It’s becoming impossible to count all the options we have these days for altering our consciousness with chemicals and plants. You can buy ketamine from club drug dealers on your phone, or by mail from online medical clinics to treat depression. Alongside vapes and gummies, C.B.D. dispensaries sell kratom, an herbal stimulant that some people use to boost work productivity and others to detox from opioids. Cannabis sellers may or may not be legally licensed, and may also sell psychedelic mushrooms. Some people source their Xanax or Adderall from sites on the dark web, others from a physician. Those seeking an alternative to coffee can head to a kava bar to sip an herbal narcotic long used in traditional Polynesian medicine.
The old distinction between medical and recreational drugs is breaking down. It’s no longer clear what even counts as a drug anymore.
During the 20th century, people generally knew that drugs meant illegal substances, purchased clandestinely with cash and clearly distinguished from medications, which might also be psychoactive, but required a doctor’s prescription. In today’s chaotic marketplace, the idea of drugs as a social evil and the belief that only doctors define what is medical is being challenged. We are in a new reality, and we need a new way to make sense of it.
The distinction between licit “medicine” and illicit “drugs” was never as binary as it appeared, but it blurred significantly in the 1990s, as drugs like MDMA, and the party scenes that accompanied them, took off among young people. Programs like DARE attempted to suppress drug use, but from pill-popping dance clubs to blockbuster films like “Pulp Fiction,” popular culture celebrated it and the stigma attached to it diminished.
The internet also transformed supply and demand. Today, drugs no longer need to be scored in wraps or baggies from sketchy neighborhoods; they can be ordered online through anonymous browsers and appear in your mailbox in professionally labeled packages. You don’t need to buy your college roommate’s Valium; you can buy it with your smartphone and a cryptocurrency app.
Demand has also changed, as people merge getting high and self-care. A recent Los Angeles Times investigation revealed that some yoga centers in the city offer mushroom gummies to accompany their sessions, despite their illegality. Mental health issues are medicated with a galaxy of mood-elevating plant extracts and pharmaceutical supplements, such as over-the-counter lithium pills or the herb St. John’s Wort. These substances may complement or replace the drugs prescribed by mental health professionals. As licensed psychedelic therapy struggles to establish itself, people are opting for ayahuasca retreats from the Amazon to Long Island, and start-up psychedelic churches offer ceremonies with toad toxins.
The arrival of legal cannabis dispensaries in the United States galvanized this transition from drug use to lifestyle choice. Cannabis use has risen sharply among the middle-aged, for whom it has become an analgesic, a relaxant and a sleep aid as much as a drug to take to get high. Cannabis dispensaries have traded the patchouli-soaked underground stylings of the hippie era for the minimalist aesthetic of a botanical health store. Wellness gurus promote lifestyle supplements such as melatonin, antioxidants and ginseng extracts, which sit alongside legal chemical highs and potent psychedelics.
If we are entering an era where what constitutes a drug is no longer coherent, we can also expect new dangers, at least in the short term. Blurring the lines between medicine, spirituality and getting high means that the risks of these new habits are often poorly understood. Cannabis, mushrooms and kratom may be relatively safe compared with heroin or crack, but excessive doses or compulsive overuse can still cause serious problems. Unregulated and illicit supply chains allow dangerous adulterants to circulate: fentanyl in illicit opiates, synthetic and toxic compounds in cannabis vapes.
It seems inevitable that much of the new landscape will remain in legal limbo: Drug laws tend to change only after the alternative to them has become a de facto reality. But as states embrace the legalization of cannabis and, in some cases, psychedelics, there are opportunities for regulators to intervene and improve public health outcomes by setting price controls, age limits and mandated product testing and labeling. However, legalization also brings its own set of challenges, not least of which is regulatory capture (most notoriously exemplified in the Food and Drug Administration’s failure to adequately regulate OxyContin). Lax or underfunded enforcement can allow unlicensed sellers to continue operating with impunity.
Navigating this new world will require a more precise understanding of the psychoactive substances that are now part of it. Instead of attempting to sort chemical compounds into good and bad, we could pay more attention to how people use them. As the medical authorities of ancient Greece routinely observed, all drugs can be medicine or poison, depending on the dose. Even aspirin and caffeine can be damaging when overused, not to mention vastly more potent substances supplied with unreliable or false information. Effective regulation and public health interventions can mitigate more obvious harms, but we also need to find a nuanced way to discuss the differences between occasional, social, habitual and problematic use, as we did long ago for alcohol, tobacco and caffeine.
A shared language will pave the way for new norms that can help us better navigate the risks and rewards of these chemicals. Instead of the rush to moral or medical judgment implied by the 20th-century conception of drugs, we need to understand their properties, the commercial environment from which they have emerged and the relationships that different people form with them.
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