As state lawmakers squabble this week over whether to legalize marijuana and how cannabis tax revenues would be spent, doctors hope to keep one thing front and center.
This is the message two leading health advocates shared as state lawmakers work toward an on-time budget that may, or may not, include legalization.
"There are a number of concerns based on the evolving experiences in the states which have legalized,” said Dr. Thomas J. Madejski, president of the Medical Society of the State of New York. “That has caused us to strongly recommend that the state take a pause before making recreational adult use marijuana widely available.”
Approval of such use in 10 states – starting with Colorado in 2013 – came with consequences that included a rise in cannabis-related motor vehicle fatalities, child hospitalizations and mental health challenges, said Madejski, a primary and palliative care doctor in Orleans County.
He and Dr. R. Lorraine Collins, associate dean for research with the University at Buffalo School of Public Health and Health Professions, said three major health concerns should keep legalization on the shelf until they can be better understood and addressed:
• Age. As is the case with tobacco, alcohol and other potentially addictive drugs, a small but growing body of research shows that regular marijuana use can impact brain development and raise the risk of addiction into at least the mid-20s. A large review of previous studies published last month in JAMA Pediatrics also suggests those who regularly use marijuana as teens have a higher risk for depression and suicide in early adulthood.
• Benefits and harms. Marijuana legalization advocates have touted a variety of health advantages cannabis brings as a growing number of states – now 34 in all – have legalized medicinal marijuana use. “The problem that we face is that people are making claims about effects that are not based on science," Collins said.
• Related health and social costs. The New York City comptroller reported last spring that recreational marijuana could become a $3 billion-plus industry statewide and bring the state up to $436 million annually in tax revenue. Madejski estimates roughly 15 percent of those who use marijuana are at risk for addiction, as is the case with alcohol and opioids – which likely will translate into higher state and employer-related health costs.
Collins – who last year served as one of 20 representatives with Gov. Andrew M. Cuomo’s Working Group on Marijuana – said it’s important for lawmakers to have a strong understanding about how to address all those issues before rolling out adult recreational use.
"It’s also best to have an established public education campaign in place before legalization takes place," said Collins, a professor in the UB Department of Community Health and Health Behavior.
Collins and Madejski both said popular attitudes about regular marijuana use rarely consider its dangers – even among some expectant and new mothers.
“You have people thinking marijuana is an herb,” Collins said. “It's natural. It helps deal with nausea. But what does it do to a growing fetus? There are just so many high-risk areas that we don't know enough about."
Marijuana has shown helpfulness in controlling seizures and managing pain in some cases – Madejski said he has seen it benefit patients who have been able to lower their reliance on opioid prescriptions – but researchers have yet to untangle how most compounds within the plant work best. That extends to how it should be ingested, whether through smoking, vaping or eating.
"We need to know more about everything related to cannabis,” added Collins, who also was part of an effort by the National Academies of Sciences, Engineering and Medicine to make recommendations about ways to expand and improve cannabis research and better inform the public. “The research that we have is completely inadequate in most areas.”
The National Institutes of Health has invested billions of dollars on alcohol-related research, including millions at the UB Research Institute on Addictions. Because of its classification, however, most marijuana research is driven by the industry that stands to benefit most from greater use. The state medical society and American Medical Association are among health-related groups that have called on the federal government to remove cannabis from the Drug Enforcement Agency Schedule I list of drugs considered the most dangerous and addictive in the nation, with no currently accepted medical use. This means that researchers who look to conduct research with the drug technically open themselves to federal criminal charges.
Heroin and LSD also are on the Schedule I list.
Still addictive, but considered less dangerous, are Schedule II drugs that include hydrocodone, methamphetamine and fentanyl; Schedule III drugs such as codeine with Tylenol, ketamine and anabolic steroids; and Schedule IV drugs that include Xanax, Darvocet and Ambien.
The lack of research hampers the ability of medical researchers and public health leaders to get a concrete feel for marijuana use, including the extent of its addictive qualities. It also has turned users into medical guinea pigs and comes with related businesses making all sorts of claims for products, including cannabidiol (CBD) oils, that have yet to undergo large-scale, double-blind, evidence-based research studies to back them up, Collins said.
"What kind of public health messages do we put out there to alert young people, the elderly, whomever about cannabis use," Collins said, "if we don't have research that says, 'Here are some of the ways it might harm your health or help you?' This needs to be linked to well-validated, scientific information that people can use to make decisions. Right now, we are in this vacuum."
“Consistent data” already exists when it comes to the impact of regular cannabis use on the developing brain, Collins said. It’s why other states have limited adult recreational use to those age 21 and over, why the drinking age stands at the same age and why New York is moving toward restricting tobacco sales to those above that age.
"The later age at which one starts to use a substance, the lesser the risk that you will become dependent on that substance," she said.
The lack of foundational research in other areas, however, raises questions and concerns about the pharmacological and neurological effects on judgment, as well as reaction time and behaviors related to driving, flying an airplane or operating heavy equipment. There also is the question of proper “dosage” and frequency of marijuana use – including the level at which motorists should be charged with driving under the influence or employees dismissed for what might be drug-related workplace decision-making.
"If we have more data, I'm very open to starting to prescribe it on a medicinal basis and, at that point, I can have an intelligent discussion with my patients about the best way to use it," Madejski said. He said he already is comfortable prescribing it to some patients who struggle with pain or are nearing the end of life.
Collins believes it is only matter of time before adult-use recreational marijuana becomes legal in New York. She is heartened that the state already features one of the most restrictive medical cannabis programs. "We're not starting from scratch," she said.
The state medical society opposed medicinal marijuana legislation.
"We still have issues about how it's been implemented,” Madejski said, “but we've been able to have a dialogue with the state Health Department and that has been constructive. … The difficulty we have is there is very little data on dosing, what combinations of CBD, THC and other ingredient dosing is best. And we have very little, if any, data on long-term consequences of use."
Madejski would like more data to inform the decision.
“We should make these decisions based on science and reason, not anecdotal reports and industry-driven positive press, which is a lot of what we've had to deal with trying to make the case that we need to go a little bit more slowly here," Madejski said.
When might the state be ready for recreational marijuana legalization?
"If ready is, 'We know everything and now we can move ahead,' then I don't think anywhere on the planet is ready,” Collins said. “We don't know a lot. But if you talk about a process that has involved key stakeholders, that will involve discussion at various levels within the Legislature and governor's office, then we're going about this in a thoughtful way."