A Doctor’s Case For Legalizing Cannabis (Wall Street Journal)

Most Americans are paying too much for marijuana. I’m not referring to people who smoke it—using the drug generally costs about as much as using alcohol. Marijuana is unaffordable for the rest of America because billions are wasted on misdirected drug education and distracted law enforcement, and we also fail to tax the large underground economy that supplies cannabis.

On Monday, the New Jersey legislature passed a bill legalizing marijuana for a short list of medical uses. Outgoing Democratic Gov. Jon Corzine says he will sign it into law. This is a positive step, as cannabis has several unique medical applications. But the debate over medical marijuana has obscured the larger issue of pot prohibition.

As a psychiatrist, I treat individuals who often suffer from devastating substance abuse. Over many years of dealing with my patients’ problems, I have come to realize that we are wasting precious resources on the fight against marijuana, which more closely resembles legal recreational drugs than illegal ones. My conscience compels me to support a comprehensive and nationwide decriminalization of marijuana.

Prohibition did decrease alcoholism and alcohol consumption in the 1920s. However, the resulting rise of violent organized crime and the loss of tax revenue were untenable and led to the repeal of Prohibition. By analogy, while the broad decriminalization of marijuana will likely reduce the societal and economic costs of pot prohibition, it could lead to more use and abuse.

The risks of marijuana use are mild compared to those of heroin, ecstasy and other illegal drugs, but the drug is not harmless. A small number of my patients cannot tolerate any use without serious impact on underlying disorders. Others become daily, heavy smokers, manifesting psychological if not physiological dependence. While most of my patients appear to suffer no ill effects from occasional use, the drug makes my work more difficult with certain individuals.

So why do I support decriminalization? First, marijuana prohibition doesn’t prevent widespread use of the drug, although it does clog our legal system with a small percentage of users and dealers unlucky enough to be prosecuted. More to the point, legal cannabis would never become the societal problem that alcohol already is.

In most of my substance-abuse patients, I am far more concerned about their consumption of booze than pot. Alcohol frequently induces violent or dangerous behavior and often-irreversible physiological dependence; marijuana does neither. Chronic use of cannabis raises the risk of lung cancer, weight gain, and lingering cognitive changes—but chronic use of alcohol can cause pancreatitis, cirrhosis and permanent dementia. In healthy but reckless teens and young adults, it is frighteningly easy to consume a lethal dose of alcohol, but it is almost impossible to do so with marijuana. Further, compared with cannabis, alcohol can cause severe impairment of judgment, which results in greater concurrent use of hard drugs.

Many believe marijuana is a gateway drug—perhaps not so harmful in itself but one that leads to the use of more serious drugs. That is not borne out in practice, except that the illegal purchase of cannabis often exposes consumers to profit-minded dealers who push the hard stuff. In this way, the gateway argument is one in favor of decriminalization. If marijuana were purchased at liquor stores rather than on street corners where heroin and crack are also sold, there would likely be a decrease in the use of more serious drugs.

The nation badly needs the revenue of a “sin tax” on marijuana, akin to alcohol and tobacco taxes. Our government could also save money by ending its battle against marijuana in the drug war and redirecting funds to proactive drug education and substance-abuse treatment. Hyperbolic rants about the evils of marijuana could give way to realistic public education about the drug’s true risks, such as driving under the influence.

Our nation can acknowledge the dangers of cigarettes, alcohol and marijuana while still permitting their use. The only logically and morally consistent argument for marijuana prohibition necessitates the criminalization of all harmful recreational drugs, including alcohol, nicotine and caffeine. We can agree that such an infringement on personal freedoms is as impractical as it is un-American. The time has come to accept that our nation’s attitude toward marijuana has been misguided for generations and that the only rational approach to cannabis is to legalize, regulate and tax it.

Originally appeared at The Wall Street Journal

David L. Nathan, MD, DFAPA (DFCR Founder, Board President) is a psychiatrist, writer, and educator in Princeton NJ. He is a Distinguished Fellow of the American Psychiatric Association and Clinical Associate Professor of Psychiatry at Rutgers Robert Wood Johnson Medical School. While maintaining a full-time private practice, he serves as Director of Continuing Medical Education for the Princeton HealthCare System (PHCS) and Director of Professional Education at Princeton House Behavioral Health (PHBH). While serving on the steering committee of New Jersey United For Marijuana Reform (NJUMR.org), Dr. Nathan was surprised by the absence of any national organization to act as the voice of physicians who wish to guide our nation along a well-regulated path to cannabis legalization. This need was the inspiration for Doctors for Cannabis Regulation.

Why cannabis should be legal for adults

David Frum is one of today’s best and most reasoned conservative political voices, so his recent CNN.com op-ed on marijuana policy was just a little disappointing. Not because he advocates the drug’s decriminalization — he rightly thinks locking people up or arresting them for casual use is a bad idea — but because he opposes its legalization for adults.

I agree with much of what he says about pot’s potential harm, especially for the young and the psychiatrically ill. Like Frum, I am a father who worries about my kids getting sidetracked by cannabis before their brains have a chance to develop. But I am also a physician who understands that the negative legal consequences of marijuana use are far worse than the medical consequences.

Frum would reduce the punishment for marijuana use for adults but nominally maintain its illegality in order to send a message to young people that pot is a “bad choice,” as if breaking the rules wasn’t as much an incentive as a deterrent for adolescents. Kids are smart enough to recognize and dismiss a “because I said so” argument when they see one. By trying to hide marijuana from innately curious young people, we have elevated its status to that of a forbidden fruit. I believe a better approach is to bring pot into the open, make it legal for people over the age of 21, and educate children from a young age about the actual dangers of its recreational use.

Throughout my career as a clinical psychiatrist, I have seen lives ruined by drugs like cocaine, painkillers and alcohol. I have also borne witness to the devastation brought upon cannabis users — almost never by abuse of the drug, but by a justice system that chooses a sledgehammer to kill a weed.

Alcohol, tobacco, marijuana, caffeine and refined sugar are among the most commonly used, potentially habit-forming recreational substances. All are best left out of our daily diets. Only marijuana is illegal, though alcohol and tobacco are clearly more harmful. In several respects, even sugar poses more of a threat to our nation’s health than pot.

I agree with Frum that chronic use of cannabis correlates with mood changes and low motivation, especially when started in adolescence. In individuals with psychosis, it may trigger or worsen their symptoms.

But these dangers are far surpassed by the perils of alcohol, which is associated with pancreatitis, gastritis, cirrhosis, permanent dementia, physiological dependence and fatal withdrawal. In healthy but reckless teens and young adults, it is frighteningly easy to consume a lethal dose of alcohol, but it is essentially impossible to do so with marijuana. Further, alcohol causes severe impairment of judgment, which results in violence, risky sexual behavior and more use of hard drugs.

Those who believe cannabis to be a gateway to opioids and other highly dangerous drugs fail to appreciate that the illegal purchase of marijuana exposes consumers to dealers who push the hard stuff. Given marijuana’s popularity in this country, the consumption of more dangerous drugs could actually decrease if pot were purchased at a liquor store rather than on the street corner where heroin and crack are sold.

There is another more pressing reason to legalize and regulate marijuana, even for the sake of our children: the potential for adulteration of black-market cannabis and the substitution of even more dangerous copycat compounds. Much like Prohibition-era fatalities from bad moonshine, harmful synthetic marijuana substitutes are proliferating, with street names like K2 and Spice. The Drug Enforcement Administration struggles to combat these compounds by outlawing them, but I see no decrease in their popularity among my patients. Natural marijuana poses much less danger than synthetic cannabinoids — legal or otherwise.

So who had the bright idea of banning cannabis in the first place? Was it physicians? Social service organizations? No. The credit goes to the Federal Bureau of Narcotics, which in 1937 pushed through laws ending the growth, trade and consumption of all forms of cannabis, including the inert but commercially useful hemp plant. America’s ban on the so-called “Weed of Madness” was based on bad science and fabricated stories of violence perpetrated under the influence. The madness of cannabis can be ascribed not so much to its users, but to those who sought to criminalize the drug so soon after the monumental failure of alcohol Prohibition.

That’s not to say our marijuana laws have failed to change drug use in America. Cannabis is more widely used today than at any time before its prohibition, even though it was domesticated in antiquity and has been cultivated ever since. Pot prohibition has also greatly increased illegal activity and violence. Otherwise law-abiding private users became criminals, and criminals became rich through the untaxed, bloody and highly lucrative illicit drug trade.

But America can fix this mess through marijuana legalization. Federal, state and local governments can regulate the cannabis trade as they do with alcohol and tobacco — monitoring the production process for safety and purity, controlling where it is sold, taxing all aspects of marijuana production and consumption, and redirecting resources from punishment to prevention.

Forget the antiquated dogma and judge pot prohibition on its own merits. If you still believe that cannabis should be illegal, then you must logically support the criminalization of alcohol and tobacco, with vigorous prosecution and even imprisonment of producers and consumers. Does that sound ridiculous? Then you must conclude that the only rational approach to cannabis is to legalize, regulate and tax it.

Originally published at CNN

David L. Nathan, MD, DFAPA (DFCR Founder, Board President) is a psychiatrist, writer, and educator in Princeton NJ. He is a Distinguished Fellow of the American Psychiatric Association and Clinical Associate Professor of Psychiatry at Rutgers Robert Wood Johnson Medical School. While maintaining a full-time private practice, he serves as Director of Continuing Medical Education for the Princeton HealthCare System (PHCS) and Director of Professional Education at Princeton House Behavioral Health (PHBH). While serving on the steering committee of New Jersey United For Marijuana Reform (NJUMR.org), Dr. Nathan was surprised by the absence of any national organization to act as the voice of physicians who wish to guide our nation along a well-regulated path to cannabis legalization. This need was the inspiration for Doctors for Cannabis Regulation.

Calls to Legalize Cannabis are Gaining America’s Support

Last week, my op-ed in favor of cannabis legalization ran on CNN.com. This week marks three years since I first wrote that marijuana should be legal. I’m amazed at how the debate has changed in just a few years.

I was inundated with messages from readers, and was humbled by some of them.

Here’s one from a Southern Baptist church pastor: “I have seen firsthand the heartache caused by America’s prohibition against marijuana. I have visited young men in prison, who I knew in my heart should not be there … It is time for us to speak out and tell the truth about marijuana …

“But so many are afraid to speak out because they fear being labeled ‘pro-drugs’… I pray daily that God will end this dreadful ‘war.’”

The overwhelmingly positive comments posted on CNN.com, especially from those who don’t use marijuana, show that more mainstream Americans are willing to voice their pro-legalization opinions. Informed adults are challenging old dogmas, and they worry less about the folly of “Reefer Madness” than refined sugar’s role in shortening their children’s lives.

Given the thousands of thoughtful comments in the past week, I’d like to address several of the most important themes readers have discussed: Damon00 writes: “A couple of years ago, comments for articles like this were much more negative. People are learning.”

Agreed. I believe that the coming of the information age has played a major role in the widely recognized shift in public opinion on legalization. Today’s readers are increasingly able to judge facts for themselves by consulting readily available and well-referenced scientific sources.

There is often confusion between the terms decriminalization and legalization, though the distinction is critical. Full legalization would empower federal, state and local governments to regulate and tax the cannabis trade. Regulation facilitates control and safety, and government debt can be reduced with taxes raised from marijuana sales.

But if we merely decriminalize marijuana, then it continues to be at least nominally illegal. Possession could get you the equivalent of a parking ticket, and those involved in the drug trade might still receive more severe punishment. Not only would this burden law enforcement, but the cannabis economy would remain unregulated and untaxed.

Make no mistake: marijuana is bad for kids, although pot’s potential harm to children is rather more subtle than that of alcohol, which can cause life-threatening physical addiction or fatal poisoning.

Studies suggest that repeated marijuana use in adolescents can cause cognitive impairment and chronically low motivation, setting teens on a path of underachievement. But if cannabis is legalized, the tax revenues it brings in can be used to fund better drug education in schools.

We must start teaching our children early, highlighting the nuanced but significant risks to underage users and avoiding the typical hyperbole that teens know they can safely ignore.

Even with the legalization of marijuana, anyone over 21 should be prosecuted for providing cannabis to anyone under 21. And remember: Drug dealers don’t check IDs, but liquor store cashiers do. Given that drug dealers aren’t going away, who would you rather have as the retailer of marijuana?

When it comes to marijuana’s role in psychiatric disorders, the medical literature and my clinical experience are ambiguous. There’s a kind of chicken and egg problem with scientific studies, and they often contradict one another. Cannabis use does correlate with mental illness, but so does poor hygiene.

Some users experience transient, mild paranoia when ingesting pot, which generally leads them to simply stop using it. Many of my patients with anxiety and depression have found that frequent use of cannabis makes their condition worse. A few report that it helps them, at least subjectively. Regardless, alcohol is a much stronger depressant than pot.

As for thought disorders like schizophrenia, evidence suggests that a very large dose of pot can make a healthy person briefly lose touch with reality, and even modest doses may trigger a more serious psychotic episode in some people who are already ill or likely to become ill. While infrequent among pot users, this is of little consolation if you are the unlucky person for whom cannabis is a match to the fuel of underlying mental illness.

On the other hand, it hardly warrants universal pot prohibition any more than the existence of peanut allergies would justify a ban on legumes.

Studies have shown that moderate to severe intoxication with marijuana does indeed increase a driver’s accident risk. But look deeper and you’ll find that this risk is similar to that of drivers with a blood alcohol level of 0.05%, which happens to be well below the federally mandated legal limit of 0.08%. So once again, pot may not be good, but alcohol is worse.

Baby boomers call it “pot,” and their kids call it “weed.” The most common and controversial term is derived from the Spanish vernacular “marihuana.” Until the 1930s, English speakers preferred the scientifically accurate name “cannabis.”

But those Americans who sought to ban the drug in the 1930s favored the previously little known and foreign-sounding term “marijuana,” which might and apparently did stir racial passions among whites.

After 75 years, haven’t our laws against marijuana shed their racist past? Apparently not. Although African-Americans are 25% more likely to use marijuana than white Americans, they are 300% more likely to be arrested for it. A criminal record greatly limits one’s opportunities for success in life. The racial divide widens, and racial tensions grow. This, dear readers, is the enduring legacy of pot prohibition.

I’m afraid we may be stuck with the contentious word “marijuana,” but it provides a useful reminder of one way in which American society was long ago manipulated into the prohibition of a plant that caused a mild euphoria in most people who tried it and a severe paranoia in many who didn’t.

Originally published at CNN

David L. Nathan, MD, DFAPA (DFCR Founder, Board President) is a psychiatrist, writer, and educator in Princeton NJ. He is a Distinguished Fellow of the American Psychiatric Association and Clinical Associate Professor of Psychiatry at Rutgers Robert Wood Johnson Medical School. While maintaining a full-time private practice, he serves as Director of Continuing Medical Education for the Princeton HealthCare System (PHCS) and Director of Professional Education at Princeton House Behavioral Health (PHBH). While serving on the steering committee of New Jersey United For Marijuana Reform (NJUMR.org), Dr. Nathan was surprised by the absence of any national organization to act as the voice of physicians who wish to guide our nation along a well-regulated path to cannabis legalization. This need was the inspiration for Doctors for Cannabis Regulation.

How to regulate cannabis when it’s legal

It’s becoming a cliché: The tide is turning in the debate over cannabis. Sanjay Gupta, CNN’s chief medical correspondent, publicly reversed his position and now supports medical cannabis. Republican Gov. Chris Christie just expanded New Jersey’s medicinal marijuana laws. In the past month, New Hampshire and Illinois have become the 19th and 20th states to approve medical marijuana.

But the debate over medical marijuana obscures the more fundamental issue of our failed war on pot and the path to smart legalization.

I had an opportunity to explore the full range of perspectives in the marijuana debate at the recent 2013 Annual Meeting of the American Psychiatric Association. What I learned can be simply stated: Nationwide cannabis legalization is coming and smart regulation is the key to its success.

At the convention, held in San Francisco, I listened to and spoke with respected leaders of the opposition to cannabis legalization, who are mostly specialized in the treatment of substance use disorders.

The Bay Area is a proving ground for California’s liberal medical marijuana laws. Amanda Reiman, policy manager for the California branch of the pro-legalization Drug Policy Alliance, took me on a tour of local cannabis dispensaries. And Oaksterdam University invited me to speak at their makeshift headquarters — their previous location was closed after a DEA raid last year — where classes are offered on all things cannabis.

The dispensaries are largely self-regulated, yet all facilities are immaculate, security is tight, and members of the staff are knowledgeable about the science of cannabis. Surely not all points of access are as well-run as these dispensaries, but they could be. And only with legalization and regulation can we expect that they would be.

Most legalization advocates and opponents share concerns about underage pot use, an opposition to incarcerating users, and a recognition that marijuana is less harmful to adults than alcohol.

Most agree public opinion has shifted in favor of cannabis legalization, although the two groups have strongly divergent feelings about the change. A minority of advocates call for America to “free the weed” with few restrictions, while opponents at the American Psychiatric Association fear that legalization would lead to “a nation of drunken stoners” after an anticipated rise in adolescent use of this and other drugs.

The substance abuse treatment community has legitimate concerns, and recreational cannabis should not be legalized — for minors.

If national polls are correct, and wisdom prevails, then America is rapidly moving toward legal cannabis for adults. We must stop arguing about the right of consenting adults to consume a relatively safe recreational drug, and discuss how — rather than whether — cannabis should be properly regulated by the federal government.

First, consider the four essential goals of marijuana regulation: keeping cannabis out of the hands of minors; reducing harm to adult users; preventing collateral harm to the public and getting the maximum economic benefit from legalization.

Our approach to federal regulation should synthesize the perspectives of both advocates and opponents of legalization. We should look to research on laws controlling alcohol, tobacco and gambling. We can also learn from Colorado and Washington, which have developed regulations for recreational cannabis, and the 18 other states — plus the District of Columbia — that have legalized medical marijuana.

We can achieve the essential goals of regulation if we:

• Require proper labeling of cannabis products, including the quantities of key ingredients like THC and CBD.

• Test cannabis products for contaminants and label accuracy.

• Require government supervision of all facilities involved in the production, distribution and sale of cannabis.

• Limit advertising, sales and public consumption of cannabis products the way we do with alcohol and/or tobacco.

• Ban cannabis packaging and advertising that targets or attracts underage users.

• Require child-resistant packaging for edible cannabis products.

• Impose penalties on adults who enable minors to get marijuana.

• Allow adults to grow a small number of cannabis plants for personal use.

• Prosecute cannabis-impaired driving with field sobriety tests.

• Continue restrictions on cannabis use by professionals and laborers when scientific evidence indicates that such use risks public safety.

• Empower states and municipalities to restrict the cannabis trade within their borders.

• Fund education of adults about the use and abuse of cannabis.

• Fund preventive youth education about the dangers of underage cannabis use.

• Fund treatment of adults and minors with cannabis use disorders.

• Tax all aspects of the cannabis trade at the highest rate that the free market will bear, using a portion of the proceeds to fund regulation, education and treatment.

Just as responsible fishermen support the conservation of marine ecosystems, even marijuana enthusiasts can offer smart ideas for the successful legalization of cannabis, the fiercest critics of pot legalization have legitimate concerns, particularly about pot’s effects on developing brains of young people. Advocates and opponents need to come together for an open-minded discussion about the regulation of marijuana in the United States.

Originally published at CNN

David L. Nathan, MD, DFAPA (DFCR Founder, Board President) is a psychiatrist, writer, and educator in Princeton NJ. He is a Distinguished Fellow of the American Psychiatric Association and Clinical Associate Professor of Psychiatry at Rutgers Robert Wood Johnson Medical School. While maintaining a full-time private practice, he serves as Director of Continuing Medical Education for the Princeton HealthCare System (PHCS) and Director of Professional Education at Princeton House Behavioral Health (PHBH). While serving on the steering committee of New Jersey United For Marijuana Reform (NJUMR.org), Dr. Nathan was surprised by the absence of any national organization to act as the voice of physicians who wish to guide our nation along a well-regulated path to cannabis legalization. This need was the inspiration for Doctors for Cannabis Regulation.

Don’t fall for warnings about cannabis

It’s no secret. Most Americans now favor making marijuana legal. The national numbers are similar to those in Rhode Island, where a recent poll showed that 57 percent of Rhode Island residents support legalization. Prohibitionists are rapidly losing the debate because the facts are against them. Nonetheless, they continue to repeat three arguments that have been thoroughly debunked by objective scientific research.

First, opponents of legalization claim that marijuana is a “gateway” to hard drugs like cocaine and heroin. Numerous studies over the past 70 years — including one commissioned by the White House — have discredited this hypothesis. Yet prohibitionists continue to claim that marijuana use leads to later use of heroin and other dangerous drugs. Roughly half of all American adults have tried marijuana. If marijuana is a “gateway drug” as opponents claim, why do we find that only 2 percent of Americans have ever tried heroin?

Second, prohibitionists commonly argue that making marijuana legal will lead to carnage on the highways. That has not been the case in Colorado, where the number of traffic fatalities in 2014 was on par with those of previous years. Furthermore, several studies have shown that marijuana causes far less driving impairment than alcohol intoxication.

Research released in February from the National Highway Traffic Safety Administration found that a blood alcohol concentration of 0.05 or above increases the odds of a fatal car accident sevenfold. The same study found that after adjusting for age, gender, race, and alcohol use, drivers who used marijuana were no more likely to be in a fatal car accident than drivers who had not used any drugs or alcohol prior to driving.

Third — and most importantly — opponents of legalization have insisted that marijuana use will skyrocket among teens when it is made legal for adults, but few of them acknowledge that marijuana is already widely available and used by adolescents under prohibition. Since the 1970s, the University of Michigan’s Monitoring the Future Study has consistently found that 80 to 90 percent of high school seniors report that marijuana is “fairly easy” or “very easy” to obtain.

While remaining legal for adults, alcohol and cigarette use among teens has steadily declined to historic lows in recent decades. But teen use of marijuana has risen despite its prohibition. In fact, marijuana prohibition could be increasing teen use. Alcohol and tobacco retailers check IDs and refuse to sell to minors, but unscrupulous street corner drug dealers will sell marijuana — along with hard drugs — to minors.

Although prohibitionists claim that making marijuana legal for adults “sends the wrong message to kids,” teen marijuana use in Colorado has remained level since legalization. The fact that prohibitionists’ dire prediction did not materialize may explain why polls show more Colorado voters now support legal marijuana than did in 2012.

My wife — who grew up in Pawtucket — and I don’t want our children to think that the legalization of cannabis for adults implies that it’s safe for them. But by making it illegal for everyone, our society is most definitely sending the message that there is no difference between use by adults and children, and kids know that’s not true. By creating a legal distinction between use by adults and minors, and by investing cannabis tax revenues into sensible education of children and teens, we can make clear that what is a permissible activity for adults is neither safe nor legal for minors.

Those concerned about the public health impact of marijuana use — and I count myself among them — are more credible and do a greater public service when they abandon talking points that run counter to available evidence and common sense. The hyperbolic claims that we have become accustomed to hearing from prohibitionists only serve to further alienate an already skeptical public.

Instead of doubling down and defending a failed policy with virtually no scientific basis, it is time to acknowledge that marijuana prohibition has failed, and that smart regulation is the solution.

Originally appeared at Providence Journal


David L. Nathan, MD, DFAPA
 (DFCR Founder, Board President)
 is a psychiatrist, writer, and educator in Princeton NJ. He is a Distinguished Fellow of the American Psychiatric Association and Clinical Associate Professor of Psychiatry at Rutgers Robert Wood Johnson Medical School. While maintaining a full-time private practice, he serves as Director of Continuing Medical Education for the Princeton HealthCare System (PHCS) and Director of Professional Education at Princeton House Behavioral Health (PHBH). While serving on the steering committee of New Jersey United For Marijuana Reform (NJUMR.org), Dr. Nathan was surprised by the absence of any national organization to act as the voice of physicians who wish to guide our nation along a well-regulated path to cannabis legalization. This need was the inspiration for Doctors for Cannabis Regulation.

An Open Letter to the National Football League

Together with the undersigned former and current players across the National Football League, we believe the time has come to reconsider your policy on cannabis. Our organization, Doctors for Cannabis Regulation (DFCR), does not promote the personal use of this often-misunderstood substance. Rather, we believe cannabis should be treated outside the criminal justice system as a public health issue. As physicians, we cannot condone sending someone to jail for using cannabis. Our profession aims to heal, not punish.

Decades of data establish beyond a doubt that banning cannabis does little to curb its use. Over the years, your arenas have only solidified this finding. Despite its prohibition, NFL players can easily access cannabis, with some players estimating that 60% of their teammates are regular consumers. No punitive sanctions, however severe, have been able to stop that. So instead of fining and suspending NFL players season after season, consider the success we’ve had in reducing teen alcohol and tobacco use rates, which have fallen significantly over the last generation. Honest education and sensible regulation go a long way toward promoting healthy behaviors.

The NFL’s Policy and Program on Substances of Abuse (Policy) prohibits the “illegal use of drugs,” including cannabis in a list that implicitly equates it with cocaine, opioids, MDMA and PCP. Within the medical community, cannabis is consistently regarded as less toxic, less addictive, and less harmful than many legal drugs like alcohol, tobacco or prescription opioid medications, let alone those illegal drugs mentioned in the Policy. Rather than concerning itself with the mere use of cannabis, we believe the Policy could more effectively focus on misuse of the drug. Your staff’s time and resources could be well spent on preventive education and legitimate substance abuse interventions – the policies already in place for alcohol.

By removing cannabis as a substance of abuse, you would also join the 76% of doctors who favor its use for medicinal purposes. As it stands now, the Policy prevents players from participating in the medical marijuana programs that are currently legal in states where 19 NFL franchises play their home games. While the discrete use of medical marijuana would seem to be allowed under the ‘Therapeutic Use Exemption’ (TUE), we understand such exemptions have never been granted as a matter of practice. In short, the NFL seems to have zero tolerance for cannabis, including in those four states and Washington D.C. where it is legal for personal consumption.

Just last month, you pledged $100 million dollars in a commitment “to look at anything and everything to protect our players and make the game safer.” In a separate memo this summer, announcing your search for a new Chief Medical Officer, you also note “no higher priority than the health and safety of our players.” Amongst other reasons, cannabis deserves the serious attention of your medical staff as a viable pain management alternative and potential neuroprotectant.

Your players are four times more likely than the general population to become addicted to painkillers. A recent study in the Journal of Drug and Alcohol Dependence found 52% of retired NFL players had used prescription pain medications during their active years. Of those, 71% reported misusing these drugs, with approximately one in seven players reporting ongoing dependence. According to another recent study in JAMA Internal Medicine, states with legal medical marijuana programs have a 25% lower incidence of fatal overdose on prescription opioid drugs, which suggests that cannabis is a much safer alternative for patients with chronic pain. At a time when 28,000 Americans per year are dying from opioid overdoses (including one of your own, Tyler Sash), the NFL could play a leading role in addressing this national epidemic. Your investment could certainly add to the growing body of evidence that indicates medical cannabis is a viable replacement for more addictive and potentially fatal medications.

Pain is just one condition where cannabis shows tremendous promise. A recent clinical trial in Israel found that cannabis produced significant benefits in 10 of 11 patients with Crohn’s disease, with 45% going into complete remission. Studies like this make the recent suspension of Buffalo Bills’ Seantrel Henderson particularly concerning. Henderson was diagnosed with the chronic inflammatory intestinal disease just last year and has since undergone two operations. Punishing a player for using cannabis as part of a genuine medical regimen seems contrary to the NFL’s renewed commitment to health and safety.

Finally, there has been preliminary though encouraging research into the neuroprotective effects of cannabinoids following traumatic brain injury, which likewise merits review. Anybody with a passion for football can hardly ignore the impact of a degenerative disease like chronic traumatic encephalopathy (CTE), which is known to have affected a staggering 96% of former NFL players. It’s why our Athletics Ambassador, former Baltimore Raven Eugene Monroe, recently donated $80,000 of his own money to University of Pennsylvania and Johns Hopkins researchers to study cannabis use among NFL players. We were delighted by the initial interest from your team, including Jeff Miller and Russell Lonser, and hope the new Chief Medical Officer offers equal attention.

It is worth noting that the National Hockey League does not even test its players for cannabis. A Major League Baseball player would have to fail multiple tests before being sanctioned, almost exclusively with fines. Incidentally, both leagues are predominantly comprised of white players. Only the NFL and the National Basketball Association (the two leagues with the higher concentration of African American players, at 68% and 74% respectively) routinely discipline their players with suspension. At present, 18 NFL players are suspended for violations of the Policy. Almost all are African American. A single failed marijuana test accounts for many, if not most, of the suspensions. The disproportionate impact of the war on drugs is beyond dispute at the national level, with blacks proving over four times more likely than whites to be arrested for cannabis possession. In the wake of this stark realization, many of the country’s cannabis laws are finally undergoing long-overdue changes. The NFL can no longer afford to dismiss these historic developments by perpetuating a policy that is so blatantly discriminatory and out-of-step with the latest in health and medicine.

We applaud your putting players’ health and safety above all else and look forward to continuing the conversation with your medical staff. In the meantime, we thank you for your time and attention to this most important issue.

November 2, 2016

Doctors for Cannabis Regulation

Board of Directors

Founder and Board President
David L. Nathan, MD, DFAPA, Princeton, NJ
Distinguished Fellow, American Psychiatric Association
Clinical Associate Professor of Psychiatry, Robert Wood Johnson Medical School

Executive Director
Brian C. Muraresku, JD, Washington, DC
DFCR Counsel and ex officio Board Member; Member, New York Bar

Sunil Kumar Aggarwal, MD, PhD, FAAPMR (BOARD TREASURER), Seattle, WA; Fellow, American Academy of Physical Medicine and Rehabilitation; Member, American Academy of Hospice and Palliative Medicine; Associate Member, New York Academy of Medicine; Affiliated Faculty, MultiCare Institute for Research and Innovation; Invited Affiliate Professor, University of Washington, Department of Geography

Darby Beck, MA (BOARD SECRETARY), Dallas, TX; Director of Media Relations and COO, Law Enforcement Against Prohibition

Malik Burnett, MD, MBA (DRUG POLICY AND PUBLIC HEALTH), Baltimore, MD; Resident physician, Johns Hopkins General Preventative Medicine Program

Julie Holland, MD (PSYCHIATRY), New York, NY; Fellow, New York Academy of Medicine; former Assistant Clinical Professor, NYU School of Medicine; Editor, The Pot Book; Medical Monitor, Clinical Cannabis PTSD Research

Udi Ofer, JD (ATTORNEY), Newark, NJ; Executive Director of ACLU-NJ

Sue Sisley, MD (INTERNAL MEDICINE AND PSYCHIATRY), Phoenix, AZ; President, Scottsdale Research Institute; former Assistant Professor, Arizona Telemedicine Program, University of Arizona College of Medicine; Site principal  investigator, FDA botanical cannabis trial for PTSD in military veterans

Honorary Board

Donald I. Abrams, MD, Chief of Hematology/Oncology, San Francisco General Hospital; Professor of Clinical Medicine, UCSF; pioneer of HIV/AIDS research and treatment

Chris Beyrer, MD, MPH, Desmond Tutu Professor in Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health; President, International AIDS Society; various positions in scientific advisory committees for WHO, NIH, UNAIDS; researcher and author

H. Westley Clark, MD, JD, MPH, CAS, FASAM, Past Director, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration (SAMHSA); author, researcher, educator

Joycelyn Elders, MD, former U.S. Surgeon General; Professor Emeritus of Pediatrics, University of Arkansas of Medical Sciences

Lester Grinspoon, MD, Associate Professor Emeritus of Psychiatry, Harvard Medical School; Author, Marihuana Reconsidered; pioneer of cannabis legalization

Carl Hart, PhD, Associate Professor of Psychology and Psychiatry, Columbia University; author and social justice advocate

David Lewis, MD, Professor Emeritus of Medicine and Community Health, Donald G. Millar Distinguished Professor of Alcohol and Addiction Studies, Brown University

Andrew Weil, MDinternationally renowned author and pioneer of integrative medicine

DFCR Athletics Ambassador and
NFL Steering Committee Co-Chair

Eugene Monroe, (offensive tackle), Baltimore, MD; University of Virginia; 2009 NFL Draft (Round 1, Pick 8); Jacksonville Jaguars (2009-2013); Baltimore Ravens (2013-2015); Sponsor, 301 Panthers Youth Organization.

NFL Steering Committee Co-Chair

Derrick Morgan (linebacker), Nashville, TN; Georgia Tech; 2010 NFL Draft; Tennessee Titans (2010-present); Pros for Africa, Starkey Hearing Foundation.

NFL Steering Committee Members

Eben Britton (offensive tackle), Los Angeles, CA; University of Arizona; Jacksonville Jaguars (2009-2012); Chicago Bears (2013-2014).

Nate Jackson (tight end), Los Angeles, CA; Menlo College; San Francisco 49ers (2002-2003); Denver Broncos (2003-2008).

Lance Johnstone (defensive end), Philadelphia, PA; Temple University; Oakland Raiders (1996-2000); Minnesota Vikings (2001-2005); Oakland Raiders (2006). President, Bill Pickett Riding Academy.

Jim McMahon (quarterback), Scottsdale, AZ; Brigham Young; Chicago Bears (1982–1988); San Diego Chargers (1989); Philadelphia Eagles (1990–1992); Minnesota Vikings (1993); Arizona Cardinals (1994); Green Bay Packers (1995–1996).

Jake Plummer (quarterback), Boulder, CO; Arizona State; Arizona Cardinals (1997–2002); Denver Broncos (2003–2006). Jake Plummer Foundation.

Kyle Turley (offensive tackle), Riverside, CA; San Diego State; 1998 NFL Draft (Round 1, Pick 7); New Orleans Saints (1998–2002); St. Louis Rams (2003–2004); Kansas City Chiefs (2006–2007).

Ricky Williams (running back), Los Angeles, CA; University of Texas (Heisman Trophy winner); New Orleans Saints (1999–2001); Miami Dolphins (2002–2005); Miami Dolphins (2007–2010); Baltimore Ravens (2011). Ricky Williams Foundation.

Fair Play for the NFL and America

Election Day is tomorrow, and while the nation is mostly preoccupied with the presidential race, nine states are deciding whether to legalize cannabis in some form. Five of those states (Arizona, California, Maine, Massachusetts and Nevada) are voting on full legalization, while another four (Arkansas, Florida, Montana and North Dakota) are deciding whether to permit medical marijuana. Polls show the ballot measures winning in all nine states, and soon we may see nearly 25% of Americans living in a state where adults can buy cannabis without fear of being arrested.

So, 2016 will likely represent a turning point in our nation’s failed prohibition of a plant that has clear medicinal properties and fewer negative health consequences than many legal drugs. You would think that NFLers would rejoice at this news, yet the League continues to maintain a ban on cannabis that has caused disruptions to the careers of many athletes. Their only crime was to use a drug that is less addictive and less harmful than the opioids that team doctors use to help athletes cope with the wear and tear of NFL play.

Dr. Sue Sisley, a clinician and cannabis researcher in Arizona, has been an ally of athletes in many sports, working with teams to enable players to receive medical marijuana through “therapeutic use exemptions” (TUEs). While she’s found success in other leagues, there has never been a TUE for cannabis granted in the NFL. She has worked with Eugene on his efforts to end the cannabis ban, and she knows David as a Board member of DFCR. Understanding the potential for synergy between athletes and physicians on the issue of cannabis policy, she introduced the two of us, and a powerful collaboration was born.

The NFL has banned cannabis use for all its athletes, including those living in states where marijuana is legal. This is a microcosm of the problem with cannabis policies in society at large. The prohibition in both cases reflects a fundamental ignorance of the science of cannabis, which is generally less harmful for adults than cigarettes, alcohol and prescription pain medications.

Another similarity is found in the way that misguided policies on marijuana have disproportionately affected people of color, both in sports, and across the United States. In sports, the discrepancy is seen in the top leagues of baseball, basketball, football and hockey. The two leagues that consist of mostly African-American players—the NFL at 69% and NBA at 74%—will suspend players for testing positive for marijuana use, which robs these athletes of precious time at the peak of their careers. On the other hand, the two sports that have few African-American players—the MLB at 8% and the NHL at 5%—do not suspend players who use marijuana.

Right now, there are 18 NFLers who have been suspended for drug infractions. About half of these suspensions are for marijuana use, and all of the athletes are people of color. In a league where many players believe that most NFLers use marijuana, this racial discrepancy is suspicious at best.

However, the implicit racial bias seen in cannabis prohibition goes far beyond the NFL. Black Americans are over four times more likely to be arrested for a marijuana offense compared with their white counterparts, despite similar usage rates. An arrest record prevents many African-Americans from getting a job, renting a home, or accessing benefits and programs they may need to support themselves and their families.

There can be no doubt: The ban on cannabis contributes to racial disparities both on and off the field. It reflects poorly on the governance of the NFL as well as the United States.

What benefit have we seen from marijuana prohibition in football or in the nation? Over 22,000,000 Americans use marijuana despite its illegality in most of the country, while an estimated 50-60% of NFLers are thought to be cannabis consumers.

If the purpose of prohibition was to prevent underage use, then that, too, is a failed effort. For decades, 80% and 90% of all 18 year olds have reported easy access to marijuana, in part because the point-of-sale is unregulated and dealers don’t check IDs. Over the same period of time, preventive education reduced the rates of underage alcohol and tobacco, while underage marijuana use rose. Consider what this says about the effectiveness of prohibiting the adult use of so-called ‘soft’ drugs.

The struggle to end the ban on cannabis in the NFL and the United States has fused two unlikely partners into the dream team of sound cannabis policy. Behind Eugene are current and former NFLers who support his advocacy and bring attention to this injustice. David leads a group of nationally recognized physicians who want to legalize, regulate and tax marijuana. Today we stand together at the line of scrimmage, ready to tackle the formidable forces of ignorance and inertia that still block the nation and the NFL from reaching the end zone of cannabis prohibition. We invite our fellow athletes and physicians to join us on the field, and we ask the rest of you cheer us on to victory.

By: Eugene Monroe and David L. Nathan

Eugene Monroe, Retired NFL Player and Medical Cannabis Advocate, was the first active NFL player to openly advocate for the use of cannabinoids to treat chronic pain and sports-related injuries. Drafted 8th overall by the Jaguars in the 2009 NFL Draft, Eugene started 13 of 15 games at left tackle for Jacksonville in his first year, missing two contests due to injury. Eugene’s value and domination on the field were confirmed yet again when the defending Super Bowl champion Baltimore Ravens orchestrated a trade to acquire the star left tackle in October 2013. Eugene enjoyed great success in his time as a Raven, consistently grading as one of the best pass blockers in the NFL. On July 21, 2016, after 7 years in the NFL, Eugene retired from the game of football at the age of 29. The sport he loves had taken its toll on his body, from chronic pain and head trauma to acute injuries, and Eugene made the decision to focus on his health and his family. Eugene is calling on the NFL to remove cannabis from the banned substances list and he continues to advocate for medical cannabis research through education, donations and speaking appearances. He is also a proud sponsor of the 301 Panthers Youth Organization and is co-author of the book Youth Sports: Start Here. To learn more about Eugene, visit www.EugeneMonroe.com.

David L. Nathan, MD, DFAPA (DFCR Founder, Board President) is a psychiatrist, writer, and educator in Princeton NJ. He is a Distinguished Fellow of the American Psychiatric Association and Clinical Associate Professor of Psychiatry at Rutgers Robert Wood Johnson Medical School. While maintaining a full-time private practice, he serves as Director of Continuing Medical Education for the Princeton HealthCare System (PHCS) and Director of Professional Education at Princeton House Behavioral Health (PHBH). While serving on the steering committee of New Jersey United For Marijuana Reform (NJUMR.org), Dr. Nathan was surprised by the absence of any national organization to act as the voice of physicians who wish to guide our nation along a well-regulated path to cannabis legalization. This need was the inspiration for Doctors for Cannabis Regulation.

The Physicians’ Case for Cannabis Legalization

While physicians continue to debate the merits of marijuana reform, legalization is advancing around the country. Although still prohibited under federal law, medical marijuana is now legal in 29 states, and in eight states cannabis may be purchased by anyone over 21. Federal support of state cannabis laws is critical and all but inevitable, as more than 60% of Americans in both red and blue states now favor full legalization for adults. In this time of contentious divisions in American politics, marijuana legalization has found bipartisan support.

The government’s own statistics explain the decades long, steady shift in public opinion. Every year, the United States makes 575,000 arrests for marijuana possession alone, which is greater than the number of arrests for all violent crimes combined.[1] American blacks are nearly four times more likely than whites to be arrested for marijuana possession, despite similar usage rates between the two groups.[2] Enforcement of marijuana laws has disproportionately affected our nation’s poor and communities of color, contributing to the crisis of mass incarceration. The war on marijuana exacerbates poverty, which is strongly correlated with – among other problems – reduced access to health care. The unjust prohibition of marijuana has done more damage to public health than marijuana itself.

Alcohol Prohibition was repealed after just thirteen years because of unintended consequences: organized crime, increased use of hard alcohol, and government waste.

So, what have we gotten from our eighty-year experiment with marijuana prohibition? Organized crime, increased use of stronger marijuana, and government waste.

And yet, Alcohol Prohibition was a success compared to our war on marijuana. Alcohol consumption decreased during the 1920s, but marijuana use has increased drastically since its prohibition. Today, 22,000,000 Americans use cannabis each month, and even more partake on a less frequent basis.[3]

While evidence shows that marijuana is, by most measures, safer than alcohol for the vast majority of adults, evidence also suggests that both marijuana and alcohol can adversely affect brain development in minors. Studies of underage users show that health effects are worse when kids start younger and consume marijuana more frequently.

But cannabis prohibition for adults does not prevent underage use. For decades, preventive education reduced the rates of alcohol and tobacco use by minors, while underage marijuana use rose steadily despite its prohibition for adults. Since the 1970s, 80-90% of eighteen-year-olds have consistently reported easy access to the drug.[4]

Unfortunately, prohibition sends the message that marijuana is dangerous for everyone, since it is illegal for everyone, and kids know that is not true. If we want our children to believe us when we say that cannabis can be harmful for them, then our laws should reflect the difference in health effects of underage and adult use.

Today, while marijuana regulation in legalized states has not been perfect, it is far better than the prohibition it replaced, and the worst fears of opponents have not materialized. Teen use has remained level in legalized states, motor vehicle accidents and deaths continue to decrease, and state governments have demonstrated a fundamental ability to control the previously untaxed and unregulated cannabis industry.[5] As evidence of these successes, polls show that popular support for legalization remains strong in legalized states.

Times are changing. In 2017, even physicians who oppose legalization generally believe that marijuana should be decriminalized, reducing penalties for users while keeping the drug illegal. Although decriminalization is certainly a step in the right direction, we believe it to be an inadequate substitute for legalization and regulation for a number of reasons.

First, decriminalization does not empower the government to regulate product labeling and purity, which leaves marijuana vulnerable to contamination and adulteration. This also renders consumers unable to judge the potency of marijuana, which is like drinking alcohol without knowing its strength. Moreover, where marijuana is merely decriminalized, the point-of-sale remains in the hands of drug dealers who will sell marijuana – as well as more dangerous drugs – to children.

Contrary to popular belief, decriminalization does not actually end the arrests of marijuana users. Despite New York State decriminalizing marijuana in the 1970s, New York City makes tens of thousands of marijuana possession arrests every year, with continuing racial disparities in enforcement. Finally, under a decriminalized system the government continues to prosecute and constrict the supply chain. This drives up the price of marijuana, making the untaxed illegal market more lucrative, competitive, and violent.

As the legalization of medical and adult use of marijuana spreads across the United States, conscientious and knowledgeable physicians are increasingly voicing support – not for marijuana use, but for effective regulation as an alternative to the failed policy of prohibition.

That is why, along with more than 50 prominent US physicians, we founded Doctors for Cannabis Regulation (DFCR), the first and only national physicians’ organization dedicated to the legalization and regulation of the adult use of marijuana. Asserting confidence in science, reason and the judgment of history, DFCR launched last year with the publication of our “Declaration of Principles.”[6] Since then we have given testimony in numerous state legislatures, met with physician groups, opened free membership to all physicians, advocated for evidence-based regulations in each of the newly legalized states, and begun discussions with members of the new Congressional Cannabis Caucus.

DFCR does not promote cannabis use. Rather, we advocate for the legalization of cannabis for adults, because effective regulation requires a legalized environment. We therefore support a core set of common-sense measures to control the marijuana industry and protect public health. The government should oversee all cannabis production, testing, distribution, and sales. Cannabis products should be labeled with significant detail, including (but not limited to) THC and CBD levels, dosing information and ingredients. There should be restrictions on marketing and advertising of cannabis products. Cannabis packaging and advertising that targets or attracts underage users should be completely prohibited. All cannabis products should have child-resistant packaging. There should be harsh penalties for adults who enable diversion of cannabis to minors. Taxation of the cannabis trade should be used to fund research, education, prevention, and substance abuse treatment, including public information for adults on the use and misuse of cannabis and youth programs that emphasize the risks of underage cannabis use.

Informed physicians may disagree about the specifics of good regulation, but we cannot abstain from the discussion. The cannabis industry now advises lawmakers on cannabis regulation, and doctors must do so as well.

Rejecting the unjust and ineffective policy of marijuana prohibition, the physicians of DFCR are helping to lead the nation on a responsible path to legalization. We invite you to join us. Working together, we can advance public health and protect our children through effective, evidence-based regulation of marijuana in the United States.

Originally published at American Journal of Public Health

David L. Nathan, MD, DFAPA (DFCR Founder, Board President) is a psychiatrist, writer, and educator in Princeton NJ. He is a Distinguished Fellow of the American Psychiatric Association and Clinical Associate Professor of Psychiatry at Rutgers Robert Wood Johnson Medical School. While maintaining a full-time private practice, he serves as Director of Continuing Medical Education for the Princeton HealthCare System (PHCS) and Director of Professional Education at Princeton House Behavioral Health (PHBH). While serving on the steering committee of New Jersey United For Marijuana Reform (NJUMR.org), Dr. Nathan was surprised by the absence of any national organization to act as the voice of physicians who wish to guide our nation along a well-regulated path to cannabis legalization. This need was the inspiration for Doctors for Cannabis Regulation.

H. Westley Clark, MD, JD, MPH, CAS, FASAM, is a former Director of the Center for Substance Abuse Treatment, where he led the U.S. Department of Health and Human Services’ national effort to provide effective and accessible treatment to Americans with addictive disorders. Dr. Clark was the former chief of the Associated Substance Abuse Programs at the U.S. Department of Veterans Affairs Medical Center (DVAMC) in San Francisco, California and a former associate clinical professor in the Department of Psychiatry at the University of California at San Francisco (UCSF).In addition to his duties at the DVAMC, Dr. Clark served as a senior program consultant to the Robert Wood Johnson, Substance Abuse Policy Program, a co-investigator on a number of the National Institute on Drug Abuse-funded research grants in conjunction with UCSF. Dr. Clark received a B.A. in Chemistry from Wayne State University in Detroit, Michigan; he holds a Medical Degree and a Masters in Public Health from the University of Michigan, Ann Arbor; where he completed a Psychiatric Residency at University Hospital, Neuropsychiatric Institute.

He obtained his Juris Doctorate from Harvard University Law School and completed a two-year Substance Abuse Fellowship at the DVAMC-SF. Dr. Clark is a noted author and educator in substance abuse treatment, anger and pain management, psychopharmacology, and medical and legal issues. He has received numerous awards for his contributions to the field of substance abuse treatment, including a 2008 President of the United States of America Rank of Distinguished Executive Award in recognition of his personal commitment to excellence in government and public service; and a 2003 President of the United States of America Rank of Meritorious Executive Award in the Senior Executive Service for his sustained superior accomplishments in management of programs of the United States Government and for noteworthy achievement of quality and efficiency in the public service. In addition, he was awarded the 2008 John P. McGovern Award from the American Society of Addiction Medicine for his contributions toward increased understanding of the relationship between addiction and society.

Medical Sciences. Born the daughter of poor sharecroppers in Arkansas, Dr. Elders earned a bachelor’s degree at Philander Smith College in Little Rock. She then spent three years in the U.S. Army, after which she attended the University of Arkansas Medical School. She completed her residency in pediatrics, later earning a master’s degree in biochemistry. After rising to the rank of Professor at the University of Arkansas Medical Center (UAMS), she became the first physician in Arkansas to receive board certification in pediatric endocrinology in 1978. Her career in public health gained much traction following her 1987 appointment as Director of the Arkansas Department of Health. In this capacity, she oversaw a tenfold increase in early childhood annual screenings. In 1992, she was elected as the President of the Association of State and Territorial Health Officers. President Clinton nominated Dr. Elders to the position of U.S. Surgeon General in 1993. Once confirmed, she became the first African-American and only the second woman to serve as Surgeon General. 

Dr. Elders’ tenure is remembered for the controversy generated by her progressive views on drug policy and sex education. During the height of the AIDS epidemic, she was a strong proponent of teaching teens about safe sex as well as abstinence. She also called for research into drug legalization as a means to reduce crime as well as drug misuse. After leaving office, Dr. Elders returned to her professorship at UAMS, while continuing to advocate for comprehensive sex education and drug policy reform. In 2010, she supported California’s Proposition 19, which would have made California the first state to legalize cannabis. The New York Times quoted her as saying, “I think we consume far more dangerous drugs that are legal: cigarette smoking, nicotine and alcohol. I feel they cause much more devastating effects physically. We need to lift the prohibition on marijuana.”

Contributors: All authors contributed to this manuscript, with Dr. Nathan as the principal author.

Acknowledgments

The authors wish to thank the DFCR Executive Director Brian Muraresku and the DFCR Board of Directors for their assistance in the preparation and publication of this article.

References

  1. Federal Bureau of Investigation. Uniform Crime Report: 2015 Crime in the United States. New York, NY: 2016. https://ucr.fbi.gov/crime-in-the-u.s/2015/crime-in-the-u.s.-2015/persons-arrested/persons-arrested
  2. American Civil Liberties Union. The War on Marijuana in Black and White. New York, NY: June 2013. p. 17. https://www.aclu.org/report/war-marijuana-black-and-white
  3. Center for Behavioral Health Statistics and Quality. Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration, 2015. http://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf
  4. Johnston, Lloyd. Monitoring the Future: National Survey Results on Drug Use, 1975-2008: Volume II: College Students and Adults Ages 19-50. Bethesda, MD: National Institute on Drug Abuse, 2009. http://monitoringthefuture.org/pubs/monographs/vol2_2008.pdf
  5. Drug Policy Alliance. “So Far, So Good: What We Know About Marijuana Legalization in Colorado, Washington, Alaska, Oregon, and Washington D.C.” October 13, 2016. http://www.drugpolicy.org/news/2016/10/so-far-so-good-what-we-know-about-marijuana-legalization-colorado-washington-alaska-ore
  6. Doctors for Cannabis Regulation. “Declaration of Principles.” Washington, DC: April 18, 2016. https://dfcr.org/declaration-of-principles/

Opinion: Emergency Physicians Need Better Education on Medical Cannabis

I was disappointed by the one-sided argument published in ACEP Now’s May 2017 article “Experiencing the Dangers of Marijuana Firsthand” by Brad Roberts, MD. Most of what the author points to as his evidence comes from dated reports and the anecdotal personal experience of a physician who describes himself as just out of residency. Most disturbing are instances in which Dr. Roberts conflates correlation with causation, such as his conclusion that legal cannabis is responsible for increased homelessness in Pueblo, Colorado. While I agree with his assertion that there are “likely some very effective ways to use cannabinoid receptors” and the need for unbiased education, his main premise is deeply flawed and stigmatizes the millions of patients who are helped daily by medical cannabis.

Many key facts were omitted from Dr. Roberts article, including recent studies that show decreases in overall prescriptions as well as hospitalizations and overdoses related to opioids in states that have legal and regulated medical cannabis programs.1,2 In fact, one study even showed a decrease in 21- to 40-year-old drivers who tested positive for opioids involved in fatal car crashes in medically legal states.3 Also absent was a description of the draconian restrictions that remain to this day on cannabis research, making it difficult to perform the type of double-blind, prospective, peer-reviewed studies that validate what countless patients already know about these medicinal compounds.4 I find it difficult to understand how Dr. Roberts can assert that medical cannabis should have a “black-box warning” since it is typically well-tolerated and there has never been a case of fatal overdose. Perhaps instead he should advocate for similar warnings for diphenhydramine, which not only causes cardiotoxicity and anticholinergic syndrome but also has psychoactive side effects?

To say there is no cited research related to cannabis use is simply untrue. Earlier this year, the National Academies of Sciences, Engineering, and Medicine performed a rigorous and conservative review of the scientific literature regarding the therapeutic use of cannabis and cannabis-derived products published since 1999. Among other conclusions, the report found strong evidence that cannabis preparations were effective in treating chronic pain, muscle spasms related to multiple sclerosis, and chemotherapy-induced nausea and vomiting.5 Another recent article reviewing 140 studies performed over the past 40 years concludes that cannabis-based medicines show promising effects in the treatment of anxiety disorders, dystonia, and some forms of epilepsy.6

We, as the medical community, suffer from a collective amnesia as it pertains to cannabis as medicine. In fact, before the arbitrary application of the Marijuana Tax Act of 1937, which effectively made cannabis illegal, physicians had published hundreds of papers recommending its use for myriad medical conditions.7 It was even listed on the American Pharmacopeia as a medicine until 1941. With recent studies reaffirming what we already knew 100 years ago, where is the outrage from medical professionals about the virtual impossibility of doing clinical trials in this country to validate formulations, dosages, and efficacy?

Dr. Roberts questions why so-called “cannabis refugees” move to Colorado for medicinal cannabis, thereby leaving “established medical care” for their illness. I think the more appropriate questions are, Why should these patients need to leave their home state in the first place? Why should crossing a state line determine whether patients are entitled to avail themselves of all potential treatments for their illnesses?

I agree that we should improve medical education as it pertains to medical cannabis. Furthermore, as a physician, I am not completely comfortable with so-called “budtenders,” who may lack proper training about medical cannabis products. However, if the medical profession does not step in, what alternative source of information do patients have?

As legalization spreads around the United States, public education is paramount. Many of the problems portrayed in Dr. Roberts’ article were likely the result of overconsumption or accidental ingestion, especially with edible formulations. These enterically absorbed preparations have a slower onset of action than inhalation, the more traditional method of consumption. Those who have not been properly educated about the associated delay in onset may ingest more edibles, resulting in a larger than desired dose.

This is no different than naive alcohol consumers overindulging as a result of their unfamiliarity with alcohol’s effects. Furthermore, the vast majority of cannabis ingestion–related emergency patients I have cared for in my 13-plus-year career have presented after consuming cannabis laced with other chemicals such as methamphetamine or formaldehyde. These preparations are almost exclusively the products of the illegal market, which would be greatly curtailed by a legal and regulated cannabis industry.

Whether referring to medical or adult recreational cannabis, we must educate the public about improper storage of all drugs, given the associated risk of accidental ingestion. There have been instances in which cannabis-containing preparations that were not properly labeled have been ingested, leading to untoward effects and even hospitalization in some cases. This is an issue that many states with legal programs have attempted to remedy alongside the cannabis industry, which has done an admirable job of self-regulating. Potentially harmful substances, whether prescription opioids, alcohol, or cannabis, should be secured away from children and unsuspecting adults to avoid these situations.

Dr. Roberts’ article represents the antiquated thinking that allows this process to continue unchecked. The medical community should educate itself about cannabis and provide guidance to patients and dispensaries on its use. I urge readers to do their own research, attend a conference, or take a CME course rather than make broad statements about cannabis based on selected anecdotes and 80 years of drug war propaganda.

By: Scott A. Bier, MD, FACEP

Originally published at ACEP Now.

Dr. Bier is vice chair of emergency medicine at Memorial Hermann The Woodlands in Shenandoah, Texas. He is also CEO of Green Well, a Texas-based company that aims to provide a full range of wellness solutions.

References

  1. Bradford AC, Bradford WD. Medical marijuana laws reduce prescription medication use in Medicare Part D. Health Aff (Millwood). 2016;35(7):1230-1236.
  2. Shi Y. Medical marijuana policies and hospitalizations related to marijuana and opioid pain relieverDrug Alcohol Depend. 2017;173:144-150.
  3. Kim JH, Santaella-Tenorio J, Mauro C, et al. State medical marijuana laws and the prevalence of opioids detected among fatally injured driversAm J Public Health. 2016;106(11):2032-2037.
  4. Kovaleski SF. Medical marijuana research hits wall of U.S. lawThe New York Times. Aug. 10, 2014:A4.
  5. National Academies of Sciences, Engineering, and Medicine. The health effects of cannabis and cannabinoids: the current state of evidence and recommendations for research. Washington, DC: The National Academies Press; 2017.
  6. Grotenhermen F, Müller-Vahl K. Medicinal uses of marijuana and cannabinoids. Crit Rev Plant Sci. 2016;35(5-6):378-405.
  7. Mikuriya T, ed. Marijuana: Medical Papers 1839-1972. Oakland, Calif: Medi-Comp Press; 1973.

Letter to the Editor, New York Times: Challenging Unsupported Claims of Cannabis Dangers

Opinion | Is Legalizing Marijuana Too Risky? – The New York Times

Alex Berenson’s Op-Ed offers hyperbolic assertions and a biased interpretation of scientific literature. Mr. Berenson claims that cannabis leads to violence. While some studies indeed show an increase in violence across specific populations of cannabis users, many others show the opposite or no effect. Violent individuals may self-medicate with cannabis, but correlation is not causation.

Prohibition has failed to decrease cannabis use while costing billions and criminalizing millions — disproportionately people of color. Fortunately, most Americans, weary of our national epidemic of unsupported claims, reject prohibitionists’ fearmongering and support a regulated system of adult cannabis use as a more humane and effective approach.

Originally printed at New York Times

Bryon Adinoff, MD (DFCR Executive Vice President) is an addiction psychiatrist and academician. He was appointed Clinical Professor at the University of Colorado School of Medicine following his retirement as Distinguished Professor of Alcohol and Drug Abuse Research in the Department of Psychiatry at the University of Texas Southwestern Medical Center and as a psychiatrist for 30 years with the Department of Veterans Affairs. He has published over 175 papers and book chapters on the neurobiology and treatment of addiction and is Editor-in-Chief of The American Journal of Drug and Alcohol Abuse. In his semi-retired status, he is evolving from focusing on the consequences of substance use itself to the consequences of the drug war. As a Founding Member, his commitment to the goals of DFCR arises from his desire to ensure that the harsh, punitive prohibition of cannabis use is replaced by a regulatory system that protects both the individual and society.

David L. Nathan, MD, DFAPA (DFCR Founder, Board President) is a psychiatrist, writer, and educator in Princeton NJ. He is a Distinguished Fellow of the American Psychiatric Association and Clinical Associate Professor of Psychiatry at Rutgers Robert Wood Johnson Medical School. While maintaining a full-time private practice, he serves as Director of Continuing Medical Education for the Princeton HealthCare System (PHCS) and Director of Professional Education at Princeton House Behavioral Health (PHBH). While serving on the steering committee of New Jersey United For Marijuana Reform (NJUMR.org), Dr. Nathan was surprised by the absence of any national organization to act as the voice of physicians who wish to guide our nation along a well-regulated path to cannabis legalization. This need was the inspiration for Doctors for Cannabis Regulation.