Cannabis and Alcohol Use

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Cannabis and Alcohol Use

By: Jane Metrik, PhD

The co-use of alcohol and cannabis has received greater attention as states expand cannabis legalization. Increasing numbers of people are using cannabinoid products to enhance alcohol reinforcing effects or as a substitute for alcohol.


Cannabis use and alcohol use disorder

Cannabis may increase the risk of heavy drinking and alcohol use disorder (AUD):

  • In prospective studies, cannabis use is associated with increased risk of heavy drinking (consuming 5 or more drinks in a single day for males, and 4 or more drinks for females) and the development and maintenance of 1,2
  • Rates of AUD are higher among cannabis users relative to nonusers, with approximately 60% of individuals with current cannabis use disorder (CUD) also meeting criteria for current AUD.3
  • Co-use of cannabis and alcohol (i.e., using both substances but not necessarily on the same occasion) is associated with heavy drinking4 and alcohol-related physical and psychological consequences among young adults.5 The negative consequences of co-use, including increased alcohol consumption and alcohol-related problems,6-11 are particularly pronounced for individuals who use cannabis and alcohol simultaneously (so the effects of each substance overlap).12 Approximately one-third of young adult alcohol drinkers endorsed simultaneous cannabis and alcohol use in the past year.13
  • Treatment studies suggest any cannabis use during and after alcohol treatment reduces the likelihood of sustained abstinence from alcohol and increases the risk of alcohol relapse.14,15
  • Conversely, reductions in cannabis use following CUD treatment have been associated with concurrent reductions in alcohol use.16

Cannabis as a substitute for alcohol

Although cannabis use appears to have a negative impact on alcohol treatment outcomes, there is also evidence of a nonlinear relationship between levels of cannabis use and alcohol outcomes in support of substitution of more frequent cannabis use for less frequent alcohol use for some individuals.17,18

  • Some studies that found substitution patterns suggest frequent cannabis use may be associated with reduced drinking among some people with AUD.15,17,19
  • Data on medical marijuana users (both general population and Veterans) suggest they drink less generally and on days when they use cannabis.20-23 Medical marijuana users also have fewer alcohol-related problems relative to individuals who use cannabis for recreational.21-25
  • Differences among individual users may explain the mixed findings on substitution and complementary effects of cannabis on alcohol, including frequency of use, cannabinoid composition and potency, AUD diagnosis, demographics, and context of co-use.24

Clinical implications

  • It is important to ask patients about their alcohol and cannabis use patterns: what cannabis formulations are used, modes of administration, and whether they use the two substances simultaneously. Screening for cannabis- and alcohol-related problems among individuals who co-use these substances is important. Patients should be cautioned that simultaneous use of cannabis and alcohol can be associated with frequent and severe negative consequences.
  • Since cannabis use may increase the risk of heavy drinking, especially among those with a history of AUD, clinicians should counsel patients with AUD about this risk and recommend that patients with AUD avoid cannabis use.
  • Evidence suggests some patients might use cannabis as a strategy to help decrease heavy alcohol use.  If patients use cannabis as a substitute for alcohol, it may be helpful to set harm reduction26,27 goals with the patient. Providers should counsel about the risk of increased use of both substances and the possibility of progression to problematic cannabis use when replacing alcohol. Evidence-based treatment options for AUD or reduction of heavy drinking28,29 should also be reviewed.

Bottom line

More research is needed to improve our understanding of cannabis-alcohol interactions and the impact of cannabis use on alcohol treatment outcomes. Evidence we do have suggests cannabis and alcohol co-use is associated with increased alcohol-related consequences. Clinicians should evaluate the frequency and intensity of co-occurring use of cannabis and alcohol, and provide intervention as clinically indicated.

Suggested Citation: Metrik, J. Cannabis and alcohol use. The Systematically Testing the Evidence on Marijuana Project. May 2022.

Author Affiliations: Center for Alcohol and Addiction Studies, Brown University School of Public Health; Providence VAMC, Mental Health and Behavioral Sciences Service

Acknowledgments: Thank you to Ashley Linden-Carmichael, PhD and Adrian J. Bravo, PhD for critically reviewing this document.

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Page Last Reviewed:  November 2023