, they did so with a different goal in mind. Many states explicitly framed adult-use legalization as a rejection of the War on Drugs and its disproportionate harms to Black and brown communities. The operators most structurally tied to that project, the ones who entered the industry through equity licensing pathways, are overwhelmingly in adult-use markets. They’re still paying 280E. Still locked out of federal banking. Still Schedule I. The federal government just selectively lifted one of the barriers crushing cannabis operators, and it lifted it for the ones who needed that help least.

The operators who didn’t get relief are the ones already operating without a safety net. When a business can’t access traditional bank loans or federal small-business financing, it doesn’t stop needing capital; instead, it’s forced to find it elsewhere. In cannabis, that has meant private lenders charging interest rates far above market, investors demanding outsized equity stakes, and financing arrangements that leave the person whose name is on the license with less and less of the company they built. The operators who can absorb those terms are the ones who came in with capital already. The ones who can’t are often those who entered through equity pathways, with priority licensing but no corresponding access to the money needed to actually use a license.

280E is what makes this cycle self-perpetuating. It doesn’t just hit at startup; it compounds every year you operate. When you can’t deduct your operating costs, every dollar of revenue gets taxed before you’ve paid rent or made payroll, and the margin to survive on your own keeps shrinking. Lifting 280E on adult-use cannabis wouldn’t just save operators money on taxes. It would widen margins enough for small businesses to stay profitable without giving up equity stakes to private lenders in exchange for the capital that banks won’t provide.

But the order doesn’t stop at forward-looking relief. On page 23, the Acting Attorney General encourages the Secretary of the Treasury to consider providing retrospective relief from 280E liability for taxable years in which a state licensee operated under a state medical license. That means potential refunds for prior years of taxes already paid.

Consider Trulieve, a billion-dollar multi-state operator that filed amended federal tax returns in 2023 claiming $143 million in 280E refunds and received $113 million back from the IRS. When asked for the legal basis, CEO Kim Rivers called the strategy a “trade secret.” Retrospective relief under this order might just be that trade secret.

An equity licensee in an adult-use market paid the same 280E rates during those same years, on the same product, in an industry separated by a licensing distinction rather than any real difference in what’s being sold. The operators with historic access to capital get relief, while small businesses and entrepreneurs keep paying. The competitive distance between them only grows from here, because the operators who can now deduct their expenses and reclaim prior taxes have an even larger advantage over those who can’t.

Under the current order, the federal government is taking the first steps in sorting cannabis operators into two tiers. Schedule III for the pharmaceutical industry and established medical capital. Schedule I for the adult-use markets where equity programs tried to produce Black and brown ownership. The communities that bore the costs of prohibition are concentrated in the tier that got nothing. Rescheduling without adult-use relief isn’t a step toward equity. It is the federal government ratifying, in the tax code, the same divide that legalization was supposed to close.

Luckily, Massachusetts will keep writing checks from the Trust Fund and will keep distributing cannabis sales tax revenue to the entrepreneurs the federal government just passed over. In FY27, there will probably be another round of grants, another few hundred applications, and another set of awards covering rent, payroll, and debt service for businesses that still can’t deduct those expenses from their federal taxes.

The operators who most needed 280E relief aren’t getting it. And while there could be more changes coming for cannabis down the line, right now, the federal government looked at an industry built on the promise of equity and decided who deserved relief. The answer was not the people to whom the promise was made.

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For the operators the order does cover, the biggest immediate change is related to tax. State medical marijuana licensees are no longer subject to 26 USC 280E, the tax provision that prevents businesses dealing in Schedule I or II controlled substances from deducting ordinary operating expenses. Because of 280E, cannabis operators have paid effective federal tax rates two to three times higher than other industries, leaving many unable to turn a profit even with strong revenue. Yet the relief isn’t settled, since the order’s text is inconsistent about who qualifies, says explicitly that nothing in it determines federal tax liability, and punts retrospective relief to Treasury. Until guidance arrives, operators will likely keep paying as if 280E still applies.

The other change is registration. Rescheduling doesn’t shift state medical licensees to Schedule III automatically; each has to apply to the DEA, pay annual fees, and meet Schedule III handling requirements. The order offers operators 60 days to file. Those who apply in that window can keep running under their state licenses while DEA reviews, with a six-month target for processing. Under the order as written, registration isn’t mandatory. Operators who don’t apply can keep running their state-legal businesses as before, but they don’t get any of the order’s benefits, including 280E relief.

Research might be the clearest winner of the order. Marijuana has been one of the hardest substances to study in the U.S. since the Controlled Substances Act placed it in Schedule I in 1970, with a research regime of specialized DEA registration, secure storage, and chain-of-custody documentation that most universities can’t support. The order lowers those barriers for covered products. The complication is that Schedule III access runs through the medical market, and the line between medical and adult-use cannabis is blurrier than the schedules suggest. In most states, the same cultivators grow the same strains for both counters. How research operates under a formally medical premise, when medical and adult-use cannabis aren’t really different products, is an open question.

Whether any of this matters much depends on what comes next. The DEA has already scheduled a June 29 hearing to consider broader rescheduling, and at the state level, medical legalization has almost always preceded adult-use. This order could be the first move rather than the last for the feds.

As written, though, the order leaves more cannabis in Schedule I than it moves out. All adult-use cannabis stays there, which means operators in recreational markets keep paying 280E and keep dealing with the banking, insurance, and investment restrictions that come with federal prohibition. Now the same product sold in the same store can carry two different federal classifications depending on who’s buying it.

Rescheduling itself wasn’t a surprise. HHS recommended Schedule III in 2023, and a 2024 Office of Legal Counsel opinion under Biden concluded DOJ had the authority. The path the DEA chose to get there was a surprise. Rescheduling normally requires public notice-and-comment rulemaking, a process that takes months or years and opens the record to public input. The Acting Attorney General skipped it by invoking 21 USC 811(d)(1). This provision was written into the Controlled Substances Act to allow the United States to carry out its international drug control obligations without being held up by domestic rulemaking. Meanwhile, the Single Convention on Narcotic Drugs, a United Nations treaty the U.S. ratified in 1967, requires signatories to keep cannabis controlled but permits medical and scientific use under appropriate oversight. So the scope of the order was limited by the treaty itself: medical and scientific use, and nothing more.

In classic form for this administration, they took a process everyone had been waiting on for two years, blew up the precedent for how it’s supposed to happen, and delivered something narrower and stranger than anyone predicted. What the order actually does will play out over months, through Treasury guidance, DEA’s registration buildout, the June hearing, and the litigation that’s already coming from every direction.

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Every state that has legalized cannabis eventually runs into the same problem. The data starts coming in, the outcomes are complicated, and an editorial board or a legislative committee decides the answer is education. Teach people about the risks. Run a public awareness campaign. If consumers just knew more, they’d make better choices.

It’s a convenient answer because it puts the responsibility on the consumer instead of the system. And it avoids the harder question: what if the system hasn’t built the infrastructure for informed choices to be possible in the first place?

In March, the Boston Globe’s editorial board did exactly this. They read the Cannabis Control Commission’s latest report and came away with a recommendation for more consumer education. The editorial board is right about one thing: anyone who chooses to consume cannabis should have the information they need to make responsible choices. On that, we agree. But the Cannabis Control Commission report they cited recommends far more than another public education campaign. The report contains a roadmap of recommendations that would make informed choices possible, from research infrastructure and better data systems to studies that have already been approved and are delayed only by funding. The editorial board had that roadmap in front of them and the platform to push for any of it. Instead, they reduced a systems-level problem to an individual education issue and called for yet another campaign.

The editorial’s argument rests on a familiar, if outdated, premise: people don’t know enough about cannabis risks, so we need to teach them more. But education is only as good as the information behind it, and you can’t teach what the science hasn’t been allowed to answer. The editorial board spent several paragraphs worried about impaired driving, but failed to mention that an already approved study on cannabis-related impaired driving and hospitalization is sitting at the commission, waiting for the Legislature to fund it. The commission isn’t asking for another campaign; they are asking for the research, data systems, and funding that would give an educational campaign the evidence to be impactful.

The very same data the editorial cites to make its case deserves a closer read. On every health knowledge question in the survey, respondents who answered ‘don’t know’ were scored as wrong. That matters because on several of these questions, a confident answer isn’t as straightforward as the survey assumes. Take the question with the highest rate of ‘incorrect’ responses: whether cannabis can help cure or prevent cancer. The correct answer is no. But physicians across Massachusetts certify cancer patients for medical cannabis to manage nausea, pain, and appetite loss. A respondent whose family member found relief during chemotherapy isn’t confused or uneducated about cannabis. They’re answering a question that doesn’t distinguish between curing a disease and meaningfully improving quality of life during treatment.

The editorial also leads with teenagers, but the commission’s own report found no obvious surge in youth use, consistent with national trends showing adolescent cannabis use at historic lows. The population that does show up in the adverse outcomes data is young adults aged 21 to 25, who sought medical care for adverse effects at four times the rate of older users. This is the age group most likely to be consuming cannabis for the first time, navigating unfamiliar products and potencies without meaningful dosing guidance on the packaging or in the dispensary. Many are on college campuses with built-in health services that lower the barrier to seeking care, which may say more about access to medical attention and the reporting of adverse events than about the severity of what they experienced.

The answer isn’t another prevention campaign aimed at teenagers in the hopes that they make responsible choices. We have tried that. It’s building a system where a patient can tell their doctor they use cannabis without stigma and where that doctor has the training and research to say something useful back. It’s making sure that when a first-time consumer picks up a product in a dispensary, the label tells them something meaningful: standardized dosing information, cannabinoid and terpene profiles, and clear guidance that makes sense to someone who isn’t already an expert.

The commission’s own research department said plainly that they lack the resources to complete anything beyond summary analysis. The Globe has the platform to push the Legislature for the funding that would change that. Instead, they placed the burden on individual consumers to educate themselves in a system that hasn’t given them the tools to do so. Consumers deserve better than that. So does the work the commission has already done to make it possible.

A version of this piece was submitted to the Boston Globe as an op-ed in March. They responded that they don't run rebuttals on the op-ed pages. You can read an open-access version of the editorial here.

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Twenty miles south of a city with some of the best hospitals in the world, there is a growing region with no hospital at all. The nearest catheterization lab is roughly 40 minutes away, and most inpatient psychiatric beds serving the area are now across county lines. A cardiac emergency that once meant a five-minute ambulance ride now means forty.

But none of that was true six years ago. Norwood Hospital served roughly 126,000 patients a year, generating $25 million in profit and running at 81 percent bed occupancy, well above the statewide average for community hospitals. Its emergency department handled nearly 40,000 visits a year, feeding a catheterization lab that anchored cardiac care for the surrounding region. It was a community hospital that was working in both numbers and practice.

Then a flood hit in the summer of 2020, and the hospital never reopened. Not because the damage couldn’t be repaired, but because four years before the water came, the company that owned it had already sold the ground beneath it.

In 2016, Steward Health Care sold the real estate beneath nine Massachusetts hospitals to Medical Properties Trust, a Birmingham-based Real Estate Investment Trust (REIT), for $1.25 billion. The hospitals kept operating, but they no longer owned their buildings. Overnight, they became tenants, collectively paying over $100 million a year in rent on facilities they had previously owned outright.

The deal was structured as a real estate transaction, which meant it fell entirely outside the state’s Determination of Need process. Regulators had the power to scrutinize a transfer of a hospital’s license, but not the sale of its bricks and mortar. Because MPT bought the land while Steward kept the license, the single most consequential transaction in the system’s history was legally invisible to the agency charged with protecting it. The deal required no state approval and no review.

A study published in The BMJ in December 2025 put numbers to what communities like Norwood have learned the hard way. Researchers led by Joseph Bruch found that hospitals acquired by REITs were 5.7 times more likely to close or go bankrupt than comparable hospitals, with one in four failing outright. When a hospital sells its real estate, it trades long-term stability for an immediate cash windfall that often flows to private equity owners rather than patient care. The rent obligations that follow drain the operating margin that would otherwise absorb a shock. The REIT model did not cause Norwood’s flood. But it stripped the financial resilience that would have let a profitable, essential hospital recover from one. That is the difference between a crisis and a permanent loss.

I came to the Norwood story through a colleague’s work on healthcare infrastructure. My research is in cannabis policy: how legal markets take shape, who benefits from them, and what happens when the structures meant to protect communities can’t keep pace with the corporate strategies operating inside them. But the more time I spent tracing the Steward deal, the harder it became to see it as someone else’s subject.

Medical Properties Trust is headquartered in Birmingham, Alabama. Steward Health Care was backed by Cerberus Capital Management, a private equity firm in New York. The people who structured the deal that determined whether Norwood Hospital could survive a flood had no connection to the town where that hospital sat. Their kids would never wait forty minutes for an ambulance. Their parents would never lose access to a psychiatric bed. When the financial structure they built made recovery impossible, they lost an asset. Norwood lost its hospital.

I have spent years watching a version of this in cannabis. Alcohol and tobacco companies positioned billions in capital inside the industry before regulators had tools to manage consolidation. By 2024, nearly four in ten senior executives at major cannabis companies had been recruited from those same industries, not despite their backgrounds in fighting public health regulation but because of them. The leadership pipeline filled from outside before equity programs could build one from within, and the people shaping the industry were not from the communities it was supposed to serve.

What I could not see, writing about cannabis alone, was what the end of that timeline looks like if the gaps stay open and nobody closes them. Norwood is what it looks like.

There is a version of the cannabis conversation that treats corporate consolidation as a foregone conclusion, that talks about “big cannabis” the way people talk about big tobacco or big pharma, as though the fight is already over and the only question left is how bad the damage gets. That framing is wrong. Not because consolidation isn’t happening, but because it treats a political choice as an inevitability. The corporate takeover of cannabis is not a fact. It is a strategy, and strategies can be beaten by people paying closer attention than the people running them.

But the strategy is further from completion than the cynics suggest. Constellation converted its Canopy Growth shares to non-voting stock and gave up its board seats. Altria let its warrant to expand ownership in Cronos expire. These companies tried to capture cannabis, and the ground shifted under them: advocates pushed back, public opinion held, and regulatory frameworks, while imperfect, made consolidation harder than they expected. The distance between where cannabis is now and where Norwood ended up is not luck. It is the result of people doing the work: following the money, reading the filings, building the case for regulation that matches the scale of what it is trying to govern.

Even when that work succeeds, it arrives with a specific limitation: it protects the next community, not the one already inside the failure. Governor Healey signed H.5159 into law, making Massachusetts the first state to bar hospital-REIT sale-leasebacks. But existing REIT arrangements are explicitly grandfathered, meaning the statute written to prevent exactly this situation cannot touch Norwood. And when the fix arrives too late, the cleanup is blunt and expensive. Seizing St. Elizabeth’s Medical Center cost taxpayers $66 million for a working hospital. At Norwood, MPT has stated publicly that it has invested over $220 million in an unfinished shell. Cannabis equity programs followed the same arc: Massachusetts built equity into its framework first, but the legislature rewrote the ballot law, municipalities extracted excessive payments, and a capital access gap left equity entrepreneurs behind while well-funded operators moved ahead. In both sectors, the policy response arrived one step behind the corporate strategy it was supposed to constrain.

The reason those tools don’t exist is written into who was sitting at the table when the deals were made, and who was not. Cerberus structured a sale-leaseback that made a hospital unable to survive a flood and walked away with the proceeds. MPT collected rent on a building that sat empty for six years. Nobody in Birmingham or New York lost a cardiac unit. Nobody lost a psychiatric bed. The cost landed entirely on the community that had no voice in the transaction, and the regulatory architecture that might have prevented it never got built because the people with the power to build it had no reason to need it.

The cannabis version is quieter, but it reaches past ownership into the product itself. THC potency in flower has nearly doubled in under a decade, while CBD content has stayed essentially flat, and the medical patients looking for low-dose, therapeutic options can barely find them. When the leadership pipeline fills from industries that spent decades optimizing the intoxicating properties of their products, there is no one at the top whose instinct is to push against that trend. The distance that lets a private equity firm structure a deal without worrying about Norwood’s cardiac patients is the same distance that lets a cannabis executive set product strategy without ever meeting the medical patient who cannot find what they need.

The gap between policy and practice is not a metaphor, and it is not unique to any one industry. It is a design flaw, and it will keep showing up until the people who live inside it have as much power to shape regulation as the people who profit from its absence.

For the second time in two years, Massachusetts is considering whether it needs to seize hospital land by force just to get a community its healthcare back. In February, state legislators held a hearing on taking the Norwood Hospital property by eminent domain, the same tool the state used at St. Elizabeth’s Medical Center at a cost of $66 million to taxpayers. Residents from Norwood and surrounding towns packed a bus to Beacon Hill to testify alongside first responders and elected officials, and what they described was a building that is two-thirds constructed and three-quarters unusable, a shell sitting empty while nine people in a boardroom in Birmingham, Alabama, decide what happens to the quarter-million people who used to depend on it. For Norwood, nearly six years into a closure that never had to happen, seizure seems to remain the only option available.

That fact alone should tell us something is broken. Not because eminent domain is the wrong call for Norwood, but because a state that regulates its utilities, its transit systems, and its energy grid with layers of intermediate oversight has no equivalent tools for hospital infrastructure. When a community loses its hospital, the state can wait or it can seize. There is nothing in between.

Before the floodwaters rushed in, Norwood Hospital was a profitable community hospital serving roughly 126,000 patients a year, generating $25 million in profit and running at 81 percent bed occupancy, well above the statewide average. Its emergency department handled nearly 40,000 visits a year, feeding a catheterization lab that anchored cardiac care for the surrounding region. Its psychiatric unit was the only inpatient behavioral health facility in the area, treating patients from more than a dozen communities with nowhere else to be admitted. Norwood Hospital did not fail. It was failed.

In 2016, Steward Health Care sold the real estate beneath nine Massachusetts hospitals to Medical Properties Trust, a Birmingham-based Real Estate Investment Trust (REIT), for $1.25 billion, and overnight, those hospitals began paying over $100 million a year in rent on buildings they used to own. Because the deal was structured as a real estate sale, it fell entirely outside the state’s process for reviewing changes to hospital ownership. Regulators had the power to scrutinize a transfer of a hospital’s license, but not the sale of its bricks and mortar, and no one in state government had to approve or even examine the single most consequential transaction in the system’s history.

We now know how dangerous that blind spot was. A study published in The BMJ in December 2025 found that REIT-acquired hospitals are 5.7 times more likely to close or go bankrupt than comparable hospitals, with one in four failing outright. The REIT model did not cause Norwood’s flood, but it stripped away the financial resilience that would have let a profitable, essential hospital recover from one, and that is the difference between a crisis and a permanent loss.

The community that depended on Norwood has spent nearly six years inside that permanent loss. Emergency transport times have tripled and quadrupled, and the catheterization lab that once anchored cardiac care for the region is gone, with the nearest one now roughly 40 minutes away. Research published in Circulation found that when drive time to emergency care increases by 30 minutes or more, heart attack mortality rises by 30 percent. All of this in a region that is not shrinking but growing, with thousands of new housing units built or approved and no hospital to serve them.

After Steward’s bankruptcy in 2024 exposed the full scale of the damage, the state moved to close the gap. Governor Healey signed H.5159 into law in January 2025, a genuine step forward. It made Massachusetts the first state in the country to bar the licensing of hospitals whose campuses are leased from REITs, and it expanded state authority over private equity transactions that had previously fallen through the cracks. But the law only applies going forward. Existing REIT arrangements in effect before April 1, 2024, are explicitly grandfathered, so the law that was written to prevent exactly this situation cannot touch it.

For Norwood, that leaves a single option: seize the property and pay for it, or at least threaten to. When the state seized St. Elizabeth’s, it paid $66 million for a working hospital on land assessed at roughly $56 million. At Norwood, the math is inverted: the land is worth $5 to $6 million, but MPT has stated publicly that it has invested over $220 million in an unfinished shell, which means the cost of using this tool is not holding steady but climbing every time the state reaches for it.

That trajectory should make the case for building something better. When a utility company in Massachusetts fails to provide adequate service, the state has tools between doing nothing and seizing property: receivership authority, intermediate penalties, and enforceable obligations to maintain service. For a REIT that sits on a half-built hospital while a quarter of a million people go without care, the state has none of that. A hospital receivership bill has been before the legislature since last year, and it would give the state exactly the kind of intermediate authority it is missing.

Massachusetts has shown it can write the law that prevents the next Norwood. The question is whether it will build the tools to reach the communities already living inside one. I write about cannabis policy, not healthcare infrastructure, but the longer I’ve spent with this story, the harder it has become to see it as someone else’s subject. The same gap between policy and practice keeps showing up across regulated industries, and communities keep paying for it. Eminent domain is not a healthcare policy. It is the absence of one. And that absence is not unique to hospitals.

Thanks to K Massi, a Master's student in Community Health Sciences at Boston University School of Public Health, for contributing to the research and development of this piece.

When I moved into my first apartment, I was ecstatic. It was my first time truly living on my own, and my first chance to make a place feel like mine. I remember the weeks before my move-in; the sleepless nights spent planning how I would lay out my furniture, where I would hang all my art, and the DIY projects I had saved that would turn a New Haven rental into a home that felt like my own for the next few years.

Going into it, I knew the apartment would need some love, but who doesn’t have a grad school apartment that needs a little TLC? The building was built in 1943, and you could tell, but it had a charm that I knew would work well with what I had in mind. There’s nothing a good scrub and a structured cleaning routine couldn’t keep up with. At least, that’s what I told myself at first.

I spent my first months making each room mine, settling into the routines of a life I had been imagining for years. Then one evening in October, after just having showered, I heard frantic knocking at my door. It was maintenance, telling me there was a major leak from my unit into the basement. He inspected the bathroom, determined it wasn’t anything I had done wrong, and chalked it up to the old caulking around the tub. He apologized for scaring me, said he would be back to re-caulk, and left. That knock was the beginning of a three-year nightmare.

Over the years, the caulking fix was redone a half-dozen times, each time failing within weeks. The bathtub enamel started peeling away in sheets, like nail polish lifting when you pick at it, and water damage appeared on my ceiling and walls, leaking down from the unit above mine. I filed more than fifteen repair requests through my landlord’s maintenance portal, not counting the handful my neighbors submitted when my unit leaked into the basement, and each one followed the same arc: someone would come, address the surface of the problem, and leave the underlying cause untouched. I kept cleaning what I could and filing work orders when it got unbearable, resigned to the fact that bathroom maintenance was my new side hobby.

Eventually, after calling the Livable City Initiative, New Haven’s housing enforcement agency, my landlord agreed to a full bathroom renovation. I was thrilled. After years of temporary fixes, this was finally going to be the real thing. I had to vacate my apartment while the work was being done and find my own accommodations during the semester, but I didn’t care. I just wanted my bathroom back.

When they told me the repairs were finished and I could come home, I walked into my bathroom and found no shower head and no faucet. The renovation that was supposed to fix everything had created new problems, leaving me without a functioning shower in my own home. It took additional rounds of follow-up to get the bathroom to a state where I could use it at all, and even then, the work wasn’t done right. They hadn’t used bathroom-appropriate sealant on the paint, and within weeks, it was dripping down the walls, and pieces of the ceiling were falling into my tub. The renovation meant to end the cycle had only made it worse.

Then one morning, as I groggily stumbled toward the bathroom, I quickly realized there was a man bent over my bathtub, tools by his side. Horrified that there was an unannounced man in my apartment and still half asleep, I screamed, went back to my room, pulled on pants, took my keys, and walked outside to calm down and gather my thoughts. I left my dog, Ember, in my bedroom as she hadn’t left the bed or my room since I had woken up.

When I collected myself enough to go back inside, every door in my apartment was open, and Ember was gone. Somewhere in the shuffle of going in and out, the maintenance worker had left the doors open without thinking about the fact that there was a dog inside. When I asked him where she was, he told me I had taken her out with me. My life flashed before my eyes as I processed immense fear and immense rage at the same time, and then pushed both aside to go looking for her. Thankfully, it wasn’t long before my neighbor, who by chance worked at the daycare Ember went to and must have been a familiar face to her, knocked on my door with her by his side, wearing a spare leash.

That was the morning I decided to leave. It didn’t matter that I had the majority of my lease still remaining, or that finding a new place on short notice would be chaotic and expensive. My apartment was no longer a place I felt safe living in, and that was a non-starter. Over the following weeks, I searched for housing in a new city, planned a last-minute move, and closed the door on the place I had once spent sleepless nights dreaming about making my own.

But what stayed with me was this: as bad as my experience was, I knew it wasn’t uncommon. And I knew that plenty of renters have had it far worse.

I didn’t have to look far to confirm it. When I started asking around, I heard from other tenants across the property management company’s portfolio who had dealt with their own versions of what I had been living through: rodent infestations, heating systems that couldn’t keep up with Connecticut winters, deferred maintenance, and steep rent increases on apartments that were barely being maintained. I even created a community survey to understand the extent of the problems across the company’s properties, and the responses painted a picture that was both validating and disheartening. Before long, tenants from completely different landlords were reaching out asking if I could help them do the same thing.

What stuck with me wasn’t just the number of people who had similar experiences. It was the fact that none of that knowledge went anywhere. Every tenant I heard from had learned something real about their building, their landlord, the conditions inside their walls. And every single one of them had learned it the hard way, after they had already signed a lease and moved in. When they left, everything they knew left with them, and the next tenant walked in just as blind as they had been, the cycle destined to repeat itself. And the more I sat with that, the more absurd it started to seem.

Think about how we approach almost every other decision in our lives. I have absolutely spent an embarrassing amount of time scrolling through Yelp reviews to pick a restaurant for a Tuesday night dinner I won’t remember in a week. We check safety ratings before buying a car, read dozens of reviews before booking a hotel for a single night, and research neighborhoods before even visiting them. But when it comes to the place where you’re going to sleep, cook, shower, and live for the next year or more, you’re going in pretty much blind.

There’s no way to find out whether the apartment you’re about to rent has a mold problem that’s been painted over three times, or whether the landlord has a pattern of ignoring repair requests, or whether the building has had the same leak for years. And this isn’t a small problem: according to the National Center for Healthy Housing, nearly half of all homes in U.S. metropolitan areas have at least one significant health or safety hazard. Public health researchers have spent decades documenting what these conditions do to the people living inside them, and they’ve built validated tools to measure it. The science on which housing conditions make people sick is not new or uncertain. What’s never been built is anything that puts it into the hands of the person standing in an apartment trying to decide whether to sign.

So I built the tool I wished I’d had before I signed my lease. RateMyPlace is a tenant-led review platform, but it’s not trying to be Yelp for apartments. It’s built on the same public health research that scientists use to assess housing quality, meaning it is designed to treat a mold problem very differently from a noisy radiator. I built it that way because I know firsthand that not all apartment problems are created equal: a dated kitchen is an inconvenience, but mold behind the walls, persistent pest infestations, and heating systems that can’t keep a home warm in winter are health hazards, and the scoring should reflect that. On RateMyPlace, it does. Health and safety conditions are weighted more heavily in a building’s score, based on the strength of the evidence behind them, so a building with serious habitability issues can’t be masked by five-star reviews from tenants who loved how easy it was to sign the lease.

I also built it with the understanding that tenants need to feel safe being honest. Reviews display move-in and move-out dates as seasons rather than exact dates, so a landlord can’t match a review back to a specific tenant, and no personally identifiable information, or the specific unit you live in, appears anywhere on the platform. If a landlord believes a review is inaccurate, there’s a dispute process for that, because this isn’t a platform designed to punish anyone. It’s designed to give renters the information they deserve, and to do it fairly.

One of the things my experience taught me is that the person you interact with as a tenant is often several layers removed from the person whose decisions actually determine your living conditions. When my property management company stopped responding to my concerns, I went looking for someone else I could reach out to and ended up on a deep dive through public records to figure out who actually owned my building. It turned out to be someone entirely separate from the property manager and leasing agent, a veteran who runs a leadership academy. I reached out to him directly, and I have a feeling that’s what finally got my bathroom renovation approved. That says everything about how the system works: the owner may not even have known what was happening in his building until a tenant tracked him down through public records. The layers between an owner and the people living in their property can run deep enough that problems simply never travel upward, and if a tenant doesn’t do that digging themselves, no one does it for them. That’s why, on the backend of RateMyPlace, I research the ownership behind every building that gets reviewed, tracing who actually owns the property through public filings. Sometimes it’s a person. Sometimes it’s an LLC. Sometimes it’s a chain of entities that makes it nearly impossible to determine who is actually responsible for the conditions in your apartment. Tenants shouldn’t have to track down their building’s owner through public records just to get a repair request taken seriously. So I do that research for them.

RateMyPlace is a passion project, and I want to be honest about where it is. I have spent countless hours researching, designing, and building this platform, but it is nothing without the people who use it. Right now, what it needs most is tenants willing to share what they know, and a little grace as the platform builds a strong foundation.

I’m not going to pretend that a review platform is going to fix the rental market. But it can do something that nothing else is doing right now: it can make sure that what tenants know doesn’t disappear when they move out. Whether that helps someone avoid a bad situation before they sign, helps tenants in a building realize they’re not alone, or simply makes a renter feel like their experience matters, it’s doing what I built it to do: putting a little bit of power back where it belongs.

If you’ve ever rented, you know something about a building that the next tenant deserves to hear. It takes a few minutes at ratemyplace.org, and it might be the thing that changes someone’s decision, or at least lets them walk in with their eyes open.

I think about my old apartment sometimes. Not just the mold, or the repairs, or the morning I found a stranger in my bathroom. I think about the fact that it was my first real home, the place where I became who I am during one of the hardest and most important stretches of my life. I loved that apartment. It deserved better than how it was treated, and so did I. Somewhere down the line, someone is going to stand in that same apartment, full of the same excitement I had, dreaming about how to make it theirs. I want them to know what they’re walking into before they sign. That’s why I built RateMyPlace, and that’s why I’m asking you to help me fill it.

Click here to rate your apartment

Last week, a study published in JAMA Health Forum reported that adolescent cannabis use is associated with double the risk of psychotic and bipolar disorder diagnoses. The research, led by Kelly Young-Wolff and colleagues at Kaiser Permanente, followed nearly half a million teenagers in Northern California through age 25, making it one of the largest studies of its kind. The coverage was predictable: “Teen Cannabis Use Doubles Psychosis and Bipolar Risk.” A finding like that carries weight, and it should.

Meanwhile, a separate analysis published in Addictive Behaviors confirmed what federal survey data has been showing for over a decade: adolescent cannabis use in the United States has been declining steadily since the late 1990s and continued to fall as states legalized. For those who have long argued that regulated access doesn’t drive youth use up, the data offered yet another confirmation.

In the usual version of this conversation, that’s where it ends. One side grabs the risk data, and the other side grabs the trend data. But what if these studies aren’t contradictions to be argued over? What if the more useful thing is to put them in conversation with each other and ask what they tell us together that neither one says alone?

What the Risk Study Actually Found

In one of the longest follow-up studies of adolescent cannabis use and psychiatric outcomes to date, Young-Wolff and colleagues screened 463,396 adolescents aged 13 to 17 for past-year cannabis use during confidential well-child visits from 2016 to 2023, then tracked their health records through age 25.

At baseline, 5.7% of adolescents reported past-year cannabis use. Those who did were significantly more likely to receive a subsequent psychiatric diagnosis, and the associations were strongest for the most serious conditions. Adolescents who reported cannabis use faced roughly double the risk of being diagnosed with a psychotic disorder (2.19 times greater) or bipolar disorder (2.01 times greater) compared to those who didn’t. The risks for depressive and anxiety disorders were smaller, around 34% and 24% higher, respectively, but still statistically significant. And there’s a timing detail that matters: cannabis use consistently preceded psychiatric diagnoses by an average of 1.7 to 2.3 years. That doesn’t prove cannabis caused the disorders, but it means the use came first, and that narrows the range of alternative explanations considerably.

A person reading those numbers might ask: Is this really about cannabis, or is it just that teens who use any substance are more likely to struggle with mental health? The researchers accounted for that. Their models adjusted for alcohol and other drug use over time, meaning the doubled risk for psychotic and bipolar disorders held even after separating cannabis use from broader patterns of substance use among teenagers.

Another fair question: could something the researchers didn’t measure, like genetic predisposition or childhood trauma, explain the entire association? To test this, the team calculated what’s called an E-value, which estimates how strong an unmeasured factor would need to be to fully account for the results. For psychotic disorders, that value was 3.79, meaning a hidden variable would need to be nearly four times as strongly linked to both cannabis use and psychosis as anything already in the model. That’s an exceptionally high bar. The researchers also stress-tested their results by excluding adolescents with any prior psychiatric diagnosis and by using different definitions of psychotic disorders. The doubled risk held every time.

However, the risks didn’t behave the same way across all four disorders. The links between cannabis use, depression, and anxiety faded as adolescents got older, and by ages 21 to 25, they were no longer statistically significant. Yet the elevated risks for psychotic and bipolar disorders persisted into young adulthood. The associations that didn’t fade were the most serious ones: conditions that can reshape a person’s life and don’t resolve over time.

All of these findings come with important caveats. The study asked adolescents one question: did you use cannabis in the past year, yes or no? It didn’t ask how often, what kind of product, or how they consumed it. The researchers themselves acknowledge this likely underestimates actual use, and note that teenagers who use more frequently may be more willing to say so on a screening form, which means the findings could reflect the consequences of heavier use rather than any single experience with cannabis. And because this is observational research, “associated with” is the honest language, not “caused.” Some adolescents with emerging psychiatric symptoms may turn to cannabis to manage what they’re experiencing before they ever receive a formal diagnosis, and if that’s the case, the association could partly run in the opposite direction. The study’s design makes that less likely, but it can’t rule it out entirely. What makes this research valuable is not that it settles these questions. It’s that it advances them further than anything at this scale has before.

Fewer Kids Are Using. That Matters Too.

The Young-Wolff findings are alarming, and they should be taken seriously; but they land in a context that most of the coverage ignores: fewer adolescents are using cannabis now than at any point in the past two decades, and that decline has continued through the legalization era.

The analysis published in Addictive Behaviors by Stephen Amrock and Agata Sajkiewicz drew on the CDC’s Youth Risk Behavior Survey (YRBSS), covering more than 254,000 high school students from 1991 to 2023. Lifetime cannabis use among high schoolers peaked at 47.3% in 1999 and dropped to 30.1% by 2023, while recent use fell from over 25% to under 20%. Early initiation, meaning use before age 13, also declined from 11.5% to 6.5%. The same decline shows up across the National Survey on Drug Use and Health and University of Michigan’s Monitoring the Future data, and state-level surveys in early-adopter legalization states like Washington and Colorado confirm the pattern.

One of the more counterintuitive findings is that adolescents report cannabis is getting harder to find, not easier. Between 2002 and 2015, those saying it would be “very easy” to obtain cannabis fell 27% overall and 42% among 12- to 14-year-olds. The mechanism researchers point to is straightforward: licensed dispensaries replaced unlicensed dealers, and regulated sellers check IDs. One Illinois study found that cannabis use was actually lower among 10th and 12th-graders living in zip codes with a dispensary nearby. The Monitoring the Future data through 2025 reflects this pattern across age groups: since states began legalizing in 2012, past-30-day use has fallen 25% among 12th graders, 45% among 10th graders, and 38% among 8th graders.

This pattern held through both waves of legalization, from medical laws in the 1990s through recreational legalization in the 2010s. Regulated access hasn’t driven youth use up. But declining use rates don’t tell us much about what happens to the adolescents who do use, or whether the products they’re encountering are more dangerous than what existed a generation ago.

The Question Nobody’s Asking

Most coverage of these two studies picks a side and stops there. One camp cites the psychiatric risk data and argues that legalization endangers children, while the other cites the trend data and argues that everything is fine. Yet neither is engaging with the actual question.

Both findings can be true at the same time. Fewer adolescents are using cannabis than at any point in the past two decades, and the ones who do use face a meaningfully elevated risk of serious psychiatric disorders. The first finding is a success story about what regulation can do. The second is a warning about what it hasn’t done yet. No regulatory system eliminates youth use entirely, and the question is not whether some adolescents will use cannabis. The question is whether the market we’re building minimizes harm for the ones who do, or whether it’s structured in ways that make things worse.

The Young-Wolff data starts to answer that question, and the answer is uncomfortable. Cannabis use in the study was not spread evenly across the population; it was more common among adolescents enrolled in Medicaid and among those living in neighborhoods scoring higher on the Neighborhood Deprivation Index, a measure of economic disadvantage. The adolescents facing the highest psychiatric risk from cannabis use are, disproportionately, the same young people in the communities that legalization was supposed to benefit.

A commercialized cannabis market built without strong public health guardrails doesn’t just fail these adolescents in the abstract. It concentrates harm where it was supposed to concentrate opportunity.

What Happens Inside the Legal Market.

The commercial cannabis market has been moving toward higher-potency products for years. Average flower THC content climbed from around 4% in the 1980s to over 21% by 2024, and concentrates and vape cartridges routinely reach 70% to 90%. High-potency flower commands premium prices, concentrates carry higher retail margins than flower, and infused pre-rolls, which combine potency with convenience, are the fastest-growing product category in the industry. The market rewards potency because potency drives profit.

None of this means dispensaries are selling to teenagers. The trend data is clear on that point: regulated, age-gated access is working, and youth use has declined. But the legal market doesn’t have to sell directly to adolescents to shape what they encounter. When those products set the baseline for what cannabis looks like in a given region, what circulates through social channels, older siblings, friends with access, exists downstream of whatever the legal market produces. The legal market determines the potency floor; it doesn’t control where those products end up.

While Young-Wolff and colleagues couldn’t isolate product potency in their data, they note that products containing high amounts of THC can disrupt endocannabinoid system development during adolescence, and they call explicitly for future research that can capture product strength. The study’s biggest measurement gap, its inability to distinguish frequency, mode of use, and product type, is not just a limitation of this research. It’s a reflection of how quickly the commercial market has moved, and in what direction.

This is where the market’s structure matters. In 2021, Colorado state Rep. Yadira Caraveo, a pediatrician, proposed capping THC potency at 15% after a state health department study flagged the risks of high-concentration products. The cannabis industry responded before the bill was formally introduced: one company estimated the cap would make 65% of products on the market illegal, and the proposal was gutted before it reached a vote. While this is just one example, it shows us the same market dynamics that push products toward higher concentrations also push against the kind of guardrails these researchers are calling for: meaningful health warnings, restrictions on marketing and packaging, and enforcement mechanisms that carry real consequences. A market designed to maximize shareholder value will resist those protections. A market designed to serve the communities it operates in has a reason to build them.

Most people in this space, advocates, consumers, and regulators, agree that protecting young people matters. That has never really been the divide. The divide is between a market built to act on that agreement and one where the incentive to sell higher-potency products at higher margins quietly overrides it.

That’s what these two studies tell us together that neither one says alone. Fewer adolescents are using cannabis than at any point in recent history, and the ones who do face serious risk. Neither finding cancels the other out. But no regulatory system will bring youth use to zero, and the question was never whether some adolescents would use cannabis. It was always what they’d encounter when they did, and whether the market we’ve built has any reason to protect the ones most likely to be harmed: the same young people, in the same communities, that legalization promised to serve.

Open Access Link to Paper here

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The promise of cannabis legalization was that it would be different. The vision was an industry built by the people who fought for it, rooted in the communities most harmed by prohibition, not handed over to the same corporations that turned tobacco and alcohol into public health crises.

That vision has shaped real policy. States have created priority licensing for people with prior convictions. Cities have invested in programs to help those most affected by the drug war enter the legal market. The focus has been on ownership and access: who gets a license, who can open a dispensary, who gets a foot in the door.

But while we’ve been watching the door, we haven’t been watching the boardroom. Who’s actually running these companies? Not who owns them on paper or who works the floor, but who sets strategy and decides how the industry behaves. A new study tracked the backgrounds of executives at five major cannabis companies. Nearly 40% came from alcohol, tobacco, or pharma. And tobacco hires are increasing.

What the Researchers Found

The study, published in the International Journal of Drug Policy, focused on five major Canadian cannabis companies: Canopy Growth, Aurora Cannabis, Tilray, Cronos Group, and Organigram. Why Canada? Federal legalization in 2018 allowed large cannabis corporations to emerge and go public in ways that U.S. prohibition still prevents. These are some of the biggest, most established players in legal cannabis, and their hiring patterns offer a window into where the industry is heading.

Researchers Marthe Ongenaert and Tom Decorte at Ghent University tracked senior leadership at two time points, January 2022 and January 2024, using LinkedIn and corporate websites to document professional backgrounds. The study also examined investment flows between cannabis and alcohol, tobacco, and pharmaceutical companies; a detailed breakdown of that side can be found in the Parabola Papers here.

In both years, 39% of top executives had professional backgrounds in alcohol, tobacco, or pharmaceutical companies. The overall percentage held steady, but the mix shifted.

In 2022, 50% of those hires came from alcohol, 10% from tobacco, and 40% from pharma. By 2024, alcohol had dropped to 41%, pharma to 35%, and tobacco had more than doubled to 24%.

Looking at specific hires, Canopy Growth’s CEO and CFO both came from Constellation Brands, the alcohol giant that invested over $4 billion CAD in the company. Aurora’s CEO previously held leadership roles in the tobacco industry. When Aurora announced his appointment, they touted his “deep, diverse experience in consumer packaged goods” and “highly regulated industries” as qualifications.

The researchers note that these transitions aren’t random. Cannabis companies are recruiting for a specific skill set: navigating regulation, managing large-scale production, and marketing controlled substances. The alcohol, tobacco, and pharmaceutical industries have all of that. They also have decades of experience in regulated markets, relationships with policymakers, and strategies for managing public health scrutiny.

The Gap in the Data

The research tells us who’s in the boardroom. It doesn’t tell us who’s working below it.

But other data fills in part of that picture. A recent report from the Massachusetts Cannabis Control Commission found that while entry-level employees roughly reflect state demographics, senior leadership remains overwhelmingly white: 77% of board members, directors, executives, and managers are white, compared to just 5% Black and 4% Hispanic. This is in a state with explicit equity mandates built into its cannabis laws.

The pattern that’s emerging isn’t subtle. Social equity programs have focused on two things: getting people harmed by prohibition into ownership, and creating jobs at the entry and operational levels. Those are meaningful goals. But the data suggests something uncomfortable: diverse hiring is happening at the bottom, while the top fills up with people who look a lot like leadership in every other industry.

The Ghent study adds another layer. It’s not just that senior leadership is disproportionately white. It’s that a significant chunk of those executives are being recruited directly from alcohol, tobacco, and pharmaceutical companies. The people setting strategy and shaping the industry’s political influence aren’t coming up through equity pathways. They’re being imported from industries with very different values.

This raises a question that nobody seems to be systematically tracking: as cannabis companies grow, who moves up? Are the people entering through equity pathways advancing into leadership, or are they staying on the floor while the C-suite gets filled from outside?

What This Means for Equity

Research from Parabola Center and RTI International found that Americans don’t trust tobacco, alcohol, or pharmaceutical companies to shape cannabis policy. They trust people with lived experience: people who use cannabis, people who’ve been directly affected by enforcement.

But the leadership pipeline is moving in the opposite direction. Tobacco hires in cannabis executive suites more than doubled between 2022 and 2024. These aren’t passive investors. They’re the people making operational decisions, setting company priorities, and representing the industry in political and regulatory conversations.

The researchers frame this as a public health concern, not a personal one. The issue isn’t that any individual executive is a bad actor. It’s those industries built on selling potentially harmful products that have developed specific ways of doing business: strategies for weakening regulations, funding favorable research, and shaping public perception. That’s the Commercial Determinants of Health in action. When cannabis companies recruit heavily from those industries, they’re not just hiring expertise; they’re importing networks, relationships, and a worldview into the cannabis industry.

Equity in cannabis can’t stop at who gets a license or who gets hired. It has to include who makes decisions and who represents the industry when policy is made. If the face of legal cannabis is equity licensees and dispensary workers, while the boardroom fills with executives from tobacco and alcohol, we already know how this story ends. We’ve watched it play out before.

Open Access Link to Paper here

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A few weeks ago, a brand I like ran a buy-one-get-one promotion, “advertised as valid anywhere the product was sold. A multi-state chain near my usual errands wouldn’t honor it. A locally owned shop on my way home did, no questions asked.

It wasn’t about the deal itself. It was what the difference revealed. The local shop was part of a community, participating in the same ecosystem as the brands on its shelves. The chain operated on its own terms, fluorescent and sterile, designed to move customers through. It’s as if the store could have been selling anything.

I’m a cannabis public health researcher. I spend my days thinking about how to build legal markets that actually serve people and public health rather than just extracting profit from them. But when I looked at my own purchasing habits, I noticed a gap I didn’t love.

I’d been telling myself I was a thoughtful consumer because I avoided the big names like Curaleaf and Trulieve. As long as I wasn’t shopping there, I figured I was fine. But that’s a pretty low bar, and it let me avoid asking harder questions about where I was actually spending my money.

So this year, I made a resolution to change that. To actually put my money where my mouth is.

I moved to Massachusetts recently after a few years in other legal markets. New Jersey and Connecticut both had limited options when I lived there. Fewer dispensaries overall, most of them run by multi-state operators, with not much to differentiate one from another. You bought what was available, where it was available. I wasn’t used to having real choices.

Massachusetts is different. The market here is more mature, with hundreds of licensed establishments and the first social equity program in the country to mandate participation from communities harmed by prohibition. For the first time, I had the freedom to purchase from stores and brands that actually aligned with my values.

And I wasn’t doing it.

I kept defaulting to brands I’d already heard of, stores that were closer to my errands, whichever had the better-looking deal at first glance. I thought: if I care so much about how we legalize cannabis, why is it so hard for me to practice what I preach?

The honest answer is that it shouldn’t be this hard, but it is.

Figuring out who owns your dispensary is harder than it should be. Ownership structures are layered and obscured. Not all locally owned shops advertise that they’re locally owned, and multi-state operators certainly don’t put “corporate chain” on their signage.

The information exists, technically. Massachusetts publishes a licensing tracker that labels social equity and economic empowerment businesses. But it’s a regulatory database, not a consumer tool. There’s no way to check your phone and see which dispensary near you is locally owned. The system puts that burden on individual consumers, and most people, understandably, just go wherever is convenient.

I only found local options because my job puts me in rooms where people talk about this kind of thing. I checked the Cannabis Control Commission’s website. I recognized some shops from community events and advocacy spaces. Some dispensaries clearly label themselves as locally owned or craft cannabis. But learning the landscape took time. A casual shopper wouldn’t have that advantage, and shouldn’t need it.

Once I started paying attention, I found that shopping local isn’t actually inconvenient. Instead of stopping at the chain near where I grocery shop, I go to a locally owned dispensary on my way home. The local spot has better prices anyway, plus deli-style flower, which I love both for the experience and for what it represents historically. And because I’m shopping closer to home, my excise taxes go back into the community I actually live in rather than a shopping center I just pass through.

The atmosphere is different, too. Local shops host events, get involved with neighborhood organizations, and show up in ways that feel connected to cannabis culture rather than detached from it. The budtenders know what they’re talking about. They’ll tell you what they actually like, what’s been sitting on the shelf too long, what’s worth the price, and what isn’t. It feels less like buying a product and more like participating in something that hasn’t been completely hollowed out yet.

But shopping at a locally owned dispensary is only the first layer. The products on those shelves come from somewhere, and it’s not always obvious where. Some brands are genuinely small and local. Others have a craft feel but a much larger footprint. The packaging doesn’t tell you which is which.

That’s what I want to figure out next. How do you trace a product back to who actually made it? What does “local” even mean when supply chains are this opaque? I don’t have answers yet, but I’m going to keep pulling at the thread.

Paying attention has already changed how I move through this market. Not because I’ve become a perfect consumer, but because I stopped letting “good enough” be the standard. That’s where it starts.