Medical Marijuana

July 21, 2017 – Volume 27, Issue 26
Does cannabis offer health benefits? By Barbara Mantel

Introduction

A conventiongoer visits a booth at the fourth annual Cannabis World Congress (Getty Images/Spencer Platt)  
A conventiongoer visits a booth at the fourth annual Cannabis World Congress and Business Exposition in New York City on June 16, 2017. The trade show attracts growers, dispensaries, doctors and others involved in the use of legal recreational and medical marijuana. Medical marijuana's effectiveness remains hotly debated. (Getty Images/Spencer Platt)

Americans overwhelmingly approve of medical marijuana, and 29 states and the District of Columbia have legalized it, allowing doctors to recommend marijuana products to registered patients. Research shows some forms of marijuana, including a synthetic drug, help treat a few conditions, including chronic pain and chemotherapy-induced nausea. But solid research is limited for other forms, such as smoked or vaped marijuana, and for conditions such as post-traumatic stress disorder, for which states have approved marijuana use. Nevertheless, medical marijuana advocates want all states to legalize it, while opponents say only the Food and Drug Administration should approve drugs for medical use. Yet, federal rules make the studies the FDA relies on difficult to undertake. Complicating the situation are Trump administration efforts to end Obama-era policies curtailing prosecution of medical marijuana in states where it is allowed. Caught in the middle are doctors, who worry they can land in legal trouble if they discuss marijuana with patients, and patients, who must rely on advice from cannabis dispensaries.

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Overview

In May 2016, soon after Elizabeth Crewe was diagnosed with cancer in both breasts, she underwent two lumpectomies. But just as her follow-up radiation treatments were winding down, she found her anxiety levels were rising.

“Any time you're facing cancer, you're staring at your own death,” says Crewe, 53, who lives in La Grange, Ill., with her husband and three teenagers.

Between anxiety, insomnia and chronic ankle pain from an old injury, Crewe decided she needed help coping. But she is allergic to opioid-based painkillers and wanted to avoid an anti-anxiety drug she would have to take daily.

So in February, Crewe turned to marijuana.Footnote *

Now she applies a topical cream to her aching ankle and vapes marijuana when her anxiety is high and before bed when she can't sleep. “It just brings me down a notch,” Crewe says. “If I'm not feeling particularly on edge, I don't use it. Whereas, if I had gotten a prescription for anti-anxiety medicine, I'd be on that all the time.”

Illinois and 28 other states, along with the District of Columbia, have legalized medical marijuana over the past 21 years, most in the last eight years. Fifteen other states allow only a marijuana extract composed mostly of cannabidiol, a compound that shows promise in treating severe epilepsy and does not produce a high. Since 2012, eight states and the District of Columbia have made adult recreational marijuana use legal.1

Meredith Bower checks out a cannabis sample at the Takoma Wellness Center (Getty Images/CQ Roll Call/Tom Williams)  
Meredith Bower checks out a cannabis sample at the Takoma Wellness Center, a medical marijuana dispensary in Washington, D.C. Bower lost a leg below the knee after a car accident and treats her phantom limb pain with cannabis. Medical marijuana is legal in 29 states and the District of Columbia. (Getty Images/CQ Roll Call/Tom Williams)

These laws reflect, and possibly affect, the growing acceptance in the United States of the use of marijuana for both recreational and medical purposes. An April poll by Quinnipiac University found that 94 percent of American voters support “allowing adults to legally use marijuana for medical purposes” if their doctor recommends it, the highest level of support to date in national Quinnipiac polls. Sixty percent favored legalizing recreational marijuana, also a record.2

Each state law allowing doctors to “recommend” — but not “prescribe” — marijuana is unique. For example, California allows physicians to recommend cannabis to registered medical marijuana patients as they see fit, but most states have a list of qualifying conditions. For example, Nevada currently allows physicians to recommend marijuana to treat symptoms for nine conditions, including AIDS, cancer and severe pain, while Washington state allows using it to treat 12 conditions, including seizures, Crohn's disease and Hepatitis C. A few states, such as Florida and New York, allow only smoke-free forms of marijuana, such as capsules, liquids and oils.3

Yet rigorous research into the potential health benefits of marijuana and its various forms lags behind these evolving mores and laws, in large part because scientists find it so daunting to get government approval — and the marijuana — needed to conduct studies. The lack of a broad base of high quality scientific data means it has been difficult to settle the long-running debate about marijuana's therapeutic value. Meanwhile, many states have stepped in and approved medical marijuana rather than wait for action by the U.S. Food and Drug Administration (FDA), which relies on such research studies when approving drugs.

“We want safe, reliable access for people who are using marijuana for medical purposes,” says Morgan Fox, communications manager at the Marijuana Policy Project, an advocacy group in Washington that wants every state to adopt a medical marijuana program and for recreational marijuana to be regulated like alcohol. “The FDA has just been far too slow to act. And there's no reason for us to wait around for the FDA when we can have a viable alternative in bringing this medicine to patients.”

The U.S. map highlights states where medical marijuana and cannabidiol are legal.  

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Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Hawaii, Illinois, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Montana, Nevada, New Hampshire, New Jersey, New Mexico, New York, Ohio, Oregon, Pennsylvania, Rhode Island, Vermont, Washington and West Virginia, plus the District of Columbia, have legalized medical marijuana. Alabama, Georgia, Iowa, Kentucky, Mississippi, Missouri, North Carolina, Oklahoma, South Carolina, Tennessee, Utah, Virginia, Wisconsin and Wyoming only allow the medical use of a marijuana extract composed largely of cannabidiol, a compound that shows promise in treating severe epilepsy. California in 1996 became the first state to allow medical marijuana.

Source: “United States,” National Organization for the Reform of Marijuana Laws, http://tinyurl.com/yasqlhst

But critics say states are jumping the gun by approving medical marijuana. States are “taking a very well defined and accomplished system that we've used for years to protect Americans from quackery and throwing it out” and replacing it with an approval process conducted by unqualified politicians rather than scientists, says Rhode Island physician Stuart Gitlow, a past president of the American Society of Addiction Medicine. The Rockville, Md.-based group of more than 4,600 physicians, clinicians and associated professionals opposes state laws legalizing medical marijuana.

Because of incomplete state record-keeping, no one knows the number of legal medical marijuana users. But based on available state data, the Marijuana Policy Project estimated more than 2.3 million users in 2016.4 Although the group did not break down that figure by age, the numbers skewed older in at least three states.

In Montana, the 51-to-60-year-old age bracket had the most registered medical marijuana users when compared with other 10-year age brackets. The same was true in New Hampshire. In Oregon, 60-to-69-year-olds outnumbered all other age groups. In all three states, as in most others, severe pain was the most-cited reason users turned to marijuana.5

“I would be in a lot worse shape if I wasn't using cannabis, both physically and mentally,” said Anita Mataraso, 72, who takes marijuana daily for arthritis and nerve pain and manages a medical marijuana club at her retirement community in San Francisco.6

Overall sales of legal medical marijuana totaled $4.7 billion last year, according to New Frontier Data, a market research firm in San Francisco. An increasing share of those sales is from edibles and from concentrates that can be swallowed, vaped or placed under the tongue. Demand for traditional dried marijuana, which can be smoked, vaped or baked into edibles, fell from 87 percent of sales to 65 percent in 2016.7

Meanwhile, state medical marijuana laws and federal law on marijuana clash. The 1970 Controlled Substances Act prohibits the cultivation, processing, distribution and use of marijuana, which the Drug Enforcement Administration (DEA) classifies under the law as a Schedule I substance, a category reserved for drugs such as heroin and LSD that are considered highly addictive with no acceptable medical use. Physicians cannot legally prescribe it.

The Trump administration is signaling that it wants to enforce the federal law and get tougher on medical marijuana businesses, a change in policy from the administration of President Barack Obama.

Under Obama, the Justice Department advised federal prosecutors to conserve their resources and stop prosecuting medical marijuana patients and businesses as long as they were in compliance with state medical marijuana laws. And in 2014, Congress cut off funding for Justice Department medical marijuana investigations in states where it was legal.

But in May, Attorney General Jeff Sessions asked congressional leaders to restore funding for investigations. Sessions called marijuana a harmful drug ripe for abuse with no accepted medical value and state medical marijuana programs a cloak for criminal enterprises.

“In particular, Cuban, Asian, Caucasian and Eurasian criminal organizations have established marijuana operations in state-approved marijuana markets,” Sessions said.8

But Alex Kreit, a professor at Thomas Jefferson School of Law in San Diego and a leading expert on drug laws, says Sessions will face political blowback from his own party if federal prosecutors start getting tough. “Among the states that have legalized marijuana for adult use,” he says, several have “Republican governors or senators who have been, by and large, pretty united in saying that if the federal government cracks down, they're going to be pretty vocal in calling out the Trump administration.”

As the debate about medical marijuana continues, here are some of the questions that physicians, patients, medical marijuana advocates and opponents are asking:

Does marijuana provide clear-cut medical benefits?

The perception is growing among Americans that marijuana has an array of proven health benefits. But marijuana's advocates and detractors have been arguing this point for decades, and the debate shows no signs of resolution.

“There is a mountain of scientific evidence that demonstrates marijuana is a safe and effective medicine for people suffering from a variety of debilitating medical conditions,” according to the Marijuana Policy Project.9

The bar graphics shows the percentage who support or oppose medical marijuana if a doctor says a patient needs it.  

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A record 94 percent of American voters back the legalization of medical marijuana, including 90 percent of Republicans and 96 percent of Democrats, according to a 2017 Quinnipiac University poll. Support exceeds 90 percent among all age segments of the adult population.

Source: “U.S. Voter Support For Marijuana Hits New High,” Quinnipiac University Poll, April 20, 2017, http://tinyurl.com/y93bnkhc

Data for the graphic are as follows:

Voter category In support of In opposition of
Republican 90% 9%
Democrat 96% 3%
Independent 95% 4%
Total 94% 5%
Age 18 to 34 97% 2%
Age 35 to 49 94% 5%
Age 50 to 64 93% 5%
Age 65 and above 93% 7%

“The reality is that for a whole host of conditions that advocates claim marijuana helps, there is no evidence,” says Kevin Sabet, president of Smart Approaches to Marijuana (SAM), a group in Alexandria, Va., that opposes the legalization of either medical or recreational marijuana.

The marijuana plant contains approximately 100 molecules called cannabinoids, which bind to receptors throughout the human body. These receptors, plus the cannabinoids produced by the human body itself, are known collectively as the endocannabinoid system, which is believed to help regulate gastrointestinal and cardiovascular activity, pain perception, hormone regulation, immune function and more.10

Cannibidiol (CBD) is a cannabinoid, and so is Delta-9-tetrahydrocannabinol, or THC, which is largely responsible for marijuana's mind-altering affects. Their concentrations can vary based upon the marijuana strain and how plants are cultivated.

But experts say not enough high-quality studies exist exploring marijuana's impact on the body to put the debate about marijuana's health benefits to rest.

“[Research] has been limited in the United States, leaving patients, health care professionals, and policy makers without the evidence they need to make sound decisions regarding the use of cannabis and cannabinoids,” a committee of the independent National Academies of Sciences, Engineering, and Medicine said in a January report.11

The amount of research on the health impact of cannabis and cannabinoids has been growing steadily over the past decade, with thousands of papers published in the United States and elsewhere. But most of them have been based on animal experiments or are not randomized control trials, which scientists consider the gold standard for medical research. The National Academies committee combed through the papers, winnowing them by relevance and quality until it had a list of just under 300.12 Its report assessed that evidence and inched the debate forward.

The committee found conclusive or substantial evidence that cannabis or cannabinoids are effective in treating chronic pain, muscle spasticity in multiple sclerosis sufferers and chemotherapy-induced nausea and vomiting. And it found moderate evidence that cannabis or cannabinoids are effective in treating some forms of insomnia.

But the committee found only limited or no evidence of their effectiveness for treating the symptoms of post-traumatic stress disorder (PTSD), anxiety, irritable bowel syndrome, epilepsy or other conditions for which some states have approved marijuana. (In May, too late for inclusion in the committee's report, American and British researchers published the results of a randomized, controlled trial of Epidiolex, a pharmaceutical-grade cannabidiol extract not yet approved for use, that showed it reduced seizure frequency in children with intractable epilepsy far better than a placebo.)13

Jahan Marcu, chief scientific officer at Americans for Safe Access, which advocates for the acceptance of cannabis as medicine, says the committee left out basic animal research, much of it positive. “I know we're not rats and mice,” says Marcu, “but all mammals share this endocannabinoid system, and its mechanistic activities have been studied in great detail.”

Fox of the Marijuana Policy Project says the committee's report did not consider patients' success stories. “It does leave out a lot of the anecdotal evidence that we've been able to gather from the medical marijuana states that have changed their laws so far,” says Fox.

But Deepak D'Souza, a psychiatry professor at the Yale University School of Medicine who does not believe states should decide what substances constitute a medicine, says the National Academies committee was right to be so selective. “Imagine if pharmaceutical companies produced drugs based on anecdotal reports. There would be mayhem,” he says. “The FDA process is in place because, for the most part, it has served the public well.”

Teri Robnett inhales cannabis with a vape pen to deal with fibromyalgia (Getty Images/The Denver Post/Andy Cross)  
Teri Robnett inhales cannabis with a vape pen to deal with fibromyalgia, a chronic pain condition; her husband, left, grinds marijuana. An April poll by Quinnipiac University found that 94 percent of American voters support “allowing adults to legally use marijuana for medical purposes” if their doctor recommends it. (Getty Images/The Denver Post/Andy Cross)

In addition, the majority of studies on the National Academies committee's final list did not involve smoked or vaped whole-plant marijuana, but instead, looked at prescription drugs. One is FDA-approved dronabinol, a synthetic THC that has been available as a capsule since 1985 under the brand name Marinol to treat chemotherapy-induced nausea and vomiting and appetite loss in people with AIDS. Another is nabiximols, a whole-plant marijuana extract with a consistent ratio of THC and cannabidiol. It is widely available as a prescription mouth spray called Sativex in Europe and Canada to treat spasticity in multiple sclerosis and cancer pain. It is undergoing clinical trials in the United States and is not yet FDA-approved.Footnote *

“People are using marijuana in forms for which the research doesn't support it,” says Sean Hennessy, a committee member and a professor of epidemiology and pharmacology at the University of Pennsylvania's Perelman School of Medicine. However, that doesn't mean those forms are not effective, but rather that they haven't been sufficiently studied, he says.

Nearly everyone on all sides of the debate agrees that more research is needed, but they differ markedly about what should be available to patients now.

“My dear hope is that there are dozens of marijuana-based medications that find their way to market,” Sabet says. “I just want them to find their way to market like every other medicine does, and that is through the FDA.”

But Fox says whole-plant marijuana, whether as dried flowers, edibles, oils and other forms, should be available to the public through dispensaries with a doctor's recommendation because they are less expensive than prescriptions, and many patients find they work better.

“Many of the compounds in marijuana work together in what's called the ‘entourage effect,’ but [the three] FDA-approved cannabinoid drugs are one compound in isolation,” says Fox.

Fox, Marcu and other proponents of medical marijuana point out that other drugs used to treat pain are more dangerous than cannabis. “More people die from Tylenol every year than have ever died from marijuana,” says Fox.

Marijuana is not entirely benign, however. “There are certainly populations for whom smoking or ingesting marijuana is not a good idea,” says Hennessy. The committee found that smoking marijuana in pregnancy is linked to low birth weight in babies and smoking it can lead to frequent chronic bronchitis. And for adolescents, “early cannabis use increases the likelihood of problematic cannabis use later in life,” says Hennessy.

In addition, “cannabis is likely to increase the risk of developing schizophrenia and other psychoses; the higher the use, the greater the risk,” the committee said.14

Do state medical marijuana laws lead to increased cannabis use or abuse?

As more states have begun to legalize medical marijuana, skeptics worry that the drug's increased availability will send a message to teens and adults alike that cannabis is acceptable, causing increased recreational usage. But researchers say that has not been the case among teenagers, while for adults the evidence is mixed.

Most studies on the impact of medical marijuana laws on teens have concluded that the passage and enactment of state laws have not led to “increased use of marijuana by young people or increased access to marijuana by young people,” says Paul Armentano, deputy director of the National Organization for the Reform of Marijuana Laws (NORML), a Washington group that has advocated for the legalization of adult marijuana use since the group was formed in 1970.

Deborah Hasin, a professor of epidemiology at Columbia University Medical Center in New York, and several colleagues conducted the largest study confirming this result.15 Relying on survey data on more than 1 million students between 1991 and 2014, the researchers looked at teens' marijuana use in the past month, the past year and their frequency of use. They considered whether states allowed dispensaries, and they accounted for lags in implementation of the laws. Each time the result was the same, says Hasin: Teens' use of marijuana did not increase after passage of a state medical marijuana law.

But Rosalie Pacula, one of Hasin's co-authors and the co-director of the Drug Policy Research Center at the RAND Corp., a think tank in Santa Monica, Calif., added a caveat. The number of marijuana dispensaries can influence teens' attitudes. A study in Colorado before and after 2009, when the U.S Justice Department advised federal attorneys to halt prosecution of medical marijuana patients, found that as dispensaries subsequently proliferated teenagers' perceived risk of marijuana dropped and their abuse of marijuana increased, compared with teens in states without medical marijuana laws.16

“We know from alcohol, higher density [of retail outlets] is associated with higher use, even among kids. We know this for tobacco as well,” says Pacula. “It's not at all surprising that preliminary studies are suggesting the same thing for marijuana.” The implication for states considering legalizing medical marijuana is that making medical marijuana available to patients, in and of itself, is not harmful to youths, but how a state implements the law can have an impact, she says.

The research on adults' illicit use or abuse of marijuana is more mixed. Several studies show no impact when a state implements a medical marijuana law, while a few others, including a new study by Hasin, have found an increase in use. The study Hasin conducted with colleagues looked at three surveys conducted between 1991, when no state had yet legalized medical marijuana, and 2013, when about 25 percent of states had these laws.17

“Overall, states that passed these laws had greater increased use of cannabis and of cannabis-use disorders than other states,” Hasin says. However, she says, the reasons are speculative. The laws might be promoting the idea that marijuana use is safe or acceptable, or it could be that some growers or dispensaries are diverting medical marijuana to the illicit market, she says.

But Armentano was critical of the adult study and the dataset Hasin chose to use, which varied from the one used in many other studies.

“Her papers have been outliers on this issue for the last few years,” says Armentano.

Hasin counters that another group of university researchers came to the same conclusion using the dataset that Armentano prefers.18

Marijuana advocates also say doctors are over-diagnosing “marijuana use disorder.” According to the National Institute on Drug Abuse (NIDA), which conducts research on drug use, those who become dependent on marijuana often report suffering from irritability, mood swings, sleep difficulties, cravings and other physical discomfort within the first week of trying to stop using it. In more extreme cases, NIDA says, marijuana use disorder can become addiction if a person cannot stop using marijuana even when it interferes with quality of life. Studies suggest that 9 percent of people who use marijuana will become dependent, rising to about 17 percent of those who started using the substance as teenagers.19

“Marijuana is an objectively less harmful substance than alcohol, and the scientific community generally agrees that marijuana is less addictive than alcohol and other drugs,” Mason Tvert, communications director for the Marijuana Policy Project, said in an email. “Unfortunately, the [psychiatric profession] and our government consider even non-problematic marijuana use to be a ‘disorder,’ whereas they acknowledge that adults can frequently consume alcohol without it being considered a disorder.”

Meanwhile, two studies have shown lower spending on prescription drugs by Medicaid and Medicare patients in states that have legalized medical marijuana.20 A few studies also have shown a beneficial impact on the overuse of prescription painkillers known as opioids. “We see lower use of opioids overall, fewer reported incidences of opioid abuse, fewer instances of opioid-related hospitalizations … and most importantly, we see a reduction in opioid-related mortality,” says Armentano.

The pie charts show the U.S. legal cannabis market, 2016 and 2025.  

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The U.S. market for legal cannabis is projected to more than triple between 2016 and 2025, with medical marijuana sales jumping from $4.7 billion to $13.2 billion during that period. In 2016, medical marijuana sales accounted for 71 percent of the cannabis market, but that share is expected to decline to 55 percent as the number of recreational users grows. The total sales for 2016 are $6.6 billion. Total estimated sales for 2025 are $24.1 billion.

Source: “The Cannabis Industry Annual Report, 2017 Legal Marijuana Outlook Executive Summary,” New Frontier Data, 2017, http://tinyurl.com/ybsszfrw

Data for the graphic are as follows:

Year of sales Adult total percentage and amount in $ billions (excluding medical marijuana sales to registered patients) Medical marijuana total percentage and amount in $ billions
2016 29% ($1.9 billion) 71% ($4.7 billion)
2025 estimate 45% ($10.9 billion) 55% ($13.2 billion)

Pacula says researchers don't know the mechanism behind that mortality drop. People could be switching to marijuana to treat chronic pain instead of using opioids at fatal dosages. In that case, the implication for a state with a serious opioid problem might be to “medicalize marijuana quickly,” says Pacula.

However, it may be that people are substituting marijuana for the sedative benzodiazepine, which is commonly misused when taken with opioids. “The likelihood of an opioid fatality when opioids are taken with marijuana is substantially less than when opioids are used with benzodiazepine,” says Pacula.

That's good news, she says, but opioid use has not dropped. In this scenario, rather than make medical marijuana available, states might be better off handing out nalaxone, a medication used to block the effects of opioids, especially in overdoses, Pacula says.

Should patients rely on dispensary staff to recommend marijuana products and strains?

Beth Collins' 17-year-old daughter has epilepsy. Several years ago, Collins wanted her to try cannabis to reduce the frequency of her seizures, but it would have been illegal in her home state of Virginia. So in December 2013, she and her daughter relocated to Colorado. However, their doctor's advice was severely circumscribed.

“We had a neurologist who signed her recommendation form but then would not talk with us again about it. He said he couldn't,” says Collins, who, after her daughter's illness, became senior director of government relations and external affairs for Americans for Safe Access. Doctors worry that discussions about marijuana strains and the dosing of THC and CBD cannabinoids may seem too close to prescribing, which is illegal under federal law, she says. So with the help of other parents on social media Collins figured out what product to try.

In 2015, Collins returned to Virginia after the state passed a law allowing the use of certain cannabis extracts to treat severe, debilitating epileptic conditions. But her daughter's Virginia doctor is not allowed to discuss cannabis with them. “The children's hospital has told her not to,” says Collins. “She'll refer to it as ‘the other treatment.’” Collins says her daughter is now off all epilepsy prescription drugs and has not had a grand mal seizure in years.

Collins' experience with doctors is not unusual for medical marijuana patients, she says. And fear of violating federal law is not the only reason physicians and hospitals are reluctant to have detailed discussions about marijuana. Clear dosing guidelines do not exist. Unlike for FDA-approved drugs, the Physician's Desk Reference, the textbook on prescribing information, says nothing about cannabis indications or dosage.

The lack of a standard dosing schedule for cannabis is due to several factors, according to The Answer Page, a Foxboro, Mass., company that provides online continuing education classes to physicians. They include the significant variation in active ingredients of medical cannabis products; the limited cannabis research in humans; the wide variety of cannabis dosages and products used in human studies; the differences in cannabinoid metabolism among patients; and the fact that patients develop tolerance to cannabis over time.21

As a result, patients are often on their own, experimenting with different cannabis strains, products and ratios of THC and CBD.

Many turn to dispensary staff for help figuring out which marijuana strains and products to try and how often to consume them. But while most states that allow medical marijuana require dispensary staff to receive some training, it is unclear how often it goes beyond storage and handling requirements and into medical and scientific knowledge.

A survey of dispensary staff in eight states and the District of Columbia published last year in the peer-reviewed journal Cannabis and Cannabinoid Research found that only 20 percent of respondents reported having medical or scientific training. Yet 94 percent said they provided cannabis advice to patients. In addition, the study found that some staff were recommending cannabis strains and cannabinoid concentrations that have “either not been shown effective for, or could exacerbate, a patient's condition.”22

Washington state has one of the strictest training requirements. Jackson Holder, 27, a buyer for Dockside Cannabis in the Seattle metro area and is certified by the state Department of Health as a medical marijuana consultant. Marijuana consultants are the only dispensary staff approved to discuss medical marijuana with customers holding state-issued medical cannabis patient cards. To be certified, one must be 21 or older, complete a health department-approved 20-hour training program and complete CPR training.

“Medical marijuana consultants are not medical professionals or doctors, and they cannot make any statements to a patient about curative properties or claims about treatment potential,” says Holder. “Their role, legally, is to route patients to the appropriate products for their given condition.”

Dispensary managers must impress on staff that their advice to patients “should not be considered medical advice but rather their opinion based on their knowledge of the product and anecdotal evidence from their customers,” says Morgan Fox of the Marijuana Policy Project. Fox also says all states should have minimum training requirements for dispensary staff, including a knowledge of the products available and their sourcing.

The National Cannabis Industry Association has not taken a position on whether training should be mandatory. But Taylor West, the group's deputy director, says competition between dispensaries might be the best way to raise staff standards. “What we're seeing in really competitive markets, like Colorado, is that dispensaries are having to provide more training for their employees because it is a significant factor in customers choosing one dispensary over another,” says West.

Some experts say patients, perhaps with help from dispensary staff, are capable of deciding dosages themselves.

The amount of THC and CBD is usually labeled on edible products, such as capsules, and so people can know how many milligrams of the cannabinoids they're ingesting, says Richard D. Richins, a staff scientist at New Mexico State University in Las Cruces and co-owner of Rio Grande Analytics, a laboratory that tests cannabis products for purity and contamination by bacteria and toxins.

That's not the case when people smoke or vape marijuana because of variations in how deep a breath they take, their lung volume and how long they hold it, he says. “However, the effect is felt fully within 10 minutes and partially within seconds. So somebody who is using it for anxiety, for example, can take a puff and see how that works for them,” says Richins.

Letting patients and dispensary staff decide dosages makes physicians uncomfortable, says Yale's D'Souza. “And when you have a drug that is potentially addictive, one has to worry about how much responsibility one gives to the person who is using it,” he says. People could become dependent if they overuse marijuana, says D'Souza.

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*Marijuana and cannabis are often used interchangeably to refer to dried or concentrated material from the cannabis plant that can be delivered through smoking or vaping, liquid tinctures, edibles, capsules, dermal patches, oral sprays or topical creams.

*The FDA has approved three single-cannabinoid synthetic drugs. They are the capsule Marinol and liquid Syndros, brand names for dronabinol; and Cesamet, the brand name for nabilone, a synthetic compound that mimics THC and is also prescribed for chemotherapy-induced nausea and vomiting.

Background

Early Medicinal Use

Chinese Emperor Shen Nung, who lived in the third millennium B.C., is credited with the first scientific investigations of cannabis. He advised drinking marijuana tea to treat ailments ranging from gout to malaria.23

At about the same time, nomadic tribes from Central Asia spread word of marijuana to the Indian subcontinent, and its medicinal use expanded across the Middle East into Europe and along the coasts of sub-Saharan Africa.24 During the 15th century, African slaves brought marijuana seeds to the Western Hemisphere, where the plant was incorporated into folk medicine to treat maladies such as rheumatism and toothaches.25

The French were the first Europeans to experiment with marijuana on a large scale. In the 1830s, psychiatrist Jacques-Joseph Moreau de Tours brought hashish, the compressed resin of the cannabis plant, from Egypt to Paris. He fed a resin-based paste to psychiatric patients and observed a calming effect. Moreau de Tours urged other psychiatrists to treat patients with the substance and introduced hashish to French artists and writers for its mind-altering effects.26

Historians credit Irish surgeon William O'Shaughnessy with the widespread introduction of marijuana into Western medicine. As a professor at the Medical College of Calcutta in the 1830s, he observed its use in India. O'Shaughnessy gave an orally administered marijuana solution to patients and reported that it reduced the pain of rheumatism, stilled seizures and eased the muscle spasms of tetanus and rabies. When he returned to England in 1842, O'Shaughnessy provided marijuana to pharmacists, and doctors in Europe and the United States began prescribing tinctures and extracts for a variety of conditions.27

Within a few decades, patent medicines containing marijuana were readily available at British and American pharmacies and grocery stores, without prescription. So were hashish pills coated with sugar, which were sold as common painkillers.28

From 1840 to 1900, “more than one hundred papers were published in Western medical literature recommending [marijuana] for various illnesses and discomforts,” wrote psychiatrist Lester Grinspoon and attorney James B. Bakalar in Marihuana: The Forbidden Medicine. 29 In 1851, cannabis was mentioned for the first time in the U.S. Pharmacopeia, which identified and standardized the mostly botanical drugs then in medical use.30

“Nevertheless, American doctors were never very excited by cannabis for drug therapy. It had too many shortcomings,” wrote psychologist Ernest L. Abel in Marihuana: The First Twelve Thousand Years. The potency of its preparations varied from pharmacy to pharmacy, its effect on patients was unpredictable, and it was slow to act because it was taken orally.31

Public Opinion Sours

In 1895, British chemists isolated a cannabinoid from the marijuana plant for the first time. But by then, chemists had created synthetic painkillers and sedatives, such as aspirin, chloral hydrate and barbiturates. Marijuana had trouble competing with these standardized drugs, as well as with fast-acting injectable opiates such as morphine. In addition, over-the-counter opium-based elixirs, nasal sprays and cough medicines were widely available.32

By 1900, according to historians, an estimated 3 percent of the U.S. population was addicted to medicinal opiates, raising public alarm. In response, the Harrison Narcotic Act of 1914 required doctors and pharmacists to record narcotic drug transactions and to pay a stamp tax on them.33

The law excluded marijuana. However, marijuana's image began to shift in the century's first three decades as the number of migrant workers from Mexico grew. The public began to associate smoking marijuana with migrant workers, and marijuana became seen as “an alien drug; the fact that it … had been an ingredient of patent medicines for decades was conveniently overlooked,” wrote historian Martin Booth in Cannabis: A History. 34

In 1930, Harry Anslinger, the head of the Federal Bureau of Narcotics, proposed including medical and recreational marijuana in the Harrison Act. Pharmaceutical manufactures successfully pushed back. Anti-marijuana legislators on the state level were more successful, and by 1934, 33 states had passed laws that made recreational, but not medical, marijuana illegal.35

Anslinger persisted. He spearheaded an anti-marijuana campaign, fabricating “lurid and sensational stories of assault, rape, murder, and mayhem allegedly perpetrated by marijuana smokers,” wrote Wendy Chapkis and Richard J. Webb in Dying to Get High: Marijuana as Medicine. 36 For example, a 1936 government-commissioned film Reefer Madness featured marijuana-smoking high school students going insane and killing their parents.

In 1937, Anslinger persuaded Congress to pass the Marijuana Tax Act, which taxed medical, industrial and recreational use of the plant and its extracts. Anslinger also continued his public campaign to discredit marijuana, and, in 1941, all mention of cannabis was removed from the U.S. Pharmacopeia. In addition, Anslinger systematically blocked marijuana research in the United States for the 30 years he led the bureau.37

War on Drugs

During the cultural upheavals of the 1960s, recreational use of marijuana skyrocketed. Anxious to learn more about the drug, the National Institutes of Health sponsored the research of Israeli scientist Raphael Mechoulam. In 1965, Mechoulam announced that he had isolated THC, marijuana's principal psychoactive cannabinoid, and he conducted clinical trials that showed THC's promise in treating neuropathic pain, hypertension and other conditions.38

In 1970, Republican President Richard M. Nixon successfully pressed for passage of the Controlled Substances Act. The law created five “schedules,” or categories, to rank drugs according to their acceptable medical use, safety profile and potential for abuse. Marijuana, along with heroin and LSD, was assigned to Schedule I, the category reserved for the most dangerous drugs with no currently accepted medical use. Physicians were forbidden to prescribe them.39

The law also created a National Commission on Marihuana and Drug Abuse, and Nixon selected members he hoped would spotlight the drug's dangers. However, after two years of study, the commission concluded that marijuana did not seriously impair health, lead to harder drugs or turn users into criminals. Nixon, who had declared a “war on drugs” in 1971, rejected the commission's conclusions.40

By the early 1970s, an increasing number of cancer patients were telling doctors that marijuana was helping with chemotherapy's side effects, and in May 1972, the National Organization for the Reform of Marijuana Laws (NORML), which had been founded two years earlier, petitioned the federal government to reschedule marijuana in order “to make the drug available for medical applications.” The government rejected the petition and repeatedly defied court orders to hold public hearings.41

In 1985, the FDA approved Marinol, a synthetic form of THC, to treat chemotherapy-induced nausea and vomiting, and later for appetite loss in AIDS patients. The DEA classified it a Schedule II drug. Finally, in the summer of 1986, the agency began the long-delayed public hearings on the rescheduling of marijuana.

People line up to attend the confirmation hearing for Sen. Jeff Sessions as U.S. (Getty Images/The Washington Post/Matt McClain)  
People line up to attend the confirmation hearing for Sen. Jeff Sessions as U.S. attorney general outside the Russell Senate Office Building in Washington on Jan. 10, 2017; he was confirmed, 52–47, in February. In May, Sessions called marijuana a harmful drug ripe for abuse with no accepted medical value and state medical marijuana programs a cloak for criminal enterprises. (Getty Images/The Washington Post/Matt McClain)

After two years of testimony and evidence, DEA Administrative Law Judge Francis J. Young ruled that a sizable minority of physicians approved of marijuana's medical use and recommended that the DEA administrator transfer marijuana to Schedule II. Administrator John Lawn refused and instead created stricter criteria for acceptable medical use of a drug.42

States were more responsive to patients' demands for marijuana. Between 1978 and 1983, 34 states enacted laws expressing support of medical marijuana. Six also authorized research programs to dispense marijuana to patients with cancer and other serious conditions. But the programs foundered when the federal government refused to supply marijuana.43

Up to this point, scientists did not understand how marijuana worked in people. Then in 1990, researchers at the U.S. National Institute of Mental Health discovered the cannabinoid receptor system in the human brain. (Later, receptors were discovered throughout the body.) Cannabinoids, such as marijuana's THC, stimulate these receptors. And in 1992, researchers identified an endocannabinoid, produced by the human body.44

Since the late 1970s, a small number of patients had been receiving medical marijuana directly from the federal government through the FDA's Compassionate Investigational New Drug Program. In the early 1990s, applications surged as AIDS patients struggling with the debilitating side effects of their prescription drugs turned to the government for help.

The administration of President George H.W. Bush responded in 1992 by terminating the investigational program for marijuana, except for the 13 patients already participating. The Department of Health and Human Services considered “widespread use of marijuana for medical purposes, especially where alternative medications are available … bad public policy and bad medical practice.”45

But the decision “only served to further fuel an explosion of popular interest and political activism,” Chapkis and Webb wrote.46

In 1996, California voters passed Proposition 215, making California the first state to allow people with a doctor's recommendation to possess and cultivate marijuana for personal use. By using the word “recommend” rather than “prescribe,” Proposition 215 made an end run around the Controlled Substance Act, which “said nothing about recommending cannabis for therapeutic use,” wrote author Martin A. Lee in Smoke Signals: A Social History of Marijuana — Medical, Recreational, and Scientific. 47

The backlash was immediate. The federal government threatened to revoke the license of any physician who recommended marijuana. A group of California physicians sued “drug czar” Barry McCaffrey and other federal officials for violating their First Amendment right to free speech. Courts issued a temporary and then a permanent injunction against federal interference in physician-patient conversations about marijuana.48

Nevertheless, most physicians remained reluctant to recommend marijuana. In addition, the California law did not exempt patients and caregivers from laws against growing marijuana or the sale or transportation of the drug, according to Lee. California and federal law enforcement officers began arresting growers, dispensary owners and even patients with valid doctor recommendations.49

In 1998, citizens of Alaska, Oregon and Washington state voted to legalize medical marijuana. But unlike California, which allowed doctors to recommend marijuana as they saw fit, these states allowed recommendations only for a small number of medical conditions.50

The next year, the National Institute of Medicine, part of the nonprofit National Academy of Sciences, issued a review of the scientific evidence and assessed the potential health benefits and risks of marijuana and its constituent cannabinoids. The report provided ammunition for both sides of the medical marijuana debate.

“For patients who suffer simultaneously from severe pain, nausea, and appetite loss, such as those with AIDS or who are undergoing chemotherapy, cannabinoid drugs might offer broad-spectrum relief not found in any other single medication,” it said.

The report dismissed the notion that marijuana leads to the use of harder drugs. But it said that smoked marijuana delivers most of the same harmful substances found in tobacco smoke and that variability of the mix of compounds in each plant makes it difficult to predict marijuana's precise effect.51

As a result, the report concluded, “the future of cannabinoid drugs lies not in smoked marijuana but in chemically defined drugs that act on the cannabinoid systems that are a natural component of human physiology. Until such drugs can be developed and made available for medical use, the report recommends interim solutions.” These included limited use of smoked marijuana for patients suffering debilitating pain for whom all other medicines had failed.52

In 1999, Maine became the fifth state to legalize medical marijuana, and the next year, Hawaii, Colorado and Nevada followed. In 2002, the 9th U.S. Court of Appeals prohibited the federal government from revoking a physician's license solely for recommending medical marijuana. The U.S. Supreme Court denied an appeal.53

Changing Federal Posture

Also in 2002, a group of medical marijuana users sued the DEA and Attorney General John Ashcroft, arguing that the Controlled Substances Act violated the Constitution's Commerce Clause, which gives Congress authority to regulate interstate but not intrastate commerce. The federal government argued that local cultivation and use of marijuana affected interstate commerce in the drug, and in 2005, the Supreme Court agreed. Gonzalez v. Raich allowed the federal government to continue prosecuting those who cultivate marijuana, distribute it and use it in states with medical marijuana laws.54

But in October 2009, the Justice Department under President Obama issued a path-breaking memorandum. It instructed the Justice Department's U.S. Attorneys not to focus limited federal resources on prosecuting seriously ill patients and their caregivers who were complying with state medical marijuana laws, although large-scale, for-profit commercial enterprises remained a potential target.55

“While the memorandum was not intended to impact the behavior of states, cities or individuals, there was huge growth in the medical marijuana industry after it was issued,” wrote then-Yale law student Samuel Kleiner in Yale Law & Policy Review. 56

In 2010, Arizona became the 15th state to legalize medical marijuana. In 2011, the DEA once again refused to reclassify marijuana as a Schedule II drug.57

The Justice Department further restricted prosecutions in 2013. In a memorandum, it advised federal prosecutors to no longer “consider the size or commercial nature of a marijuana operation alone” in determining whether to investigate it for selling to minors or violating other priorities of the federal government. And in 2014, the Obama administration gave banks guidance on conducting transactions with marijuana dispensaries. Because marijuana is illegal under federal law, banks had refused to deal with dispensaries, and dispensaries were forced to operate as all-cash businesses.58

That same year, Congress blocked the Justice Department from allocating funds to prosecute the cultivation, sale or use of medical marijuana in states where it was legal. Rep. Dana Rohrabacher, R-Calif., co-sponsor of the measure, known as the Rohrabacher-Farr amendment, told conservatives that it would force the federal government to respect states' rights.59 Congress has continued to extend the amendment, most recently in May as part of the Consolidated Appropriations Act of 2017.60

In 2016, the DEA once again rejected petitions to reschedule marijuana, but it announced a policy change to make marijuana research easier: It would expand the number of DEA-registered manufacturers of experimental marijuana from its single supplier at the University of Mississippi. The agency is considering 25 applications so far, according to DEA spokesman Melvin Patterson.

As of July 2017, 29 states and the District of Columbia had legalized medical marijuana.

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Current Situation

Action in Congress

Eight Republican and Democratic members of Congress are pushing a bill that would prohibit federal law enforcement officials from prosecuting the manufacture, distribution, possession or use of medical marijuana in states where it is legal. The Compassionate Access, Research Expansion and Respect States Act would not legalize medical marijuana in all 50 states but would amend the Controlled Substances Act to allow states to set their own medical marijuana policies.

If it becomes law, patients, caregivers, doctors and businesses, including banks, participating in state medical marijuana programs would no longer be in violation of federal law.

“Federal marijuana policy has long overstepped the boundaries of common sense, fiscal prudence and compassion,” said Sen. Cory Booker, D-N.J., a co-sponsor. “This bill will help ensure that people who can benefit from medical marijuana — from children suffering from chronic illnesses to veterans battling PTSD — can do so without worrying about the federal government standing in the way.”61

U.S. Sen. Cory Booker, D-N.J., visits with 4-year-old Morgan Hintz (Getty Images/Mark WIlson)  
U.S. Sen. Cory Booker, D-N.J., visits with 4-year-old Morgan Hintz, who has epilepsy, during a Capitol Hill news conference on medical marijuana on March 10, 2015. Her mother wants her to be able to use cannabidiol to control her seizures. Eight members of Congress are pushing legislation that would, among other things, expand its availability to patients in states without medical marijuana laws. (Getty Images/Mark WIlson)

The bill also would lift a prohibition against doctors in the Department of Veterans Affairs from recommending marijuana for certain conditions, such as PTSD and chronic pain, in states where it is legal. And it would remove cannabidiol from the Controlled Substances Act's schedules, thus expanding its availability to patients in states without medical marijuana laws.62

Sens. Booker, Kirsten Gillibrand, D-N.Y., Rand Paul, R-Ky., Lisa Murkowski, R-Alaska, Al Franken, D-Minn., and Mike Lee, R-Utah, along with Reps. Steve Cohen, D-Tenn., and Don Young, R-Alaska, introduced the bill on June 15. Booker, Gillibrand and Paul had introduced a version in the Senate in 2015, but the bill never got out of committee. Supporters are hoping this year will be different.

“The addition of Sens. Lee and Murkowski as original co-sponsors should inspire other Republicans to seriously consider this legislation and the absurd federal overreach that it seeks to correct,” said Don Murphy, director of conservative outreach at the Marijuana Policy Project.63

But Sabet of Smart Approaches to Marijuana opposes the legislation. “This bill would completely undermine the FDA approval process and encourage the use of marijuana and marijuana products that have not been proven either safe or effective,” he said.64

The bill's introduction in June came just two days after Attorney General Sessions' letter to congressional leaders became public asking Congress to undo the Rohrabacher-Farr amendment, which must be renewed annually. “I believe it would be unwise for Congress to restrict the discretion of the Department to fund particular prosecutions,” Sessions wrote, “particularly in the midst of an historic drug epidemic and potentially long-term uptick in violent crime.”65

However, the drug epidemic Sessions referred to involves opioids and heroin, not marijuana, and some research has shown that in states with medical marijuana programs, opioid-related deaths and overdoses have fallen.66

John Hudak, deputy director of the Center for Effective Public Management at the Brookings Institution, a centrist think tank in Washington, called Sessions' arguments a “scare tactic” that “could appeal to rank-and-file members or to committee chairs in Congress in ways that could threaten the future of this Amendment.”67

State Actions

Medical marijuana enjoys bipartisan support on the state level, as recent legislative activity shows.

When West Virginia legalized medical marijuana in April, its bill was passed by a Republican-controlled Legislature. The same was true in Pennsylvania and Ohio, which passed medical marijuana laws in 2016. In Arkansas, Florida and North Dakota, whose legislatures are Democratic-controlled, the issue went straight to citizens, who voted to legalize medical marijuana last November while also helping put Donald Trump in the White House.68

States are breaking even, and in some cases, making money on their medical marijuana programs. States require medical marijuana dispensaries to pay annual licensing fees, and individuals to purchase registration cards that are renewed every year or two. That revenue covers the cost of state oversight. Some states, such as Arizona, Michigan and Oregon, generate a surplus, according to the Marijuana Policy Project. In addition, most states impose a sales tax on dispensary sales.69

Several states are expanding the list of medical conditions covered by existing laws. In June alone, New Hampshire added moderate-to-severe chronic pain to the list of serious conditions that can be treated with cannabis; Vermont added post-traumatic stress disorder (PTSD), Parkinson's disease and Crohn's disease; and Colorado added PTSD. The New York legislature passed a bill adding PTSD, and it awaits Gov. Andrew Cuomo's signature.70

In fact, 26 states now include PTSD as a qualifying condition. “Veterans with PTSD should not have to choose between FDA-approved medications that carry a blackbox suicide warning and off-label drugs with no clinical efficacy and horrible side effects,” said Michael Krawitz, executive director of Veterans for Medical Cannabis Access, as New York debated the change to its law. “There is another way: Medical marijuana has helped veterans have a restful night's sleep instead of night terrors, and thus experience a better quality of life.”71

Military veterans have been lobbying states for years to add PTSD to their list of conditions treatable with cannabis, despite the lack of randomized controlled studies evaluating marijuana's effectiveness for the condition. According to scientists at the U.S. Department of Veterans Affairs, “there is no evidence at this time that marijuana is an effective treatment for PTSD. In fact, research suggests that marijuana can be harmful to individuals with PTSD.” These individuals, the scientists said, “have particular difficulty stopping their use of marijuana and responding to treatment for marijuana addiction.”72

But the research drought could soon become at least a trickle. In 2016, the DEA and the FDA approved the first-ever randomized controlled trial of marijuana to treat PTSD in U.S. veterans. The Multidisciplinary Association for Psychedelic Studies, a nonprofit in Santa Cruz, Calif., that promotes research on psychedelics and marijuana, is overseeing the study, funded by a grant from the state of Colorado. The study is testing the safety and efficacy of smoked marijuana with varying ratios of THC and cannabidiol in 76 military veterans who have not responded to traditional treatment of PTSD.73

Not every state is expanding its medical marijuana laws. Citing a lack of supporting scientific research, New Mexico Health Secretary Lynn Gallagher in June rejected the state's Medical Cannabis Advisory Board's recommendation to add Alzheimer's disease and opioid addiction to the list of conditions suitable for marijuana treatment.74

Not in My Backyard

Under local zoning rules, municipalities decide such things as where marijuana businesses can locate, their hours of operation and their size. But some states allow local officials to go further and ban marijuana businesses. In June, for example, Marshall, Mich., voted to allow growers but not dispensaries. Fife, Wash., bans both medical and recreational marijuana sales. And dozens of California cities prohibit some or all types of marijuana operations.75

After Ohio passed a medical marijuana law in September, Ohio state Sen. Kenny Yuko, a Democrat, pleaded with municipalities to “keep an open mind.” In a letter to towns, Yuko wrote, “Please consider all the good that this medicine can do for the citizens of your communities.”76

But at least two dozen municipalities have ignored Yuko and banned or imposed a moratorium on growers, processors or dispensaries, even though medical marijuana won't become available to Ohio residents until 2018 as the state develops rules for its use.77

Sidney, Ohio, is one such municipality. In May, the City Council told its law director to draft legislation to ban the cultivation, processing and dispensing of medical marijuana within city limits. Council member Janet Born said three doctors had told her that effective alternative medications to marijuana exist. “Also, marijuana, no matter how mild or ineffectual it seems, still impairs the brain … and many of those people will try driving,” Born said. “And that's why I think we should not have it.”78

Residents of towns that have banned dispensaries can still use medical marijuana if recommended by a doctor, but they will have to buy it elsewhere.

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Outlook

Strong Growth Predicted

The New Frontier Data research firm predicts that U.S. medical marijuana sales will grow at a compound annual rate of 12 percent in the next nine years, from $4.7 billion in 2016 to $13.2 billion in 2025. Those projections assume marijuana remains a Schedule I substance and that no more states pass legalization measures.79

But the status quo, at least among states, is unlikely to remain, say advocates on both sides of the medical marijuana debate.

“There definitely will be more states working toward passing medical marijuana bills, as well as others improving their existing programs” by, for example, adding qualifying medical conditions and allowing more kinds of cannabis products to be sold, says Fox of the Marijuana Policy Project.

Sabet of Smart Approaches to Marijuana agrees that more states are likely to adopt medical marijuana programs, an outcome he opposes, and he blames a well-funded public relations campaign by the cannabis industry.

“Under the guise of compassion, for-profit businesses are bypassing the FDA and instead funding political advocacy to gain legitimacy,” says Sabet.

Fox responds that people directly involved in the legal marijuana industry are a small part of the Marijuana Policy Project's donor base — only about 10 percent. “The rest comes from regular donors and philanthropists who recognize that sick people deserve safe, reliable access to medical marijuana,” he says, “and that responsible adults should not be criminalized for using a substance that is safer than alcohol.”

Both Fox and Sabet expect the DEA under the Trump administration to continue to refuse to reschedule marijuana from the Schedule I category.

Gitlow, the past president of the American Society of Addiction Medicine, says the DEA could fashion a compromise. It could create a Schedule I-A for drugs with an ‘unknown medical application,’ implement rules to encourage well-designed clinical research for such drugs and place marijuana in that category, he says.

The American Medical Association recommends the government review marijuana's status as a Schedule I drug and make the rules for its research easier. But the nation's largest association of physicians is quick to add that its recommendation is not an endorsement of state-based medical cannabis programs or the legalization of marijuana.80

After the 2020 presidential election, federal policy may change, but the details are difficult to predict, according to New Frontier Data.

“It remains possible that there will be sweeping changes to federal cannabis laws within the next decade, including the rescheduling of cannabis from its current status as a Schedule I substance — included in the ranks of the most dangerous drugs — to Schedule II or III status,” the research firm said, “or potentially a complete de-scheduling, which would bring cannabis regulations closer to those for alcohol.”81

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Pro/Con

Should the U.S. reclassify cannabis from a Schedule I drug?

Pro

Dr. Donald O. Lyman, M.D.
Chair, Council on Science and Public Health, California Medical Association. Written for CQ Researcher, July 2017

The federal criminalization of cannabis has failed, and 29 states and the District of Columbia have legalized cannabis for medical use, while eight states have legalized it for adult use. These actions recognize both the clinical utility of cannabis and the failure of the policy of criminalization to control access to it.

The California Medical Association (CMA), which represents 43,000 physicians, believes the United States needs a federal framework with robust regulations, patient safety standards and legally sanctioned research to support regulatory agencies and to document the benefits and risks of medical and nonmedical use.

This belief is why CMA endorsed Proposition 64 (Adult Use of Marijuana Act, 2016) to support universal adult access within a tightly controlled regulatory system, and why it wrote a 2011 white paper which, in part, argued for the reclassification of cannabis.

When California approved Proposition 215 in 1996, the cultivation and use of cannabis was decriminalized for seriously ill individuals who obtained a physician's recommendation. However, because the drug is still criminalized federally, physicians recommending cannabis are in an untenable position. We are the gatekeepers to a medically beneficial substance, but there is no normal regulatory system allowing access to it.

Literature on medical cannabis is sufficiently convincing to recommend it for treating some illnesses and conditions, including pain, nausea and anorexia. Yet, the literature on medical cannabis is not comprehensive, cannabis dosage is not well standardized and little information exists about its side effects. The current Schedule 1 classification prevents the very research needed to regulate cannabis appropriately.

Schedule 1 is defined as drugs, such as cocaine and LSD, with no currently accepted medical use and a high potential for abuse. As such, this definition does not reasonably apply to cannabis.

Without cannabis policy rooted in evidence-based science, our patients and neighbors will continue to access cannabis, possibly without discussing it with their physician, that has not been tested for purity, standardized for dosage or tempered by safeguards to protect all users.

Until the system is changed, physicians will continue to be in an unsustainable position. The U.S. government should invest in researching the benefits and risks of cannabis and in developing evidence-based regulations and quality controls that protect the public and help patients.

Con

Jeffrey Zinsmeister
Executive Vice President and Director of Government Relations, Smart Approaches to Marijuana. Written for CQ Researcher, July 2017

If a pharmaceutical giant asked the government to reclassify a prescription drug, skipping Food and Drug Administration (FDA) trials, we would be outraged. Why should marijuana be any different?

Raw, “whole plant” marijuana is in Schedule I with drugs like heroin not because it is just as dangerous but because FDA scientists found just last year that it is addictive and has no accepted medical use, unlike drugs in other schedules.

Additionally, marijuana differs from approved medications in two critical ways. FDA-approved medicine is dosed and standardized. The pill you buy in Boston is the same as the one you buy in Seattle. Not so with marijuana. And since when did we smoke medications?

In contrast to raw marijuana, specific compounds derived from marijuana can be in other schedules. Some of them have been sold legally for decades, such as a pure form of THC, the plant's psychoactive ingredient. Similarly, a pure form of cannabidiol, or CBD, a compound derived from marijuana that helps certain cases of childhood epilepsy, is in the final phases of FDA approval.

But huge for-profit marijuana special interests are spending millions lobbying Congress to blur this distinction and undermine the FDA process. They argue that their product is somehow different from other medicines.

As evidence, these pot lobbyists use very sick people, often children, who have seen some benefits from using medications derived from marijuana (such as cannabidiol). But therein lies the crucial distinction. Those medications — specific compounds derived from the marijuana plant — differ from smoking or eating the plant itself, just as using morphine differs from smoking opium. Precious little evidence shows that smoking or eating marijuana has medical benefits. But the pot industry has glommed on to a handful of small observational studies and distorted them into a narrative of peer-reviewed scientific proof.

Finally, even if Congress bowed to lobbyists and rescheduled marijuana by fiat, it would still only be for sale when incorporated into an FDA-approved, standardized product that can pass clinical trials. There is no scientific evidence today that this is possible with the raw marijuana plant.

The “medical marijuana” debate is just another attempt to undermine the FDA system for money. Like an unscrupulous Big Pharma company, pot businesses see easy money in selling an unapproved, unregulated product. Compassion has nothing to do with it.

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Chronology

 
1840s–1890sMarijuana is introduced to Western medicine.
1842Irish surgeon William O'Shaughnessy introduces marijuana to Western medicine.
1851Cannabis is mentioned for the first time in the U.S. Pharmacopeia; patent medicines containing marijuana are readily available in Britain and the U.S.
1895British chemists isolate a cannabinoid from the marijuana plant.
1900s–1940sThe public turns to opiates and synthetic painkillers.
1900Three percent of the U.S. population is addicted to medicinal opiates.
1934Thirty-three states outlaw marijuana except as medicine.
1937Marijuana prescriptions plunge after the government begins taxing all uses of marijuana.
1941U.S. Pharmacopeia drops all mention of marijuana.
1960s–1990sRecreational marijuana use skyrockets.
1965Israeli scientist Raphael Mechoulam announces isolation of THC, marijuana's principal psychoactive cannabinoid.
1970Controlled Substances Act creates five schedules, or categories, and Justice Department classifies marijuana in Schedule I, reserved for the most dangerous drugs with no accepted medical use; it cannot be grown, distributed or prescribed.
1972National Organization for Reform of Marijuana Laws (NORML) petitions the government to reschedule marijuana so doctors can prescribe it.
1985The government classifies synthetic THC as a Schedule II drug, allowing doctors to prescribe it for chemotherapy-induced nausea and vomiting and AIDS-related appetite loss.
1988Drug Enforcement Administration (DEA) rejects NORML's petition, and marijuana remains in Schedule I.
1990National Institute of Mental Health researchers discover the cannabinoid receptor system in the human brain.
1992After a rise in applications from AIDS patients, the George H.W. Bush administration discontinues a “compassionate use” program that had supplied a small number of seriously ill patients with government-grown marijuana.
1996California becomes the first state to legalize medical marijuana…. U.S. threatens to revoke the licenses of physicians who recommend cannabis.
1999Institute of Medicine says marijuana might provide relief to patients simultaneously suffering severe pain, nausea and appetite loss.
2000-PresentMedical marijuana becomes more widely accepted.
2005Supreme Court rules the Controlled Substances Act is constitutional.
2010Obama administration tells U.S. Attorneys to no longer prosecute seriously ill patients using cannabis if they are in compliance with state medical marijuana laws.
2014Obama administration makes it easier for banks to do business with medical marijuana dispensaries…. Congress blocks the Justice Department from spending money on medical marijuana prosecutions.
2016DEA again keeps marijuana a Schedule I drug but begins accepting applications for more government-registered growers in order to increase the amount of cannabis available for research.
2017National Academies of Sciences, Engineering, and Medicine concludes marijuana and cannabinoids are helpful in treating chronic pain, muscle spasms in multiple sclerosis and chemotherapy-induced nausea and vomiting but that evidence is lacking for many others…. In April, West Virginia becomes 29th state to legalize medical marijuana.
  

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Short Features

“We have major delays in getting done what we need to get done.”

It took Ryan Vandrey, a psychiatry professor at the Johns Hopkins University School of Medicine in Baltimore, 18 months to get regulatory approval to study the health impact of marijuana on 76 people. The problem, he said, is that the federal government considers marijuana a Schedule I drug — a classification that places cannabis alongside heroin and other illegal drugs that are considered highly addictive and of no redeeming medical value.

“Every research protocol we design and want to do has to go through a number of extra regulatory approvals before we can do them,” Vandrey told the website Live Science last year. “The consequence of that is, we have major delays in getting done what we need to get done.”1

A committee of the National Academies of Sciences, Engineering, and Medicine, an independent producer of expert policy reports in Washington, faulted the federal government for making it hard for scientists to study marijuana's potential therapeutic effects. The lack of studies due to the restrictions, the committee said in a report in January, is creating a knowledge gap that is placing public health at risk.2

Researchers wishing to study marijuana and its compounds must be specially licensed, and they have to apply to both the Drug Enforcement Administration (DEA) and the Food and Drug Administration (FDA) for approvals.

Zachary Lowe clones marijuana plants at Holistic (Getty Images/The Washington Post/Linda Davidson)  
Zachary Lowe clones marijuana plants at Holistic Remedies and Organic Wellness, a licensed medical marijuana growing and processing firm in Washington, D.C., on Sept. 7, 2016. (Getty Images/The Washington Post/Linda Davidson)

If the agencies give the green light, researchers must then contact the National Institute of Drug Abuse, a federal agency that studies addiction, for further approval and to place an order for marijuana with the specific concentrations of cannabinoids they wish to study.3 The institute is the sole supplier of marijuana for government-approved research, which it gets under contract from one sanctioned producer: the University of Mississippi.

In addition, researchers often need to submit their marijuana research proposals for review to state government agencies, a state board of medical examiners and the researchers' home institution.

The National Academies called the entire process “daunting” and said it has discouraged a number of scientists from pursuing cannabis research.4

Former President Barack Obama's administration took two steps to lower those hurdles. In 2015, the government no longer required the Public Health Service to approve marijuana research protocols, trimming the number of steps in the review process. And in August 2016, the DEA announced it would explore expanding the number of official producers of research marijuana beyond the University of Mississippi. It is considering 25 applications so far, Melvin Patterson, a DEA spokesman, said in an email.

“This change should provide researchers with a more varied and robust supply of marijuana,” Patterson said.

All sides on the marijuana debate applaud the moves but say more can be done. However, they disagree on potential next steps.

“The biggest research barrier is that marijuana is a Schedule I agent,” says Sean Hennessy, a member of the National Academies committee and a professor of epidemiology and pharmacology at the University of Pennsylvania Perelman School of Medicine.

But last August, the DEA denied the latest petition to reclassify marijuana, relying on the FDA's assessment that it still belongs in the Schedule I category.

Jahan Marcu, the chief scientific officer at Americans for Safe Access, a Washington group that advocates for the acceptance of cannabis as medicine, says he hopes the National Academies' January report will finally lead to a reclassification: The committee found either conclusive or substantial evidence that cannabis or cannabinoids can effectively treat chronic pain, muscle spasticity in multiple sclerosis patients and chemotherapy-induced nausea and vomiting.

“The National Academies is saying there is evidence that marijuana has therapeutic value, which is not the definition of a Schedule I drug,” says Marcu.

Jeffrey Zinsmeister, director of government relations at Smart Approaches to Marijuana, an Alexandria, Va., group that opposes the legalization of medical and recreational marijuana, disagrees. “There are definitely bureaucratic stumbling blocks to research of both the plant and its compounds,” he says. “But to say that you have to reschedule the drug to get appropriate levels of research is incorrect.”

Instead, his organization wants to make it easier for researchers to amend a research protocol without having to reapply for government approval; allow researchers to store marijuana in locked cabinets rather than in a bolted safe, as some local DEA offices require; and permit researchers to cultivate their own marijuana for their studies.

“All that can be done without removing the product from Schedule I,” says Zinsmeister. “Reclassification is supposed to be done as a consequence of the research, not as something that would come before.”

— Barbara Mantel

[1] Rachael Rettner, “New Medical Marijuana Policy Is a Catch-22, Researchers Say,” Live Science, Aug. 15, 2016, http://tinyurl.com/ybjwtvv6.

[2] “The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research,” National Academies of Sciences, Engineering, and Medicine, Jan. 12, 2017, pp. 1, 378, http://tinyurl.com/ya4pzskm.

[3] “NIDA's Role in Providing Marijuana for Research,” National Institute on Drug Abuse, revised March 2017, http://tinyurl.com/ya2cfm3v.

[4] “The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research,” op. cit., pp. 378, 381.

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Companies are struggling to reconcile state, federal laws over use of the drug.

Kathryn Russo is an attorney with Jackson Lewis, a nationwide workplace law firm based in White Plains, N.Y. In this interview with CQ Researcher, she explains the complexities of states' medical marijuana laws. In mid-July, a Massachusetts court issued a decision on medical marijuana when Russo was unavailable for a follow-up question on that case; attorney Matthew Nieman of Jackson Lewis answered that question in her stead. The interviews have been edited for space and clarity.

CQR: Currently, 29 states and the District of Columbia have medical marijuana laws. In all of these places, employers can test for marijuana use. But how common is workplace drug testing?

K.R.: It's pretty common. Most employers who conduct drug testing do so for safety reasons. For example, employers in the construction industry and the health care industry.

Have you seen employers stop testing for marijuana in states allowing medical marijuana?

I haven't seen a lot of employers eliminating marijuana from their drug-testing panels.

How long do traces of marijuana linger in the body?

Alcohol is processed through the kidneys and is basically flushed out of your system pretty quickly, within hours, whereas drugs go into the fatty tissues of the body and stay there. That's why you can test positive on a workplace drug test days or even weeks after you use the drugs.

So someone testing positive for marijuana may not necessarily be under the influence or be impaired at work?

That is really the whole controversy, right there. Drug tests can't tell an employer exactly when or where a person used drugs.

How many states offer strong workplace protections for certified medical marijuana users?

Attorney Kathryn Russo of Jackson Lewis (Courtesy Kathryn Russo)  
Attorney Kathryn Russo: “I haven't seen a lot of employers eliminating marijuana from their drug testing panels.” (Courtesy Kathryn Russo)

There are about 12 states where the medical marijuana law has anti-discrimination language of some type. It will say something like, “An employer cannot discriminate against a person on the basis that he or she is a qualified medical marijuana patient.” The states are Arizona, Arkansas, Connecticut, Delaware, Illinois, Maine, Minnesota, New York, Nevada, Pennsylvania, Rhode Island and West Virginia.

Do these states allow an employee to be fired if he or she is obviously impaired on the job or using marijuana on the premises?

Almost every state with a medical marijuana law has a provision saying that employers don't have to allow people to use marijuana at work or to be under the influence of marijuana at work. So even if you have a medical marijuana user who is protected by these anti-discrimination provisions in certain states, if they are using at work, the employer can fire them. The problem is, what if you are not certain they are using at work but they are acting as if they are under the influence? If you send them for a drug test and the test is positive, we're back to the dilemma of a positive test result that doesn't prove when the person used it.

How many qualified medical marijuana users in any of these 12 states have challenged their firing because of a positive drug test?

The only case is in Rhode Island.

In that case, Darlington Fabrics refused to hire someone for a paid internship because she disclosed she was a certified medical marijuana user and would fail a drug test. She sued, and the state court sided with her.

This is the first employment discrimination case where the court ruled in favor of the medical marijuana user. There had been previous cases in other states — not these 12 states — and employers always won.

What was the court's reasoning?

The court didn't seem to think there was a conflict between federal law, which says marijuana is illegal, and state law. What the court zeroed in on is that Rhode Island state law regulates only workplace conduct. So an employer can regulate only what an employee does in the workplace and not what an employee or applicant does outside.

Darlington Fabrics said it would appeal. But in the meantime, are there implications for Rhode Island employers?

It would seem to me that an employer would have to hire an applicant who is using medical marijuana even if they say, as this applicant did, “I'm going to fail the drug test because I use medical marijuana.” Most employers in this situation are looking at how dangerous is the person's job, and [asking] if that person is using medical marijuana, “Am I confident that they're going to be able to do their job safely?” So this ruling is troubling to Rhode Island employers who have people in dangerous jobs.

Are there implications for employers outside of Rhode Island?

No, this was a state court ruling. But I suspect we're going to start seeing other state courts follow suit.

Certified medical marijuana users have lost workplace anti-discrimination cases in other states. I think the courts followed federal law, which says marijuana is illegal.

Some of the older medical marijuana statutes have been tested in court, in California, Colorado, Michigan, Montana and a few other states. And those are the states where employers have prevailed in litigation. One of the reasons employers prevailed there is that those laws did not contain any protections for employees. The newer medical marijuana laws include this anti-discrimination language.

The Massachusetts Supreme Judicial Court ruled on July 17 that an employee who used medical marijuana for Crohn's disease can proceed with her lawsuit challenging her firing after failing a drug test. Is this ruling a big deal?

Yes, it's significant. The court rejected the idea that just because marijuana is illegal under federal law, employers can refuse to accommodate a medical marijuana user who is considered disabled under state disability law. The court expressly noted that the employee could lose at trial. But it said that because the employee shared information about her Crohn's disease, the employer was required to determine if they could accommodate her — even if her request was to use an illegal federal drug. It remains to be seen how the case develops, but, at a minimum, Massachusetts employers need to reflect before terminating someone for a failed drug test when presented with a medical marijuana card.

Do any states expressly allow employers to fire certified medical marijuana users who test positive for marijuana?

Ohio law does permit employers to establish zero-tolerance drug policies. It also has some language that prohibits employees from suing employers who take action against them because they use medical marijuana. And Florida's recently signed medical marijuana law also has some language prohibiting claims against employers for discrimination or wrongful discharge.

To add to the confusion, companies that contract with the federal government are required to have drug-free workplaces. Does the federal Drug Free Workplace Act conflict with state medical marijuana laws?

It does. If you are a federal contractor, you don't have to do drug testing but you do have to have a drug policy that prohibits the employees working under that contract from using illegal drugs. But the question is, is it illegal? Marijuana is illegal under federal law but not under certain state laws. The way most federal contractors look at it is, marijuana is illegal under federal law, so if we're going to comply with the Drug Free Workplace Act, we need to prohibit it.

Have any court cases dealt with this contradiction?

Not yet. I'm waiting to see that case.

— Barbara Mantel

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Bibliography

Books

Chapkis, Wendy, and Richard J. Webb , Dying to Get High: Marijuana as Medicine , NYU Press, 2008. A sociologist (Chapkis) and an educator (Webb) explore some of the complex issues surrounding medical marijuana, including patient rights and barriers to research.

Grinspoon, Lester, and James B. Bakalar , Marihuana: The Forbidden Medicine , Yale University Press, 1997. A psychiatrist (Grinspoon) and a lawyer (Bakalar) discuss the history of marijuana, including social attitudes toward the drug, and argue for its legalization.

Lee, Martin A. , Smoke Signals: A Social History of Marijuana — Medicinal, Recreational and Scientific , Simon and Schuster, 2012. A journalist and activist examines the medical, recreational, scientific and economic dimensions of marijuana.

Articles

Borchardt, Debra , “New York State Adds PTSD To Medical Marijuana Program, Will Menstrual Cramps Be Next?” Forbes, May 11, 2017, http://tinyurl.com/y7fguf75. The New York legislature has placed post-traumatic stress disorder on its list of conditions for which physicians may recommend marijuana.

Borchardt, Jackie , “Ohio lawmaker urges cities not to ban medical marijuana before state sets rules,” Cleveland.com, Sept. 8, 2016, http://tinyurl.com/yashnd8s. A Democratic legislator is asking Ohio municipalities to not ban medical marijuana.

Hu, Winnie , “When Older Age Comes With a Daily Dose of Cannabis,” The New York Times, Feb. 19, 2017, http://tinyurl.com/gnem38y. Older Americans are increasingly using marijuana to treat aches and pains.

Ingraham, Christopher , “Jeff Sessions personally asked Congress to let him prosecute medical-marijuana providers,” The Washington Post, June 13, 2017, http://tinyurl.com/yamubcrf. U.S. Attorney General Jeff Sessions is seeking congressional funding to investigate medical marijuana providers.

Quirk, Mary Beth , “Medical Marijuana Safe From DOJ Prosecution — For Now,” Consumerist, May 10, 2017, http://tinyurl.com/yar3elkx. Congress renewed a prohibition against U.S. Justice Department interference in state medical marijuana programs.

Rettner, Rachael , “New Medical Marijuana Policy Is a Catch-22, Researchers Say,” Live Science, Aug. 15, 2017, http://tinyurl.com/ybjwtvv6. Federal regulations place barriers to marijuana research, but the U.S. government will not relax regulations without more research into marijuana's health benefits.

Rubin, Rita , “Medical Marijuana Is Legal in Most States, but Physicians Have Little Evidence to Guide Them,” JAMA, April 25, 2017, http://tinyurl.com/y8noglpa. Little research is available to guide doctors on what dose and strain of marijuana to recommend to patients.

Reports and Studies

“The Cannabis Industry Annual Report: 2017 Legal Marijuana Outlook,” New Frontier Data, 2017, http://tinyurl.com/y9u3qwgb. A firm providing data analytics to the cannabis industry predicts continuing growth in sales for legal medical and recreational marijuana.

“The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research,” National Academies of Sciences, Engineering, and Medicine, Jan. 12, 2017, http://tinyurl.com/yc3gx7j6. An independent, expert panel concludes that scientific research supports marijuana's health benefits for three medical conditions — chronic pain, muscle spasticity in multiple sclerosis and chemotherapy-induced nausea and vomiting — but that there's scant or no research to support its use for many other conditions.

Bradford, Ashley C., and W. David Bradford , “Medical Marijuana Laws May Be Associated with a Decline In The Number Of Prescriptions for Medicaid Enrollees,” Health Affairs, April 19, 2017, http://tinyurl.com/mtvxd6q. Researchers say that states with medical marijuana laws saw a decline in prescriptions for medications among Medicaid enrollees.

Hasin, Deborah S., et al., “Medical marijuana laws and adolescent marijuana use in the USA from 1991 to 2014: results from annual, repeated cross-sectional surveys,” The Lancet Psychiatry, June 15, 2015, http://tinyurl.com/yc2fod7m. Medical marijuana laws had no impact on teen use of marijuana, university researchers say.

Hasin, Deborah S., et al., “US Adult Illicit Cannabis Use, Cannabis Use Disorder, and Medical Marijuana Laws: 1991–1992 to 2012–2013,” JAMA Psychiatry, June 2017, http://tinyurl.com/yatp2vyt. University researchers find that medical marijuana laws are associated with an increase in illicit marijuana use and dependence in adults.

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The Next Step

Legalization Drive

Laslo, Matt , “Medical Marijuana: How Six Senators Are Leading Fight for Federally Legal Weed,” Rolling Stone, June 22, 2017, https://tinyurl.com/ydb7xxgg. A bipartisan group of six senators has introduced a bill that would allow states' medical marijuana laws to supersede the federal prohibition on cannabis.

Robinson, Grant , “Task force to examine medical marijuana in Tennessee,” WBIR, June 16, 2017, https://tinyurl.com/yb6323oe. Tennessee is creating a task force of state senators and representatives to explore legalizing medical marijuana in the state.

Smith, Aaron , “Vermont expands medical marijuana plan,” CNN, June 12, 2017, https://tinyurl.com/y872kkgm. Vermont's governor has signed a bill adding Parkinson's disease, Crohn's disease and post-traumatic stress disorder to the list of conditions that can be treated with medical marijuana.

Therapeutic Value

Grover, Natalie , “High hopes ride on marijuana painkillers amid opioid crisis,” Reuters, June 23, 2017, https://tinyurl.com/yasqqgg5. In the battle against opioid abuse, some drugmakers are developing marijuana-based painkillers.

Kramer, Molly , “My aging parents smuggle medical marijuana,” Salon, July 8, 2017, https://tinyurl.com/ybvwo4wp. A daughter recounts how her parents decided to smuggle marijuana from California to help her father deal with painful side effects of cancer and chemotherapy.

Scutti, Susan , “New potential for marijuana: Treating drug addiction,” CNN, May 17, 2017, https://tinyurl.com/ybfjt7gu. Some addiction specialists have turned to marijuana to help people with severe addictions.

State Implementation

Cox, Erin , “Maryland approves first medical marijuana dispensary,” The Baltimore Sun, July 5, 2017, https://tinyurl.com/y93jl3pf. The state's first medical marijuana dispensary opened in Frederick, but the one company authorized to grow cannabis in the state will not have its first complete batch until after Labor Day.

Dixon, Lance , “After new state limitations, Coral Gables will ban medical marijuana dispensaries,” The Miami Herald, July 11, 2017, https://tinyurl.com/y7gdfkcc. Florida law allows municipalities to ban marijuana dispensaries, and Coral Gables became the first major city in Miami-Dade County to do so, citing federal law prohibiting the cultivation, processing, distribution and use of marijuana as its justification.

Nicholson, Blake , “State sets tentative timeline for medical marijuana system,” The Associated Press, The Bismarck Tribune, July 11, 2017, https://tinyurl.com/y9tycs88. The North Dakota Health Department has asked companies to send letters of intent by July 28 if they want to manufacture or distribute medical marijuana.

Trump Administration

Sherer, Stephen , “Medical marijuana patients need an antidote for Jeff Sessions,” The Hill, July 10, 2017, https://tinyurl.com/y9ekbw27. The executive director of Americans for Safe Access, which advocates for safe and equal access to medical marijuana, is urging Congress to renew the Rohrabacher-Farr amendment to ensure the Justice Department does not start prosecutions in states with legalized medical or recreational marijuana.

Ventura, Jesse , “Trump will cripple states if he reverses marijuana legalization,” CNBC, July 11, 2017, https://tinyurl.com/yc5k5cnz. A former Minnesota governor argues that if the Trump administration forces states to reverse their laws legalizing recreational and medical marijuana, it could hurt those states' economies because of the amount of money the industry is generating.

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Contacts

American Society of Addiction Medicine
11400 Rockville Pike, Suite 200, Rockville, MD 20852
301-656-3920
www.asam.org
Organization representing physicians, clinicians and associated professionals that opposes marijuana legalization.

Americans for Safe Access
1624 U St., N.W., Suite 200, Washington, DC 20009
202-857-4272
www.safeaccessnow.org
Advocacy group seeking legal access to cannabis for therapeutic use and research.

Drug Enforcement Administration
700 Army Navy Drive, Arlington, VA 22202
202-307-1000
www.dea.gov
Federal agency combating drug use and smuggling.

Marijuana Policy Project
PO Box 77492, Capitol Hill, Washington, DC 20013
202-462-5747
www.mpp.org
Advocacy group that lobbies to remove criminal penalties for marijuana use, particularly for medical use.

National Academies of Sciences, Engineering, and Medicine
500 5th St., N.W., Washington, DC 20001
202-334-2000
www.nationalacademies.org
Private, nonprofit institutions providing expert advice to the government and public.

NORML (National Organization for the Reform of Marijuana Laws)
1100 H St., N.W., Suite 830, Washington, DC 20005
202-483-5500
www.norml.org
Advocacy group that lobbies for the legalization of adult use of marijuana.

RAND Drug Policy Research Center
RAND Corp., 1776 Main St., Santa Monica, CA 90407
301-393-0411
www.rand.org/multi/dprc.html
Think tank that conducts research into issues involving alcohol and other drugs.

Smart Approaches to Marijuana
1001 N. Fairfax St., Suite 201, Alexandria, VA 22314
www.learnaboutsam.org
Advocacy group that opposes marijuana legalization and favors medical research of marijuana-derived compounds.

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Footnotes

[1] “United States,” National Organization for the Reform of Marijuana Laws, http://tinyurl.com/yasqlhst.

[2] “U.S. Voter Support For Marijuana Hits New High,” Quinnipiac University Poll, April 20, 2017, http://tinyurl.com/y93bnkhc.

[3] Medical Marijuana Patient Cardholder Registry, Nevada Division of Public and Behavioral Health, last updated March 15, 2017, http://tinyurl.com/yaqgmoq3; “United States,” op. cit.

[4] Medical Marijuana Patient Numbers, Marijuana Policy Project, last updated June 23, 2017, https://tinyurl.com/y7mmxj5k.

[5] “Montana Marijuana Program (MMP): May 2017 Registry Information,” Montana Department of Public Health and Human Services, May 2017, https://tinyurl.com/yarosg3j; “Therapeutic Cannabis Program 2016 Data Report,” New Hampshire Department of Health and Human Services, pp. 7, 17, https://tinyurl.com/yae93skb; and “Oregon Medical Marijuana Program Statistical Snapshot: April, 2017,” Oregon Health Authority, April 2017, pp. 3–4, https://tinyurl.com/ycgnauco.

[6] Winnie Hu, “When Retirement Comes With a Daily Dose of Cannabis,” The New York Times, Feb. 19, 2017, https://tinyurl.com/gnem38y.

[7] “The Cannabis Industry Annual Report: 2017 Legal Marijuana Outlook,” New Frontier Data, 2017, p. 2, https://tinyurl.com/y9u3qwgb; Alex Pasquariello and Alicia Wallace, “New studies shine light on cannabis consumers' spending habits,” The Cannabist, April 26, 2017, https://tinyurl.com/y8u7tkp8.

[8] Jeff Sessions' letter, May 1, 2017, https://tinyurl.com/y7ghdkj3.

[9] “Effective Arguments for Medical Marijuana Advocates,” Marijuana Policy Project, updated April 28, 2017, p. 2, https://tinyurl.com/ycpdj5un.

[10] “Endocannabinoid Basics,” Medical Genomics, https://tinyurl.com/ycyxwyd4.

[11] “The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research,” National Academies of Sciences, Engineering, and Medicine, Jan. 12, 2017, p. 378, https://tinyurl.com/yc3gx7j6.

[12] Ibid., p. 416.

[13] Ibid.; Orrin Devinsky, “Trial of Cannabidiol for Drug-Resistant Seizures in the Dravet Syndrome,” The New England Journal of Medicine, May 25, 2017, http://tinyurl.com/yahg3egj.

[14] Ibid., p. 289.

[15] Deborah S. Hasin et al., “Medical marijuana laws and adolescent marijuana use in the USA from 1991 to 2014: results from annual, repeated cross-sectional surveys,” The Lancet Psychiatry, June 15, 2015, https://tinyurl.com/yc2fod7m.

[16] Joseph Schuermeyer et al., “Temporal trends in marijuana attitudes, availability and use in Colorado compared to non-medical marijuana states: 2003–2011,” Drug and Alcohol Dependence, 2014, https://tinyurl.com/y7fg5fpc.

[17] Deborah S. Hasin et al., “US Adult Illicit Cannabis Use, Cannabis Use Disorder, and Medical Marijuana Laws: 1991–1992 to 2012–2013,” JAMA Psychiatry, June 2017, https://tinyurl.com/yatp2vyt.

[18] Hefei Wen et al., “The effect of medical marijuana laws on adolescent and adult use of marijuana, alcohol, and other substances,” Journal of Health Economics, July 2015, https://tinyurl.com/ybcz2ejj.

[19] “Is Marijuana Addictive?” National Institute on Drug Abuse, updated April 2017, https://tinyurl.com/oksoklx.

[20] Ashley C. Bradford and W. David Bradford, “Medical Marijuana Laws May Be Associated with a Decline In The Number Of Prescriptions for Medicaid Enrollees,” Health Affairs, April 19, 2017, https://tinyurl.com/mtvxd6q; Ashley C. Bradford and W. David Bradford, “Medical Marijuana Laws Reduce Prescription Medication Use in Medicare Part D,” Health Affairs, July 2016, https://tinyurl.com/zmb4pbo.

[21] “New York State Practitioner Education — Medical Use of Marijuana Course,” The Answer Page, https://tinyurl.com/y7wzk8se.

[22] Nancy A. Haug et al., “Training and Practices of Cannabis Dispensary Staff,” Cannabis and Cannabinoid Research, December 2016, https://tinyurl.com/yaf2a8uk.

[23] Martin Booth, Cannabis: A History (2003), p. 19.

[24] Barney Warf, “High Points: An Historical Geography of Cannabis,” Geographical Review, October 2014, https://tinyurl.com/y8njo2vk.

[25] Ethan B. Russo, “History of Cannabis and Its Preparations in Saga, Science, and Sobriquet,” Chemistry & Biodiversity, 2007, p. 1637, https://tinyurl.com/ybe2u65r.

[26] Martin A. Lee, Smoke Signals: A Social History of Marijuana — Medicinal, Recreational and Scientific (2012), pp. 26–28.

[27] Lester Grinspoon and James B. Bakalar, Marihuana: The Forbidden Medicine (1993), p. 4; Tod H. Mikuriya, “Marijuana in Medicine, Past, Present and Future,” California Medicine, January 1969, p. 34, https://tinyurl.com/y853l4vn.

[28] Booth, op. cit., pp. 94, 95.

[29] Grinspoon and Bakalar, op. cit., p. 4.

[30] “The Antique Cannabis Book,” May 2016, Appendix C, https://tinyurl.com/yconewk2.

[31] Ernest L. Abel, Marihuana: The First Twelve Thousand Years (1980), pp. 183–184.

[32] Booth, op. cit., pp. 96–97; See Kathy Koch, “Medical Marijuana: Should doctors be able to prescribe the drug?” CQ Researcher, April 20, 1999, pp. 705–728.

[33] Booth, ibid., pp. 127, 134.

[34] Ibid., pp. 132–133.

[35] Wendy Chapkis and Richard J. Webb, Dying to Get High: Marijuana as Medicine (2008), p. 23.

[36] Ibid., p. 24.

[37] Ibid., pp. 24, 25, 26.

[38] Lee, op. cit., pp. 80–82.

[39] Ibid., pp. 118–119.

[40] Chapkis and Webb, op. cit., pp. 28–29.

[41] Ibid., pp. 29–30.

[42] Grinspoon and Bakalar, op. cit., pp. 14–17.

[43] Lee, op. cit., p. 166.

[44] “Historical Timeline: History of Marijuana as Medicine — 2900 BC to Present,” ProCon.org, last updated Jan. 30, 2017, https://tinyurl.com/h6n7e46; Dustin Sulak, “Introduction to the Endocannabinoid System,” National Organization for the Reform of Marijuana Laws, https://tinyurl.com/bhj3dsg.

[45] Ibid., “Historical Timeline: History of Marijuana as medicine — 2900 BC to Present”; “Kiyoshi Kuromiya et al., Plaintiffs, v. The United States of America, Defendant,” U.S. District Court for the Eastern District of Pennsylvania, p. 4, https://tinyurl.com/yauauw69.

[46] Chapkis and Webb, op. cit., p. 32.

[47] Lee, op. cit., p. 251.

[48] Chapkis and Webb, op. cit., p. 253.

[49] Lee, op. cit., pp. 253–54, 256–58, 264.

[50] Ibid., p. 275.

[51] Janet E. Joy, John A. Benson Jr. and Stanley J. Watson Jr., eds., “Marijuana and Medicine: Assessing the Science Base,” Institute of Medicine, 1999, pp. viii–ix, https://tinyurl.com/y9j7zn6d.

[52] Ibid., p. ix, https://tinyurl.com/y9j7zn6d.

[53] “Historical Timeline: History of Marijuana as Medicine — 2900 BC to Present,” op. cit.

[54] Ibid.; the Supreme Court case can be found at https://tinyurl.com/y95vtgod.

[55] “The Ogden Memorandum,” U.S. Department of Justice, Oct. 19, 2009, https://tinyurl.com/ybgd8hr3.

[56] Samuel Kleiner, “The Limits of Pledging Prosecutorial Discretion: The Ogden Memorandum's Failure to Create an Entrapment by Estoppel Defense,” Yale Law & Policy Review, 2014, https://tinyurl.com/y9j3qmvh.

[57] “Historical Timeline: History of Marijuana as Medicine — 2900 BC to Present,” op. cit.

[58] “Cole Memorandum,” U.S. Department of Justice, Aug. 29, 2013, https://tinyurl.com/y7ggddxu.

[59] “Historical Timeline: History of Marijuana as Medicine — 2900 BC to Present,” op. cit.

[60] Mary Beth Quirk, “Medical Marijuana Safe From DOJ Prosecution — For Now,” Consumerist, May 10, 2017, https://tinyurl.com/yar3elkx.

[61] “Lawmakers Reintroduce Bipartisan, Bicameral Medical Marijuana Bill,” press release, Office of U.S. Sen. Cory Booker, June 15, 2017, https://tinyurl.com/yb3eotfv.

[62] Ibid.

[63] “Bipartisan Bill to End Federal Prohibition of Medical Marijuana Reintroduced in U.S. Senate,” Marijuana Policy Project, June 15, 2017, https://tinyurl.com/ybbgxbdy.

[64] Anisha Gianchandani, “Statement from SAM President Kevin Sabet on Senators Booker and Gillibrand's Marijuana Legislation to Bypass FDA,” Smart Approaches to Marijuana, June 15, 2016, http://tinyurl.com/ycmjtv3b.

[65] Letter from Jeff Sessions, Office of the Attorney General, May 1, 2017, https://tinyurl.com/y7ghdkj3.

[66] Marcus A. Bachhuber et al., “Medical Cannabis Laws and Opioid Analgesic Overdose Mortality in the United States, 1999–2010,” JAMA Internal Medicine, Aug. 25, 2014, https://tinyurl.com/luohzzf.

[67] Christopher Ingraham, “Jeff Sessions personally asked Congress to let him prosecute medical-marijuana providers,” The Washington Post, June 13, 2017, https://tinyurl.com/yamubcrf.

[68] “West Virginia Becomes 29th Medical Marijuana State as Gov. Jim Justice Signs SB 386 Into Law,” Marijuana Policy Project, April 19, 2017, https://tinyurl.com/ybebvbju.

[69] “State Medical Marijuana Programs' Financial Information,” Marijuana Policy Project, https://tinyurl.com/y7rnpd8o.

[70] “N.Y.: Legislature passes bill to add PTSD to medical marijuana program,” Marijuana Policy Project, June 20, 2017, https://tinyurl.com/y9vx9563.

[71] Debra Borchardt, “New York State Adds PTSD To Medical Marijuana Program, Will Menstrual Cramps Be Next?” Forbes, May 11, 2017, https://tinyurl.com/y7fguf75.

[72] Marcel O. Bonn-Miller and Glenna S. Rousseau, “Marijuana Use and PTSD among Veterans,” U.S. Department of Veterans Affairs, last updated May 10, 2017, https://tinyurl.com/ycr38g8l.

[73] “DEA Approves First-Ever Trial of Medical Marijuana for PTSD in Veterans,” Multidisciplinary Association for Psychedelic Studies, April 21, 2016, https://tinyurl.com/j4sfcbq.

[74] “Medical Marijuana for New Mexico Opiate Addicts Rejected,” The Associated Press, U.S. News & World Report, June 15, 2017, https://tinyurl.com/y7c6clfm.

[75] “Washington Marijuana Business to Open in City With Ban,” Cannabis Law Group, March 15, 2017, https://tinyurl.com/ybsbuv88, Allison Edrington, “List of Cities, Counties Banning Commercial Cannabis in California,” The Ganjier, Jan. 25, 2016, https://tinyurl.com/y7hq5tbx.

[76] Jackie Borchardt, “Ohio lawmaker urges cities not to ban medical marijuana before state sets rules,” Cleveland.com, Sept. 8, 2016, https://tinyurl.com/yashnd8s.

[77] Tom Knox, “4 Greater Cincinnati cities among those banning medical marijuana businesses, May 24, 2017, Cincinnati Business Courier, https://tinyurl.com/ybnf4b8n.

[78] Sheryl Roadcap, “Council pursues ban on medical marijuana,” Sidney Daily News, May 10, 2017, https://tinyurl.com/y8bom4ag.

[79] “The Cannabis Industry Annual Report: 2017 Legal Marijuana Outlook,” New Frontier Data, 2017, p. 3, https://tinyurl.com/y9u3qwgb.

[80] “AMA Policy: Medical Marijuana,” American Medical Association, https://tinyurl.com/y6wzolo2.

[81] “The Cannabis Industry Annual Report,” op. cit.

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About the Author

Barbara Mantel, author of this week's edition of CQ Researcher  

Barbara Mantel is a freelance writer in New York City. She has been a Kiplinger Fellow and has won several journalism awards, including the National Press Club's Best Consumer Journalism Award and the Front Page Award. She was a correspondent for NPR and the founding senior editor and producer for public radio's “Science Friday.” She holds a B.A. in history and economics from the University of Virginia and an M.A. in economics from Northwestern University.

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Document APA Citation
Mantel, B. (2017, July 21). Medical marijuana. CQ researcher, 27, 605-628. Retrieved from http://library.cqpress.com/
Document ID: cqresrre2017072100
Document URL: http://library.cqpress.com/cqresearcher/cqresrre2017072100
ISSUE TRACKER for Related Reports
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Jul. 21, 2017  Medical Marijuana
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Aug. 20, 1999  Medical Marijuana
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Aug. 09, 1967  Legalization of Marijuana
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