With marijuana legalization official in Colorado as of January 1, ADAW talked to treatment and prevention advocates last week about the implications of increased use of this drug, not only in states that have legal or medical marijuana, but nationwide.

“This will increase the number of people, particularly kids, who use marijuana,” said A. Thomas McLellan, Ph.D., founder and executive director of the Treatment Research Institute. “After that, it’s simply a mathematical function — the number of kids with auto accidents and kids with compulsive use will increase.”

Already, more than 6 percent of 12th graders use marijuana daily, based on last year’s Monitoring the Future survey (see ADAW, Dec. 23, 2013). This was before legalization, noted McLellan. “When substances like alcohol and drugs are made more available, you get more people drinking and using, and a significant chunk of them get health problems,” he said.

McLellan is hardly alone when he says that marijuana “doesn’t have the kinds of immediate or long-term consequences” that many other drugs have. “It really is right in there with nicotine and alcohol,” he said.

In fact, ADAW has not reported many articles about marijuana, since until recently the story has been mainly a prevention success story, with the top drugs sending people to treatment being alcohol and opioids.

If marijuana becomes the new recreational drug, will it become the new alcohol? That’s the social experiment that is going to play out over the coming months, said McLellan.

Prohibition then and now

Alcohol prohibition was repealed because of public demand for alcohol and the government’s demand for revenue — not because of science, said McLellan, adding that in terms of public health, alcohol prohibition was a success. “It’s the same situation today with marijuana,” he said. “A lot of revenue comes from tobacco and alcohol taxation, but that revenue doesn’t come close to covering the costs of those two legal substances.”

Marijuana legalization is popular for some reasons that make sense: the “onerous criminal justice policies” that have been in effect against people who are not dealers, and the disproportionate effect of those policies on poor people and blacks, said McLellan. “I agree with those arguments,” he told ADAW. “I understand the desire to decriminalize, but legalization is very different from decriminalization.” McLellan favors civil penalties for possession, such as small fines.

“This is a repeat of the history of alcohol prohibition and then legalization as society made the decision not based on science,” said Charles P. O’Brien, M.D., Ph.D., professor of psychiatry at the University of Pennsylvania. “This does not mean that alcohol and marijuana are never harmful drugs, but that society has made the decision to use them in spite of the harm to some people,” he told ADAW.

In fact, an Institute of Medicine panel that O’Brien was on recommended in 1981 exactly what is now taking place: that states be laboratories for looking at marijuana as a public health, not criminal problem — that prohibition be repealed. The National Academy of Sciences disowned the report, but, said O’Brien, “we turned out to be accurate.”

“The major recommendation was that the federal government should not continue to prosecute but allow the states to experiment with different strategies because there was not enough data to support a specific federal position,” said O’Brien. (For a copy of the report, go to http://druglibrary.net/schaffer/Library/studies/nas/back.htm.)

The National Association of State Alcohol and Drug Abuse Directors (NASADAD) has a focus on prevention, treatment and recovery, explained Executive Director Rob Morrison in an interview last week. “Regardless of what someone thinks they know about the topic [of marijuana legalization], we look at this through the lens of state substance abuse agencies,” he said. “We can’t be wrong in helping to talk through that lens.” Secondly, the public health impact comes first, he said, noting that some researchers predict marijuana use will double or triple as a result of legalization. “There are health problems, and we stick to the facts and research,” he said.

More data needed: NIDA

Based on limited data, the National Institute on Drug Abuse (NIDA) has determined that marijuana is harmful to the developing brain, said Susan Weiss, M.D., associate director for scientific affairs. “The data are not definitive at this point, mainly because you can’t randomly assign people to smoke marijuana or not smoke marijuana, and then follow them,” Weiss told ADAW. However, she cited a study from New Zealand that did show a decline in IQ among people with marijuana dependence, and evidence from brain imaging studies showing deficits in neuroconnectivity. Marijuana use, especially by the young, in particular is related to decrements in the hippocampus, which controls memory, said Weiss. Finally, there is the animal study showing that animals exposed to drugs in their adolescent period have changes in the brain that last into adulthood (see ADAW, Sept. 22, 2008).

“The real question — and this is something we need to study more — is to look at the prospective studies of people before they start using marijuana and follow them over time,” said Weiss. “It will be confusing, because most people who use marijuana also use other drugs like alcohol and tobacco.”

Nevertheless, there is enough data now to show that regular marijuana use is associated with dropping out of school, lower quality of life and addiction, said Weiss. “People try to quit and can’t,” she said. “This doesn’t mean we have a definitive answer.”

How many more people will become compulsive users of marijuana as a result of legalization is not known, said Weiss. “The numbers we have from studies indicate that something like 9 percent of users will become addicted,” she said. “But we don’t know what will happen when the culture changes, and it’s a much more accepted form of behavior whether that figure will go up.”

Despite all that is unknown, Weiss is also concerned about the future. “We have an alcohol industry, we have a tobacco industry, and they target young people,” she said. “Having another business that’s going to be doing the same sort of thing doesn’t seem like it could have a good outcome.”

The pro-legalization view

Carl Hart, Ph.D., associate professor of psychology at Columbia University and a board member of the Drug Policy Alliance (the powerhouse behind marijuana legalization), is probably the most highly respected addiction expert on the pro-legalization side. He agreed with McLellan about alcohol prohibition — that it worked in terms of public health. But that is a narrow perspective, he said. “The majority of people who used alcohol did so safely,” he said. When prohibition was repealed, money no longer needed to go toward law enforcement, he said.

Hart conceded that people can be dependent on marijuana. “If people are overindulging, we are concerned,” he said. What constitutes overindulging in marijuana? The answer is not that different from the one for alcohol, said Hart. “You want to monitor whether or not they are meeting their responsibilities,” he said. “A couple drinks a day and they’re meeting their responsibilities” is okay, he said. “A joint when you go to sleep at night” is okay. That said, Hart also noted that there are different routes of administration for marijuana, some of which may be less harmful than others: in addition to smoking, there is vaporizing or oral (edibles).

And Hart stressed that in terms of recommendations, he is only talking about adults, not children. The 6 percent of 12th graders who use marijuana daily do have a problem, he said. But Hart criticized the substance abuse treatment field for focusing on drugs instead of the “real problems these people face.” What are the real problems faced by the 6 percent of 12th graders who use daily? “I don’t know. I would need to interview all of them,” he said.

Hart doesn’t believe legalization will increase marijuana use. “For the first several months, you’ll see people who are curious,” he said. “But what’s going to overshadow everything else will be the money, in terms of state tax revenue.”

Implications for prevention

Hart and many other proponents of legalization frequently point to celebrities and successful people who have smoked marijuana. The response of Kevin Sabet, Ph.D., is “Who cares?” Sabet, who is an assistant professor of psychiatry and the director of the Drug Policy Institute at the University of Florida, said that the important question is this: “Does it make sense to go around and tell kids and other populations that X celebrity or politician who is successful once used drugs?” Addiction to drugs, in fact, is a rare occurrence among everyone who has tried them, said Sabet. “That’s where Carl [Hart] and I would agree,” he said. “But that doesn’t negate the fact that the 15 percent who do become addicted cause a great amount of harm to themselves.”

There are many parallels to alcohol, which also is used by many people without ill effects, said Sabet, who points to the financial strategy behind the move by states. Alcohol prohibition was repealed in the hopes that there wouldn’t need to be a federal income tax, he said. “I think today a lot of decision-makers and the public are chasing marijuana as yet another answer to fill state coffers, and I think we're going to be sorely disappointed in the end,” he said.

State lotteries provide a more recent example of this phenomenon: instead of solving the public education funding crisis, state lotteries are contributing to gambling problems. The master settlement under which tobacco funds were supposed to help fund treatment for addiction has instead gone into state general funds. And for every alcohol and tobacco revenue dollar going to the government, the public must bear ten dollars in social costs, said Sabet. “Legalizing marijuana or any other drug is not going to solve our financial crises,” he said. “It's going to put us deeper in the hole because we’re not only going to be paying for new regulations, but the costs associated with increased addiction.”

Sabet believes in decriminalization, if that means “removing criminal penalties for small amounts and instead focusing on a public health model.” That is a very different direction from the direction of legalization, he said. “We are on the road to create the new Big Tobacco of our time, full of advertising and lies and everything that we tried to get rid of with the tobacco industry.”

Sabet, who is also a founder, with former Congressman Patrick Kennedy, of Project SAM (Smart Approaches to Marijuana), said he hopes we don’t “have to repeat history and learn those painful lessons once again.” More can be done, he said: investing in early intervention and innovative programs that divert young people away from the criminal justice system and toward health, for example.

Many more states have established medical marijuana programs, an initiative that is also contributing to the perception of decreased risk of use. Recently we looked at why medications like dronabinol are being ignored (see ADAW, June 17, 2013). “Medical science is lacking” in medical marijuana, said McLellan, who said “medical marijuana is a charade” that is really a lead-in to promoting recreational use.

“We’ve worked for years with tobacco and alcohol, and we do know that reducing access and availability and reducing social norms is what works,” said Sue Thau, public policy consultant for Community Anti-Drug Coalitions of America (CADCA). Now the science of prevention calls for more metrics, she said. “We’re going to make sure we have baseline data for all of the possible implications” involving marijuana use by youth, she said.

“As preventionists, it is our job, for all substances of abuse that are problems for youth — alcohol, tobacco, marijuana, over-the-counter, inhalants and so on — that we work to change the perception of harm,” said Thau. For marijuana, CADCA needs to look at local conditions and then determine the next steps across all sectors to ensure that young people get science-based messages.

“It’s a fact that we don’t have the data,” said McLellan. “So for now, let’s turn to common sense. Is there anyone on the planet who thinks that more marijuana availability will make it easier for kids to do well in school?”