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Commentary: Marijuana Legalization Takes Center Stage This Election Season

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With Election Day just around the corner, voters in multiple locations will again be confronted with cannabis-related questions. Seven state legislatures appear to still believe that there is a medical use for marijuana despite a lack of agreement from the medical community. Legislation is pending in each of those states. “Medical marijuana” has simply been the camel’s nose under the tent, with the true goal of legalization covered up with a supposedly scientific approach.

Three states are now getting to the heart of the matter with outright legalization on the table. Colorado’s Amendment 64, the “Regulate Marijuana Like Alcohol Act,” will permit those over 20 to possess, use, display, purchase and transport limited amounts of marijuana. Washington’s Measure 502 would also allow limited possession of marijuana by those over age 20. The Oregon Cannabis Tax Act, Measure 80, would create the Oregon Cannabis Commission to regulate the sale and cultivation of marijuana for those over age 20.

In each case, there is a less-than-subtle approach to licensing and regulation, with excise taxes, fees and other revenue generating components representing a critical argument used in favor of passage. Proponents indicate that the Oregon Act will generate over $140 million in taxes, while Washington expects $350 million to expand state spending on drug education, prevention and treatment. Colorado’s bill indicates that the first $40 million raised each year will be credited to the public school and capital construction fund.

The legislatures in each state appear to have ignored the many associated costs which will quickly swallow the revenue described. This includes increased utilization of the drug at younger ages with associated addictive and physical illness, diminished productivity caused by cognitive abnormalities, and increased drugged driving and associated morbidity/mortality.

In July, the American Society of Addiction Medicine (ASAM) considered the question of marijuana legalization, concluding:

1)  That physicians lead efforts to oppose legislative or ballot initiatives that would result in the legalization of marijuana production, distribution, marketing, possession and use by the general public, and that all physicians incorporate screening and intervention for risky substance use, including marijuana use, as well as diagnosis, treatment and disease management for addiction into their routine medical practice;

2)   That public education campaigns be undertaken to inform the public that addiction associated with cannabinoids is a significant public health threat, and that marijuana is not a safe product to use, especially, but not only, by smoking;

3)   That parents be informed that the marijuana their children are exposed to today is of much higher potency than the marijuana that was widely available in the 1960s through the 1980s, and that the potential for the development of addiction and for the development and progression of psychotic conditions are enhanced when high-potency marijuana products are used by adolescents because of the unique vulnerability of the adolescent brain;

4)   That when cases of marijuana-related substance use disorders are identified and the diagnosis confirmed by professional assessment, carefully monitored treatment to establish abstinence be offered to afflicted persons and such treatment and insurance coverage for it be readily available;

5)   That drugged driving associated with marijuana use be subject to additional epidemiological research and research on the treatment needs of drivers. Increased efforts are needed to prevent its occurrence which should include substantial legal consequences at the level of the consequences for drunk driving;

6)   That, given the significant role the criminal justice system plays in discouraging marijuana use, states promote programs that enhance linkages between the criminal justice system and the addiction treatment system, using models such as Drug Courts and HOPE Probation.

ASAM asserts that the anticipated public health costs of marijuana legalization are significant and are not sufficiently appreciated by the general public or by public policymakers. Physicians and other health professionals must become more aware of the anticipated undesirable outcomes of marijuana legalization and encourage public education on these facts.

Stuart Gitlow MD MPH MBA is a member of the American Medical Association’s Council on Science & Public Health, and Acting President of the American Society of Addiction Medicine. This Op-Ed represents his personal opinion and does not imply any position or policy taken by either the AMA or ASAM.

20 Responses to this article

  1. jim meeks / September 12, 2012 at 4:07 pm

    i cannot understand why we are still having this discussion. There is a place in the medical world for Marijuana. it works the best for stopping the wreching,stomach turning pain from chemo….a couple of ”puffs”off of a high grade joint of marijuana does work, it will stop the pain and allow me to continue with my LIFE. dont knock it less you have tried it.

  2. Joe Miller / September 11, 2012 at 6:00 pm

    It should be noted that recent statistics show that the drugs with which he have had the most success in lowering youth use rates are the legal substances alcohol and tobacco which we control and regulate rather than prohibit as it relates to general adult useage.

  3. Joe Miller / September 11, 2012 at 5:56 pm

    Dr. Gitlow, if the idea is to keep cannabis out of the hands of children then placing the responsibility for the production and distribution of the substance into the hands of criminal predators via the black market through prohibitionist policy is hardly a step forward.

    Eric, you’re confusing prohibitionist policies with control and regulation.

  4. Avatar of Eric
    Eric / September 9, 2012 at 5:14 pm

    Excellent commentary Dr. Gitlow! People often say prohibition doesn’t work and Nixon started the drug war! Both of these statements are false. Prohibition on drugs and alcohol largely began in the 1400′s. Egypt was the first country to prohibit marijuana in the 1400′s. Muslim countries prohibited alcohol. During the 1800′s numerous municipalities around the U.S. created varied alcohol & drug prohibitions. Alcohol still has prohibitions today (.08 for driving, culpability of bartenders, no sales after 2-3am, no drinking in public,no alcohol under 21, etc.) Alcohol consumption is 7 times lower per capita now than it was in the early 1800′s. Tobacco prohibitions have dramatically reduced tobacco use in the U.S. The Harrison narcotic act of 1914 has reduced opiate dependence. If you think opiate dependence is bad today, read about the history of post Civil War opiate dependence. There certainly appears to be a “sweet spot” for prohibition to be most effective. The first “Drug War” was started by Great Britain in the late 1800′s. But it wasn’t a war to stop drugs, rather it was the opposite. They waged a war against China for their right to sell opium to the Chinese. When the government didn’t want Great Britain selling their poison to the citizens, Great Britain waged war, and occupied Hong Kong for 99 years. Thirteen months ago Russia declared their own “War on Drugs.” Native Americans often say that “The War” against them was won by alcohol. Mass drug production (including alcohol) and exploitation of vulnerable people is a new phenomenon in world history over the past 300 years. By now, you would think that people would have learned about the impure motives of greedy individuals who seek to exploit vulnerable populations through the mass production of drugs of abuse, simply by witnessing the behavior of the alcohol industry, tobacco industry, pharmaceutical industry, and illicit drug industry. There’s definitely a “sweet spot” in prohibition where you get the biggest bang for the buck, while preserving individual rights. We just need to work smarter to find that spot. Opening a new market for exploitation of vulnerable populations is not the answer.

  5. Avatar of J.R. Neuberger
    J.R. Neuberger / September 8, 2012 at 9:09 am

    We could have a room full of marijuana, smoke it and no one would overdose or become addicted. Yet time continues to be wasted by the abstinence-based lobby looking to increase their revenues by creating “addictions” where none exist. Let’s spend our efforts on those things that are truly harmful. The world would be a much better place if marijuana replaced alcohol as the “social” drug utilized by most of the population. Regulate, tax and keep it out of the hands of children, but stop demonizing that which anyone who has ever used it knows is harmless and has, in many, many ways, been a positive social influence within our society. In the 60′s and 70′s I personally witnessed dozens of people, because of marijuana’s influence, discover the realization that we are all people, equal on this earth. It played a role in breaking down the racial and ethnic stereotypes that were so prevalent in our society in those times. It’s a harmless psychotropic substance that expanded the awareness of millions and was a positive influence on our culture and society.

  6. Dr. John Gardin / September 8, 2012 at 1:54 am

    I applaud Dr. Gitlow for boldly stating what those of us treating individuals with substance use disorders already know. Does cannabis have potential medicinal properties? Most likely. Does smoking anything make sense? Not so much. There is that “first do no harm” thing, after all. It’s important to understand that the overwhelming number of people obtaining medical marijuana cards in Oregon, for example, aren’t cancer patients or glaucoma patients or even pain patients. They are individuals who use cannabis for sleep, to relax, to assist with digestion – any excuse they can come up with to legitimize their recreational use of cannabis. When our so-called medical marijuana law was passed, we expected 2,000-3,000 cards to be issued. We have now distributed over 40,000 cards and counting. No medical oversight of the cannabis itself. No medical oversight of the “patients” with these cards. There is nothing “medical” about it.

  7. Peter Wolczuk / September 7, 2012 at 11:30 pm

    As in many other venues, there seems to be a conclusion being pushed that, if marijuana is not allowed as a recreational drug, then it will not be be allowed under prescription. Where does that come from? Opiates, for instance, are illegal for “recreational” purposes in many places where it is prescribed when there is a true medical need. Why would we have to assume that the same won’t be allowed for cannabis?
    Neither Doctor Gitlow, nor the ASAM members who have put out their conclusion, need to spend a few days wracked with nausea that nothing else alleviates to know that there are worthwhile medications which are dangerous if used improperly. Nor do they need an absurd guilt trip.
    It’s no wonder that the article mentions a true goal being covered up with a supposedly scientific approach.
    And that doesn’t even go near the many tirades that are thrown out about marijuana being harmless. Tirades which sound more like an addict in denial than a responsible person.
    As for criminalizing average citizens, I’m sure that the legislative bodies are quite capable of writing a law that specifies the harsh penalties for large volume traffickers, rather than for victim users.

  8. Avatar of Edward
    Edward / September 7, 2012 at 9:19 pm

    I agree with Dr. Gitlow. The recently published study in the Proceedings of the National Academy of Sciences, “Peristent Cannabis Users Show Neuropsychologicial Decline from Childhood to Midlife” is damning to the pro-legalization or pro-medication camps. This prospective longitudinal cohort study represents the gold standard of epidemiological research, and is one of hundreds of reports from the Dunedin Multidisciplinary Health Study Group. The results are plain: cannabis is highly neurotoxic. The results are worse with exposure when young, but there seems to be a clear dose/effect relationship. The striking finding is that even among 38 year olds whose use was only between 13 and 18, there was still a 4% drop in IQ scores. Similar research in alcoholics shows a return of normal findings after 2 years, but with cannabis, the damage is so extensive that 20 years does not correct it. This makes sense since cannabinoid receptors are widely distributed in the brain. Disrupting their normal function with a multitude of cannabinoids is simply stupid- and makes you stupid- probably permanently. When this study’s results become more widely known among scientists, there will be much stronger reasons for fervent opposition to the attempts to legalize cannabis.

    This research should result in more studies of Marinol’s effects on cognition at therapeutic doses. Only a purified, pharmaceutical grade cannabinoid with proven safety should have any role to play in medical care, and as a last resort for those who fail safer therapies.

  9. Avatar of Amanda Reiman, PhD
    Amanda Reiman, PhD / September 7, 2012 at 6:41 pm

    What I find most interesting about this (besides the complete lack of regard for science) is the last statement, “This Op-Ed represents his personal opinion and does not imply any position or policy taken by either the AMA or ASAM.” Well, his opinion can’t reflect the AMA’s position, because they do not share his view. The AMA calls for the rescheduling of marijuana to fully understand and investigate its therapeutic potential, believing that, “effective patient care requires the free and unfettered exchange of information on treatment alternatives and that discussion of these alternatives between physicians and patients should not subject either party to criminal sanctions.” Furthermore, the California AMA declared in 2011 that they support the legalization of marijuana.The decision was made so physicians may have access to better research, which is not possible under current drug policy. So, Dr. Gitlow can have his OPINION, but the medical profession has spoken, and they side with science, not propaganda.

  10. Richard Paul Steeb / September 7, 2012 at 3:38 pm

    “Seven state legislatures appear to still believe that there is a medical use for marijuana”? Really? Astonishing…

    Since Sir William Brooke O’Shaughnessey, western medicine has been aware of the noble herb’s medicinal properties– Whether you neo-Inquisitors “approve” today or not.

    Three words, genius: “Storm Crow’s List”. Name a substance on this planet that is nearer to a literal panacea.

  11. perryrants / September 7, 2012 at 2:38 pm

    how did they calculate those tax revenues? who pays-the seller or the buyer. at what price point does it go into bootlegging to avoid taxes like alcohol and tobaco?

  12. Scott Kellogg, PhD / September 7, 2012 at 1:15 pm

    I am surprised that Dr. Gitlow, who is such a respected and knowledgeable physician, would write an article that was so lacking in nuance. In terms of Medical Marijuana, NIDA has refused to support research on its possible benefits; as one NIDA spokesperson put it: “We generally do not fund research focused on the potential beneficial medical effects of marijuana.”
    Given that there is a growing population of patients with chronic pain problems as well as growing problem of patients and non-patients with addictions to pharmaceutical opiates, the pain-reducing properties of marijuana is something that would certainly warrant serious attention. It is because NIDA and other government agencies refused to support the vital scientific work that was necessary to see if marijuana could, in fact, be helpful with medical illnesses that the issue is now going to the ballot box.
    I am not a supporter of recreational drug use and I think that alcohol consumption should be dramatically minimized. However, spending taxpayers’ money to arrest, prosecute, and imprison those who use cannabis is wasteful and not something that can afford to do. While there are certainly negative consequences to marijuana use – including a 10 percent addiction rate – they are generally much less destructive than those connected to alcohol. This applies not only the individual, but also to society. While this is something health professionals might have trouble doing enthusiastically, we should probably be encouraging people to shift from alcohol to marijuana as the costs to individuals, their families, and society will be lower.
    It is time that we begin to have much more sophisticated and nuanced discussions about the use of drugs in our society; discussions that are based on Science, Clinical Practice, and the experiences of users.
    [For a link to the story on NIDA: http://www.nytimes.com/2010/01/19/health/policy/19marijuana.html

  13. PWKaplan / September 7, 2012 at 12:54 pm

    This is just so sad for so many reasons. I do not smoke pot and have no interest in marijuana personally. But I have had friends with cancer for whom it was the only thing that overcame the nausea and vomiting associated with chemotherapy and advanced stage illness. When will these idealogues figure out that criminalizing drugs does not keep people from using them. It just adds billions to the cost of law enforcement and makes the drug cartels rich. Oh, and it makes criminals of otherwise harmless, law-abiding citizens. But let us not consider alleviating suffering in the service of giving doctors more control over our lives–they’ve done such a good job managing health care to date. Dr. Gitlow should spend a few days wracked with nausea that nothing else alleviates, then let’s see how much of a camel’s nose he thinks medical marijuana is. Societies like the Netherlands, which decriminalized marijuana (and other drugs) years ago, have not fallen apart, nor have there been significant increases in addiction. Fear mongers like Gitlow need to get off their high horses and attend to the only issue that he makes sense about–treatment on demand.

  14. Richard Paul Steeb / September 10, 2012 at 11:52 am

    The prohibition of Earth’s most widely beneficial plant species is a crime against humanity. It shall NOT stand.

  15. Stuart Gitlow / September 10, 2012 at 4:24 pm

    Dr. Reiman:
    Thank you for your comment. I’m afraid you’ve misquoted the AMA’s position. You wrote that the AMA calls for the rescheduling of marijuana. It has done no such thing.

    I was a member of the Council that wrote the AMA policy, which passed in 2009. We did not call for rescheduling of marijuana but simply noted that its status as a Schedule I substance should be reviewed so as to facilitate research and development of cannabinoid-based medication should scientific evidence indicate value in such medication. (See AMA CSAPH Rep 3-I-09, page 16).

    We agreed very much that the anecdotal evidence suggests there to be potential value in cannabinoids and wanted to smooth the way for study and research, but in no way were suggesting or endorsing such issues as “medical marijuana,” marijuana legalization, or that marijuana itself meets contemporary standards for medication.

  16. Stuart Gitlow / September 10, 2012 at 4:33 pm

    JR,
    You raise a fascinating question which inspired me to imagine a world in which alcohol doesn’t exist but wherein marijuana is the socially acceptable drug utilized just as alcohol is now. Clearly we would have lower rates of alcoholic cirrhosis and alcoholic dementia. But might we not replace that with an overall loss of productivity, motivation, and drive? I don’t see it as leaping from the frying pan into the fire, but perhaps simply leaping from one frying pan and into another.

    Just as small doses of alcohol tend not to produce long-lasting negative effects, the same could be said for other psychoactive substances. And while in your room full of marijuana, no one would overdose, that would also be true if the room were full of tobacco. And tobacco is one of our nation’s leading causes of illness and death.

    Given that alcohol and tobacco together are the major drivers of the increasing healthcare costs that have inspired so much legislation of late, why would we add another such burden to either our youth or our economy?

  17. Eric / September 12, 2012 at 3:39 pm

    Joe, you’re confused. Prohibition, control and regulation are all on the same continuum. For example, if you look up CFR’s and Revised Statutes in all U.S. states they state “minors are prohibited…” “sales of tobacco to those under 18 is prohibited,” “smoking in restaurants is prohibited.” These are, in fact, prohibitions with criminal sanctions. It’s unfortunate that people are unable to embrace the concept of a continuum of legality, they only see the world in black and white, legal or illegal. Marijuana is a misdemeanor in the Netherlands, but they have a non-enforcement policy. My state has even lower penalties than the Netherlands. In my state possession of less than an ounce is a “violation,” less than a misdemeanor, equal to “jaywalking.”

  18. Joe Miller / September 12, 2012 at 6:21 pm

    No offense intended Eric but you seem to be having a problem understanding context. In this discussion prohibitionist policies prevent the production and distribution of these substances in any manner. Laws that control and regulate them do not. The verbiage you cite in statutory law is just that: verbiage. You need to look at the bigger picture rather than just reading your penal code.

  19. Eric / September 16, 2012 at 2:50 am

    Joe, laws are more than just verbiage. The rule of law is how our civilization evolves with safety, equality and justice. Without the rule of law, we would simply have dictatorships (kings & queens) or religious laws (religious dictatorships). I just don’t see how it’s possible to legalize marijuana any time soon. The U.S. has signed treaties on illegal drugs in 1912, 1924, and virtually every year nowadays through U.N. Conventions on narcotics. We can’t legalize marijuana without violating international agreements with other countries. For example, contrary to urban myth, marijuana is still illegal in the Netherlands. Rather, they have adopted a non-enforcement policy. Several municipalities around the U.S. have developed non-enforcement policies, which is different than legalizing marijuana. Marijuana will likely be legalized sometime, but doubtful in the near future. Additionally, there is conflicting data regarding the impacts of legalization. Scientific American and numerous notable U.S. researchers have applauded the huge success of decriminalization in Portugal. On the other hand the European Monitoring Centre (a non-biased epidemiological research organization) reports: In Portugal, between 2001 and 2009, lifetime use of all illicit drugs increased from 7.8% to 12%, lifetime use of cannabis increased from 7.6% to 11.7%, cocaine use more than doubled, from 0.9% to 1.9%, ecstasy nearly doubled from 0.7% to 1.3%, and heroin increased from 0.7% to 1.1%.

    So what are we supposed to believe? And now, the Netherlands are creating prohibitions, in 2007 they banned the sale of alcohol in marijuana coffee houses, they’re banning high potency marijuana, and they’re banning tourist from consuming marijuana.

    I go back to my statement that there must be a sweet spot in prohibition that preserves the rights of individuals while protecting the interest of society, while respecting internal treaties and agreements.

  20. Avatar of Michael Sendkowski
    Michael Sendkowski / September 18, 2012 at 11:12 am

    Stuart,

    The one argument against marijuana use that I can not stand to hear is that everyone that uses it is a “lazy, non motivated slouch with no goals or future.” People that have never used marijuana always get the impression that every stoner is the same good for nothing bum that is portrayed in movies, magazines, and maybe in your very own high school when you were younger. I earned a college degree, an excellent computer programming job, and a related side business I do from home with many happy clients. I know many other everyday users that are highly functioning with college degrees and good jobs. So do not try to lump everyone together as so many of you anti-marijuana advocates do, because you are only focusing on a negative stigma associated with it and not the FACT that many people live highly functioning and productive lives.

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