"Anticipated public health costs of marijuana legalization are significant"

Over at Join Together, a commentary by Dr. Stuart Gitlow, a member of the American Medical Association's Council on Science & Public Health and Acting President of the American Society of Addiction Medicine, has this to say about marijuana legalization:


With Election Day just around the corner, voters in multiple locations will again be confronted with cannabis-related questions . . . 

In each case, there is a less-than-subtle approach to licensing and regulation, with excise taxes, fees and other revenue generating components representing a critical argument used in favor of passage . . . The legislatures in each state appear to have ignored the many associated costs which will quickly swallow the revenue described. This includes increased utilization of the drug at younger ages with associated addictive and physical illness, diminished productivity caused by cognitive abnormalities, and increased drugged driving and associated morbidity/mortality.

In July, the American Society of Addiction Medicine (ASAM) considered the question of marijuana legalization, concluding:

1)  That physicians lead efforts to oppose legislative or ballot initiatives that would result in the legalization of marijuana production, distribution, marketing, possession and use by the general public, and that all physicians incorporate screening and intervention for risky substance use, including marijuana use, as well as diagnosis, treatment and disease management for addiction into their routine medical practice;

2)   That public education campaigns be undertaken to inform the public that addiction associated with cannabinoids is a significant public health threat, and that marijuana is not a safe product to use, especially, but not only, by smoking;

3)   That parents be informed that the marijuana their children are exposed to today is of much higher potency than the marijuana that was widely available in the 1960s through the 1980s, and that the potential for the development of addiction and for the development and progression of psychotic conditions are enhanced when high-potency marijuana products are used by adolescents because of the unique vulnerability of the adolescent brain;

4)   That when cases of marijuana-related substance use disorders are identified and the diagnosis confirmed by professional assessment, carefully monitored treatment to establish abstinence be offered to afflicted persons and such treatment and insurance coverage for it be readily available;

5)   That drugged driving associated with marijuana use be subject to additional epidemiological research and research on the treatment needs of drivers. Increased efforts are needed to prevent its occurrence which should include substantial legal consequences at the level of the consequences for drunk driving;

6)   That, given the significant role the criminal justice system plays in discouraging marijuana use, states promote programs that enhance linkages between the criminal justice system and the addiction treatment system, using models such as Drug Courts and HOPE Probation.

ASAM asserts that the anticipated public health costs of marijuana legalization are significant and are not sufficiently appreciated by the general public or by public policymakers. Physicians and other health professionals must become more aware of the anticipated undesirable outcomes of marijuana legalization and encourage public education on these facts.

Portugal did not legalize marijuana production and possession

Over the past few days, I have posted information about marijuana policy in the Netherlands from the American Society of Addiction Medicine's White Paper opposing state marijuana legalization initiatives.  Now on to Portugal, another country that marijuana legalization proponents often refer to.  However, when all of the facts about Portugal's drug policy are examined, it becomes readily apparent that what happens in that country is nothing like what legalization proponents are proposing in the United States, including Washington.

From the White Paper:


Portugal has decriminalized the use and possession of a 10-day supply of any illicit drug, including marijuana, changing it from a criminal offense to an administrative one.  Like the Netherlands, all drug sales and manufacturing -- including marijuana -- remain illegal in Portugal and are met with criminal sanctions.  The implementation of decriminalization for drug possession changed the way in which drug users are handled in Portugal.  Rather than being subject to arrest, drug users are summoned by the police to their local district's Commission for the Dissuasion of Drug Abuse (CDT), three-member groups in charge of evaluating and ruling on the drug possession offense.  CDT's dispense administrative punishments for most drug users, some of which are suspended if treatment is obtained, though there is no monitoring mechanism to ensure treatment participation or completion.  The large majority of CDT cases involve only marijuana.  There is limited evidence to identify the effects of Portugal's drug policy changes, and particularly to separate the effects of decriminalization from other changes recently made and the relevance of these changes for any other country, including the United States. 

Comparing the Portuguese experience with the decriminalization of marijuana possession with what is contained in I-502, the following things stick out.  I-502: 

-- does not just decriminalize marijuana possession but legalizes the growth, production, sale, and possession of marijuana creating a new free-market marijuana industry.

-- does not provide funding for the enforcement of the new regulatory system or laws.  Portuguese police issue citations to people they see possessing drugs and refer them to CDT's.

-- does not set aside additional money for publicly-funded substance abuse treatment.  Portugal has increased funding for substance abuse treatment.

Dutch government says their tolerant marijuana laws create nuisances and crime

To follow up with yesterday's post about marijuana laws in the Netherlands, below is more from the American Society of Addiction Medicine's White Paper opposing state marijuana initiatives.

The potency (i.e. concentrations of delta-9-tetrahydrocannabinol, THC) of marijuana and hashish sold in coffee shops [in the Netherlands] has significantly increased over time.  As a result of increases in international drug tourism and drug trade, commercialization of the marijuana industry, and stronger links to organized crime, the drug policy of the Netherlands is now changing.  The Dutch government states that in order "to combat the nuisance and crime associated with coffee shops and the trade in drugs," "coffee shops must become smaller and easier to control."  De facto decriminalization has and will remain intact for all "soft" drugs, including marijuana and hashish in the Netherlands; however, marijuana with THC content of 15% or more is now considered a "hard" drug and is banned from sale.  Coffee shops are no longer public; they are private clubs with limited membership for persons 18 and older who can prove they are residents of the Netherlands and they must be located at a distance from schools.  These and related changes are currently underway and will all be in place by January 1, 2013.  


Comparing the Dutch experience with tolerant marijuana laws with what is contained in Initiative 502, on which Washingtonians will vote in November, the following things stick out.  I-502:

• does not contain any provisions that would ensure our state does not become the next destination for international drug tourism.  
• does not contain any regulations regarding the THC content of marijuana.  
• does not contain money for the increased need for law enforcement that may be needed to deal with a possible increase in organized crime.
• does not ban mass media marketing and advertising of marijuana, part of what it means to have a commercialized marijuana industry.  

Addiction experts statement: In the Netherlands marijuana is tolerated, not legal

Yesterday's post included a statement released by the American Society of Addiction Medicine opposing state marijuana legalization initiatives.  The statement is part of a White Paper released by the organization that provides a comprehensive overview of the marijuana-related issues that they took into consideration when developing it.  Section V of the White Paper provides international context.  Here is an excerpt:

Those in favor of legalizing marijuana in the United States sometimes turn to the experience of other nations with less restrictive approaches to drug policy, particularly the Netherlands and Portugal, to inform their cause.  As noted, no country has legalized marijuana use and sale.  In the Netherlands, the use, possession, and sale of marijuana all remain illegal.  The laws which would typically ban marijuana "coffee shops" (where marijuana is sold) and marijuana users within these shops are not enforced is a policy of "toleration."  Historically, Dutch coffee shops have been permitted to sell marijuana under simple, but strict conditions such as without advertisement, in limited amounts (5 grams) per person each day, only to adults age 18 and older, and without "cause of nuisance."  The marijuana sold in these shops has been and continues to be illegally grown and/or imported.

In other words, what is being proposed by marijuana legalization proponents in the United States, including Washington, is not at all similar to what is allowed in the Netherlands.

Addiction medicine physicians oppose state marijuana initiatives

Yesterday, the American Society for Addiction Medicine, the country's foremost association of physicians who diagnose and treat substance abuse addiction, released a statement opposing all of the state ballots that propose to legalize marijuana. 

From their statement:

ASAM asserts that the significant public health problems and costs related to marijuana legalization are not well-understood by the public or policymakers. ASAM's conclusion that marijuana legalization would threaten public health is based on the following:

·         Marijuana use is neither safe nor harmless. Marijuana contains psychoactive cannabinoids which can produce a sense of discomfort and even paranoid thoughts in some users. Cannabinoids interact with brain circuits in comparable ways to opioids, cocaine and other addictive drugs. Marijuana use is associated with damage to specific organs and tissues and impairments to behavioral and brain functioning.

·         Of greatest concern is marijuana use during adolescence—a time of ongoing brain development and heightened vulnerability to addiction. Research shows that heavy marijuana use decreases neurocognitive performance, with worse neurocognitive effects seen among those who begin marijuana use early.

·         Marijuana is addictive. Repeated marijuana use is reinforcing because the drug increases activation of reward circuitry in the brain. Approximately 9% of people who try marijuana become dependent. For those who begin using the drug in their teens, approximately 17% become dependent. These figures are similar to alcohol dependence.

·        Legalization would promote the public perception that marijuana is harmless at the same time that availability of the drug would grow exponentially. The rate of marijuana use and marijuana-related substance use disorders, including addiction, would increase.

·         Increased marijuana addiction would heighten demand for substance use disorder treatment services, which already are inadequate for current needs.

·         Marijuana use is associated with increased rates, and worsening symptoms, of psychosis. Increased marijuana use caused by legalization and increased access to high-potency marijuana could result in rising rates of psychotic illnesses.

·         Marijuana-related crashes are major traffic safety threats; marijuana use doubles the risk of a crash. Research inWashington State showed that 12% of drivers killed in car crashes were positive for marijuana. Legalization would increase drugged driving. 

      Marijuana legalization will increase its availability to young people, who are the most at risk from this drug. Research shows that marijuana leads to a host of significant health, social, learning and behavioral problems in young users.