Courtney took her first marijuana puffs at 17. Two decades later, she was raising a toddler son and hiding her dependence from most family members. She would light her pipe more than a dozen times a day, sneaking to the garage of her Missouri home while her son napped.

She still loves the earthy smell. But weed long ago stopped making her giggly. It was not unusual for the 37-year-old to lose her train of thought mid-conversation or zone out while playing with her son. Many times, Courtney said, she tried to quit, flushing her stash and dumping her pipe to no avail, except for the nine months she was pregnant. Courtney felt she was addicted.

“It’s been frustrating because you’re not taken seriously,” Courtney said. “People say it’s not as severe as meth, or alcohol, that it’s not that bad. They think it’s not an addiction.”

Over the years, Courtney has tried to quit, flushing her stash and dumping her pipe to no avail, she said, except for when she was pregnant with her son, who is now a toddler. Photo for The Washington Post by Arin Yoon

At a time when marijuana has been legalized for recreational and medicinal use in more than 20 states – and the potency of the drug has been increased – many experts believe that most people can use it without significant negative consequences, not unlike enjoying occasional alcoholic drinks. But for users like Courtney, the struggles to quit are real and complicated by the powerful cultural perception that marijuana is natural and therapeutic, not a substance that can be addicting.

Courtney’s story reflects broader tensions about marijuana’s health consequences.

For decades, weed’s deleterious health effects were exaggerated, experts said, leading to excessive criminalization. But as legal recreational sales have expanded – Maryland in July became the latest state to permit sale of marijuana products for recreational use – the suggestion that marijuana is addictive has often met with derision, especially because science isn’t always clear on the benefits and harms. There can be reluctance to seek treatment. And other substances stir deeper fears and greater attention: Opioids are driving an overdose crisis killing more than 100,000 people each year in the United States.

“Because there are so many mixed messages in our society about cannabis, I think it’s very easy for people to minimize and rationalize problematic use of cannabis,” said Aaron Norton, a Florida mental health counselor who supports legalization of recreational and medical marijuana but believes it should be more tightly regulated.

Courtney and other marijuana users interviewed by The Washington Post spoke on the condition that only their first name or initials be used because they fear being stigmatized or because relatives or employers are not aware of their use.

Twenty-three states and D.C. have legalized recreational marijuana, and all of those states except for Virginia and Minnesota have recreational sales up and running. Medical use is lawful in 38 states.

The number of regular users has increased. According to a 2019 federal government survey, an estimated 31.6 million people age 12 or older used marijuana within the past month, up from 22.2 million five years earlier. The estimate rose to 36.4 million in 2021, although the numbers are not directly comparable because researchers changed how they collect data.

Medical experts and even many proponents of legalized marijuana acknowledge it can be addictive – akin to alcohol or some prescription drugs. Estimates vary on the prevalence of what is known as cannabis use disorder. One study from researchers at Columbia University and the National Institute on Alcohol Abuse and Alcoholism found that nearly 3 in 10 users in 2012-2013 experienced cannabis use disorder.

“The majority of people who use cannabis products in general can handle it,” said Adrianne Trogden, a Louisiana addiction counselor. “But there are still people who cannot – and they need help.”

Darren Weiss, president of Verano, a cannabis company operating in 14 states, agreed that public health and industry officials should not dismiss the potential for cannabis to be abused, but maintained that concerns are often overwrought.

“Addiction is a fact of life,” Weiss said. “There are folks who are addicted to caffeine, to sex, to all sorts of different things.”

The rise in marijuana use among teens has been highly publicized, along with concerns about the effects of more potent products on the developing adolescent brain. In May, the National Institute on Drug Abuse published a study asserting that young men with cannabis-use disorder have an increased risk of developing schizophrenia, although critics have pointed to other studies that cast doubt on the extent of the role marijuana plays in psychotic episodes.

Further fueling concerns among some experts: In the 1990s, THC, the psychoactive compound responsible for inducing a high, constituted about 5 percent of a typical joint or smoke from a bong or pipe, according to the Drug Enforcement Administration. Today, the THC content in smokable marijuana in recreational products can range between 15 and 21 percent, while products popular with young people such as edibles and oils can contain well over 50 percent.

Higher THC levels could increase the risk the brain will get conditioned to want more of the high-potency marijuana, said Nora Volkow, NIDA’s director. Last year, a study published in the journal Lancet Psychiatry found that higher potency THC was associated with an increased risk of cannabis use disorder.

Weiss questioned claims that higher potency marijuana is more likely to cause addiction. Still, he acknowledged that companies market to cannabis enthusiasts who will pay more for higher-potency products – because of the economics of the industry.

If marijuana could be sold by pharmacy chains or liquor stores, Weiss said there would be more incentive to sell lower-potency products marketed at casual consumers. More sales of lower-octane marijuana to a broader customer base would equal higher revenue, he said.

“There are a lot of people who demonize industry and think we are pushing high potency, similar to what the tobacco industry did, as a way of hooking consumers … and it couldn’t be further from the truth,” Weiss said.

The Substance Abuse and Mental Health Services Administration estimates at least 16.3 million people in the United States had a cannabis-use disorder in 2021, putting it behind only alcohol. The agency’s yearly estimates rose in 2020 after it incorporated broadened American Psychiatric Association criteria on diagnosing substance use disorders.

Most cannabis-use disorder cases were characterized as mild, which means patients experience just two or three of 11 benchmark symptoms, such as increased tolerance, intense cravings or repeated attempts to stop marijuana use. An estimated 26 percent of cases are considered moderate, while 16 percent are severe, according to SAMHSA’s National Survey on Drug Use and Health.

“It’s the second-most common addiction Americans are struggling with, but nobody hears about it,” said James H. Berry, a psychiatrist and addiction expert at West Virginia University.

Still, experts caution that mild cases of cannabis-use disorder may not fit under what the public generally considers “addiction.” The effect on users’ lives may be less severe – perhaps marijuana smoking has merely caused friction with a spouse. For those patients, interventions are typically geared toward minimizing the drug’s harm, said Trogden, the Louisiana counselor: “Maybe some counseling sessions, [introducing] some coping strategies, or education on how to use responsibly,” she said.

For people who consume medical marijuana, the risk of being misdiagnosed with a use disorder is a real threat, said Tammy Chung, an addiction researcher at Rutgers University. They can meet criteria for a use disorder, such as developing withdrawal symptoms and a higher tolerance for THC, despite being under the supervision of a medical provider.

“The threshold for cannabis-use disorder is relatively low,” said Chung, who has recommended revamping how the disorder is diagnosed.

E.H., a 44-year-old San Francisco-area schoolteacher, was never formally diagnosed with cannabis use disorder but had a medical marijuana card for years. He believes his decades of smoking marijuana day and night affected his life in profound ways. His habit was costing up to $300 a week, and he obsessed about needing to stay high. E.H. stopped using marijuana for a few years – until California legalized recreational marijuana in 2016. He waited in line at a dispensary for hours to buy a celebratory joint, then quickly spiraled back into daily use.

Today, he said he has been sober for nearly a year after joining Marijuana Anonymous. But he’s sheepish about telling people about his struggle lest they chide him for betraying the California counterculture cool of his youth.

“It feels like if you don’t smoke marijuana, you’re one of the sellouts,” E.H. said.

It’s not unusual for people to turn to recreational marijuana products, believing they treat assorted ailments – and doing so without a doctor’s guidance. Smita Das, an addiction psychiatrist at Stanford University, said she encounters patients who use marijuana to treat anxiety.

“But what we know is that actually [the marijuana] is probably worsening their anxiety over time,” Das said.

People with more serious addiction issues confront challenges in seeking care, including a lack of affordable treatment and few beds in rehabilitation centers, said Eric A. Voth, a retired addiction specialist and member of the International Academy on the Science and Impact of Cannabis, an organization of doctors that educates about the potential harms of marijuana.

Voth said that while criminal courts often mandate treatment, for others living on the streets, “there’s really no one pressing you to get into treatment.”

Twenty-three states and D.C. have legalized recreational marijuana, and medical use is lawful in 38 states. Photo for The Washington Post by Arin Yoon

He recalled a 24-year-old man in Colorado living under a bridge and dealing with psychiatric problems exacerbated by marijuana. He was finally accepted into a rehabilitation program that specializes in the intersection of addiction and mental health disorders and improved, but later relapsed on cannabis and then fentanyl.

The man’s mother said early recovery was complicated by doctors dismissive of THC playing a role in her son’s mental health crises.

“He gets mixed messages in the recovery world and in society, he sure does, too,” said the mother, who spoke on the condition of anonymity to protect her son’s privacy. “Young people are being told it’s totally safe.”

Ben Cort, who leads the Colorado center where the man was treated, acknowledged that activists sounding alarms about the health consequences of cannabis have a credibility problem following a history of racially disparate enforcement of drug laws and exaggerated claims about marijuana’s harmful effects.

“‘Reefer Madness’ comes out, then the stiff penalties and everybody’s like, ‘It’s weed. What’s the big deal?'” Cort said. “You went from this huge overstatement of risk to this dramatic understatement of risk.”

Unlike with opioids, alcohol and even tobacco use disorders, no medication exists to treat marijuana addiction – although that could soon change. On June 8, French biopharmaceutical company Aelis Farma announced promising research on a drug that blocks harmful signals sent by THC to key receptors in the brain, without disrupting those receptors enough to cause harmful psychiatric effects.

Volunteers taking the drug reported marijuana had less of an effect, without experiencing withdrawal, said Meg Haney, director of the Cannabis Research Laboratory at Columbia University Irving Medical Center, who ran the NIDA-funded study. She said the drug could one day help compulsive users. “There’s evidence to show if you can go from being a daily smoker down to two, three, even four days a week, you already show important changes in your quality of life,” Haney said.

For now, treatment revolves around behavioral therapy. The Veterans Health Administration offers patients gift cards for canteen services if they forgo marijuana, a treatment known as contingency management. Health records show the rate of veterans under age 35 diagnosed with the disorder more than doubled between 2005 and 2019.

M.B., a 24-year-old from Southern California, credits her recovery to Marijuana Anonymous, modeled after 12-step programs such as Alcoholics Anonymous. Even within those groups, M.B. said, people with marijuana addictions aren’t always taken seriously.

“The problems that come up with cannabis-use disorder are very real. This was not always something that was talked about,” she said. “We were sort of laughed out of 12-step spaces.”

She smoked daily throughout her teen years before she was diagnosed with cannabis-use disorder when she was about 20. At rock bottom, M.B. said, she smoked or used a vape pen roughly every hour, often waking up at night to take hits. M.B. said she believes her habit led to at least one psychotic episode and to the draining of her finances, even as she lived at home with her parents. She spent so much buying weed that she stole money from family to pay bills.

M.B. joined the program online in 2020 during the height of the pandemic, although the withdrawals weren’t easy. For about a week, she couldn’t keep down food, suffered intense headaches and felt so uncomfortable that she showered constantly.

“I was really angry, crying all the time,” M.B. said. “I had really intense dreams that I was smoking.”

For Courtney, the young mother from Missouri, quitting wasn’t made easier after the state in fall 2022 became the 21st to legalize recreational marijuana. Missouri’s nascent weed industry has boomed – combined sales of recreational and medical marijuana could top $1 billion this year.

“You smell it in the air when you’re sitting at a stoplight,” Courtney said.

She tried Marijuana Anonymous meetings online, but it wasn’t the right fit. She considered an outpatient treatment center, but the nearest was 45 minutes away – too far to drive while raising a toddler.

Instead, her group therapy came in the form of a Reddit forum dedicated to supporting people who want to stop consuming marijuana products. The forum is dotted with stories on the effects of withdrawal, including panic attacks, insomnia and bouts of crying, but also triumphs: long anxiety-relieving walks, regular yoga, improved family time.

A few days after detailing her struggles to a reporter, Courtney reflected on the future. Did she want her son growing up to see her smoking marijuana so often? So she smashed her glass pipe and flushed her remaining weed.

The cravings weren’t as bad as she feared. But she has suffered irritability, headaches, a loss of appetite, night sweats and vivid dreams. “I still feel like the worst is ahead of me,” Courtney said after five days without using.

She and her husband earlier bought tickets to attend a three-day music festival, where the smell of marijuana wafting in the air would be a certainty. They decided to forge ahead with a plan: If she felt uncomfortable, they would leave.

The last night of the festival, Courtney relapsed with a smoke. But since then, Courtney says, she has been clean for two months.

“I’m doing really well,” she said. “I feel clearheaded and more present.”