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There has been a huge increase in legalization and use of cannabis (marijuana) in recent years. Despite federal prohibition of all cannabis use, 33 states and the District of Columbia have legalized marijuana for medical purposes; 11 of them and DC have further legalized it for recreational uses, and 15 other states have decriminalized marijuana use to some extent.
Each step raises ethical issues for health care providers, patients, and government officials.
The case in favor of using marijuana for medical purposes was made in a letter from the World Health Organization to the secretary general of the United Nations on January 24, 2019. Some 30 countries around the world had legalized medical marijuana as of 2018.
The letter followed an expert committee’s conclusion that cannabis and cannabinoids derived from the marijuana plant are relatively low risk and carry positive health benefits, including pain reduction and improvement of motor functions in patients with Parkinson’s. It called for more research to better evaluate the benefits and harms.
An expert committee appointed by the National Academies of Sciences, Engineering and Medicine also raised some red flags about marijuana use in a report issued in January 2017. The panel considered more than 10,000 scientific abstracts published since 1999 and reached almost 100 separate conclusions.
Therapeutically, it found evidence that cannabis or cannabinoids could reduce pain symptoms, the muscle spasms associated with multiple sclerosis, and the nausea and vomiting caused by chemotherapy. On the downside, it found suggestive evidence that cannabis use prior to driving increases the risk of a motor vehicle accidents and, in states where cannabis use is legal, increased the risk that young children would find and ingest the substance in overdose quantities.
Parents and other adults surely have an ethical obligation to keep cannabis out of the reach of children.
The panel found “moderate evidence” that cannabis can lead to abuse of other substances such as alcohol, tobacco, and illicit drugs. It also found “limited evidence” that cannabis can impair learning, memory, and attention, even in individuals who have stopped smoking cannabis. It can also impair subsequent academic achievement, social relationships, and may increase the risk of unemployment and low income.
The panel cited a recent nationwide survey which estimated that 22 million Americans aged 12 and older had used marijuana in the last 30 days and that 90 percent of the adult users used it primarily for recreational purpose while only 10 percent used it solely for medical purposes. Around 36 percent used it for both purposes. This is an alarming increase in the recreational markets where oversight is minimal.
The risks of rapid expansion have been documented in Colorado, the first state to legalize recreational marijuana. Edibles there produced a disproportionate share of pot-related crises in emergency rooms, according to a report in The New York Times on March 25. Edibles were also more likely than inhaled pot to cause severe intoxication, acute psychiatric symptoms in people with no history of psychiatric illness, and cardiovascular problems. The lead author of the report, published in the April 16 issue of the Annals of Internal Medicine, told reporter Roni Caryn Rabin that he does not think edibles should be available in the retail recreational market.
Meanwhile, the state medical societies in New York, New Jersey, Connecticut, and Delaware issued a joint statement in March opposing the legalization of recreational marijuana because there is not enough research proving it is safe.
Even though two-thirds of the states have legalized marijuana for medicinal purposes, enrolling some two to three million people in their programs, the vast majority of health care systems won’t provide cannabis to their patients or allow them to bring their own supply. The facilities are reluctant because cannabis remains classified by the government as a schedule 1 drug, making it technically illegal to use for any purpose, including medical.
The greatest risk to public health is probably posed by cannabidiol oils (CBD) added to edible food products, such as cookies and brownies. The problem is that CBD is not psychoactive and does not cause the highs characterized by THC. It can take hours before it kicks in, so users may mistakenly believe it isn’t working and eat some more, compounding the risk. The edibles may also contain too much or too little of the supposedly active ingredient or contain toxic contaminants introduced during production, which is not tightly regulated by the Food and Drug Administration (FDA).
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