AJPH PERSPECTIVES
The Physicians’ Case for Marijuana Legalization Although physicians continue to debate the merits of marijuana reform, legalization is advancing around the country. While still prohibited under federal law, medical marijuana is now legal in 29 states, and in 8 states, cannabis may be purchased by anyone older than 21 years. Federal support of state cannabis laws is critical and all but inevitable, because more than 60% of Americans in both red and blue states now favor full legalization for adults. In this time of contentious divisions in American politics, marijuana legalization has found bipartisan support. The government’s own statistics explain the decades-long, steady shift in public opinion. 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.1 American Blacks are nearly four times more likely than Whites to be arrested for marijuana possession, despite similar usage rates between the two groups.2 Enforcement of marijuana laws has disproportionately affected our nation’s poor and communities of color, contributing to the crisis of mass incarceration. The war on marijuana exacerbates poverty, which is strongly correlated with— among other problems—reduced access to health care. The unjust prohibition of marijuana has done more damage to public health than has marijuana itself.
MARIJUANA PROHIBITION HAS FAILED Alcohol prohibition was repealed after just 13 years
1746
Editorial
Nathan et al.
because of unintended consequences: organized crime, increased use of hard alcohol, and government waste. What have we gotten from our 80-year experiment with marijuana prohibition? Organized crime, increased use of stronger marijuana, and government waste. And yet, the prohibition of alcohol was a success compared with our war on marijuana. Alcohol consumption decreased during the 1920s, but marijuana use has increased drastically during its prohibition. Today, 22 000 000 Americans use cannabis each month, and even more consume it on a less frequent basis.3 Although evidence shows that marijuana is, by most measures, safer than alcohol for the vast majority of adults, evidence also suggests that both marijuana and alcohol can adversely affect brain development in minors. Studies of underage users show that health effects are worse when children start younger and consume marijuana more frequently. But cannabis prohibition for adults does not prevent underage use. For decades, preventive education reduced the rates of alcohol and tobacco use by minors, whereas underage marijuana use has fluctuated despite its prohibition for adults. Since the 1970s, 80% to 90% of those aged 18 years have consistently reported easy access to the drug.4 Unfortunately, prohibition sends the message that marijuana is dangerous for everyone, because it is illegal for everyone, and children know that is not true. If we want our children to believe us when we say that cannabis can be harmful for them, our laws should
reflect the difference in health effects of underage and adult use. Today, although marijuana regulation in legalized states has not been perfect, it is far better than the prohibition it replaced, and the worst fears of opponents have not materialized. Adolescent use has remained level in states where marijuana is legal, motor vehicle accidents and deaths continue to decrease, and state governments have demonstrated a fundamental ability to control the previously untaxed and unregulated cannabis industry.5 These successes are reflected in polls, which show that popular support for legalization remains strong in states where marijuana is legal.
DECRIMINALIZATION VS LEGALIZATION Times are changing. In 2017, even physicians who oppose legalization generally believe that marijuana should be decriminalized, reducing penalties for users while keeping the drug illegal. Although decriminalization is certainly a step in the right direction, we believe it to be an inadequate substitute for legalization and regulation for a number of reasons.
First, decriminalization does not empower the government to regulate product labeling and purity, which leaves marijuana vulnerable to contamination and adulteration. This also renders consumers unable to judge the potency of marijuana, which is like drinking alcohol without knowing its strength. Moreover, where marijuana is merely decriminalized, the point of sale remains in the hands of drug dealers, who will sell marijuana— as well as more dangerous drugs—to children. Contrary to popular belief, decriminalization does not actually end the arrests of marijuana users. Despite New York State decriminalizing marijuana in the 1970s, New York City makes tens of thousands of marijuana possession arrests every year, with continuing racial disparities in enforcement. Finally, under a decriminalized system, the government prosecutes marijuana growers and sellers, thus constricting the supply chain. This drives up the price of marijuana, making the untaxed illegal product more lucrative, the market for it more competitive and violent, and purchasing it more dangerous.
DOCTORS FOR CANNABIS REGULATION As the legalization of medical and adult use of marijuana spreads across the United States,
ABOUT THE AUTHORS David L. Nathan is the founder of Doctors for Cannabis Regulation and is with the Rutgers Robert Wood Johnson Medical School, Piscataway Township, NJ. At the time of writing, H. Westley Clark was the retired director of the Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, Rockville, MD. Joycelyn Elders was the 15th US Surgeon General. Correspondence should be sent to David L. Nathan, MD, DFAPA, Board President, Doctors for Cannabis Regulation, P.O. Box 40183, Washington, DC 20016 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This editorial was accepted July 27, 2017. doi: 10.2105/AJPH.2017.304052
AJPH
November 2017, Vol 107, No. 11
AJPH PERSPECTIVES
conscientious and knowledgeable physicians are increasingly voicing support—not for marijuana use but for effective regulation as an alternative to the failed policy of prohibition. That is why, along with more than 50 prominent US physicians, we founded Doctors for Cannabis Regulation (DFCR), the first and only national physicians’ organization dedicated to the legalization and regulation of the adult use of marijuana. Asserting confidence in science, reason, and the judgment of history, DFCR launched last year with the publication of our “Declaration of Principles.”6 Since then we have testified in numerous state legislatures, met with physician groups, opened free membership to all physicians, advocated evidence-based regulations in each of the states where marijuana has recently become legal, and begun discussions with members of the new Congressional Cannabis Caucus. DFCR 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. Cannabis packaging and advertising that targets or attracts underage users should be completely prohibited. All cannabis products should have childresistant packaging. There should be strong penalties for adults who enable the diversion of cannabis to minors. Money from the taxation of the cannabis trade should be used to fund research, education, prevention, and substance abuse treatment. These should include public information for adults on the use and
misuse of cannabis and youth programs that emphasize the risks of underage cannabis use. Informed physicians may disagree about the specifics of good regulation, but we cannot abstain from the discussion. The cannabis industry now advises lawmakers on cannabis regulation, and doctors must do so as well. Rejecting the unjust and ineffective policy of marijuana prohibition, the physicians of DFCR are helping to lead the nation on a responsible path to legalization. We invite you to join us. Working together, we can advance public health and protect our children through effective, evidence-based regulation of marijuana in the United States. David L. Nathan, MD, DFAPA H. Westley Clark, MD, JD, MPH Joycelyn Elders, MD, MS CONTRIBUTORS All authors contributed to the editorial, with D. L. Nathan as the principal author.
ACKNOWLEDGMENTS The authors wish to thank the Doctors for Cannabis Regulation (DFCR) executive director Brian Muraresku and the DFCR
In Memoriam: John H. (Jack) Bryant, MD, 1925–2017 I can hear his voice, still: “This is the most important work of my life.” This was Jack Bryant in 2010, at the age of 85 years, describing to me the work that he and his wife Nancy were doing with community health workers in the slums outside Nairobi, Kenya, to identify patterns of attachment and early childhood development among orphans. Jack died in early July 2017, after a long and distinguished career in the field of international health.
November 2017, Vol 107, No. 11
AJPH
BEGINNINGS The biographical particulars of his life are easily accessible: John H. Bryant, born in 1925 in Arizona, served as a Navy pilot in World War II, completed undergraduate studies at the University of Arizona, and then earned his MD at the Columbia University College of Physicians and Surgeons in 1953.1 His early career path was clinical: a residency in medicine at Presbyterian Hospital in New York City,
a postgraduate research position at the National Institutes of Health, fellowships in biochemistry at the National Institute of Arthritis and Metabolic Diseases and at the Max
board of directors for their assistance in the preparation and publication of this editorial.
REFERENCES 1. Federal Bureau of Investigation. 2015 Crime in the United States. 2016. Available at: https://ucr.fbi.gov/crimein-the-u.s/2015/crime-in-the-u.s.2015/persons-arrested/persons-arrested. Accessed August 13, 2017. 2. American Civil Liberties Union. Report: the war on marijuana in black and white. 2013. Available at: https://www. aclu.org/report/war-marijuana-blackand-white. Accessed August 13, 2017. 3. Center for Behavioral Health Statistics and Quality. Behavioral Health Trends in the United States: Results From the 2014 National Survey on Drug Use and Health. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2015. 4. Johnston LD, O’Malley PM, Bachman JG, Schulenberg JE. Monitoring the Future: National Survey Results on Drug Use, 1975–2008: Volume II: College Students and Adults Ages 19–50. Bethesda, MD: National Institute on Drug Abuse; 2009. 5. Drug Policy Alliance. So far, so good: what we know about marijuana legalization in Colorado, Washington, Alaska, Oregon, and Washington, DC. 2016. Available at: http://www.drugpolicy. org/news/2016/10/so-far-so-goodwhat-we-know-about-marijuanalegalization-colorado-washington-alaskaore. Accessed August 13, 2017. 6. Doctors for Cannabis Regulation. Declaration of principles. 2016. Available at: http://dfcr.org/declaration-ofprinciples. Accessed August 13, 2017.
Planck Institute for Biochemistry in Munich, and finally a fellowship in hematology at Washington University in St. Louis, Missouri.
1960s: A NEW PATH This early clinical focus took an abrupt turn, as he later described
ABOUT THE AUTHOR Paul Campbell Erwin is with the Department of Public Health, University of Tennessee, Knoxville, and is also an AJPH associate editor. Correspondence should be sent to Paul Campbell Erwin, MD, DrPH, Department of Public Health, University of Tennessee, 1914 Andy Holt Ave, Knoxville, TN 37996 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This editorial was accepted August 6, 2017. doi: 10.2105/AJPH.2017.304073
Erwin
Editorial
1747
The Physicians’ Case for Marijuana Legalization Although physicians continue to debate the merits of marijuana reform, legalization is advancing around the country. While still prohibited under federal law, medical marijuana is now legal in 29 states, and in 8 states, cannabis may be purchased by anyone older than 21 years. Federal support of state cannabis laws is critical and all but inevitable, because more than 60% of Americans in both red and blue states now favor full legalization for adults. In this time of contentious divisions in American politics, marijuana legalization has found bipartisan support. The government’s own statistics explain the decades-long, steady shift in public opinion. 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.1 American Blacks are nearly four times more likely than Whites to be arrested for marijuana possession, despite similar usage rates between the two groups.2 Enforcement of marijuana laws has disproportionately affected our nation’s poor and communities of color, contributing to the crisis of mass incarceration. The war on marijuana exacerbates poverty, which is strongly correlated with— among other problems—reduced access to health care. The unjust prohibition of marijuana has done more damage to public health than has marijuana itself.
MARIJUANA PROHIBITION HAS FAILED Alcohol prohibition was repealed after just 13 years
1746
Editorial
Nathan et al.
because of unintended consequences: organized crime, increased use of hard alcohol, and government waste. What have we gotten from our 80-year experiment with marijuana prohibition? Organized crime, increased use of stronger marijuana, and government waste. And yet, the prohibition of alcohol was a success compared with our war on marijuana. Alcohol consumption decreased during the 1920s, but marijuana use has increased drastically during its prohibition. Today, 22 000 000 Americans use cannabis each month, and even more consume it on a less frequent basis.3 Although evidence shows that marijuana is, by most measures, safer than alcohol for the vast majority of adults, evidence also suggests that both marijuana and alcohol can adversely affect brain development in minors. Studies of underage users show that health effects are worse when children start younger and consume marijuana more frequently. But cannabis prohibition for adults does not prevent underage use. For decades, preventive education reduced the rates of alcohol and tobacco use by minors, whereas underage marijuana use has fluctuated despite its prohibition for adults. Since the 1970s, 80% to 90% of those aged 18 years have consistently reported easy access to the drug.4 Unfortunately, prohibition sends the message that marijuana is dangerous for everyone, because it is illegal for everyone, and children know that is not true. If we want our children to believe us when we say that cannabis can be harmful for them, our laws should
reflect the difference in health effects of underage and adult use. Today, although marijuana regulation in legalized states has not been perfect, it is far better than the prohibition it replaced, and the worst fears of opponents have not materialized. Adolescent use has remained level in states where marijuana is legal, motor vehicle accidents and deaths continue to decrease, and state governments have demonstrated a fundamental ability to control the previously untaxed and unregulated cannabis industry.5 These successes are reflected in polls, which show that popular support for legalization remains strong in states where marijuana is legal.
DECRIMINALIZATION VS LEGALIZATION Times are changing. In 2017, even physicians who oppose legalization generally believe that marijuana should be decriminalized, reducing penalties for users while keeping the drug illegal. Although decriminalization is certainly a step in the right direction, we believe it to be an inadequate substitute for legalization and regulation for a number of reasons.
First, decriminalization does not empower the government to regulate product labeling and purity, which leaves marijuana vulnerable to contamination and adulteration. This also renders consumers unable to judge the potency of marijuana, which is like drinking alcohol without knowing its strength. Moreover, where marijuana is merely decriminalized, the point of sale remains in the hands of drug dealers, who will sell marijuana— as well as more dangerous drugs—to children. Contrary to popular belief, decriminalization does not actually end the arrests of marijuana users. Despite New York State decriminalizing marijuana in the 1970s, New York City makes tens of thousands of marijuana possession arrests every year, with continuing racial disparities in enforcement. Finally, under a decriminalized system, the government prosecutes marijuana growers and sellers, thus constricting the supply chain. This drives up the price of marijuana, making the untaxed illegal product more lucrative, the market for it more competitive and violent, and purchasing it more dangerous.
DOCTORS FOR CANNABIS REGULATION As the legalization of medical and adult use of marijuana spreads across the United States,
ABOUT THE AUTHORS David L. Nathan is the founder of Doctors for Cannabis Regulation and is with the Rutgers Robert Wood Johnson Medical School, Piscataway Township, NJ. At the time of writing, H. Westley Clark was the retired director of the Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, Rockville, MD. Joycelyn Elders was the 15th US Surgeon General. Correspondence should be sent to David L. Nathan, MD, DFAPA, Board President, Doctors for Cannabis Regulation, P.O. Box 40183, Washington, DC 20016 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This editorial was accepted July 27, 2017. doi: 10.2105/AJPH.2017.304052
AJPH
November 2017, Vol 107, No. 11
AJPH PERSPECTIVES
conscientious and knowledgeable physicians are increasingly voicing support—not for marijuana use but for effective regulation as an alternative to the failed policy of prohibition. That is why, along with more than 50 prominent US physicians, we founded Doctors for Cannabis Regulation (DFCR), the first and only national physicians’ organization dedicated to the legalization and regulation of the adult use of marijuana. Asserting confidence in science, reason, and the judgment of history, DFCR launched last year with the publication of our “Declaration of Principles.”6 Since then we have testified in numerous state legislatures, met with physician groups, opened free membership to all physicians, advocated evidence-based regulations in each of the states where marijuana has recently become legal, and begun discussions with members of the new Congressional Cannabis Caucus. DFCR 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. Cannabis packaging and advertising that targets or attracts underage users should be completely prohibited. All cannabis products should have childresistant packaging. There should be strong penalties for adults who enable the diversion of cannabis to minors. Money from the taxation of the cannabis trade should be used to fund research, education, prevention, and substance abuse treatment. These should include public information for adults on the use and
misuse of cannabis and youth programs that emphasize the risks of underage cannabis use. Informed physicians may disagree about the specifics of good regulation, but we cannot abstain from the discussion. The cannabis industry now advises lawmakers on cannabis regulation, and doctors must do so as well. Rejecting the unjust and ineffective policy of marijuana prohibition, the physicians of DFCR are helping to lead the nation on a responsible path to legalization. We invite you to join us. Working together, we can advance public health and protect our children through effective, evidence-based regulation of marijuana in the United States. David L. Nathan, MD, DFAPA H. Westley Clark, MD, JD, MPH Joycelyn Elders, MD, MS CONTRIBUTORS All authors contributed to the editorial, with D. L. Nathan as the principal author.
ACKNOWLEDGMENTS The authors wish to thank the Doctors for Cannabis Regulation (DFCR) executive director Brian Muraresku and the DFCR
In Memoriam: John H. (Jack) Bryant, MD, 1925–2017 I can hear his voice, still: “This is the most important work of my life.” This was Jack Bryant in 2010, at the age of 85 years, describing to me the work that he and his wife Nancy were doing with community health workers in the slums outside Nairobi, Kenya, to identify patterns of attachment and early childhood development among orphans. Jack died in early July 2017, after a long and distinguished career in the field of international health.
November 2017, Vol 107, No. 11
AJPH
BEGINNINGS The biographical particulars of his life are easily accessible: John H. Bryant, born in 1925 in Arizona, served as a Navy pilot in World War II, completed undergraduate studies at the University of Arizona, and then earned his MD at the Columbia University College of Physicians and Surgeons in 1953.1 His early career path was clinical: a residency in medicine at Presbyterian Hospital in New York City,
a postgraduate research position at the National Institutes of Health, fellowships in biochemistry at the National Institute of Arthritis and Metabolic Diseases and at the Max
board of directors for their assistance in the preparation and publication of this editorial.
REFERENCES 1. Federal Bureau of Investigation. 2015 Crime in the United States. 2016. Available at: https://ucr.fbi.gov/crimein-the-u.s/2015/crime-in-the-u.s.2015/persons-arrested/persons-arrested. Accessed August 13, 2017. 2. American Civil Liberties Union. Report: the war on marijuana in black and white. 2013. Available at: https://www. aclu.org/report/war-marijuana-blackand-white. Accessed August 13, 2017. 3. Center for Behavioral Health Statistics and Quality. Behavioral Health Trends in the United States: Results From the 2014 National Survey on Drug Use and Health. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2015. 4. Johnston LD, O’Malley PM, Bachman JG, Schulenberg JE. Monitoring the Future: National Survey Results on Drug Use, 1975–2008: Volume II: College Students and Adults Ages 19–50. Bethesda, MD: National Institute on Drug Abuse; 2009. 5. Drug Policy Alliance. So far, so good: what we know about marijuana legalization in Colorado, Washington, Alaska, Oregon, and Washington, DC. 2016. Available at: http://www.drugpolicy. org/news/2016/10/so-far-so-goodwhat-we-know-about-marijuanalegalization-colorado-washington-alaskaore. Accessed August 13, 2017. 6. Doctors for Cannabis Regulation. Declaration of principles. 2016. Available at: http://dfcr.org/declaration-ofprinciples. Accessed August 13, 2017.
Planck Institute for Biochemistry in Munich, and finally a fellowship in hematology at Washington University in St. Louis, Missouri.
1960s: A NEW PATH This early clinical focus took an abrupt turn, as he later described
ABOUT THE AUTHOR Paul Campbell Erwin is with the Department of Public Health, University of Tennessee, Knoxville, and is also an AJPH associate editor. Correspondence should be sent to Paul Campbell Erwin, MD, DrPH, Department of Public Health, University of Tennessee, 1914 Andy Holt Ave, Knoxville, TN 37996 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This editorial was accepted August 6, 2017. doi: 10.2105/AJPH.2017.304073
Erwin
Editorial
1747
