"What's MDMA? Is that marijuana?"

I'm at a doctor for a checkup, and she’s looking over my forms, on one of which I admit to using MDMA around every other month.

When I explain that MDMA is actually the active ingredient in ecstasy (if you’re getting what you hoped for, at least), she responds, “Why do you do that? To feel good, I suppose? Exercise is better for that. That’s not a good thing for a young person to do, especially while you’re trying to build a career.”

I bite my tongue to avoid telling her I’ve actually used it for my career; I came up with the idea for my book and some of the best pieces I’ve published on it. Or that it’s helped me overcome anxiety, which isn’t surprising given it’s been used to treat anxiety in forthcoming research from the Multidisciplinary Association for Psychedelic Studies (MAPS) that has shown “promising” results, a MAPS representative tells me.

Or that I used it not at clubs, but at home, where I could write down my ideas under a sober trip-sitter’s supervision. Or that I’ve spent hours researching the negative effects and decided that the benefits of occasional use were worth it to me. I wasn’t hoping for her to give me the green light; I just would’ve liked her to see where I was coming from and maybe even help me further reduce the risk, rather than stereotype me as a careless drug user.

That isn’t necessarily her fault—she probably didn’t learn what people might get out of recreational drugs in med school. As more states legalize marijuana, however, this is changing. But as of now, “most of the training in medical school and residency is around the recognition of drug abuse, drug misuse, and drug addiction,” says Alana Biggers, assistant professor of clinical medicine at the University of Illinois-Chicago College of Medicine.

More from Tonic:

Kevin Chase, a first-year osteopathic medical student at the Ohio University Heritage College of Osteopathic Medicine, says he’s learned about the molecular structure and effects of illegal drugs the same way he’s learned about legal ones, but there isn’t much research on anything beyond their risks. “Until there is more research, recreational drug use will continue to be met with skepticism or outright discouragement from doctors,” he says.

I asked around and it turns out some doctors are not just unhelpful, but alarmist too. Daniel Saynt, 34, founder of The New Society For Wellness, a Brooklyn-based digital agency, had just started smoking weed once or twice a week in college when he asked his doctor what he should know about its effects. The doctor replied that he’d get cancer if he kept smoking. “I remember feeling ashamed because he made it seem so dangerous," he says.

Mitchell Robert Colbert, a 30-year-old cannabis industry consultant in Oakland, California, treated his anxiety and depression illegally with weed for six years before asking his primary care physician for a medical cannabis card. "You know you can go pay someone for that, but we don't do that here," he replied. He then asked for one from his therapist, who was also an MD, but she replied that she “knew someone who ruined their life” with weed.

To avoid these scenarios, many people just don’t admit to using drugs. A 2,058-person NetQuote survey from 2016 found that 34.6 percent of people ages 25 to 34 and 38.8 percent of people ages 18 to 24 had lied to doctors about their substance use.

“I know all of the reasons that I should share my full medical history when I go to the doctor, but when it comes to [drugs], I choose not to,” says one anonymous 32-year-old woman working in PR in Amsterdam (Yes, even in Amsterdam she keeps this a secret). “I have a demanding and fast-paced career, hobbies and passions that I pursue in my free time, and close, healthy relationships with family and friends. I also regularly use MDMA and psychedelics like LSD and mushrooms.”

After over a year of using these drugs two to three times a month, she’s lost weight that she’s been trying to for years, and drastically reduced her depression and anxiety—something that 15 years of therapy and psychiatric drugs failed to do. She’s concerned that if doctors knew about her drug use, they’d deem it dangerous and pressure her to once again try methods that haven’t worked for her.

Lying to doctors about substance use can become problematic when they prescribe medications or treatments that may interact with certain drugs, Biggers says. It also gives them an incomplete picture of what might be contributing to a patient’s health issues. But the onus to open up this conversation isn’t just on the patient.

“[Patients] are afraid of being judged,” says James Giordano, professor in the departments of neurology and biochemistry and chief of the neuroethics studies program at Georgetown University Medical Center. To assuage this fear, doctors should tell their patients upfront that they won’t judge or scold them but simply need certain information to make informed decisions, he says.

Doctors need a nuanced understanding of drugs that lets them approach drug use on a case-by-case basis, he adds. If someone smokes pot once in awhile and doesn’t have any medical issues, for example, the doctor might just file away that information and not bring it up. If they’re smoking every day and are overweight, however, they might inform them that the munchies could contribute to weight gain.

Even then, though, physicians should acknowledge that drug use is ultimately a patient’s choice and try to understand why they’re making that choice, rather than assume they’re just irresponsible or reckless or an addict, Giordano says. This also means keeping up with the latest research so that they comprehend why someone might, for example, microdose LSD to spark creativity at work or take MDMA with their partners to work through relationship issues. In short, they need to understand that not all drugs or uses of them are equally problematic—and to the extent that they are problematic, teaching people how to reduce harm works better than just telling them not to use drugs.

“Drugs are not uniform, and drugs do different things to different people. It is part of a clinician's responsibility to be able to probe these facts in a clear and proven way with each patient,” Giordano explains. “It would be like you telling me ‘I run with scissors.’ Medically, that’s not a very good thing to do. If you say, ‘I frequently run with blunt-edge scissors and I keep the pointy edge down,’ I would say, ‘I understand.’ This is a person, and if this patient chooses to engage in illicit drug use, then that physician has to appreciate that that is a factor in that patient's life.”

When searching for this kind of doctor, some trial and error is unavoidable, Biggers says. Asking friends for recommendations, reading online reviews, and researching how a prospective doctor presents themselves online can all help, though.

Fortunately, since being drug-shamed by his doctor and therapist, Colbert got his card at a cannabis clinic for an extra $100 and is now a medical marijuana patient. He says it’s the only thing that’s ever alleviated his depression and anxiety.

As for Saynt, he’s found a more open-minded doctor who can discuss the potential risks of his drug use without exaggerating or moralizing them. “I became more responsible because I was able to have conversations with my doctor where I didn't feel there was anything to hide,” he says. “There's a real issue with doctors in America right now that is being caused by this lack of communication. How will you know how to treat me if I'm not able to tell you what's wrong?”