Don't Rush to Legalize Marijuana, Warns Former Surgeon General

Alicia Ault

November 08, 2016

Former US Surgeon General Richard Carmona, MD, MPH, is urging against hasty adoption of laws that would legalize marijuana for medical or recreational purposes.

The physician, now the Distinguished Professor of Public Health at the Mel and Enid Zuckerman College of Public Health at the University of Arizona, Phoenix, offered his opinion in a November 4

"As of today, it appears that the proverbial cart has been placed before the horse and the horse is blinded by the cloud of smoke," Dr Carmona writes.

On November 8, voters in nine states will take up ballot initiatives that would legalize marijuana for either medicinal or recreational use.

Voters in Florida, Montana, North Dakota and Arkansas will weigh measures that expand or establish the availability of medical marijuana. In California, Nevada, Arizona, Massachusetts, and Maine, voters will decide whether to legalize cannabis for adults aged 21 years or older.

Marijuana is already legal for recreational use by adults in Colorado, Washington, Oregon, Alaska, and Washington, DC. Twenty-five states, the District of Columbia, Guam, and Puerto Rico now have medical marijuana programs, according to the National Conference of State Legislatures.

Another 17 states allow use of products that have low levels of tetrahydrocannabinol and high levels of cannabidiol for medical reasons in limited situations or as a legal defense.

Only eight states prohibit access to marijuana for any purpose.

A Gallup poll of American adults conducted in early October found that 60% of respondents supported full legalization of marijuana – the highest percentage since the organization first asked about legalization in 1969.

Dr Carmona, who served as the 17th surgeon general of the United States from 2002 to 2006 under President George W. Bush, says that medical and recreational use of marijuana should be considered separately. Marijuana has been found to "impair normal brain development in those who start using at an early age," and it also impairs driving ability, he writes.

The short- and long-term consequences of recreational use "may generate a significant cloud of complications and preventable illness which ultimately we will all pay for," he notes.

For medical use, information does not exist on the dose, frequency of use, potency, potential side effects, and the risks and benefits of use, he says.

"This discussion is neither 'pro nor con' for medical or recreational use of marijuana," says Dr Carmona. "It is intended to provide a scientific informed consent discussion with our elected leaders and the public in order that appropriate prospective policy may be promulgated before expanded marijuana use," he writes.

The American Medical Association has tended to agree with Dr Carmona that marijuana should not be legalized. In 2013, it passed a resolution stating that marijuana is a dangerous drug and a threat to public health. But the resolution also urged leniency for users, adding that "public health based strategies, rather than incarceration, should be utilized in the handling of individuals possessing cannabis for personal use."

Another group, Doctors for Regulation of Cannabis (DFRC), believes that cannabis should be fully legalized, in part because prohibition has been a failure, said David L. Nathan, MD, DFAPA, founder and board president of the Washington, DC–based organization.

The DFRC was established in early 2016 and includes former Surgeon General Joycelyn Elders, MD, and Westley Clark, MD, FASAM, a former director of the Center for Substance Abuse Treatment at the Substance Abuse and Mental Health Services Administration, on its honorary board.

Dr Nathan said he agrees with Dr Carmona that medical use and recreational use should be viewed separately.

"There is a dearth of good evidence for a number of the conditions for which marijuana is being used medically," Dr Nathan told Medscape Medical News.

Legalization would help provide the regulatory structure to test for potency and purity, ensure proper labeling, allow claims to be properly vetted, and require licensing of retailers, who would be held accountable to screen for underage buyers.

Marijuana can be safely used by consenting adults — those older than 21 years — said Dr Nathan, who is also clinical associate professor of psychiatry at Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey. The use of marijuana does not result in lethal overdose and is "less harmful than the use of alcohol and tobacco," he noted.

Noting the harms to the developing brain, Dr Nathan said, "Legalization of marijuana for adults should never imply societal acceptance of underage use."

Marijuana prohibition has failed to stop teens and children from using the substance, and it "leads to racial bias in law enforcement, as African Americans are over four times more likely to be arrested for marijuana infractions than their white counterparts despite similar usage rates," he said.

People who are arrested and incarcerated for marijuana use have trouble finding employment and have other difficulties that can worsen poverty, he said, adding that the impoverished have worse access to healthcare.

"So if we're looking at this from a public health standpoint, we need to understand that marijuana prohibition itself is injurious to public health," said Dr Nathan.

His organization — which receives no funding from industry and is financed by its 100 or so individual physician members ― has lobbied in support of the ballot initiatives in California and Massachusetts, as those two states have an appropriate regulatory framework, said Dr Nathan.

He is hopeful that the California ballot measure will succeed. "If the initiative goes through in California, nearly 25% of the US population will be living in a state where marijuana is legal," he noted.

Dr Carmona and Dr Nathan have disclosed no relevant financial relationships.

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