Crucial public health issues facing legalizing marijuana

So what do I know about this issue? As the physician and City public health administrator tasked with the initial implementation of Proposition 215 (legalizing medical marijuana) – I learned a lot.

On the data side, I compiled every bit of published research about marijuana (positive and negative) from the previous thirty years, researching every conceivable symptom and/or adverse event. The results were published and widely cited. I also gave talks using this same information about the health implications (and the quality of the data to support or refute claims) to any group interested in hearing it.

So how’d that go? While giving the exact same talk, using the exact same slides, I received impulsive, giddy gifts from both a San Francisco medical marijuana club (an enameled marijuana pin – “finally, a physician willing to speak the truth about how safe marijuana is!”) and from the Santa Clara police department (a navy-blue district attorney mug – “finally, a physician willing to tell the truth about how dangerous this drug is!”). I had simultaneously become the unwilling darling of both ends of the spectrum. I learned from this experience two things:

1) there is a desperate need for data-based information looking at marijuana in the less-emotional context of a pharmaceutical medication, and

2) no matter how data-dry and context-bias-free you present marijuana information, passionate people will often hear what they want to hear.

Given the hazards of negotiating that landmine of reactions, and the justifiable fears of being labeled either a “pot doctor” or a “reactionary,” most physicians will not publicly get involved in a discussion of legalizing marijuana. It’s a topic they won’t touch – at all – not even with a ten-foot-stethoscope. But as we head closer to potentially legal pot, several public health issues should not be ignored (please be aware – these issues are in no way the opinion/policy of the San Francisco Department of Public Health – they are my own).

Why should you care about these public health issues? If you are in favor of legalizing pot, ignoring these issues will mean that whatever proposition may be passed is likely to die an ugly and swift death from either a) adverse publicity, or b) regulatory problems. If you are against legalizing pot, these are issues to consider as emotions run higher. If you, like most Americans, are ambivalent or slightly in favor, view this as a checklist to assess whether or not the current initiative includes appropriate public health measures.

As currently reported, the currently proposed ballot measure doesn’t include any of these common sense measures. Any taxes derived would be on a county-by-county basis (imagine how frequently one county will move to undercut another), with none of the taxes designated to help with predictable public health problems that result from legalization. Without designation of tax revenue, any taxes on marijuana will be a cash cow for politicians, and do little or nothing for the people who bear the repercussions of legalization. My thinking is, hey, if a lot of money is bankrolling this initiative, and we’re going to treat marijuana like any other pharmaceutical, then why not do this thing right the first time?

Six Crucial Public Health Issues:

1) Second-hand smoke: From the viewpoint of a pair of lungs, there is no difference between marijuana and cigarettes – with three exceptions: a) the “active” ingredient is different (nicotine for one, tetra-hydro-cannabinols, or THCs, for another), b) marijuana classically is smoked without a filter – meaning the carcinogens and tars/particulates are more concentrated (especially at the end) and c) typically people smoke many fewer joints per day than cigarettes. Using a water-pipe, or bong, has been shown to reduce particulates/tars, but to actually increase the concentration of carcinogenic vapor compounds. There is no data on the long-term bystander (second-hand) effects of water-pipe smoking. In marijuana’s favor – marijuana smokers typically smoke a much smaller daily amount than cigarette smokers. But whether it’s cigarettes or pot, second-hand smoke is still second-hand smoke.

Ignoring the issue of second-hand smoke will not make it go away. The EPA (and, now, possibly the FDA) is undoubtedly going to have a lot to say about cafes full of marijuana smoke, with the EPA recently declaring marijuana a carcinogen. In addition, cafe employees (particularly those with lung/respiratory/asthma issues) are in a prime position to bring the kind of lawsuits that have been successfully waged against the tobacco industry (yes, I’ve seen the studies about asthma and marijuana – particulates/smoke/second-hand smoke are still a major issue). What are the options? First, marijuana doesn’t have to be smoked – it can be eaten (classic: duh -brownies), dissolved in butter, or even drunk in teas (which is how Queen Victoria preferred hers). If marijuana purchasers still want to smoke (which is common – smoked marijuana gives a more rapid, peaking, and titratable high), a second option for cafes is that marijuana users who choose to smoke on site can be corralled into enclosed areas with negative air-flow and filters, in the same way cigarette smokers are at the airport. It’s socially unappealing, but effective at heading off predictable problems. Third, a well-written marijuana proposition would optimally adopt the same safeguards against second-hand smoke as those in place for tobacco.

2) Substance abuse/mental health implications: Recent, high-quality, long-term, robust research involving thousands upon thousands of people over generations of time, in several populations and countries, has shown that marijuana, especially in teen boys, leads to a measurable increase in the future development of schizophrenia – even when controlling for family and environment. These findings, very similar to unrelated alcohol research, show that risks are both dose-related, and are higher the lower the age at first exposure – all findings consistent with what we know, neurophysiologically, about the developing brain. Schizophrenia and marijuana is an issue that has gotten surprisingly little press in this country. Initial reactions to these results years ago were that a) it must be a fluke, b) it must be that the people who will get schizophrenia gravitate early to marijuana (and other drugs) in order to self-medicate – in other words a “false” association, and c) these aren’t “real” schizophrenics. Sadly, all three of those arguments have been thoroughly de-bunked by subsequent well-done studies. See published articles here, here, here and here. Short of taking a group of 11-year-olds and secretly giving half marijuana, and half placebo for twenty years, then waiting to see what happens – this is as “proven” as it can be. The effect is even dose-dependent. Frankly, researchers have moved beyond looking for an association and are now working to specifically identify the genes and neurotransmitters marijuana affects to induce schizophrenia.

Bottom line? At a minimum, increased rates of schizophrenia in a population (even if small) has to be a serious public health concern – schizophrenia can destroy entire lives, and families. Already, we, without national healthcare, have little/no resources to deal with this devastating, chronic, debilitating disease.

So what is happening? Even among reasonable clinicians, discussions around this elephant-in-the-room issue, when it comes to legalizing marijuana, are that a) for all practical purposes, marijuana is relatively easily available to teens already, and b) we don’t want this to be true, so we’ll either just say it’s not true, or we won’t talk about it at all…again, another stand that is not likely to work in the long-run. So, what to do? First, it’s unlikely that this issue will make it into the public consciousness strongly enough to block marijuana legalization. Furthermore, most people’s concerns in the area of long-term implications about widespread marijuana use are focused on addiction and crime. There is probably no good single answer, but optimally, a well-written proposition would include a fixed, permanent allocation of derived tax revenues devoted to substance abuse treatment, detox, and mental health services. Personally, I think a fixed amount of alcohol tax revenue should have been allocated to detox and substance abuse treatment when Prohibition was repealed – I’d be quite happy to have 50 cents off every bottle of Cabernet I purchase going to sobering centers and detox/rehab – our streets would look very different if it did.

First obligatory conflict of interest notice: I do not in any way receive funding from (or work for) any of these programs, although I am a medical provider to many patients suffering from mental health and substance abuse conditions – people who cannot access these scarce and underfunded resources.

3) Driving while high: Responsible propositions should include language to safeguard against, and discourage, driving while high. This is a complicated topic, clinically, because although the data is clear that people who drive while high are definitely impaired, the data on how long someone is impaired after using marijuana is highly variable to the individual. One approach would be to include in a proposition a grant-funded amount to determine how to advise, regulate against, and, frankly, prosecute users who drive-while-high, as well as an educational campaign to prevent it. Again, ignoring this issue will not make it go away, and – besides the preventable human tragedy – all it would take is a rash of high-profile disasters to get legalized marijuana reversed.

4) Childproofing: Every pharmaceutical agent has what is called a therapeutic index, which is a measure of how easy it is to overdose and die from the substance. Marijuana is, for adults, one of the safest medications ever, with no reported lethal overdoses. That, however, is NOT true for babies and toddlers, in whom coma has been reported, with risks of its corollary, death, particularly for infants. There are many reasons to formalize pot sales in classic pill-type bottles. One is that the tinted container will help prevent the breakdown of active ingredient from light exposure. The second is that optional child-proof lids will go a long ways toward preventing the potentially disastrous outcome of baby deaths post-marijuana legalization. Although some people may shriek in opposition, it is neither excessive, nor extreme – instead, just common sense – to ask adults to childproof their mind-altering and coma-inducing medications.

5) Teen protection: Again, just like with childproofing, responsible marijuana propositions should have at least the stated goal of developing (and funding from revenues) safeguards against access to marijuana by teens. Some of you may be guffawing at this idea as a laughably improbable goal. However, research in both smoking and marijuana has taught us that exposure to potentially-addictive substances at an earlier age leads to more addiction to the substance, and worse long-term outcomes (see schizophrenia, above). Legalized pot is, again, likely to be overturned if reasonable safeguards are not in place. Imagine media exposure that potentially reveals widespread easy access to legal pot by teens, and the fallout in families, and communities. The current proposed initiative states the age of 21 for legal usage, but more explicit language should be included to fund and develop monitoring mechanisms on sales, similar to tobacco and alcohol. Cigarette studies have shown that teens are very sensitive to pricing – something to consider in setting taxation levels.

6) Quality control: It’s clear that, despite widespread, serious quality and safety issues, supplements continue to sell and are popular. So why should we care if marijuana is highly variable in terms of potency and safety? First, studies have revealed the potential for widespread adulteration in a product that is usually sold by weight – including an old CDC report showing that frank dried stool was added to marijuana. Even without adverse health outcomes, one big story like that hitting the headlines will be forever damning to efforts to keep marijuana safe and legal. Second, contamination with molds and bacteria is particularly a concern for people using marijuana for medical reasons because it can lead to serious negative health outcomes. So what can be done? Probably, if marijuana goes mainstream, people will be more savvy about identifying which source provides a high-quality product. There should, however, be an industry-driven bottom “floor” for quality handling procedures – or else, like the Georgia peanut Salmonella outbreak, the FDA will come calling – potentially too late to head off massive adverse publicity, or repeal of legalization.

Jan Gurley is an internal medicine physician who blogs at Doc Gurley.

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  • PaulfromTexas

    I’ve had three doctors and two nurses tell me to smoke pot, just in the last two months, and I live in a fairly urban, yet distant Texas city, a conservative place. I already take Marinol in prescription and still the dox tell me to take more, …..
    If they found this substance in the jungle today, there would be fistfights in front of the patent ofice about places in line.
    Regulate and tax, and make it work for those who would use it, remove the stigma. Pot doesn’t kill people but dox and pharmaceuticals account for 250k deaths a yr.A disparity.

  • gerridoc

    Thank you for an excellent article.

  • Wellescent Health Blog

    It is good to see such an objective article on the subject of marijuana usage within the context of its use as a controlled substance without all the baggage that typically surrounds it. Almost every time marijuana is brought up, it does seem to attract polarized viewpoints rather than an intelligent analysis of the pros and cons and how marijuana could most safely be provided to the population that needs/wants it.

  • Cheebs1

    There is at least one more possibility for ingesting marijuana that you, and most health professionals, have left out. Vaporizing is the most beneficial way of ingesting this substance. A ceramic heating plate gently heats the plant material to release only the pertinent cannabinoids and none of the carcinogens. I highly recommend that helth professionals continue their education and the subject. The last point I would like to make is to direct your, and other readers, attention to the most definitive study of marjuana smoking done by Donald Tashkin from UCLA. Dr. Tashkin was NIDA’s main doctor that originally hypothesized the carcinogenic properties of smoked marijuana. He performed a 30 year study that shows that even though marijuana smoke contains some of the same particulate matter and carcinogens that cigarette smoke contains, it not only does not lead to lung cancer , but actually has an insular effect and decreases the chances of consumers of both marijuana and cigarettes from developing lung cancer. Kudos to helping pass prop215 but there is a reason that doctors and lawyers have a continuing education level that must be met.

  • Steffan Lozinak

    hehe… 1st, I think enclosed smoking quarters is a great idea and I feel that it would much more accepted among marijuna smokers than with cigarette smokers. The “smoking” area may even be a bit of a scene in and of itself, and could be advertised with hookahs.

    2nd. I agree that marijuanas mental addiction rate is very high and clinics and education about this should be a focus. It is in many ways, very much a painkiller and has some of the same mental addictive properties as one. Especially considering how much it “kills” emotional pains.

    As far as it’s link to schizophrenia goes, this does not surprise me at all as hallucinogens and schizophrenia seem to be closely related. I feel, as with most mental disorders, we as a people know very little about what it is and why it occurs, on a non chemical level. Just like with depression, we can see that chemicals at “this” level make one depressed, we don’t know why the chemicals go to that level.

    I have plenty of theories on these subjects, but that is not for here.

    Anyway, that’s all I will say for now, great article!! And though I personally am not a huge fan of marijuana, I full believe people should have the right to use it if they are so inclined. Cheers

  • Will from Texas

    I recommend that Dr. Gurley reads the following book, Marijuana is Safer: So Why Are We Driving People to Drink?, which provides references to ample scientific studies alleviating her six public health issues.

    1) Second Hand Smoke – Yes, Cheebs1 is correct – though there may be more carcinogens in cannabis, ample stuides show that long term use is not associated with cancer, rather cannabis has anti-carcinogenic properties. Also, Dr. Gurley admits that there are no studies yet that prove any harm to non-smokers from second-hand marijuana smoke. Would it make sense that second-hand marijuana smoke would cause cancer when marijuana has anti-carcinogenic properties? If marijuana WERE like tobacco (which it thankfully is not), second-hand smoke might even increase the anti-carcinogenic properties (as tobacco is the opposite and second-hand smoke can be far worse.)

    2) Substance Abuse/Mental Health Issues – Yes, many people are currently enrolled in addiction treatment programs for marijuana habits. However, the majority of marijuana smokers currently in drug treatment were arrested for marijuana possession and ordered into treatment as a condition of their probation. Tobacco, alcohol, heroin, cocaine, and even caffeine are all much more addicting than cannabis. Regarding violence, an underground market fueled by prohibition causes violence between gangs and police, not from marijuana’s habit nor its chemical structure. Marijuana users are not the likely type to create violent situations, but users of alcohol, methamphetamines, cocaine, and heroin do indeed spur violence to feed one’s addiction and/or when intoxicated. Regarding mental health issues, patients predisposed to schizophrenia or other mental health disorders are best off not taking mind-altering substances as an altered state of mind is the last thing they need. One can look at this as similar to the chicken-egg scenario, and ultimately with millions of US citizens currently smoking marijuana, how many are suffering from mental health disorders? …not enough to justify a fear of mental health disorders INDUCED by marijuana alone. Alcohol is by far the winner of induced mental health disorders and violence , just to start with.

    3) Driving While High – True marijuana has shown to affect driving ability. However, what Dr. Gurley fails to mention are the results of crash culpability studies and the decision to drive. The statistical incidences of motor vehicle accidents involving drivers under the influence of marijuana have proven to be no different or very little different than control groups with no medication. – This website provides references to 12 scientific studies showing the crash culpability studies that place marijuana in a positive light of safety and show the unfortunate detriments of alcohol, the far more dangerous substance. Finally, while alcohol may induce bravado and confidence leading to the likelihood of a driving attempt, marijuana users do not feel this urge to drive while in their altered states. Most choose not to.

    4) Childproofing – True, marijuana may be accidentally ingested by infants or children. The rare case of coma is unfortunate if directly attributable to cannabis. However, childproofing is a concern for a multitude of household items not limited to the many pharmaceuticals that are much more likely to cause irreparable harm to infants than cannabis: sharp objects, stairs, chemicals, etc. What this comes down to is consumer and parent responsibility, not government control.

    5) Teen Protection – True, drug use among teens is an issue. However, rates of use have not dropped with prohibition, and teens report that illegal drugs are easier to acquire as dealers do not check IDs. Developing teens need to be protected, but an end to prohibition will put power into the hands of professional, responsible vendors. Education is yet another important part of teen use and abuse, and teens need to understand that if something is a gateway substance (milk and sex come to mind), alcohol is the cultural norm instituted in weddings, sports, church, and other regular activities that provides the first stepping stone for mind-altering substances. Use rates have dropped in the Netherlands after legalization, and rates have not seen significant rises in US states with legal medical cannabis. I would want my children to have the safer option of marijuana for enjoyable recreation, as the norms of alcohol and tobacco kill hundreds of thousands annually and marijuana alone (even though rare cases exist of coma development in infants) is still one of the safest substances known to humankind.

    6) Quality Control – True, marijuana may vary in terms of quality and potency, but this goes with many products. Dangerous bacteria and fecal matter in our industrial meat complex is a far greater concern. Furthermore, where is the data showing that marijuana grown legally today under state laws and distributed via dispensaries does not provide quality control to the medical marijuana patient? I believe your data may come predominately from marijuana of illegal grows and Mexican “dirt weed,” being sold to uneducated recreational users. Please correct me if I’m wrong. Governmental control should be more focused on pharmaceuticals that cause ridiculous side affects and have little to no testing before wide release to the general public. Marijuana has been consumed by humans for thousands of years…and most pharmaceuticals are far more damaging.

    Public health issues regarding marijuana should focus on these issues: the future negative social health of the citizen arrested every 9 seconds for marijuana possession, the negative mental and social health affects caused by incarceration in the prison system of millions of citizens for drug possession, the positive health of the medical marijuana patients, and the physical lives saved from the end of a marijuana drug war.

    Please respectfully consider these related facts and educated scenarios.

    Thank you.

  • Brandon

    Will from Texas, you just made the perfect rebuttal to this article. I think this article actually had many valid concerns, but most seem to be forgetting the negative effects of prohibition. I think cannabis smokers would actually like to smoke in their own spaces, it’s called a hotbox Jan, and in this situation second hand smoke is a very good thing. If you actually read the entire initiative Jan, you will see that it actually puts stricter rules on smokers than under prohibition. The initiative was written to be passed, and some concessions had to be made, it’s the only way unfortunately, no thanks to police or politicians. I have a few friends who smoke weed and drive, which is not easy, but they are not posing a threat to other drivers because they slow down and increase their following distance to compensate. The only reason they drive is because prohibition forces them to smoke in places where they won’t get caught, and they have to drive usually to do so. The last thing they want to do is go out and drive and do things that require a lot of energy. They usually plan ahead and get everything done before they get high, because they know they won’t want to do anything after getting high, which is kinda ironic. Putting child safety mechanisms on things that contain marijuana seems really unnecessary and bothersome for the user. Do you know how hard it would be to get those caps off when you’re high? Pretty impossible. And plus what’s the point? Is an infant or toddler really capable of getting into someone’s stash and smoking it properly? I don’t think they would even know to smoke it. Plus pot smells funky and looks like veggies, almost like cooked asparagus, what kid would want to put that in their mouth? The reason why kids eat pills is because they look like candy. Pot looks nothing like candy. Now, I think edibles might be a problem, but usually people don’t leave those hanging around too long. My mom has had schizophrenia since I was 6, and you are right, it really tears families apart. But, the thing that triggered that was stress, not pot, she’s never smoked anything. I’m currently trying to get her to try medical marijuana because she’s always so anxious and stressed from her condition, plus she has fibromyalgia which may be a result of her prolonged stress. I think anything that can calm her nerves and thought processes like cannabis does could help. But I really enjoyed this article, I haven’t seen too many people bring up these points, they should definitely be considered once Tax Cannabis 2010 passes, hopefully.

  • ninguem

    One advantage of legalizing marijuana is we will stop hearing all the bleating nonsense about all the great medical benefits it is supposed to have.

  • andrew

    “Especially considering how much it “kills” emotional pains.”

    Really, you don’t find when you’re depressed and smoke it usually makes you more depressed? I find it enhances emotion in me… to the point of sometimes crying at sappy TV commercials.

    Marijuana is the “safest therapeutic substances known to man.” and that quote comes from a DEA judge.

  • Chronlon

    There will always be critics, Jan, but I think your article is eye opening. Everyone I ever speak with about the subject tries to tell me that there are no negative byproducts of legalizing marijuana. To Will from Texas, everyone I know who smokes weed from good friends to moderate acquaintances, drives high. Now you might come back with a comment about the type of people that I know and associate with, but these people, in profession, range from MD’s to local officials to garbage men. They run the whole gambit of professions and typical character types. “Finally, while alcohol may induce bravado and confidence leading to the likelihood of a driving attempt, marijuana users do not feel this urge to drive while in their altered states. Most choose not to.”, I find that most people don’t have increased confidence, just most of them are in denial about the true cognitive effects of marijuana use. Lastly, being someone who has done a lot of research papers in the medical and scientific fields, your “which came first” argument about the chicken and the egg regarding links to schizophrenia and marijuana abuse is flaccid. The use of old adages can simplify arguments but also mislead readers into believing validity of that argument. Just because Schizophrenia doesn’t occur in EVERYONE who smoked weed habitually in their life does not mean that marijuana does not cause Schizophrenia. Smoking is directly proven to cause lung cancer, yet there are many people in the population who smoke from the time they are 15 to the time they are 80 and never develop cancer or heart disease. Would you take examples like that and then posit that most people “predisposed” to lung cancer might also be drawn socially or genetically to smoking cigarettes? I doubt it.

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