Introduction and Legalization

Currently, there are nine states with legislation that allows recreational or medicinal use of marijuana. The state of Alaska allows recreational use for adults 21 and over. California was the first state to legalize medical marijuana in 1996 and recently passed a law where recreational use will be permitted: the state will issue marijuana licenses to dispensaries for recreational use beginning in January 2018. Colorado and Washington were the first two states to pass legislation allowing recreational use of marijuana in 2012. Over one billion dollars in marijuana sales has been recorded in the state of Washington since legislation passed for the use of recreational marijuana, with over $250 million collected from excise taxes.1 Revenues from the state of Colorado has been recorded as $31 million dollars from the 2016 cash fund tax collected at 2.9% and $67 million from the 2016 10% retail tax, up from $42 million in 2015.2

Election results in 2016 proceeded with a law in Maine whereby anyone over 21 years old can be in possession of 2.5 ounces of marijuana and allowing retail stores to open in 2018. Massachusetts now allows residents to carry and consume small amounts of marijuana, starting in early 2018. In Nevada, residents will be able to purchase up to one ounce for recreational use by 2018. In 2015, Oregon now allows personal growing up to four plants of marijuana and in the time between July 2015 and June 2016, collected $15 million in tax revenue from the sale of marijuana. The legalization of nonmedical marijuana use passed in Washington DC in 2014. Legalization allows for use by the public, but also allows government regulation and monitoring of sales for tax revenue and licensing. Several advocates of legalization of marijuana feel decriminalization is the first step towards legalization. Decriminalization indicates that the activity is still illegal, but enforcement and penalties are not as severe (Figure 1).

Figure 1. Marijuana Legal Status Map.3

Surveys of the general public have indicated that support and acceptance for legalization of marijuana has increased to 50%, when compared to just 16% in 1990 (Figure 2). This acceptance in translated by younger users as safe with minimal health consequences.4

Figure 2. Percent Supporting Marijuana Legalization.3

Marijuana is considered a Schedule I substance by the federal government under the Controlled Substance Act, which is described to have no recognized medicinal use and a potential risk for abuse.5,20 New legislation has been introduced by two congressmen in Florida, Matt Gaetz (R) and Darren Soto (D) to change the status of marijuana to a Schedule III drug of the Controlled Substance Act which indicates potential for abuse and may lead to moderate physical dependence or high psychological dependence.6

The controversy over the medical uses for marijuana (cannabis) continues as the American Medical Association (AMA) has released a November 2013 statement that “cannabis is a dangerous drug and as such is a public health concern… but acknowledged the changing attitudes toward marijuana among the American public.”7 The AMA encourages continued research of marijuana and potential medical uses. Currently the medical conditions for which patients can use cannabis as determined by legislation are: cancer, glaucoma, HIV/AIDS, muscle spasms, seizures, severe pain, severe nausea and cachexia (weight loss, muscle atrophy, fatigue and loss of appetite). Specifically, therapeutic benefits for spasticity symptoms of Multiple Sclerosis (MS) are being studied, and the use of cannabis for cancer pain is suggested. In certain states, other debilitating medical conditions can warrant the use of cannabis: amyotrophic lateral sclerosis (ALS or Lou Gehrig’s Disease), Alzheimer’s disease and post-traumatic stress disorder (PTSD). Synthetic cannaboids that are prescribed such as Marinol (Dronabinol) and Cesamet (Nabilone) are classified as Schedule II and III and used for the nausea and loss of appetite with chemotherapy patients. Clinical trials using Sativex® for use in MS spasticity and cancer pain are currently in Phase II and III studies in the U.S, but already in use in Europe. To date, the AMA statement has not changed their position, but a small group of physicians as reported by the Washington post in April 2016 are endorsing the legalization of marijuana for adult recreational use, citing regulations can help with public safety.8

Statistics of marijuana use in the U.S. from a national survey by the National Institute on Drug Abuse from 1996-2016 indicate almost one of every four high school seniors have used marijuana regularly and more than half do not perceive marijuana use as harmful (Figure 3).9 Peak usage for marijuana occurs in the late teens and early twenties, yet slightly less than half of adults polled by the Pew Research Center reveal using marijuana with 12% using it in the past year (Figure 4).5

Figure 3. Past Month Marijuana Use.9
Infographic of past month marijana use
Figure 4. Marijuana Use Increased Over the Last Decade.5
Infographic showing the increase of marijuana use of the last decade

The CDC demonstrates the percentage of past month marijuana use* among persons aged ≥18 years, by highest level of education completed — National Survey on Drug Use and Health, United States, 2002–2014, which continues as an upward trend, but still remains below 15% (Figure 5).10

Figure 5. Percentage of Past Month Use of Marijuana.10
Chart showing percentage of past month use of marijuana

The chemical in marijuana, delta-9-tetrahydrocannabinol (THC) that targets the cannabinoid receptors has been determined to be more potent today than it was just a few decades ago in the 1980s. The THC concentrations averaged 15% in 2012, compared to 4% in the 1980s. This higher concentration may increase the risk of effects from the drug and/or the potential addiction.

The number of emergency room (ER) visits in 2008 documented in the U.S. connected to marijuana use has steadily increased to over 370,000, particularly in the 12-17 year old age group. Data from the Children’s Hospital in Denver Colorado has demonstrated an increase in ER visits from 106 in 2005 to 631 in 2014, when legalization occurred.11 Due to the impact on judgment and perception, driving can be dangerous when smoking marijuana and after alcohol, it is the second most frequent substance found in drivers implicated in fatal automobile accidents.