Introduction and Legalization

Currently, there are ten states and the District of Columbia with legislation that allow recreational or medicinal use of marijuana. Several other states also have laws that legalize the use of marijuana for recreational or medicinal use. Among the states that allow recreational use of marijuana for adults 21 years and older are Alaska, California, Colorado, Maine, Massachusetts, Michigan, Nevada, Oregon, Vermont and Washington. Other states allow for limited use of medical marijuana in the form of oils, pills and cannabis-infused products; most states have also decriminalized possession of small amounts of marijuana. Medical use of marijuana for specific conditions varies in different states; for example use in severe epileptic conditions are allowable in Alabama and Mississippi.

California was the first state to legalize medical marijuana in 1996 with Colorado and Washington being the first two states to pass legislation allowing recreational use of marijuana in 2012. Data from retail sales of marijuana in Washington indicate sales of almost 2 billion dollars with tax revenue reaching $700 million dollars from 2014-2019.1 The state of Colorado reports increasing retail marijuana sales with a slight decrease in the sale of medical marijuana (Figure 1).

Figure 1. Colorado Marijuana Sales.2
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Retail sales of marijuana in Massachusetts had transactions worth over 23 million dollars in the first two months, with a tax of 17% benefiting the commonwealth.3 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 2).

Figure 2. Marijuana Legal Status Map.4
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Surveys of the general public have indicated an increase in support and acceptance for legalization of marijuana has to 62%, when compared to just 16% in 1990 (Figure 3). This acceptance in translated by younger users as safe with minimal health consequences.5

Figure 3. Percent Supporting Marijuana Legalization.7
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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.8,23 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.9

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.”10 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.11

Statistics of marijuana use in the U.S. from a national survey by the National Institute on Drug Abuse from 1996-2018 indicate daily use of marijuana is highest among high school seniors, with a decreased use among 8th graders (Figure 4).12 Vaping nicotine and or marijuana has increased over all age groups (8th graders - 12 graders), with cigarette use declining (Figure 5). 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 7).8

Figure 4. Daily Marijuana Use.13
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Figure 5. Vaping Nicotine or Marijuana Among Teens.13
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Figure 6. Decline of Cigarette use Among Teens.13
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Figure 7. Marijuana Use Increased Over the Last Decade.13
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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.14 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.