How Does Cannabis Legalization Affect Public Health?

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Cannabis has had a dynamic history these last hundred years, from widespread use to prohibition to a renewing acceptance. As more and more countries accept the science surrounding the plant, many are wondering how will cannabis legalization affect public health? This is a hotly debated topic, with those opposed to legalization expecting society to suffer because of these changes, and those in support seeing it as a return to common sense and access to democratically available natural medicine.

At the heart of this debate is the fundamental idea of whether or not governments should be regulating our ability to make decisions about our own health and explore our own consciousness. Should we allow people to cultivate and consume mind altering plants that have been used by indigenous cultures for thousands of years? Or, are the negative effects that cannabis has on individuals and society as a whole more detrimental than their benefits to individuals? If we were to list all these benefits and problems side by side, to which side of the scale would the balance lean?

That is what we will be exploring in today’s article, and trying to elicit out new perspectives based on the most recent evidence. The first states in the US to legalize cannabis were Colorado and Washington in 2012, this has been followed by a global shift in eased regulations, from Europe to Uruguay, and from Turkey to Thailand. As these places ease restrictions, habits of use change, and over the years we can start to see changing trends in the data. After 8 years, more and more obvious trends are starting to appear, and will surely change further as more countries expand in these efforts.

What are the arguments for legalization?

The arguments for prohibition probably were seeded in truth, but grew largely on alternative motives, fear, and deception. The criminalization of cannabis started around one hundred years ago, and was largely based on propaganda and hypocrisy rather than science or data. This can be highlighted by the fact that the relatively benign plant is scheduled alongside such obviously dangerous drugs as heroin, cocaine, and amphetamines, while the most dangerous drugs to society, alcohol and tobacco, are sold openly at gas stations and supermarkets.

The initiatives to legalize cannabis, in the US and other countries, have largely followed the same path. And has primarily been citizen imitated and directed. It usually begins with education awareness raising about the plant after a century of propaganda and misinformation. The main points of these movements have been:

  • Cannabis use is already common among young adults, and is safer than alcohol, tobacco, and opioids.
  • Punishments for cannabis crimes outweighs the problems caused by cannabis itself.
  • Cannabis laws disproportionately affect minority populations.
  • Cannabis decriminalization reduces black markets and the money flowing to violent gangs and cartels.

Decriminalization for adults is better policy because it eliminates the illicit market, it can be regulated and controlled, it reduces cost of policing, and it enables governments to raise revenue through taxation.

The arguments against legalization include that it will increase the prevalence of cannabis use among youth and adolescents, increase the prevalence and demand for treatment of cannabis use disorder, increase the demand on emergency departments, increase the potency of THC content in cannabis, and increase the prevalence of fatal car crashes and accidents or injuries.

What does the data so far show us?

Over the last two years we have brought you articles detailing the effects of cannabis legalization in Colorado and the US as a whole, but now a new review has been published, which is the most comprehensive to date.

Some of the previous observations from Colorado still hold true more universally. The legalization of cannabis has been followed by a substantial reduction in retail prices, reducing the financial burden on users and decrease the viability of the crop for the illicit purposes of cartels and gangs. It has also allowed adults to obtain the substance without fear of penalty, reduced the number of incarcerations, expunged criminal records, and allowed those convicted of drug offenses to begin moving forward in their lives. It has greatly diversified the number of cannabis products available for sale, increasing the availability of products which are not smoked, thus reducing some of the health implications of cannabis consumption. It has reduced the appeal of more dangerous synthetic cannabinoids or research drugs. And lastly, has improved quality and reduced the risk of contamination and mold.

The price of cannabis has fallen steeply as the fear of incarceration is gone and the ability to scale up and vertically integrate operations has expanded. This effect is only set to accelerate as legalization becomes broader. It may eventually reach a point where interstate and multi-national corporations are allowed to expand into the market to further cut production and distribution costs and fund government lobbyists. This can be a great thing for consumers, but has been pointed out in Thailand, may also undermine the democratic nature of the plants use, and create monopolies as in the tobacco industry.

So, on the societal level, there are mixed feelings about the legalization, but in most cases the fears are unjustified. As we have discussed in detail in previous articles, the rates of adolescent use have actually decreased since legalization, the effects on driving have been ambiguous and insignificant, the effect on crime has been minimal, and homelessness rates have actually decreased.

Although there was an initial doubling of emergency department admissions for cannabis, none of these where life threatening or required long-term treatment, and this increase has been accompanied by a decrease in hospital admissions for opioids. Overall, the effect on public health costs are essentially neutral. Probably the most significant societal level issue arising from the legalization is the accidental exposure of children, which rose from 0 in 2009 to 14 in 2014 in Colorado. However, this number still pales in comparison to the rates of exposure to alcohol, prescription medications, cleaning agents, or other illicit drugs by children.

The adverse personal health effects of cannabis legalization

As illustrated above, most of the original fears concerning cannabis legalization have not been realized. And others, such as the dangers of increased potency or the risk of cannabis use disorder appear to be more subjective than factual. There is so far no evidence that increased potency will lead to increased ill health effects, and there is just as much argument for the benefits of increased potency on reducing the amount required to be consumed and thus reducing the resources required for growing, the cost, and the risks associated with smoking. Likewise, there is no consensus on the implication of the so-called cannabis use disorder. Unlike alcoholism, there is little data to imply that cannabis is physically addictive or leads to disorders from its use. Furthermore, the data shows that diagnoses of this disorder have fallen, both in legal and non-legal areas.

What has been shown, however, is an increase in the incidences of hyperemesis, or patients presenting to the emergency department with uncontrolled vomiting and nausea. Cannabinoid Hyperemesis Syndrome was first described in 2004, and is characterized by chronic cannabis use, cyclic episodes of nausea and vomiting, and the learned behavior of hot bathing. In Colorado, hospital admissions due to cannabinoid hyperemesis have increased by 46%. Although not life threatening, they can lead to dehydration, weight loss, and electrolyte imbalances. This usually requires brief hospitalization, and abstinence from further cannabis consumption.

Another striking statistic from Colorado is that admissions to the emergency department for mental illnesses increased 5-fold relative to other states without cannabis legalization. It should be noted however that correlation does not imply causation, and that the increase in mental illness causes has not been directly tied to cannabis use, and my just be a factor of increased accessibility and reduced stigma surrounding reporting.

So, although the effects of cannabis legalization are largely positive, there do appear to be some real and measurable negative effects as well. There is still no definitive answer to the outcomes of legalization, but to a large extent, it would appear that most of the original fears have not been realized. Furthermore, those fears that where realized have been of a lesser degree than initially proposed, and are largely treatable.

The issues of children being exposed to cannabis were largely addressed in 2007, with new labeling and packaging guidelines. Although this will not completely solve the issue, it has made it much more difficult for children to get access to the drug, and made it safer to have in the home than Tylenol or alcohol. Through further education, like those already in place for household chemicals and medications, can further alleviate this issue and prevent accidental exposures. This education is also needed for adults, to allow pregnant mothers to make informed decisions about cannabis use.

The issue of Cannabinoid Hyperemesis is also real, but extremely rare. The mechanisms are still not understood, and it is largely recognized, even by the FDA, that cannabis is an antiemetic, and should control nausea and vomiting not cause it. This appears to be a matter of individual genetics and biology, and means that some people may not be able to use cannabis. Like common allergens, precautions must be taken, but it should not restrict the use for everyone.

Lastly, the issue of emergency room presentations for mental illness. This is a field for which data is alarming, but still inconclusive. There is only epidemiological data available, which fails to take into account many other factors, such as genetics, history of trauma or abuse, environmental factors, previous drug use, and many others. This is a field which needs to be investigated further, but at this time is not a valid argument for the criminalization of cannabis.

Most countries in the world allow people to take risks with their own bodies. We are permitted to drive motorcycles, eat fast food, bungee jump, smoke cigarettes, drink alcohol, own tigers, and swim with sharks.  Many feel that the role of the government in a democratic nation is to regulate issues which have societal level effects, rather than personal ones. As we have described above, the more data we get about the legalization of cannabis the more it appears that societal level fears were all unfounded. There may be real issues on the individual level, but is it the government’s job to control how people decide to treat their own bodies and minds?

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