Marijuana Law, Policy & Reform

Student presentation: "Chronic pain management: Exploring the relationship between marijuana, and opioid use"

As I have mentioned before, I am always pleased when students in my Marijuana Law, Policy & Reform seminar focus for their research and class presentations on medical marijuana topics. It is certainly understandable, but still problematic, that medical-related issues get now seemingly a lot less attention that adult-use issues. But this week in my class, the fourth scheduled presentation will be on cannabis and pain management.  Here is her description of the topic (along with background readings):

While marijuana use for its’ medicinal properties is nowhere near a new piece of conversation, there are several areas of this topic that are under-researched.  In the U.S. 51.6 million adults suffer from chronic pain.  Many of these adults are prescribed opioids to lessen the pain.  Lessening the pain by no means actually eliminates the pain, and that is where marijuana comes into play.

The relationship between marijuana, and opioid use can be quite complex, especially considering the U.S.’s history, and present issues with misuse of opioids.  Understanding how these two drugs interact together is pertinent to helping people who suffer from chronic pain.  Generally, studies have found that using marijuana has lessened patient dependency with opioids when used as a pain management tool.

However, being able to use marijuana as a gap filler or pain management tool is not so easily done.  Recreational, and medicinal legalization in a state does not guarantee that a person will be able to access this type of approach.  State laws play a big role in this issue.  My paper aims to explore why people on opioids are turning to marijuana to supplement their pain management, the results of such, risks associated, which demographics are affected at disparate rates, as well as the various laws, and regulations that hinder the ability to safely use marijuana as a pain management tool.

Related Links: 

For information on relevant state laws pertaining to doctors in this space: "‘Conscience’ Bills Let Medical Providers Opt Out of Providing a Wide Range of Care."

For information on results of using marijuana as a pain management tool while on opioids: "Cannabis as a Substitute for Opioid-Based Pain Medication: Patient Self-Report."

Tulsa Law Review examining "Contemporary Cannabis: Wading Through a Post-Prohibition Era"

I was asked to post this call for papers, which I am happy to do:

Tulsa Law Review, in conjunction with the University of Tulsa College of Law and the University of Tulsa, is hosting a Symposium on Cannabis Law and Policy on March 1, 2024.

Theme: Contemporary Cannabis: Wading Through a Post-Prohibition Era

Tulsa Law Review invites interested parties to write and submit relevant articles for publication consideration in our 2024 Symposium Issue.  One panel will focus on evidentiary and interdisciplinary issues with the increasing legalization of cannabis at the medical and recreation level.  The other panel will discuss legalization at the state level and its effects on corporate and banking spheres.

With the recent announcement of the US Department of Health and Human Services’ recommendation to reclassify marijuana as a Schedule III substance, we are excited to facilitate a thoughtful discussion and a variety of papers surrounding this timely topic.

Questions and paper proposals should be submitted to Cameron Skinner, Tulsa Law Review symposium editor, [email protected]

"The impact of timing of in utero marijuana exposure on fetal growth"

The title of this post is the title of this new original research authored by multiple researchers and just published in the journal Frontiers in Pediatrics.  Here is its abstract:

Objective: To examine whether timing of in utero marijuana exposure independently and negatively impacts fetal growth, and if these effects are global or specific to certain growth parameters.

Study design: The two study groups were marijuana users (N = 109) and a randomly selected control group of biochemically verified non-users (n = 171). Study data were obtained via manual abstraction of electronic medical records.

Results: After control for significant confounders, regression results indicated significant (p < .05) decrease in newborn weight following first trimester marijuana exposure only (−154 g) and following marijuana exposure throughout gestation (−185 g) compared to controls. There were also significant deficits in head circumference following marijuana exposure in the first and second trimester only (−.83 cm) and marijuana exposure throughout pregnancy (−.79 cm) compared to controls. Newborn length was not significantly predicted by marijuana exposure.

Conclusions: Timing of marijuana exposure appears to play a key role in specific fetal growth deficits, with exposure throughout gestation most detrimental. However even first trimester exposure may result in decreased weight. Timing and amount of use could be confounded in this study as those who quit early in pregnancy may have been lighter users than those who continued throughout pregnancy. More research is clearly needed to better understand the role of amount and timing of in utero marijuana exposure in predicting different aspects of fetal growth, however, this study suggests that women should be encouraged to avoid marijuana use at any point in pregnancy.

Student presentation exploring "Cannabinoid Hyperemesis Syndrome"

As regular readers know, students in my Marijuana Law, Policy & Reform seminar are now in the midst of "taking over" my class through presentations on the research topics of their choice.  Before their presentations, students are expected to provide in this space some background on their topic and links to some readings or relevant materials.  The first of our presentations for next week will be looking at "Cannabinoid Hyperemesis Syndrome".  Here is how my student has described his topic along with background readings he has provided for his classmates (and the rest of us):

As more American states end cannabis prohibition, regulators and lawmakers are faced with the difficult task of implementing rules to govern the growth, sale, and use of a plant that we still seem to know very little about.  Empirically and anecdotally, moderate cannabis use looks to be less harmful than use of other legal regulated substances like alcohol and tobacco.  As with nearly all substances, however, excessive chronic use of cannabis can have negative health effects.  One such side effect is Cannabinoid Hyperemesis Syndrome (CHS), a relatively rare syndrome which was first reported in Australia in 2004 and is characterized by cyclical vomiting and nausea paired with compulsive hot bathing in heavy cannabis users.  Despite being first described nearly two decades ago, many questions remain as to the actual prevalence and exact causes of the syndrome. 

This paper will discuss current data surrounding CHS and the implications this condition has for the ever-growing post-prohibition world of cannabis.  More studies are certainly necessary to determine how to prevent and treat CHS so that we can form a responsible and common-sense cannabis policy.  There is a significant possibility that current data and studies about CHS will be used to argue for continued prohibition in states that have not yet legalized the plant.  However, based on what we currently know about the syndrome, the existence of CHS is not a reason to continue prohibition.  While extremely heavy high-THC cannabis users should be concerned with developing the adverse symptoms of CHS, moderate and infrequent users do not generally develop the condition.  Furthermore, CHS is relatively rare and, if diagnosed early, has a simple cure — upon ceasing cannabis use, symptoms recede quickly and do not return until the afflicted user re-ingests cannabinoids. 

After a review of the data, the discussion will turn to possible responses to CHS rates such as THC limits, education of cannabis users, and proactive moves the cannabis industry can make to lessen the likelihood that CHS is used as a scare tactic to continue prohibition. Rather than perpetuate a misguided prohibition scheme that unfairly punishes users of cannabis, a substance empirically less harmful than legal substances such as alcohol or tobacco, we should continue to study CHS, determine with relative certainty what causes it, and educate the public on harm-reduction methods that will prevent CHS.  

Background reading

From Leafy, "Is "scromiting" from smoking weed a thing?"

From Forbes, "Science Reveals The Cannabis Industry’s Greatest Lie: You’re Buying Weed Wrong (And So Is Everyone Else)"

From JAMA Open Network, "Changes in Emergency Department Visits for Cannabis Hyperemesis Syndrome Following Recreational Cannabis Legalization and Subsequent Commercialization in Ontario, Canada"

Student presentation exploring "Medical Marijuana and the Mental Health Crisis"

When students in my Marijuana Law, Policy & Reform seminar "take over" the second half of my class by giving presentations, they always cover a diverse array of cutting-edge topics.   So, this very first week of  presentations, a look at tax issues will be followed by a presentations focused on "Medical Marijuana and the Mental Health Crisis."   Here is how my student has described her topic along with background readings she has provided:

The mental health crisis in the United States is growing.  The stigmas surrounding mental health, as well as the barriers surrounding treatment, lead many individuals to self-soothe.  Drug use may be one method of choice. Medical marijuana could be an effective form of treatment, particularly for anxiety and panic disorders, but the lack of research and education about its efficacy and use make it an unrealistic option for many.

Though medical marijuana is growing in popularity as an alternative treatment method, it remains taboo throughout the world of practicing physicians.  Medical marijuana is not prescribed by a doctor – though it can be recommended (see Conant v. Walters, 309 F.3d 629 (9th Cir. 2002)) – and medical education does not present marijuana as a viable treatment option.  These limitations pose significant obstacles to both research and effective use, perpetuating a growing crisis with a limited number of answers.  This presentation will discuss the role of medical marijuana in treating mental illness, focusing on the systematic barriers that leave prescribers without authority and patients without aid.

Suggested Reading:

National Alliance on Mental Illness, "Mental Health By the Numbers"

Susan A. Stoner, Alcohol and Drug Abuse Institute, "Effects of Marijuana on Mental Health: Anxiety Disorders"

Anastasia Evanoff et. al, "Physicians-in-training are not prepared to prescribe medical marijuana," 180 Drug and Alcohol Dependence Volume 151 (Nov. 2017).

"Medical Cannabis and Autism Spectrum Disorder – Ohio's Marijuana Policy and its Intersection with the Historical Controversial Cannabis Treatment"

In a very busy semester, I have fallen a bit behind posting some recently produced papers that are part of the on-going series of student papers supported by the Drug Enforcement and Policy Center.  I am hopeful about catching up in the days ahead, as I continue to relish the he chance to highlight great work by OSU law students and recent graduates.  And the title of this post is the title of this paper authored by Lindsey Mead who is in the midst of her 3L year at The Ohio State University Moritz College of Law.  Here is its abstract: 

In the state of Ohio, medical marijuana is offered as a treatment option for many different illnesses and disorders including Alzheimer’s disease, Tourette’s syndrome, and Crohn’s disease.  However, one condition missing from this list of syndromes that may legally use medical marijuana as a form of treatment is autism spectrum disorder. This paper aims to understand why autism spectrum disorder is not included in this list while also analyzing relevant present legislation such as House Bill 60 and Senate Bill 261.  To answer these questions, this paper examines the benefits of treating autism with medical marijuana as well as the reasoning for why this treatment has been perceived so negatively.

Highlighting all we do not know about marijuana-infused drinks

This lengthy New York Times article, headlined "Weed Drinks Are a Buzzy Alcohol Substitute. But Are They Safe?", provides a useful overview of "weed drinks" with an emphasis what we do not know about a growing consumer product sector.  I recommend the piece in full, and here are a few excerpts:

According to BDSA, a market research firm in Colorado that specializes in legal cannabis, dollar sales of marijuana beverages are up by around 65 percent from 2020 to 2021 in the 12 states they track. In California, the state with the largest market for weed drinks, the number of cannabis beverages available nearly doubled from 2020 to 2021, growing to 747 distinct products, according to Headset, a company that collects and analyzes data on cannabis....

Cannabis-infused beverages are often branded as a healthier alternative to alcohol — “No painful days after drinking or regrets,” a tagline on Cann’s site reads. These kinds of drinks carry a connotation of health, said Emily Moquin, a food and beverage analyst at Morning Consult. They tout themselves as “hangover-free” and without the high calories of alcohol; they claim to help you feel “focused,” balanced, relaxed. One cannabis beverage company even suggests pairing their drinks with a spa day.

But experts worry that products like weed drinks are becoming more popular than health research can keep up with, leaving big questions about how best to consume them and what impacts they may have on the brain and body....

“It’s really a Wild West of products out there,” Dr. MacKillop said. Some drinks contain just THC, or CBD or both, and drinks on the market vary vastly in how many milligrams of these compounds they contain.

While there is no standard unit for THC product potency, Dr. MacKillop said, most experts in the field consider five milligrams of THC to be a typical single dose, and the National Institute on Drug Abuse sets it as standard unit of research.

According to Headset, over half of cannabis beverage units sold in the U.S. in 2021 contained 100 milligrams of THC, an amount that could significantly intoxicate or impair the average person....

Because weed drinks are so new, they are “an incredibly understudied class of cannabis products,” Dr. MacKillop said. There aren’t yet robust studies on how drinkable cannabis products affect the body long term, Dr. Vandrey added, and it’s unclear how the health effects — positive or negative — of marijuana translate into a drinkable beverage.

“The cannabis industry has evolved much faster than the data,” he said. “This is just another great example of that.”

Notable accounts of current politics and practicalities surrounding marijuana reform

I have recently seen two good new press reviews of the essential politics of federal marijuana reform as of January 2022 and of a key practical issue that has been a concern since the start of modern state marijuana reforms.  Here are full headlines, links and excerpts from these pieces:

From Politico, "Big Weed is on the brink of scoring big political wins. So where are they?: Competing agendas have stifled the effectiveness of the burgeoning industry on Capitol Hill."

Marijuana advocates are stuck in the weeds. Cannabis policy has never had a rosier outlook on Capitol Hill: Democrats control both Congress and the White House, seven new states just legalized recreational marijuana, and the cannabis industry has gained powerful new allies in companies like Amazon and conservative groups like Americans for Prosperity that are backing federal reform. The industry has even lured powerful advocates like former GOP House Speaker John Boehner and former Democratic Senate Majority Leader Tom Daschle to help push its agenda.

But nearly one year into this Congress, not one piece of cannabis legislation has been sent to the president's desk. There is growing fear among advocates that the window to act is closing. Industry lobbyists and legalization advocates say the movement has been stymied by a lack of consensus on the legislative strategy. Liberal advocacy groups are pushing for a comprehensive overhaul of federal cannabis policies with the aim of helping people harmed by criminal enforcement, while industry groups are seeking any piecemeal policy victory that could provide momentum toward more sweeping changes.

“There are certain people who are willing to forgo any of it if they don’t get all of it,” said one marijuana lobbyist, speaking on condition of anonymity in order to candidly discuss the industry’s struggles. The lobbyist noted that such a viewpoint is not universally shared, causing a disagreement “that’s stunting the legalization effort.”

From Bloomberg, "U.S. Grapples With How to Gauge Just How High Cannabis Users Are"

“Everybody wants a cannabis breathalyzer — something like what we have for alcohol where you breathe into a device and it tells a THC level and whether that means you’re impaired or not,” said Jodi Gilman, an associate professor in psychiatry at Harvard Medical School and lead author of the imaging study.  “But that’s not how it works for cannabis, we need a new paradigm.”

Companies have been trying to crack the stoned-test for a while.  Hound Labs, which makes a marijuana breathalyzer, said in September it had raised $20 million to scale its product.  Cannabix Technologies Inc. recently reported it had made headway creating a more portable device, while Lifeloc Technologies Inc. said it was finalizing the platform for a rapid marijuana breathalyzer that could be used for roadside testing.

There are concerns, however, that tests based on THC levels may be unfair to those who have it in their system but aren’t actually impaired.  This can be the case for some who consumed cannabis days ago, or with frequent users who’ve built up a tolerance — who may use it for medical reasons.  “You wouldn't want to penalize that person,” Gilman told me. “What this technology will do is differentiate impaired from not-impaired, which is different than distinguishing cannabis from no-cannabis.”

Latest issue of JNCI Monographs with multiple articles on cannabis policy and research

The December 2021 issue of JNCI Monographs has a series of papers stemming from a symposium last year organized by the National Cancer Institute exploring cannabis policy, public health and research. Here are just some of the great-looking articles in the issue:

"The National Cancer Institute and Cannabis and Cannabinoids Research"

"Cannabis Policy in the United States: Implications for Public Health"

"Nonmedical Cannabis Use: Patterns and Correlates of Use, Exposure, and Harm, and Cancer Risk"

"Cannabis and the Cancer Patient"

"Challenges for Clinical Cannabis and Cannabinoid Research in the United States"

Here is a short excerpt from the first of these article:

Recent survey evidence suggests that one-quarter of cancer patients have used cannabis, often to manage common cancer symptoms or treatment side effects, such as anorexia, nausea, and pain, and there is some evidence of ameliorative effects. A majority of US oncologists engage in discussions about cannabis use with patients, and although almost one-half of them recommend it clinically, few oncologists feel sufficiently informed to make recommendations to their patients regarding the use of cannabis. In general, studies that replicate the effects of cannabis and its constituents are needed as are improvements in research quality and surveillance capacity.

"An Overview of Decriminalization Efforts in Regard to Psychedelic Plants in the United States, 2019-2020"

The title of this post is the title of this paper recently posted to SSRN and authored by Aaron Roberts, a student at The Ohio State University Moritz College of Law.  (This paper is yet another in the on-going series of student papers supported by the Drug Enforcement and Policy Center.)   Here is this paper's abstract:  

This paper examines the recent developments made in psychedelic-related drug policy in the United States.  The paper gives an overview of the decriminalization efforts made at the state and local levels.  The paper also looks at the historical, cultural, political, and public health factors that have shaped psychedelic policy throughout American history and into the current day.  Lastly, the paper shares some concerns about discrimination and unequal access present in psychedelic-assisted psychotherapy.

"Cannabis as Treatment for Chronic Pelvic Pain in Women: An Opportunity for the Cannabis Wellness Industry"

The title of this post is the title of this new paper recently posted to SSRN and authored by Jamie Feyko, a rising 3L at The Ohio State University Moritz College of Law.  (This paper is yet another in the on-going series of student papers supported by the Drug Enforcement and Policy Center.)   Here is this latest paper's abstract:  

In a healthcare landscape that routinely ignores women’s pain, many women turn to cannabis to manage their otherwise debilitating chronic pelvic pain caused by conditions such as endometriosis and polycystic ovary syndrome.  This paper explores how the Controlled Substances Act wrongly characterized cannabis as having “no medicinal value” and the effects this federal illegality still has on women seeking alternative pain management therapies for chronic pelvic pain.  Additionally, this paper explains why and how cannabis helps relieve such pain through discussing the effects of cannabinoids like THC and CBD on the body’s inflammatory response and the body’s endocannabinoid system.  Women, as the leading consumers in our society, have expressed a need and a desire for products that provide relief from chronic pelvic pain and increase sexual pleasure.  The 2018 Farm Bill opened the doors to CBD businesses looking to break into the women’s sexual and reproductive wellness market.  The market for women-centric CBD pain relief and sexual enjoyment is far from saturated, and this paper encourages those in the CBD industry (or those looking to enter the industry) to take note.

"Nowhere to Now, Where? Reconciling Public Cannabis Use in a Public Health Legal Framework"

The title of this post is the title of this notable new paper authored by Daniel Orenstein now available via SSRN. Here is its abstract:

States continue to legalize recreational cannabis, but most have heavily restricted where consumption of newly licit cannabis is permitted.  Every legalizing state has thus far prohibited open, outdoor public use, either limiting lawful use to private property or allowing a small number of licensed indoor venues for consumption outside of public view, an approach borrowed from alcohol control.  In contrast, some non-U.S. jurisdictions have adopted a tobacco control approach, allowing limited outdoor public use while prohibiting indoor public use.  Each approach presents individual and population health risks that reflect the complex intersection of health, social inequities, and community norms.

Cannabis consumers face uncertain but potentially significant health risks from use, and the relative availability of use locations also implicates existing inequities in policing practices and housing.  Those who do not use cannabis but are exposed to others’ use face possible harms from secondhand smoke and from intoxicated behavior, with such risks likely to be inequitably distributed due to existing employment and housing patterns.  Communities as a whole also face risks, including that changing cannabis norms may increase use prevalence or intensity and that concentration of cannabis outlets in under-resourced communities may prove as detrimental as the concentration of other disfavored businesses has been.

Each public use approach carries attendant risks, but a regulatory framework based on the tobacco control model best balances the protection of public health and the promotion of equity and social justice.  This model recognizes the parallels between cannabis and tobacco (in addition to those between cannabis and alcohol).  This approach also provides a pathway to mitigating the public health risks of cannabis legalization by leveraging an approach that has proven effective at reducing secondhand exposures and denormalizing smoking behavior in the tobacco context.

"What’s the best minimum legal age for cannabis?"

The question in the title of this post is the headline of this effective new Leafly article, which builds off the research noted in this prior post about the "right" minimum age for legal access to recreational cannabis.  Here are excerpts:

When it comes to legal cannabis, the random collection of ages across North America is curious. Every US state that allows recreational cannabis sales requires customers to be at least 21 years old. In Canada the minimum age is 19, except in Alberta (where it’s 18) and Québec (which started at 18 but raised it to 21 earlier this year).

In most jurisdictions, medical marijuana is legal for people age 18 and older, with a doctor’s recommendation.

What difference does it really make if someone is 18, 19 or 21? A research team at Memorial University in Newfoundland, Canada, recently investigated the question. Instead of looking at the immediate health and safety of young adults, they assessed later life outcomes — namely educational attainment, lifetime cigarette smoking habits, and general physical and mental health. In their study, the Memorial University team concluded that the ideal minimum legal age for cannabis was 19....

Health experts cite THC exposure in adolescents causes changes to the brain’s folding patterns, decreased neural connectivity, thinning of the cortex and lower white matter, among other symptoms. However, one recent study suggests any changes to brain structure caused by cannabis use in adolescence cleared up by the time subjects were in their 30s.

Another ongoing study in the Saguenay region of Quebec took MRI scans of over 1,000 adolescent brains in 2002, and the same subjects are currently being re-evaluated as adults — results pending.

If the serious nature of brain health is such a risk, why not just make cannabis illegal until a person’s mid-20s? In the real world, policymakers have to weigh human nature’s penchant for the forbidden with appropriate rules and consequences. In an ideal world, sure — and in this ideal world underage kids never go looking for cannabis from illicit sources, either. In the real world, though, policymakers have to weigh human nature’s penchant for the forbidden with appropriate rules and consequences. In an ideal world, alcohol would also be outlawed for health reasons, but we all know how Prohibition worked out.

Prior to the Oct. 2018 opening of legal cannabis sales in Canada, a government task force took a hard look at the best-legal-age question. That group found that the higher the minimum legal age, the more likely adolescents will seek out unregulated sources, risking both consumption of potentially more dangerous products and also incarceration.

Prior related post:

• "Too young for Cannabis? Choice of minimum legal age for legalized non-medical Cannabis in Canada"

Notable new research and commentary on marijuana reforms and traffic fatalities

The JAMA Internal Medicine journal has this week published online notable new original research and commentary on roadway fatalities in some states that have legalized marijuana use by all adults (called RCL in the works).  Here is the main piece and its main results and conclusions from its abstract:

"Association of Recreational Cannabis Laws in Colorado and Washington State With Changes in Traffic Fatalities, 2005-2017":

Results

Implementation of RCLs was associated with increases in traffic fatalities in Colorado but not in Washington State.  The difference between Colorado and its synthetic control in the post-RCL period was 1.46 deaths per 1 billion vehicle miles traveled (VMT) per year (an estimated equivalent of 75 excess fatalities per year; probability = 0.047).  The difference between Washington State and its synthetic control was 0.08 deaths per 1 billion VMT per year (probability = 0.674).  Results were robust in most sensitivity analyses.  The difference between Colorado and synthetic Colorado was 1.84 fatalities per 1 billion VMT per year (94 excess deaths per year; probability = 0.055) after excluding neighboring states and 2.16 fatalities per 1 billion VMT per year (111 excess deaths per year; probability = 0.063) after excluding states without MCLs.  The effect was smaller when using the enactment date (24 excess deaths per year; probability = 0.116).

Conclusions and Relevance

This study found evidence of an increase in traffic fatalities after the implementation of RCLs in Colorado but not in Washington State.  Differences in how RCLs were implemented (eg, density of recreational cannabis stores), out-of-state cannabis tourism, and local factors may explain the different results.  These findings highlight the importance of RCLs as a factor that may increase traffic fatalities and call for the identification of policies and enforcement strategies that can help prevent unintended consequences of cannabis legalization.

And here are two follow-up pieces published with this main piece:

Invited Commentary: "Reducing Impaired Driving Fatalities: Data Need to Drive Testing, Enforcement, and Policy"

Research Letter: "Change in Traffic Fatality Rates in the First 4 States to Legalize Recreational Marijuana"

Student presentation on "CBD and its efficacy as a sleep aid"

The last of a big group of student presentations in my Marijuana Law, Policy & Reform seminar will focus on "CBD and its efficacy as a sleep aid." Here some background readings he has provided:

CBD Sources

1. "CBD & Parkinson's Disease"
2. "Is CBD legal? Here’s what you need to know, according to science"
3. "Cannabidiol can improve complex sleep‐related behaviours associated with rapid eye movement sleep behaviour disorder in Parkinson's disease patients: a case series"
4. "Is CBD legal in your state? Check this chart to find out"
5. "Cannabidiol (CBD) — what we know and what we don’t
6. "Every Question You Have About CBD—Answered" 

Sleep Sources

1. "The State of Sleep"
2. "What to know about sleep deprivation"
3. "Prescription sleeping pills: What's right for you?"
4.  "Are Sleeping Pills Safe?"
5.  "1 in 3 adults don’t get enough sleep"

FDA Approved MJ derived medicine

 "FDA Approves First Drug Comprised of an Active Ingredient Derived from Marijuana to Treat Rare, Severe Forms of Epilepsy"

Parkinson’s Source

"Parkinson's Disease"

Should the public health community applaud shifts from alcohol to marijuana (and support cannabis beverages)?

The question in the title of this post is prompted by this interesting recent Forbes piece headlined "Cannabis Taking A Larger Share Of Alcohol Industry Amid Concern Over Calories And Hangovers." Here are excerpts:

The growing concern over calories and hangovers is driving more millennials to replace alcohol with cannabis in their social life — a trend that pushes investors to increasingly eye the infused beverage industry as an opportunity.

A recent Monitoring the Future research found US millennials drink far less alcohol than previous generations: The percentage of college students who drink alcohol daily declined from 6.5% in 1980 to 2.2% in 2017.  By contrast, there was a significant increase in daily marijuana use among young US adults, especially during 2019, the research further revealed, resonating with the gradual legalization of medical and recreational marijuana across the country....

Financial services company Cowen predicts the sales of recreational cannabis in the US will increase more than 700% from $6 billion in 2016 to $50 billion in 2026, prompting beverage companies of all sizes, such as Ceria, to tap into the space to grow their profits.  Keith Villa, the creator of Blue Moon Brewing Company, launched Ceria in 2018 – a company produces a cannabis-infused and non-alcoholic craft beer brand Grainwave.  Breweries that manufactures similar products include Colorado-based New Belgium Brewing and Dad & Dude’s Breweria, as well as SweetWater Brewing Co. of Georgia.  Several mainstream CPG heavyweights, including Coca-Cola, PepsiCo and Mondelēz, also reportedly consider launching infused food products, but nothing so far has materialized.

These existing infused beverages in the market, however, do not appeal widely to consumers who are already frequent cannabis users, at least according to Jake Bullock, co-founder of cannabis-infused social tonic startup Cann.  Cann produces cannabis-infused beverage products that are low in calories.  “As a result, the mainstream consumer is not entering the market as quickly,” he wrote me via email, stressing the cannabis industry has lagged the growth projections many analysts and companies have made.  “It is clear that cannabis is here to stay and will only continue to penetrate existing markets and new states over time,” Bullock added....

The other element that prevents more people from exploring THC-added food is their confusion with CBD products.  The other co-founder of Cann, Luke Anderson, notes many consumers who are curious about cannabis turn to CBD to explore the plant, but often time, they don’t know the difference between the cannabinoids.  “This has created a lot of confusion in the market, with people thinking they would 'feel something' after trying a CBD-only product and not being able to tell what was physiologically happening versus a placebo effect,” he said.

“This experience may have discouraged people from exploring micro doses of THC, which are quite safe but give you a very palpable buzz.  While CBD products play in a crowded health and wellness segment of grocery aisles.”

Anderson said his company has aimed to reshape the alcohol industry with a small amount of THC in each can since it was first launched about a year ago.  Cann prides itself in balancing 2 mg of sativa-dominant hybrid THC and 4mg of CBD to provide a “sessionable experience” without high calories and the hangover.

When the modern marijuana reform movement got started, I was often in the habit of saying that it would likely be a "public health win" if a lot of alcohol use was replaced by marijuana use. This article suggest this is already happening, and I presume a growing cannabis beverage market would enhance the number of folks who might substitute cannabis for alcohol. But, as the question in this post title reveals, I am not knowledgeable enough about the public health literature to say for sure that these trends ought to be applauded.

"Marijuana policies: A call to shift from a criminal justice approach to a public health approach"

The title of this post is the title of this Hill commentary authored by Elizabeth Long and Diana Fishbein.  Here are excerpts:

Despite the billions of dollars, marijuana prohibition has cost society; this strategy has failed to protect communities. Instead, it has caused great harm, particularly for marginalized populations. These adverse outcomes are rooted in policies enacted to tackle this public health problem that has little to do with public health. Marijuana possession continues to be treated as a criminal matter, even though, historically, there are no examples of criminal law solving a public health matter....

While decriminalization of marijuana is projected to have many economic and social benefits, legislation must balance decriminalization with the need to prevent teenage use. Teenage marijuana use can alter the course of brain development and increase risk for dependence and possibly addiction. Heavy use in adolescence has been associated with several developmental delays. Importantly, when teenagers believe using a drug is not harmful, they are more likely to use it....

A substantial body of research justifies reallocating resources from criminal justice to public health policies. A public health approach focuses on the implementation and enforcement of regulations to manage health risks through policy changes, such as taxation, regulation of advertising, and age limits. Several policy recommendations are offered here for consideration:

1. Support a detailed, comprehensive, scientific evaluation of the impacts from current laws surrounding both medical marijuana and adult-use to guide future legislation.
2. Re-categorize marijuana from Schedule I to Schedule III or IV to be more consistent with its known pharmacological properties and effects.
3. Update the regulatory structure by applying uniform standards to the types of products that can be sold or marketed to the public.
4. Invest prevention resources in delaying the age of initiation of marijuana use past the period when the brain is still developing (around age 25) to reduce the impact on neurodevelopment.
5. Support screening, early detection, and intervention. Focus both on at-risk youth who have not yet initiated to avert pathways to use in adolescence and youth who have already begun using marijuana to avoid negative consequences. 

"Yes, marijuana has a gateway effect. But so do most addictive substances."

The title of this post is the title of this notable new Washington Post commentary.  I am not keen on the headline, but I am keep on the contents, especially because a Democratic Prez Candidate Debate scheduled for tonight makes this piece is a timely must-read.  But that is true primarily because it is authored by Keith Humphreys, who I always consider to be a timely must-read.  Here are excerpts:

When former vice president Joe Biden asserted over the weekend that marijuana shouldn’t be legal because it might be a “gateway” to hard drug use, pro-legalization critics were quick to paint him as an out-of-touch codger still fighting the last drug war.  But the reaction isn’t entirely fair: Yes, the marijuana gateway theory that was omnipresent in the 1980s was at best distorted and at worst dishonest.  Nevertheless, gateways between marijuana and other addictive substances are real — and they swing in both directions.

During the heyday of anti-marijuana sentiment in America, fear-based prevention programs warned adolescents that a huge percentage of adults who experienced some horrible drug-related outcome (e.g., becoming addicted to heroin) had used marijuana when they were younger.  These statistics were technically accurate, but even as teenagers, most of my classmates and I could see the logical flaws in the implication that marijuana was inevitably a road to ruin.  Just because most people who used heroin had previously used marijuana didn’t prove that most people who used marijuana would go on to use heroin.

But strip away that era’s ideological agenda, designed to assign marijuana a unique and powerful role in ruining lives, and a more nuanced underlying truth about gateways reveals itself. People who become users of almost any addictive substance are at higher risk of subsequently using and having problems with other substances.  A recent National Academies of Sciences, Engineering, and Medicine report found moderate evidence that this is the case for cannabis, but it’s also true of other drugs, including legal ones such as alcohol and tobacco.  At least three causal forces can create such gateways.

First, people can become habituated to particular routes of administering drugs....

Social networks are the second force behind drug gateways. Drug use, like many other behaviors, is very commonly a social activity. This creates gateway effects between drugs in part because classes of behavior (e.g., playing sports, traveling to exotic locales, collecting antiques or, yes, taking drugs) come to seem more normal when your friends all engage in them.... 

Gateways can also result from users’ desire to combine the effect of a new drug with a familiar one.  Established cocaine users sometimes become heavy drinkers (and vice versa) because they find the cocaethylene produced in the body by this drug combination particularly euphoric. Similarly, the fact that many people take the trouble to carve out cigars and fill them with marijuana (known as smoking “blunts”) demonstrates that tobacco and marijuana combined is uniquely reinforcing to some users.

So those who mocked Biden’s claim that marijuana could be a gateway to other drugs thus got the science wrong. There are plenty of ways using the drug can make people more likely to use other substances.

But research also shows that singling out marijuana is wrong; the gateway effect is in fact shared by many substances.  If Biden continues to oppose the legalization of marijuana on the grounds that marijuana could lead to other drugs, it is only fair that he should answer another question: Why have we made alcohol and tobacco legal and often subjected them to insufficient restrictions when they are powerful gateways, too?

"The Complicated Relationship Between Marijuana Use and Parenting"

The title of this post is the title of this new paper recently posted to SSRN and authored by Kathryn Foust, a recent graduate The Ohio State University Moritz College of Law.  This paper is the sixteenth paper in an on-going series of student papers supported by the Drug Enforcement and Policy Center.  (The fifteen prior papers in this series are linked below.)    Here is this latest paper's abstract:

The intersection between marijuana and parenting is both highly controversial and largely unexplored.  Despite the trend of legalization (medicinal and recreational) across the country, there is a widening discrepancy between criminal laws and child welfare policies.  Even in states where marijuana is recreationally legal, a parent might still be charged with child abuse or neglect as a result of his or her marijuana use.  Although second-hand marijuana smoke has proven to be a relatively low risk of harm to children, other areas of concern have not been adequately studied, such as the effects of marijuana use during pregnancy and/or breastfeeding.  Despite the lack of reliable scientific studies on the impact of ingestion by children, some initial studies have shown a marked increase in frequency of accidental ingestions and resulting hospital treatment in states that have legalized marijuana.  The palatability and attractiveness of “edibles” is likely the cause of this measurable and dramatic increase. Overall, parental marijuana use has been inadequately studied by science, but some reliable data is available which could be used overhaul existing children’s services policies.

Prior student papers in this series:

• "The Canna(business) of Higher Education"
• "Marijuana Banking in New York and Around the US: 'Swim at Your Own Risk'"
• "Intellectual Property Survey: Cannabis Plant Types, Methods of Extraction, IP Protection, and One Patent That Could Ruin It All"
• "Marijuana in the Workplace: Distinguishing Between On-Duty and Off-Duty Consumption"
• "An Argument Against Regulating Cannabis Like Alcohol"
• "The State of Marijuana in The Buckeye State and Fiscal Policy Considerations of Legalized Recreational Marijuana"
• "Race Based Statutes at Play with Cannabis: Cultivating a Process for Weeding Out the Competition"
• "Tribal Cannabis: Balancing Tribal Sovereignty and Cooperative Enforcement"
• "Land of the Free, Home of the (Disgruntled) Brave: The Case for Allowing Veterans Access to Medical Marijuana"
• "Cannabidiol (CBD) in the Therapeutics Industry"
• "The Good, the Bad, and the Ugly: Why IRC § 280E Is Not the Industry Killer It Is Portrayed to Be"
• "Achieving Diversity in the Marijuana Industry: Should States Implement Social Equity into Their Regimes?"
• "Cannabis Legalization: Dealing with the Black Market"
• "Pop Culture's Influence on Recreational Marijuana Use & Legislation: A Case Study on Snoop Dogg"
• "Going Green in American Professional Sports: Why Marijuana Usage Should Be Allowed and What Policy Changes Should Ensue"

"A special exception for CBD in foods and supplements?"

The question in the title of this post is the headline if this notable new editorial in the journal Drug Discovery Today authored by Patricia Zettler and Erika Lietzan.  (Disclosure/humble brag: Professor Zettler is on the Ohio State College of Law faculty and a member of our Drug Enforcement and Policy Center.)  Here are excerpts from the start and end of the piece:

In the last two years the cannabidiol (CBD) market has exploded. Consumers can purchase CBD-containing oils, lotions, gummies, tea, coffee, water, popcorn, and cereal, on store shelves and online. Celebrities and athletes are touting the benefits of these products, and sales are forecast to exceed $20 billion in the next five years.  This market explosion has coincided with the U.S. Food & Drug Administration (FDA)’s 2018 approval of the first CBD drug (Epidiolex), for treating seizures associated with two rare and severe forms of epilepsy in children, as well as the 2018 Farm Bill, which removed cannabis with low levels of delta-9-tetrahydocannabinol (THC) — “hemp” — from the federal list of controlled substances.  And it comes on the heels of nearly 40 states enacting comprehensive laws to legalize cannabis for medical use (and sometimes recreational use) within their borders.

Yet significant questions remain about the legal status of these widely available CBD products.  Most sales of CBD-containing foods and supplements violate the “drug exclusion rules” in the Federal Food, Drug, and Cosmetic Act (FDCA).  But FDA has yet to enforce those rules, apart from sending warning letters to a few sellers.  The agency is instead considering what approach to take.  Several former agency officials — including former Commissioner Scott Gottlieb — have urged FDA to create a sensible, science-based path forward for consumer products.  The time is ripe for the agency, lawmakers, health care providers, the drug discovery community, and the public to consider the purpose of the drug exclusion rules and what a different approach — exempting CBD — might mean for consumer and patient access and safety, as well as innovation incentives....

As a practical matter, CBD-containing foods and supplements may be here to stay.  Lawmakers or FDA may decide that the drug exclusion rules are unwarranted for CBD, given the federal descheduling of hemp, state legalization of cannabis products, and (eventually) rigorous evidence that CBD products are relatively safe.  But FDA should not default into this position simply because a robust, albeit unlawful, market has already emerged.  A decision to give CBD special treatment should be made thoughtfully and with public participation, accounting for possible gains in consumer access and choice, as well as the lost opportunity to learn, and harness, CBD’s full therapeutic potential.