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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