​Marijuana: Proceed with Caution

“As more states legalize recreational marijuana, will there be a silver lining or unintended consequences? Lawmakers need to pause for a deeper understanding because lives are at stake.”

– Doug Tieman, Caron President & CEO

In a perfect world, harmful, mind altering drugs would not be available at all. However, this is not the world we live in today. Next to heroin and opioids, marijuana is the most talked about drug in recent years. And, it has received a significant amount of attention on the legislative scene. As of November 2016, medical marijuana legislation has passed in 28 states, 20 states have decriminalized recreational marijuana possession, and 8 states passed laws legalizing recreational marijuana. Medical and recreational marijuana use is also legal in the District of Columbia.

For states that may be considering recreational marijuana legalization, addressing the issues of how to best approach such policy change requires thorough analysis and research. The same holds true for those states that are attempting to manage the myriad of challenges arising from already enacted recreational marijuana legislation. To date, states that have passed marijuana legislation have instituted several restrictions, such as permitting marijuana possession up to 1 oz. in public and up to 8 oz. at home, restricting ownership to four plants or up to six per residence and out of public view, and keeping it illegal to smoke marijuana in public, to name a few. After recreational marijuana was legalized in Colorado, the state enacted packaging and labeling rules for edibles in response to an increase in recreational marijuana overdoses. These restrictions speak to the variations in states’ attempts to regulate the use and sale of recreational marijuana.

Caron Treatment Centers, with 60 years of experience providing leading-edge drug and alcohol addiction treatment, believes it is time to take a realistic look at marijuana in today’s society with the intent of providing policymakers with certain recommendations if considering recreational marijuana legalization. Caron does not endorse the legalization of recreational marijuana. The goal of this paper is to provide Caron’s expertise, experience, and useful information to policymakers in those states that have already legalized or may be considering the policy changes in this area. The recommendations are made based on Caron’s research, and observations in the treatment field to prevent use, minimize harm, and to ensure that any tax revenue generated from recreational marijuana sales are directed to prevention, education, additional research, and treatment.

The importance of directing tax revenue to fund prevention, education, research, and treatment in the legalization of recreational marijuana is key to this issue. Caron is a private non-profit and, as such, does not accept public funding for residential substance use disorder treatment. This places Caron in a unique position to advocate for tax dollars going toward publicly funded treatment given that we would never receive any of those dollars. Caron is motivated by a public health approach. Playing “catch up” has been disastrous to public health and treatment funding, as evidenced by the history of tobacco and alcohol. In spite of the knowledge that marijuana is unhealthy, legalization continues, so it is all the more critical that policymakers have the necessary tools to address these concerns regarding the legalization of recreational marijuana.

Caron’s recommendations will specifically address the impact of marijuana use on brain development, along with perceived risk. Further recommendations include legalization considerations encompassing taxation, driving, edibles, and decriminalization. These recommendations are based on current research and understanding. Further research is needed to expand upon what has already been established to eliminate areas of uncertainty with marijuana usage.

Marijuana and the Developing Brain

Brain Impact

As more states begin to address the issue of legalizing recreational marijuana, it is imperative that legislators recognize the dangers use may pose specifically for teens and young adults under the age of 25 and pregnant women. Despite efforts to control marijuana in the United States, approximately 1.8 million teens used marijuana in the past month.[1] In fact, in Monitoring the Future’s (MTF) December 2016 Survey press release, marijuana use among 12th graders remained high at 22.5% monthly and an alarming 6% daily use.[2] During Caron’s 2015-2016 fiscal year, 92% of adolescent patients (under 18) and 72% of young adult patients (18-25) indicated cannabis as a drug of choice. Another significant concern is that approximately 50% of opiate/heroin addicted adolescent patients treated at Caron started their drug use with marijuana with the other 50% beginning with alcohol.

In addition to marijuana use potentially leading to substance use disorders, the impact of usage amongst adolescence and young adults also includes physical and psychological effects. A 2014 study by the National Institutes of Health (NIH) found teens heavily engaged in marijuana use often show disadvantages in brain development and performance, as well as alterations in brain functioning.[3] The Substance Abuse and Mental Health Services Administration (SAMHSA) links heavy marijuana use in adolescence to an increased risk for developing mental illness and poorer cognitive thinking.[4] In addition, the short term impact of recreational marijuana use cannot be overlooked. These include impaired coordination, skewed sensory and time perception, difficulty with thought process, concentration and problem solving, shortened attention span and distractibility, decreased alertness, and impaired learning and memory.

Susan Weiss, PhD, director of the division of extramural research at the National Institute on Drug Abuse (NIDA), says that a growing body of literature on the topic points in the same direction: starting young and using frequently may disrupt brain development.[5] However, other research findings remain inconclusive and provide an inconsistent picture of the long-term effects of marijuana use on the brain.[6] These inconsistencies indicate a need for further research.

Although some research results on this topic are mixed, studies associate regular marijuana use during adolescence with an average loss of eight IQ points. Those who initiated marijuana use as adults did not show the same effect, suggesting that marijuana has its strongest long-term impact on young users whose brains are still developing.[7]

What is consistently reported in research is that adolescent brain development continues well into a person’s 20s.[8] Caron shares these concerns about the impact of marijuana use on brain development, and so based on available research, it is our recommendation that if states are considering any legislation to legalize recreational marijuana use, they should limit the purchase and use of the drug to those aged 25 and older. Recreational marijuana use for those under the age of 25 should remain illegal and require ID to prevent underage sales. While some may consider this “impractical” since the legal age to consume alcohol is 21 and to purchase tobacco products is 18, Caron’s recommendation is based on the documented research that shows marijuana’s impact on the developing brain.

Caron believes it is also important to provide marijuana use guidelines for pregnant and nursing mothers. According to NIDA, marijuana use during pregnancy is linked to increased risk of both brain and behavioral problems in babies. If a pregnant woman uses marijuana, the drug may affect certain developing parts of the fetus' brain.[9] Unlike fetal alcohol syndrome, little is known about how marijuana may affect fetal development. Caron supports the Centers for Disease Control and Prevention (CDC) recommendation stating, “Women who are pregnant, or considering becoming pregnant, should not use marijuana, even in states where marijuana is legal. Women using marijuana for medical reasons should speak with their doctor about an alternative therapy with pregnancy-specific safety data.”[10]

Perceived Risk and Usage

Turning to a well-respected source regarding adolescent and young adult use of recreational marijuana, Caron looks again to Monitoring the Future (MTF) of 2015. This long-term ongoing study reveals the behaviors, attitudes, and values of American secondary school students, college students, and young adults. Lessons learned through the MTF study show that perceived benefits and apparent adverse consequences associated with specific drugs impact usage rates. According to the MTF study, teen smoking was at its peak in 1997, but has since dropped by 75%.[11] This is attributed to concerted efforts to reduce youth smoking. Similar, though less dramatic, decreases in episodic or “binge” drinking are attributed to education and use prevention strategies. [12]

Furthermore, in the MTF Survey Press Release of 2016, marijuana use in the prior 12 months has been declining gradually since 2010 among 8th graders and more dramatically since 2013 among 10th graders. However, usage among 12th graders has held steady since 2011. These periods of declining use, or in the case of 12th graders steady use, followed several years of increasing use,[13] which may also be attributed to prevention and education.

When the perceived risk of using a drug outweighs the supposed benefit, teens are less likely to use that drug. In addition to establishing the minimum age for purchase and use of recreational marijuana, Caron strongly recommends incorporating a comprehensive, consistent approach to education and prevention, enforcing restrictions on advertising and promotion, promoting anti-use advertising, and implementing stop-use curriculums to address concerns regarding adolescent and young adult recreational marijuana use. Caron also recommends prohibiting flavorings, reducing physical access by reducing the number of outlets or limiting hours and days of sale, and applying taxation to fund these initiatives to prevent adolescent and young adult use.

Legalization Considerations

Taxation for Prevention, Education, Research, and Treatment

If states are considering legalizing recreational marijuana, Caron believes it is important to look to what is working in terms of regulating tobacco and alcohol. In Alaska, marijuana statutes and regulations fall under the state’s Alcohol and Marijuana Control Office, while in Colorado, marijuana is regulated through the Colorado Department of Revenue, separate from Liquor & Tobacco Enforcement. Oregon processes marijuana license applications through the state’s Liquor Control Commission. From Caron’s perspective, it makes sense to apply state statutes, legislation, and regulations through liquor control boards or departments, and, when available, sell recreational marijuana through state-run stores. These departments provide an established structure of application and licensing, as well as provide a regulatory framework for control of sales and revenue.

Of particular concern is that the potential for additional tax revenue can be alluring to states considering legalization, especially those trying to balance their budgets. However, tax revenue from legalized recreational marijuana must be directed to addressing the addiction epidemic and assist that portion of the American population struggling with substance use disorders. Tax dollars must be used to fund research, prevention education in schools, access to behavioral healthcare treatment, and run broad-based anti-use ad campaigns. In other words, recreational marijuana legalization will assuredly increase use amongst individuals, adding to states’ current addiction crisis and lack of funding for treatment that plagues the nation. Directing tax revenue from legalized recreational marijuana to anything other than prevention, education, research and treatment is irresponsible and dangerous to the communities served.

Driving

Another area drawing attention in the deliberation to legalized recreational marijuana use is that of Driving Under the Influence (DUI). All states define driving with a Blood Alcohol Content (BAC) at or above 0.08% as a crime. A 2016 study by the American Automobile Association (AAA) Foundation for Traffic Safety shows one in seven, or 14%, of surveyed drivers self-disclosed driving with a BAC near or over the legal limit, and 4.6% disclosed driving under the influence of marijuana. It is important to note that the report states there is no threshold that indicates when a marijuana smoker may be too impaired to drive.[14]

Since no standard level of marijuana impairment has been established, similar to what exists regarding BAC, Caron supports laws currently in place in some states making any use of the drug by those behind the wheel illegal, reinforced by trained drug recognition experts (DRE) and law enforcement officers empowered to make arrests based on observed impairment.

Edibles

In states where recreational marijuana use has been legalized, the availability of “edibles” is increasing. Marijuana edibles are cannabis-infused foods that are growing in popularity. Beyond “pot brownies”, edibles have grown out of the medical marijuana market as an alternative for those whom smoking is not an option, i.e., children with severe epilepsy. To address this, the Food and Drug Administration (FDA) has approved synthetic cannabinoids as pharmaceutical products for use with individuals for whom smoking is not an option or is undesirable.[15] In addition, CBD oil has been drawing attention because if its potential therapeutic effects; however, further clinical evaluation is warranted.[16] Cannabinoids (the active compounds of the marijuana plant) stimulate specific receptors throughout the body to produce pharmacologic effects, particularly in the central nervous and immune system.[17]

Today, marijuana dispensaries and marijuana stores often sell edibles in a vast array of sweets and shapes familiar and appealing to children, including cookies, chocolate bars and pieces, gummies, hard candy, fruit chews, dessert bars, etc. Unlike alcohol and cigarettes, edible use can be easily concealed or masqueraded as ordinary edible items. This is of real concern when edibles can be consumed in school, at work, or in public without notice. Additionally, the ease of consumption of marijuana in this form poses a risk to teens. NIDA highlights this particular issue, noting “teens who live in states where medical marijuana is legal report a higher use of marijuana edibles. For example, among 12th graders reporting marijuana use in the past year, 40.2 percent consumed marijuana in food in states with medical marijuana laws compared to 28.1 percent in states without such laws.”[18] Furthermore, a June 2015 Journal of the American Medical Association (JAMA) study reported that edible cannabis products failed to meet the basic label accuracy standards for pharmaceuticals. More than 50% of the products tested had less cannabinoid content than labeled, while other products contained significantly more THC (the psychoactive compound in marijuana). The study recommends regulation and quality assurance for marijuana edibles.[19]

Even more alarming is Volume 4 of the Rocky Mountain High Intensity Drug Trafficking Area (RMHIDTA) Impact Report, which states that the number of Colorado children reported to a poison control center or examined at a hospital for unintentional marijuana exposure has spiked since the state legalized marijuana. The report goes on to say that at one children’s hospital in Colorado, “Nearly half of hospital visits since 2009 involved edibles such as brownies and candies.”[20] Considering the dangers with underage edible ingestion, the inconsistencies of cannabinoid content labelling, and the availability of FDA-approved synthetic cannabinoid options, Caron believes there is no need to manufacture or market marijuana edibles.

Home Grows

When Colorado voted to legalize marijuana, the legislation provided the right to limited home-growing of marijuana plants for both caregivers and for personal use. For example, caregivers can cultivate up to 99 plants for medical marijuana use, and individuals can grow up to six marijuana plants, with up to 3 flowing plants, for recreational use.[21] Some have exploited these home grow provisions and loopholes in the law, and the State of Colorado recently acknowledged that medical and recreational marijuana legalization has contributed to a large, unregulated market with grey marketeers operating under the guise of caregivers, cooperative members, or law abiding residents.[22]

The grey market for marijuana in Colorado is negatively impacting communities. Some of the consequences include legally grown marijuana being diverted for out-of-state use and sale, diversion to youth, and the expansion of organized criminal enterprise.[23] Similarly, Newsweek reported that in Oregon, as much as 80 percent of the state’s cannabis crops end up in other states where recreational marijuana is not legalized. [24] As with marijuana edibles, Caron does not believe there is a necessity for home-growing marijuana, and recommends that marijuana plants be limited to state-regulated growing and processing facilities.

Decriminalization

Some states are considering the decriminalization of recreational marijuana. The Economist (June 18, 2014) draws the distinction between legalization and decriminalization by stating that decriminalization does not mean people can use drugs with impunity, but that legal action will not be taken against those who possess small amounts of marijuana for personal use. However, decriminalization does not take marijuana out of the hands of dealers, meaning the criminal monopoly over the drug remains unregulated with profits feeding back into the supply side of the business.[25] Decriminalization of recreational marijuana use does not generate tax revenue, nor does it reduce the tax burden on state residents. For these reasons, Caron cannot support decriminalization of recreational marijuana use as a mid-stage or final legislative result.

Proceed with Caution... If At All

There is a misconception that because marijuana is a plant or because it is legal in some states, it is not as harmful as alcohol or tobacco, or even harmful at all. Similar to alcohol and tobacco, there are potential health risks associated with recreational marijuana use, such as breathing problems, increased heart rate, and risk of heart attack. Long-term use of marijuana has been linked to mental health problems, such as anxiety and depression, in some users.[26] It is also worth noting that about 4 million people met the criteria for marijuana use disorder in 2015, and 15.7 million were identified with an alcohol use disorder.[27] Caron recommends healthcare professionals routinely educate patients about the health risks of tobacco, alcohol and recreational marijuana, as each has the potential to create physical harm or addiction when other factors are taken into consideration.

Caron emphasizes that legalization does not lessen the potential and known negative consequences of recreational marijuana use by those with a genetic predisposition to a substance use disorder or even for those without it. With legalization, Caron cautions that an increase in access means an increase in usage, and as a result, a corresponding increase in individuals suffering from substance use disorders should be expected. This speaks to a greater need for tax revenue to be directed toward treatment.

Conclusion

Ideally, for individual health and total wellness, each of us would choose to eat smart, exercise regularly, reduce stress, and abstain from introducing mind-altering chemicals into our bodies. While there are many who do practice very healthy lifestyles without tobacco, alcohol, or marijuana use, there are those who may use these substances in moderation. Recognizing the many individuals and families who today live in recovery from substance use disorders, and those who may be actively struggling with the disease of addiction, Caron will continue to advocate to raise awareness around this issue while providing quality, research-based information and treatment.

In closing, Caron is providing these recommendations as a tool for legislators when addressing the legalization of recreational marijuana use to minimize harm and to ensure that any tax revenue generated is directed solely for prevention, education, additional research, and treatment. To fully understand the true risks of recreational marijuana use and how legalization will impact their communities, Caron strongly recommends policymakers follow the lessons learned from states where recreational marijuana has been legalized, as well as study the documented statistics on usage. If lawmakers still believe legalization is right for their states or is a demand from their constituencies, Caron urges policymakers to move slowly, with deliberation and careful consideration.

Caron’s CEO Doug Tieman shares his thoughts on marijuana. Click here to read his blog.

[1] http://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2015/NSDUH-FFR1-2015/NSDUH-FFR1-2015.pdf.

[2] Teen use of any illicit drug other than marijuana at new low, same true for alcohol. (December 13, 2016). In Monitoring the Future. Retrieved December 19, 2016, from http://www.monitoringthefuture.org//pressreleases/16drugpr_complete.pdf.

[3] Jacobus, J., & Tapert, S. F. (2014). Effects of Cannabis on the Adolescent Brain. Current Pharmaceutical Design, 20(13), 2186–2193.

[4] Marijuana (Cannabis). (n.d.). In SAMHSA. Retrieved October 31, 2016, from http://www.samhsa.gov/atod/marijuana.

[5] Marijuana and the developing brain. (November 2015.) In American Psychological Association (APA). Retrieved October 31, 2016, from http://www.apa.org/monitor/2015/11/marijuana-brain.aspx.

[6] Filbey, F. M., Aslan, S., Calhoun, V. D., Spence, J. S., Damaraju, E., Caprihan, A., & Segall, J. (2014). Long-term effects of marijuana use on the brain. Proceedings of the National Academy of Sciences of the United States of America, 111(47), 16913–16918.

[7] What are marijuana’s long-term effects on the brain? (n.d). In NIH National Institute on Drug Abuse. Retrieved November 8, 2016, from https://www.drugabuse.gov/publications/research-reports/marijuana/how-does-marijuana-use-affect-your-brain-body.

[8] Johnson, S. B., Blum, R. W., & Giedd, J. N. (2009). Adolescent Maturity and the Brain: The Promise and Pitfalls of Neuroscience Research in Adolescent Health Policy. The Journal of Adolescent Health: Official Publication of the Society for Adolescent Medicine, 45(3), 216–221. http://doi.org/10.1016/j.jadoh...

[9] DrugFacts-Marijuana. (Revised March 2016). In NIH National Institute on Drug Abuse. Retrieved on October 31, 2016, from https://www.drugabuse.gov/publications/drugfacts/marijuana.

[10] Make a PACT for Prevention. (n.d.). In Centers for Disease Control and Prevention. Retrieved October 31, 2016, from http://www.cdc.gov/ncbddd/birthdefects/prevention.html.

[11] Teen cigarette smoking drops to historic low in 2015. (December 16, 2015). In Monitoring the Future. Retrieved October 21, 2016, from http://www.monitoringthefuture.org//pubs/monographs/mtf-vol1_2015.pdf.

[12] Johnston, L. D., O'Malley, P. M., Miech, R. A., Bachman, J. G., & Schulenberg, J. E. (2016). Monitoring the Future national survey results on drug use, 1975-2015: Overview, key findings on adolescent drug use. Ann Arbor: Institute for Social Research, The University of Michigan, 98 pp.

[13] Teen use of any illicit drug other than marijuana at new low, same true for alcohol. (December 13, 2016). In Monitoring the Future. Retrieved December 19, 2016, from http://www.monitoringthefuture.org//pressreleases/16drugpr_complete.pdf.

[14] Driving Under the Influence of Alcohol and Marijuana: Beliefs and Behaviors, United States, 2013-2015. (May 2016). In AAA Foundation for Traffic Safety. Retrieved October 31, 2016, from http://www.monitoringthefuture.org/pressreleases/16drugpr_complete.pdf.

[15] Pharmaceutical products already exist; they are called Marinol & Cesamet. (n.d.) In Drug Enforcement Administration. Retrieved December 22, 2016, from https://www.dea.gov/divisions/sea/in_focus/marinol-cessmet.pdf.

[16] Cannabidiol: Barriers to Research and Potential Medical Benefits. (June 24, 2015). In NIH: National Institute on Drug Abuse. Retrieved December 22, 2016, from https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2016/biology-potential-therapeutic-effects-cannabidiol.

[17] Cannabis and Cannabinoids (PDQ®). (December 8, 2016). In U.S. National Library of Medicine. Retrieved on December 22, 2016, from https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0032740/.

[18]Teen substance use shows promising decline. (December 13, 2016). In NIH National Institute on Drug Abuse. Retrieved on December 19, 2016, from https://www.drugabuse.gov/news-events/news-releases/2016/12/teen-substance-use-shows-promising-decline.

[19] Vandrey R, Raber JC, Raber ME, Douglass B, Miller C, Bonn-Miller MO. Cannabinoid Dose and Label Accuracy in Edible Medical Cannabis Products. JAMA. 2015;313(24):2491-2493. doi:10.1001/jama.2015.6613

[20] The Legalization of Marijuana in Colorado, The Impact, Volume 4. (September 2016). In Rocky Mountain High Intensity Trafficking Area Colorado, Montana, Utah, and Wyoming. Retrieved October 31, 2016, from http://www.rmhidta.org/default.aspx/MenuItemID/687/MenuGroup/RMHIDTAHome.htm.

[21] Marijuana Grey Market. (August 16, 2016). In Colorado, Office of the Governor. Retrieved on December 8, 2016, from https://www.colorado.gov/pacific/sites/default/files/16Marijuana0817Marijuana%20Grey%20Market.pdf.

[22] Marijuana Grey Market. (August 16, 2016). In Colorado, Office of the Governor. Retrieved on December 8, 2016, from https://www.colorado.gov/pacific/sites/default/files/16Marijuana0817Marijuana%20Grey%20Market.pdf.

[23] Marijuana Grey Market. (August 16, 2016). In Colorado, Office of the Governor. Retrieved on December 8, 2016, from https://www.colorado.gov/pacific/sites/default/files/16Marijuana0817Marijuana%20Grey%20Market.pdf.

[24] Pot is still lighting up the black market. (February 14, 2016). In Newsweek. Retrieved October 31, 2016, from http://www.newsweek.com/weed-black-market-424706.

[25] The difference between legalization and decriminalization. (June 18, 2014). In The Economist. Retrieved on October 31, 2016, from http://www.economist.com/blogs/economist-explains/2014/06/economist-explains-10.

[26] DrugFacts – Marijuana. (updated March 2016). In NIDA. Retrieved October 31, 2016, from https://www.drugabuse.gov/publications/drugfacts/marijuana.

[27] Key Substance Use and Mental Health Indicators in the United States: Results from the 2015 National Survey on Drug Use and Health. (2016). In Substance Abuse and Mental Health Services Administration (SAMHSA). Retrieved October 31, 2016, from http://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2015/NSDUH-FFR1-2015/NSDUH-FFR1-2015.pdf.