A two-day seminar last week, sponsored by the National Institute on Drug Abuse (NIDA), included a presentation on public health and marijuana. While much of the seminar was spent on neuroscience, some presenters focused on the real-world effects of legalization. Though marijuana is still illegal on a federal level, states are moving ahead with various forms of decriminalization, medical use and outright legalization of recreational use. We attended via computer, and report on a session held March 23 on policy and public health.

Should marijuana be recreational, like alcohol…

Mark Kleiman, Ph.D., professor of public policy and the director of the Crime Reduction and Justice Initiative at New York University’s Marron Institute of Urban Management, compared marijuana use to alcohol use, and called for defining a standard dose — which would be the cannabis equivalent of a drink of alcohol — and a better understanding of the rate of “use-to-intoxication” — the cannabis equivalent of binge drinking.

In America, many people drink to get drunk, and many people smoke marijuana to get stoned, said Kleiman, who is also founder and chairman of BOTEC Analysis.

“There are cultures — like in Australia — where it’s routine to pass a joint around before a dinner party,” he said. “Everyone takes one little puff — it makes the food taste better and the conversation go better. But an American comes in and takes an American-style drag — he’s a barbarian.”

There is research that is desperately needed, said Kleiman. “We’d like to know the conditional probabilities of cannabis use disorder based on age at first use,” he said. “And we’d like to know how much of this is due to age and how much is due to kids who smoke marijuana at age 14 having neglectful parents.”

The brain research going on now is a “spectacular achievement,” said Kleiman. “People will be writing about it 200 years from now, but at some point, people have to take their eye off the ball of figuring out how the neurons act, and have to look at how people behave and what the policies are.”

And in particular, Kleiman said research into “spontaneous recovery” is needed. “This is 90 percent of the people who we never look at, as we study failed treatment regimen after failed treatment regimen,” he said.

There has been a quadrupling in heavy use of cannabis, but an increase of only 50 percent in prevalence of use, said Kleiman. The price of an ounce of marijuana hasn’t gone up, but since the THC content is much stronger, “the price of an hour stoned is falling radically,” he said. And as the price continues to go down, increases in heavy use are likely to go up, said Kleiman.

Kleiman does not believe that the perception of risk drives use. “Risk perceptions are way down, but use by teenagers is not way up,” he said. “The problem is that everybody thinks there is some way they can use this to scare a 15-year-old.”

As heavy marijuana use goes up, heavy alcohol use should go down, said Kleiman — but it hasn’t. There have been reductions in opioid use in relation to heavy marijuana use, he said. “That’s the only good news we’ve heard in the past four years,” he said.

Researchers should help provide education on the effects of cannabis, said Kleiman. “If we’re not giving people advice about what effect cannabis will have on them, they’re going to be getting that advice from the bud tenders,” he said. “We should be able to compete in that market.” Kleiman believes that the main research agenda, as cannabis becomes a legal drug, should be to “help people use safely, to help people get the effect they want.”

But none of these answers will come from discovering more cannabinoid receptors, he said.

It’s also important to measure the costs of illegality — how many people go to jail, how many can’t get a job. “Cannabis can be harmful, but so can an arrest record,” he said.

…Or like tobacco, something nobody wants to use?

“We want marijuana to be like tobacco — we don’t want people to be thrown in jail for using it, and we want nobody to want to use it,” said Stanton Glantz, Ph.D., professor of medicine and director of the University of California, San Francisco Center for Tobacco Control Research and Education. Ideally, there would be proper clinical trials for medical use, and then the Food and Drug Administration would approve them, he said. “Right now, medical use is more like the vitamin supplements, the nutritional supplements,” he said.

But tobacco has been the great success story: smoking has drastically decreased. And Glantz noted that people advocating for marijuana legalization are “changing from the hippie-dippies, the mom-and-pops, the medical dispensaries, to venture capitalists.” He sent an assistant to a big marijuana meeting and found people who “weren’t smoking it because it isn’t good for them, but who were seeing the dollar signs,” he said. “We are on the verge of a new tobacco industry, and that’s what scares me.”

Glantz said a cigarette is a carefully designed nicotine delivery system, which is engineered to maximize potential and sales. He’s worried that financial interests in marijuana will now back a legalization with “campaign contributions and lobbyists.”

He said that the tobacco industry started getting concerned decades ago, when their products were increasingly seen as dangerous and the possibility of marijuana legalization appeared on the horizon. “We never figured out exactly what they wanted to do — whether they wanted to get into the marijuana business or compete against them,” he said. “But they worked on product engineering, thought about marketing, and the minute this is legal federally, they’ll be there.”

“My hope for avoiding a catastrophe is to be there, concurrently with legalization, with a strong public health framework to make marijuana something nobody wants,” said Glantz. “We need to figure out how to warn people about this.”

NIDA director Nora Volkow, M.D., closed the meeting March 23 by noting that tobacco is a significant killer, and that alcohol is the third-leading cause of death worldwide. “We don’t want to emulate alcohol and tobacco” when it comes to marijuana, she said, noting that “monetary interests drive decision-making.” Processes need to “minimize the harmful effects,” she said. “But it’s clear that the legalization process is ongoing,” she said, “and it behooves us to understand the programs that give the greatest protection.”

Protecting children, adolescents and young adults is the most important, said Volkow.

Bottom Line…

In the impending legalization of marijuana, what will the public health message be: is it a recreational substance like alcohol or a to-be-avoided health menace like tobacco?