Understanding The Case For Cannabis; It Is Not Harmless
Too often the case for legalizing cannabis is based in part on the belief that it is a relatively harmless drug or at least less harmful than the legal drug alcohol. Both of those beliefs are incorrect.
Previously we showed evidence that there is no safe use of alcohol in any amount. Alcohol is a toxic, psychoactive, and dependence-producing substance that begins to have negative impact on the human body from the first drop, is addictive for millions of Americans, and is abused by millions more. Comparing any drug favorably to these facts is at best faulty logic.
The research on cannabis is not as well developed as that for alcohol. Now that research is increasing, and it clearly indicates that cannabis use is as dangerous to health as alcohol if not more so.
We want to be clear that the medical uses of cannabis are researched, proven and developing. Pain management in particular is a very difficult clinical issue in America and the increasing use of cannabis as prescribed is a welcome development. Medical marijuana is tested especially as a pain management application and should be deployed under medical supervision.
Previously we discussed how as many as 100 million Americans use alcohol responsibly and in moderation. The case for managed, recreational use of cannabis is a much harder justification. The National Institutes for Drug Abuse (NIDA, “Cannabis”, February 2024) report several issues resulting from marijuana use. To start, the widely held belief that marijuana is not addictive is false. NIDA reports that 22-30% of regular users over time will develop cannabis use disorder – emotional and/or physical dependence.
In addition, NIDA cites the following issues with short term use:
· Intoxication and associated perception, motor skill and reasoning effects which occur rapidly
· Psychotic experiences including anxiety, fear, distrust, panic, or hallucinations occurring with excessive amounts or excessive dosages
· Cardiovascular issues due to elevated heart rate
· Respiratory issues from rapid and irregular breathing
Speaking of long term use NIDA notes:
· Lung damage when the method of delivery is smoking
· Heart disease with long-term cannabis use with increased risk of stroke, heart attack, and arrythmias
· Gastrointestinal problems including acid reflux, pancreatitis, and peptic ulcer disease
· Increased cancer risk with an increased likelihood of developing head, neck, or throat cancer particularly in people who smoke cannabis.
NIDA also noted behavioral health issues including problems in cognitive functions like learning and memory, attention, processing speed, perceptual motor function, and language. Some evidence has linked cannabis use to earlier onset of psychosis in people with genetic risk factors including schizophrenia, as well as worsened symptoms in people who already have these conditions.
The largest research study ever conducted recently occurred at the University of Colorado Anschutz School of Medicine (“Brain Function Outcomes of Recent and Lifetime Cannabis Use”; Joshua Gowin, Ph.D. et al) and found that heavy cannabis use appeared to reduce brain activity in certain areas of the brain involved in important cognitive functions such as decision-making, memory, attention and emotional processing.
Given this recent and emerging research the biomedical case against marijuana use appears stronger than that for alcohol. Nevertheless, like alcohol, there seem to be social benefits as there are 43 million adults (17% of adults) using marijuana.
Our point here is not to make a final determination on cannabis legalization but to be certain that any consideration is based in the best evidence available. According to Pew Research 88% of Americans believe that marijuana should be legal in some circumstances and 57% believe it should be legal for recreational use. At the same time, and contrary to widespread belief, USA Today surveys found that slightly less than half of Americans have tried marijuana and about 17% use marijuana regularly.
The researched and more informed case for cannabis legalization is based on four arguments. First, is that the pain management and other therapeutic uses are proven, needed and should be allowed for prescription under medical supervision. Second is that there is today widespread acceptance of cannabis and widespread use. Public opinion is in favor of legalization. Third is that unregulated use is causing exactly the biomedical and behavioral health outcomes the research predicts, and that legalization will allow for regulating the product that is used. Fourth is that we are creating a costly and terrible social injustice by imprisoning people for using a product that is widely used and much safer than one legal product that being nicotine.
We agree with the argument about “medical marijuana”. Those prescriptions should be made under the supervision of a prescribing health care professional. The potential for cannabis use disorder (CUD) should be disclosed and monitored as should the availability of clinical support for CUD be offered to the patient.
The argument about public acceptance and widespread use is over stated. As previously noted, public opinion favors legalization both for some purpose (87%) and for recreational use (58%). As we also noted, only about 16% of American adults use cannabis recreationally. This compares with 70% of American adults who use alcohol. One might argue that the legal issue suppresses marijuana use in this comparison. It would seem unlikely to overcome that large of a difference. Marijuana use is not widespread but limited to 1 in 6 Americans.
The argument about the negative characteristics of unregulated marijuana supply merit consideration. Interestingly a review of the web site for the National Organization for Reform of Marijuana Laws (NORML) does not focus on the safety of cannabis. Rather, NORML focuses on two issues. One is legalization of the evidenced based prescription of cannabis for those proven medical purposes. The second is the dangers of the unregulated market through which some of the estimated 40 million users procure their marijuana.
Writing in the Journal of Public Health (“The Physicians’ Case for Marijuana Legalization”, David L Nathan et al, 2017) David Nathan et al make the physicians case for legalization. “DFCR (Doctors For Cannabis Regulation) does not promote cannabis use. Rather, we advocate the legalization of cannabis for adults, because effective regulation requires legalization. We support a core set of common sense measures to control the marijuana industry and protect public health. The government should oversee all cannabis production, testing, distribution, and sales. Cannabis products should be labeled with significant detail, including (but not limited to) THC (tetrahydrocannabinol—the principal psychoactive constituent of cannabis) and CBD (cannabidiol—an active cannabinoid in cannabis) levels, dosing information, and ingredients. There should be restrictions on the marketing and advertising of cannabis products.”
As marijuana has well-documented adverse health impacts as noted above, one of the principal questions in the legalization debate is whether liberalized marijuana laws will lead to increased prevalence of use. Writing in the Annual Review of Medicine (“Marijuana Legalization: Impact on Physicians and Public Health”, Samuel T Wilkinson et al, 2016) found that, “Generally, U.S. states that have legalized medical or recreational marijuana have higher rates of use than those where all forms of marijuana remain illegal. However, it is difficult to ascertain whether this is attributable to legalization or is associated with regional variation in permissive attitudes or perceived risk with regard to marijuana. The evidence is unclear”. While use seems greater in legalized States, this could be the result of legislation following use, not use following legislation.
Finally, there is the argument that current enforcement of cannabis laws has made criminals of people with a disease (substance use disorder) and disproportionately people of color. In the same report DFCR makes the case. “Every year, the United States makes 575,000 arrests for marijuana possession alone, which is greater than the number of arrests for all violent crimes combined. American Blacks are nearly four times more likely than Whites to be arrested for marijuana possession, despite similar usage rates between the two groups. Enforcement of marijuana laws has disproportionately affected our nation’s poor and communities of color, contributing to the crisis of mass incarceration. “
In sum, the argument for legalized cannabis based on a comparison to alcohol is flawed in two ways. First is that it is a comparison to a drug that kills 98,000 Americans annually. Second, it is not true that cannabis is less harmful than alcohol. Similarly, the argument that cannabis does not create significant national health effects is not true.
The case that prohibition has failed for most drugs is mixed. Certainly where we have tried prohibition of alcohol we have failed. On the other hand, prohibition for other schedule 1 narcotics such as opioids including heroin and fentanyl has been successful excepting the deadly nature of opioids. Only 3.6% of Americans use opioids including heroin and fentanyl and that number has declined greatly over the past twelve months. Overdose deaths from opioids is also decreasing according to the CDC. Nonetheless, with more than 40 million American adults using cannabis it seems likely that prohibition continues to be an ineffective strategy.
The case for legalization along with managing the supply chain merits consideration. A recent report from the Pew Research Center (“Four-in-ten U.S. drug arrests in 2018 were for marijuana offenses – mostly possession”, Pew Research Center, 2020) reports that 40% of the 1.6 million drug arrests in the U.S. for drug related crime were for marijuana and that 92% of those were for possession. As has been often reported, those arrests fall disproportionately on people of color.
Managing the supply chain is also a credible argument. In States where cannabis is legal for medical or recreational purposes supply is licensed, regulated and inspected, advertising is regulated, and warning labels are required. As a result, the buyer can be much more assured about purity and the doses of the psychoactive substance THC can be controlled. Street marijuana can and often does contain a variety of unintended impurities such as mold, e-coli, and unhealthy miscellaneous spores. Oftentimes street marijuana is laced with other drugs to increase potency such as ecstasy, heroin, fentanyl and cocaine.
According to CBS News recreational cannabis is now legal in 24 States. Medical marijuana is legal in these and another 13 States. In the remaining States marijuana is not legal although some CBD products may be allowed. Public opinion is swaying elected official behavior.
As to the case of public opinion, our view is that good public policy involves weighing the demonstrated “will of the people” against good, evidenced based, public policy research where they diverge.
U.S. jurisdictions that have not legalized medical uses should do so. Of course, strict controls should be put in place as is the case for other schedule 2 narcotics. Those jurisdictions considering initiating legalization and continuing recreational use should consider that marijuana is not a harmless, recreational drug but more dangerous than alcohol. However, they should also note the arguments that 1 in 6 Americans are using an unregulated and often dangerous product that is sold “on the street” and, further, arrests for marijuana seem disproportionate to other crimes and certainly disproportionate by race. Controlling the supply chain has the potential to reduce the harm being done by street drugs among a population that is quite clearly not affected by prohibition. Decriminalizing possession at certain amounts has the potential to reduce what seems to be a disproportionate arrest record which in 92% of the cases involves possession rather than distribution or providing to minors.
Gene Gilchrist
March 2025
