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• Research article
• Open access
• Published: 04 February 2020

Marijuana legalization and historical trends in marijuana use among US residents aged 12–25: results from the 1979–2016 National Survey on drug use and health

• Xinguang Chen 1 ,
• Xiangfan Chen 2 &
• Hong Yan 2  

BMC Public Health volume  20 , Article number:  156 ( 2020 ) Cite this article

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Marijuana is the most commonly used illicit drug in the United States. More and more states legalized medical and recreational marijuana use. Adolescents and emerging adults are at high risk for marijuana use. This ecological study aims to examine historical trends in marijuana use among youth along with marijuana legalization.

Data ( n  = 749,152) were from the 31-wave National Survey on Drug Use and Health (NSDUH), 1979–2016. Current marijuana use, if use marijuana in the past 30 days, was used as outcome variable. Age was measured as the chronological age self-reported by the participants, period was the year when the survey was conducted, and cohort was estimated as period subtracted age. Rate of current marijuana use was decomposed into independent age, period and cohort effects using the hierarchical age-period-cohort (HAPC) model.

After controlling for age, cohort and other covariates, the estimated period effect indicated declines in marijuana use in 1979–1992 and 2001–2006, and increases in 1992–2001 and 2006–2016. The period effect was positively and significantly associated with the proportion of people covered by Medical Marijuana Laws (MML) (correlation coefficients: 0.89 for total sample, 0.81 for males and 0.93 for females, all three p values < 0.01), but was not significantly associated with the Recreational Marijuana Laws (RML). The estimated cohort effect showed a historical decline in marijuana use in those who were born in 1954–1972, a sudden increase in 1972–1984, followed by a decline in 1984–2003.

The model derived trends in marijuana use were coincident with the laws and regulations on marijuana and other drugs in the United States since the 1950s. With more states legalizing marijuana use in the United States, emphasizing responsible use would be essential to protect youth from using marijuana.

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Introduction

Marijuana use and laws in the united states.

Marijuana is one of the most commonly used drugs in the United States (US) [ 1 ]. In 2015, 8.3% of the US population aged 12 years and older used marijuana in the past month; 16.4% of adolescents aged 12–17 years used in lifetime and 7.0% used in the past month [ 2 ]. The effects of marijuana on a person’s health are mixed. Despite potential benefits (e.g., relieve pain) [ 3 ], using marijuana is associated with a number of adverse effects, particularly among adolescents. Typical adverse effects include impaired short-term memory, cognitive impairment, diminished life satisfaction, and increased risk of using other substances [ 4 ].

Since 1937 when the Marijuana Tax Act was issued, a series of federal laws have been subsequently enacted to regulate marijuana use, including the Boggs Act (1952), Narcotics Control Act (1956), Controlled Substance Act (1970), and Anti-Drug Abuse Act (1986) [ 5 , 6 ]. These laws regulated the sale, possession, use, and cultivation of marijuana [ 6 ]. For example, the Boggs Act increased the punishment of marijuana possession, and the Controlled Substance Act categorized the marijuana into the Schedule I Drugs which have a high potential for abuse, no medical use, and not safe to use without medical supervision [ 5 , 6 ]. These federal laws may have contributed to changes in the historical trend of marijuana use among youth.

Movements to decriminalize and legalize marijuana use

Starting in the late 1960s, marijuana decriminalization became a movement, advocating reformation of federal laws regulating marijuana [ 7 ]. As a result, 11 US states had taken measures to decriminalize marijuana use by reducing the penalty of possession of small amount of marijuana [ 7 ].

The legalization of marijuana started in 1993 when Surgeon General Elder proposed to study marijuana legalization [ 8 ]. California was the first state that passed Medical Marijuana Laws (MML) in 1996 [ 9 ]. After California, more and more states established laws permitting marijuana use for medical and/or recreational purposes. To date, 33 states and the District of Columbia have established MML, including 11 states with recreational marijuana laws (RML) [ 9 ]. Compared with the legalization of marijuana use in the European countries which were more divided that many of them have medical marijuana registered as a treatment option with few having legalized recreational use [ 10 , 11 , 12 , 13 ], the legalization of marijuana in the US were more mixed with 11 states legalized medical and recreational use consecutively, such as California, Nevada, Washington, etc. These state laws may alter people’s attitudes and behaviors, finally may lead to the increased risk of marijuana use, particularly among young people [ 13 ]. Reported studies indicate that state marijuana laws were associated with increases in acceptance of and accessibility to marijuana, declines in perceived harm, and formation of new norms supporting marijuana use [ 14 ].

Marijuana harm to adolescents and young adults

Adolescents and young adults constitute a large proportion of the US population. Data from the US Census Bureau indicate that approximately 60 million of the US population are in the 12–25 years age range [ 15 ]. These people are vulnerable to drugs, including marijuana [ 16 ]. Marijuana is more prevalent among people in this age range than in other ages [ 17 ]. One well-known factor for explaining the marijuana use among people in this age range is the theory of imbalanced cognitive and physical development [ 4 ]. The delayed brain development of youth reduces their capability to cognitively process social, emotional and incentive events against risk behaviors, such as marijuana use [ 18 ]. Understanding the impact of marijuana laws on marijuana use among this population with a historical perspective is of great legal, social and public health significance.

Inconsistent results regarding the impact of marijuana laws on marijuana use

A number of studies have examined the impact of marijuana laws on marijuana use across the world, but reported inconsistent results [ 13 ]. Some studies reported no association between marijuana laws and marijuana use [ 14 , 19 , 20 , 21 , 22 , 23 , 24 , 25 ], some reported a protective effect of the laws against marijuana use [ 24 , 26 ], some reported mixed effects [ 27 , 28 ], while some others reported a risk effect that marijuana laws increased marijuana use [ 29 , 30 ]. Despite much information, our review of these reported studies revealed several limitations. First of all, these studies often targeted a short time span, ignoring the long period trend before marijuana legalization. Despite the fact that marijuana laws enact in a specific year, the process of legalization often lasts for several years. Individuals may have already changed their attitudes and behaviors before the year when the law is enacted. Therefore, it may not be valid when comparing marijuana use before and after the year at a single time point when the law is enacted and ignoring the secular historical trend [ 19 , 30 , 31 ]. Second, many studies adapted the difference-in-difference analytical approach designated for analyzing randomized controlled trials. No US state is randomized to legalize the marijuana laws, and no state can be established as controls. Thus, the impact of laws cannot be efficiently detected using this approach. Third, since marijuana legalization is a public process, and the information of marijuana legalization in one state can be easily spread to states without the marijuana laws. The information diffusion cannot be ruled out, reducing the validity of the non-marijuana law states as the controls to compare the between-state differences [ 31 ].

Alternatively, evidence derived based on a historical perspective may provide new information regarding the impact of laws and regulations on marijuana use, including state marijuana laws in the past two decades. Marijuana users may stop using to comply with the laws/regulations, while non-marijuana users may start to use if marijuana is legal. Data from several studies with national data since 1996 demonstrate that attitudes, beliefs, perceptions, and use of marijuana among people in the US were associated with state marijuana laws [ 29 , 32 ].

Age-period-cohort modeling: looking into the past with recent data

To investigate historical trends over a long period, including the time period with no data, we can use the classic age-period-cohort modeling (APC) approach. The APC model can successfully discompose the rate or prevalence of marijuana use into independent age, period and cohort effects [ 33 , 34 ]. Age effect refers to the risk associated with the aging process, including the biological and social accumulation process. Period effect is risk associated with the external environmental events in specific years that exert effect on all age groups, representing the unbiased historical trend of marijuana use which controlling for the influences from age and birth cohort. Cohort effect refers to the risk associated with the specific year of birth. A typical example is that people born in 2011 in Fukushima, Japan may have greater risk of cancer due to the nuclear disaster [ 35 ], so a person aged 80 in 2091 contains the information of cancer risk in 2011 when he/she was born. Similarly, a participant aged 25 in 1979 contains information on the risk of marijuana use 25 years ago in 1954 when that person was born. With this method, we can describe historical trends of marijuana use using information stored by participants in older ages [ 33 ]. The estimated period and cohort effects can be used to present the unbiased historical trend of specific topics, including marijuana use [ 34 , 36 , 37 , 38 ]. Furthermore, the newly established hierarchical APC (HAPC) modeling is capable of analyzing individual-level data to provide more precise measures of historical trends [ 33 ]. The HAPC model has been used in various fields, including social and behavioral science, and public health [ 39 , 40 ].

Several studies have investigated marijuana use with APC modeling method [ 17 , 41 , 42 ]. However, these studies covered only a small portion of the decades with state marijuana legalization [ 17 , 42 ]. For example, the study conducted by Miech and colleagues only covered periods from 1985 to 2009 [ 17 ]. Among these studies, one focused on a longer state marijuana legalization period, but did not provide detailed information regarding the impact of marijuana laws because the survey was every 5 years and researchers used a large 5-year age group which leads to a wide 10-year birth cohort. The averaging of the cohort effects in 10 years could reduce the capability of detecting sensitive changes of marijuana use corresponding to the historical events [ 41 ].

Purpose of the study

In this study, we examined the historical trends in marijuana use among youth using HAPC modeling to obtain the period and cohort effects. These two effects provide unbiased and independent information to characterize historical trends in marijuana use after controlling for age and other covariates. We conceptually linked the model-derived time trends to both federal and state laws/regulations regarding marijuana and other drug use in 1954–2016. The ultimate goal is to provide evidence informing federal and state legislation and public health decision-making to promote responsible marijuana use and to protect young people from marijuana use-related adverse consequences.

Materials and methods

Data sources and study population.

Data were derived from 31 waves of National Survey on Drug Use and Health (NSDUH), 1979–2016. NSDUH is a multi-year cross-sectional survey program sponsored by the Substance Abuse and Mental Health Services Administration. The survey was conducted every 3 years before 1990, and annually thereafter. The aim is to provide data on the use of tobacco, alcohol, illicit drug and mental health among the US population.

Survey participants were noninstitutionalized US civilians 12 years of age and older. Participants were recruited by NSDUH using a multi-stage clustered random sampling method. Several changes were made to the NSDUH after its establishment [ 43 ]. First, the name of the survey was changed from the National Household Survey on Drug Abuse (NHSDA) to NSDUH in 2002. Second, starting in 2002, adolescent participants receive $30 as incentives to improve the response rate. Third, survey mode was changed from personal interviews with self-enumerated answer sheets (before 1999) to the computer-assisted person interviews (CAPI) and audio computer-assisted self-interviews (ACASI) (since 1999). These changes may confound the historical trends [ 43 ], thus we used two dummy variables as covariates, one for the survey mode change in 1999 and another for the survey method change in 2002 to control for potential confounding effect.

Data acquisition

Data were downloaded from the designated website ( https://nsduhweb.rti.org/respweb/homepage.cfm ). A database was used to store and merge the data by year for analysis. Among all participants, data for those aged 12–25 years ( n  = 749,152) were included. We excluded participants aged 26 and older because the public data did not provide information on single or two-year age that was needed for HAPC modeling (details see statistical analysis section). We obtained approval from the Institutional Review Board at the University of Florida to conduct this study.

Variables and measurements

Current marijuana use: the dependent variable. Participants were defined as current marijuana users if they reported marijuana use within the past 30 days. We used the variable harmonization method to create a comparable measure across 31-wave NSDUH data [ 44 ]. Slightly different questions were used in NSDUH. In 1979–1993, participants were asked: “When was the most recent time that you used marijuana or hash?” Starting in 1994, the question was changed to “How long has it been since you last used marijuana or hashish?” To harmonize the marijuana use variable, participants were coded as current marijuana users if their response to the question indicated the last time to use marijuana was within past 30 days.

Chronological age, time period and birth cohort were the predictors. (1) Chronological age in years was measured with participants’ age at the survey. APC modeling requires the same age measure for all participants [ 33 ]. Since no data by single-year age were available for participants older than 21, we grouped all participants into two-year age groups. A total of 7 age groups, 12–13, ..., 24–25 were used. (2) Time period was measured with the year when the survey was conducted, including 1979, 1982, 1985, 1988, 1990, 1991... 2016. (3). Birth cohort was the year of birth, and it was measured by subtracting age from the survey year.

The proportion of people covered by MML: This variable was created by dividing the population in all states with MML over the total US population. The proportion was computed by year from 1996 when California first passed the MML to 2016 when a total of 29 states legalized medical marijuana use. The estimated proportion ranged from 12% in 1996 to 61% in 2016. The proportion of people covered by RML: This variable was derived by dividing the population in all states with RML with the total US population. The estimated proportion ranged from 4% in 2012 to 21% in 2016. These two variables were used to quantitatively assess the relationships between marijuana laws and changes in the risk of marijuana use.

Covariates: Demographic variables gender (male/female) and race/ethnicity (White, Black, Hispanic and others) were used to describe the study sample.

Statistical analysis

We estimated the prevalence of current marijuana use by year using the survey estimation method, considering the complex multi-stage cluster random sampling design and unequal probability. A prevalence rate is not a simple indicator, but consisting of the impact of chronological age, time period and birth cohort, named as age, period and cohort effects, respectively. Thus, it is biased if a prevalence rate is directly used to depict the historical trend. HAPC modeling is an epidemiological method capable of decomposing prevalence rate into mutually independent age, period and cohort effects with individual-level data, while the estimated period and cohort effects provide an unbiased measure of historical trend controlling for the effects of age and other covariates. In this study, we analyzed the data using the two-level HAPC cross-classified random-effects model (CCREM) [ 36 ]:

Where M ijk represents the rate of marijuana use for participants in age group i (12–13, 14,15...), period j (1979, 1982,...) and birth cohort k (1954–55, 1956–57...); parameter α i (age effect) was modeled as the fixed effect; and parameters β j (period effect) and γ k (cohort effect) were modeled as random effects; and β m was used to control m covariates, including the two dummy variables assessing changes made to the NSDUH in 1999 and 2002, respectively.

The HAPC modeling analysis was executed using the PROC GLIMMIX. Sample weights were included to obtain results representing the total US population aged 12–25. A ridge-stabilized Newton-Raphson algorithm was used for parameter estimation. Modeling analysis was conducted for the overall sample, stratified by gender. The estimated age effect α i , period β j and cohort γ k (i.e., the log-linear regression coefficients) were directly plotted to visualize the pattern of change.

To gain insight into the relationship between legal events and regulations at the national level, we listed these events/regulations along with the estimated time trends in the risk of marijuana from HAPC modeling. To provide a quantitative measure, we associated the estimated period effect with the proportions of US population living with MML and RML using Pearson correlation. All statistical analyses for this study were conducted using the software SAS, version 9.4 (SAS Institute Inc., Cary, NC).

Sample characteristics

Data for a total of 749,152 participants (12–25 years old) from all 31-wave NSDUH covering a 38-year period were analyzed. Among the total sample (Table  1 ), 48.96% were male and 58.78% were White, 14.84% Black, and 18.40% Hispanic.

Prevalence rate of current marijuana use

As shown in Fig.  1 , the estimated prevalence rates of current marijuana use from 1979 to 2016 show a “V” shaped pattern. The rate was 27.57% in 1979, it declined to 8.02% in 1992, followed by a gradual increase to 14.70% by 2016. The pattern was the same for both male and female with males more likely to use than females during the whole period.

Prevalence rate (%) of current marijuana use among US residents 12 to 25 years of age during 1979–2016, overall and stratified by gender. Derived from data from the 1979–2016 National Survey on Drug Use and Health (NSDUH)

HAPC modeling and results

Estimated age effects α i from the CCREM [ 1 ] for current marijuana use are presented in Fig.  2 . The risk by age shows a 2-phase pattern –a rapid increase phase from ages 12 to 19, followed by a gradually declining phase. The pattern was persistent for the overall sample and for both male and female subsamples.

Age effect for the risk of current marijuana use, overall and stratified by male and female, estimated with hierarchical age-period-cohort modeling method with 31 waves of NSDUH data during 1979–2016. Age effect α i were log-linear regression coefficients estimated using CCREM (1), see text for more details

The estimated period effects β j from the CCREM [ 1 ] are presented in Fig.  3 . The period effect reflects the risk of current marijuana use due to significant events occurring over the period, particularly federal and state laws and regulations. After controlling for the impacts of age, cohort and other covariates, the estimated period effect indicates that the risk of current marijuana use had two declining trends (1979–1992 and 2001–2006), and two increasing trends (1992–2001 and 2006–2016). Epidemiologically, the time trends characterized by the estimated period effects in Fig. 3 are more valid than the prevalence rates presented in Fig. 1 because the former was adjusted for confounders while the later was not.

Period effect for the risk of marijuana use for US adolescents and young adults, overall and by male/female estimated with hierarchical age-period-cohort modeling method and its correlation with the proportion of US population covered by Medical Marijuana Laws and Recreational Marijuana Laws. Period effect β j were log-linear regression coefficients estimated using CCREM (1), see text for more details

Correlation of the period effect with proportions of the population covered by marijuana laws: The Pearson correlation coefficient of the period effect with the proportions of US population covered by MML during 1996–2016 was 0.89 for the total sample, 0.81 for male and 0.93 for female, respectively ( p  < 0.01 for all). The correlation between period effect and proportion of US population covered by RML was 0.64 for the total sample, 0.59 for male and 0.49 for female ( p  > 0.05 for all).

Likewise, the estimated cohort effects γ k from the CCREM [ 1 ] are presented in Fig.  4 . The cohort effect reflects changes in the risk of current marijuana use over the period indicated by the year of birth of the survey participants after the impacts of age, period and other covariates are adjusted. Results in the figure show three distinctive cohorts with different risk patterns of current marijuana use during 1954–2003: (1) the Historical Declining Cohort (HDC): those born in 1954–1972, and characterized by a gradual and linear declining trend with some fluctuations; (2) the Sudden Increase Cohort (SIC): those born from 1972 to 1984, characterized with a rapid almost linear increasing trend; and (3) the Contemporary Declining Cohort (CDC): those born during 1984 and 2003, and characterized with a progressive declining over time. The detailed results of HAPC modeling analysis were also shown in Additional file 1 : Table S1.

Cohort effect for the risk of marijuana use among US adolescents and young adults born during 1954–2003, overall and by male/female, estimated with hierarchical age-period-cohort modeling method. Cohort effect γ k were log-linear regression coefficients estimated using CCREM (1), see text for more details

This study provides new data regarding the risk of marijuana use in youth in the US during 1954–2016. This is a period in the US history with substantial increases and declines in drug use, including marijuana; accompanied with many ups and downs in legal actions against drug use since the 1970s and progressive marijuana legalization at the state level from the later 1990s till today (see Additional file 1 : Table S2). Findings of the study indicate four-phase period effect and three-phase cohort effect, corresponding to various historical events of marijuana laws, regulations and social movements.

Coincident relationship between the period effect and legal drug control

The period effect derived from the HAPC model provides a net effect of the impact of time on marijuana use after the impact of age and birth cohort were adjusted. Findings in this study indicate that there was a progressive decline in the period effect during 1979 and 1992. This trend was corresponding to a period with the strongest legal actions at the national level, the War on Drugs by President Nixon (1969–1974) President Reagan (1981–1989) [ 45 ], and President Bush (1989) [ 45 ],and the Anti-Drug Abuse Act (1986) [ 5 ].

The estimated period effect shows an increasing trend in 1992–2001. During this period, President Clinton advocated for the use of treatment to replace incarceration (1992) [ 45 ], Surgeon General Elders proposed to study marijuana legalization (1993–1994) [ 8 ], President Clinton’s position of the need to re-examine the entire policy against people who use drugs, and decriminalization of marijuana (2000) [ 45 ] and the passage of MML in eight US states.

The estimated period effect shows a declining trend in 2001–2006. Important laws/regulations include the Student Drug Testing Program promoted by President Bush, and the broadened the public schools’ authority to test illegal drugs among students given by the US Supreme Court (2002) [ 46 ].

The estimated period effect increases in 2006–2016. This is the period when the proportion of the population covered by MML progressively increased. This relation was further proved by a positive correlation between the estimated period effect and the proportion of the population covered by MML. In addition, several other events occurred. For example, over 500 economists wrote an open letter to President Bush, Congress and Governors of the US and called for marijuana legalization (2005) [ 47 ], and President Obama ended the federal interference with the state MML, treated marijuana as public health issues, and avoided using the term of “War on Drugs” [ 45 ]. The study also indicates that the proportion of population covered by RML was positively associated with the period effect although not significant which may be due to the limited number of data points of RML. Future studies may follow up to investigate the relationship between RML and rate of marijuana use.

Coincident relationship between the cohort effect and legal drug control

Cohort effect is the risk of marijuana use associated with the specific year of birth. People born in different years are exposed to different laws, regulations in the past, therefore, the risk of marijuana use for people may differ when they enter adolescence and adulthood. Findings in this study indicate three distinctive cohorts: HDC (1954–1972), SIC (1972–1984) and CDC (1984–2003). During HDC, the overall level of marijuana use was declining. Various laws/regulations of drug use in general and marijuana in particular may explain the declining trend. First, multiple laws passed to regulate the marijuana and other substance use before and during this period remained in effect, for example, the Marijuana Tax Act (1937), the Boggs Act (1952), the Narcotics Control Act (1956) and the Controlled Substance Act (1970). Secondly, the formation of government departments focusing on drug use prevention and control may contribute to the cohort effect, such as the Bureau of Narcotics and Dangerous Drugs (1968) [ 48 ]. People born during this period may be exposed to the macro environment with laws and regulations against marijuana, thus, they may be less likely to use marijuana.

Compared to people born before 1972, the cohort effect for participants born during 1972 and 1984 was in coincidence with the increased risk of using marijuana shown as SIC. This trend was accompanied by the state and federal movements for marijuana use, which may alter the social environment and public attitudes and beliefs from prohibitive to acceptive. For example, seven states passed laws to decriminalize the marijuana use and reduced the penalty for personal possession of small amount of marijuana in 1976 [ 7 ]. Four more states joined the movement in two subsequent years [ 7 ]. People born during this period may have experienced tolerated environment of marijuana, and they may become more acceptable of marijuana use, increasing their likelihood of using marijuana.

A declining cohort CDC appeared immediately after 1984 and extended to 2003. This declining cohort effect was corresponding to a number of laws, regulations and movements prohibiting drug use. Typical examples included the War on Drugs initiated by President Nixon (1980s), the expansion of the drug war by President Reagan (1980s), the highly-publicized anti-drug campaign “Just Say No” by First Lady Nancy Reagan (early 1980s) [ 45 ], and the Zero Tolerance Policies in mid-to-late 1980s [ 45 ], the Anti-Drug Abuse Act (1986) [ 5 ], the nationally televised speech of War on Drugs declared by President Bush in 1989 and the escalated War on Drugs by President Clinton (1993–2001) [ 45 ]. Meanwhile many activities of the federal government and social groups may also influence the social environment of using marijuana. For example, the Federal government opposed to legalize the cultivation of industrial hemp, and Federal agents shut down marijuana sales club in San Francisco in 1998 [ 48 ]. Individuals born in these years grew up in an environment against marijuana use which may decrease their likelihood of using marijuana when they enter adolescence and young adulthood.

This study applied the age-period-cohort model to investigate the independent age, period and cohort effects, and indicated that the model derived trends in marijuana use among adolescents and young adults were coincident with the laws and regulations on marijuana use in the United States since the 1950s. With more states legalizing marijuana use in the United States, emphasizing responsible use would be essential to protect youth from using marijuana.

Limitations

This study has limitations. First, study data were collected through a household survey, which is subject to underreporting. Second, no causal relationship can be warranted using cross-sectional data, and further studies are needed to verify the association between the specific laws/regulation and the risk of marijuana use. Third, data were available to measure single-year age up to age 21 and two-year age group up to 25, preventing researchers from examining the risk of marijuana use for participants in other ages. Lastly, data derived from NSDUH were nation-wide, and future studies are needed to analyze state-level data and investigate the between-state differences. Although a systematic review of all laws and regulations related to marijuana and other drugs is beyond the scope of this study, findings from our study provide new data from a historical perspective much needed for the current trend in marijuana legalization across the nation to get the benefit from marijuana while to protect vulnerable children and youth in the US. It provides an opportunity for stack-holders to make public decisions by reviewing the findings of this analysis together with the laws and regulations at the federal and state levels over a long period since the 1950s.

Availability of data and materials

The data of the study are available from the designated repository ( https://nsduhweb.rti.org/respweb/homepage.cfm ).

Abbreviations

Audio computer-assisted self-interviews

Age-period-cohort modeling

Computer-assisted person interviews

Cross-classified random-effects model

Contemporary Declining Cohort

Hierarchical age-period-cohort

Historical Declining Cohort

Medical Marijuana Laws

National Household Survey on Drug Abuse

National Survey on Drug Use and Health

Recreational Marijuana Laws

Sudden Increase Cohort

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Department of Epidemiology, University of Florida, Gainesville, FL, 32608, USA

Bin Yu & Xinguang Chen

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BY designed the study, collected the data, conducted the data analysis, drafted and reviewed the manuscript; XGC designed the study and reviewed the manuscript. XFC and HY reviewed the manuscript. All authors read and approved the final version of the manuscript.

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Additional file 1: table s1..

Estimated Age, Period, Cohort Effects for the Trend of Marijuana Use in Past Month among Adolescents and Emerging Adults Aged 12 to 25 Years, NSDUH, 1979-2016. Table S2. Laws at the federal and state levels related to marijuana use.

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Yu, B., Chen, X., Chen, X. et al. Marijuana legalization and historical trends in marijuana use among US residents aged 12–25: results from the 1979–2016 National Survey on drug use and health. BMC Public Health 20 , 156 (2020). https://doi.org/10.1186/s12889-020-8253-4

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2018 Theses Doctoral

Essays on Cannabis Legalization

Thomas, Danna Kang

Though the drug remains illegal at the federal level, in recent years states and localities have increasingly liberalized their marijuana laws in order to generate tax revenue and save resources on marijuana law enforcement. Many states have adopted some form of medical marijuana and/or marijuana decriminalization laws, and as of 2017, Washington, Colorado, Maine, California, Oregon, Massachusetts, Nevada, Alaska, and the District of Columbia have all legalized marijuana for recreational use. In 2016 recreational marijuana generated over $1.8 billion in sales. Hence, studying marijuana reforms and the policies and outcomes of early recreational marijuana adopters is an important area of research. However, perhaps due to the fact that legalized recreational cannabis is a recent phenomenon, a scarcity of research exists on the impacts of recreational cannabis legalization and the efficacy and efficiency of cannabis regulation. This dissertation aims to fill this gap, using the Washington recreational marijuana market as the primary setting to study cannabis legalization in the United States. Of first order importance in the regulation of sin goods such as cannabis is quantifying the value of the marginal damages of negative externalities. Hence, Chapter 1 (co-authored with Lin Tian) explores the impact of marijuana dispensary location on neighborhood property values, exploiting plausibly exogenous variation in marijuana retailer location. Policymakers and advocates have long expressed concerns that the positive effects of the legalization--e.g., increases in tax revenue--are well spread spatially, but the negative effects are highly localized through channels such as crime. Hence, we use changes in property values to measure individuals' willingness to pay to avoid localized externalities caused by the arrival of marijuana dispensaries. Our key identification strategy is to compare changes in housing sales around winners and losers in a lottery for recreational marijuana retail licenses. (Due to location restrictions, license applicants were required to provide an address of where they would like to locate.) Hence, we have the locations of both actual entrants and potential entrants, which provides a natural difference-in-differences set-up. Using data from King County, Washington, we find an almost 2.4% decrease in the value of properties within a 0.5 mile radius of an entrant, a $9,400 decline in median property values. The aforementioned retail license lottery was used to distribute licenses due to a license quota. Retail license quotas are often used by states to regulate entry into sin goods markets as quotas can restrict consumption by decreasing access and by reducing competition (and, therefore, increasing markups). However, license quotas also create allocative inefficiency. For example, license quotas are often based on the population of a city or county. Hence, licenses are not necessarily allocated to the areas where they offer the highest marginal benefit. Moreover, as seen in the case of the Washington recreational marijuana market, licenses are often distributed via lottery, meaning that in the absence of an efficiency secondary market for licenses, the license recipients are not necessarily the most efficient potential entrants. This allocative inefficiency is generated by heterogeneity in firms and consumers. Therefore, in Chapter 2, I develop a model of demand and firm pricing in order to investigate firm-level heterogeneity and inefficiency. Demand is differentiated by geography and incorporates consumer demographics. I estimate this demand model using data on firm sales from Washington. Utilizing the estimates and firm pricing model, I back out a non-parametric distribution of firm variable costs. These variable costs differ by product and firm and provide a measure of firm inefficiency. I find that variable costs have lower inventory turnover; hence, randomly choosing entrants in a lottery could be a large contributor to allocative inefficiency. Chapter 3 explores the sources of allocative inefficiency in license distribution in the Washington recreational marijuana market. A difficulty in studying the welfare effects of license quotas is finding credible counterfactuals of unrestricted entry. Therefore, I take a structural approach: I first develop a three stage model that endogenizes firm entry and incorporates the spatial demand and pricing model discussed in Chapter 2. Using the estimates of the demand and pricing model, I estimate firms' fixed costs and use data on locations of those potential entrants that did not win Washington's retail license lottery to simulate counterfactual entry patterns. I find that allowing firms to enter freely at Washington's current marijuana tax rate increases total surplus by 21.5% relative to a baseline simulation of Washington's license quota regime. Geographic misallocation and random allocation of licenses account for 6.6\% and 65.9\% of this difference, respectively. Moreover, as the primary objective of these quotas is to mitigate the negative externalities of marijuana consumption, I study alternative state tax policies that directly control for the marginal damages of marijuana consumption. Free entry with tax rates that keep the quantity of marijuana or THC consumed equal to baseline consumption increases welfare by 6.9% and 11.7%, respectively. I also explore the possibility of heterogeneous marginal damages of consumption across geography, backing out the non-uniform sales tax across geography that is consistent with Washington's license quota policy. Free entry with a non-uniform sales tax increases efficiency by over 7% relative to the baseline simulation of license quotas due to improvements in license allocation.

• Cannabis--Law and legislation
• Marijuana industry
• Drug legalization
• Drugs--Economic aspects

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How To Write an Essay About Marijuana Legalization

Introduction to marijuana legalization.

When embarking on an essay about marijuana legalization, it's crucial to begin with a comprehensive overview of the topic. Marijuana legalization is a multifaceted issue that encompasses legal, medical, social, and economic dimensions. Your introduction should briefly touch upon the history of marijuana use and its legal status over time, setting the stage for a deeper exploration of the arguments for and against legalization. Establish your thesis statement, outlining the specific aspect of marijuana legalization you will focus on, whether it's the potential medical benefits, the social implications, or the economic impact of legalizing marijuana.

Examining the Arguments for Legalization

In this section, delve into the arguments commonly made in favor of legalizing marijuana. These arguments often include the potential medical benefits of marijuana, such as its use in pain management and treatment of certain medical conditions. Discuss the viewpoint that legalization could lead to better regulation and quality control of the substance, as well as potentially reduce crime rates related to illegal drug trade. It's also important to consider the economic aspect, such as the revenue generated from taxing legal marijuana sales. Provide well-researched evidence and examples to support these arguments, ensuring that your essay presents a balanced and informed perspective.

Exploring the Counterarguments

Next, address the arguments against marijuana legalization. These may include concerns about the health risks associated with marijuana use, such as potential impacts on mental health and cognitive function, especially among young people. Discuss the fears that legalization might lead to increased usage rates, particularly in adolescents, and the potential for marijuana to act as a gateway drug. There's also the argument regarding the challenges of enforcing regulations and controlling the quality and distribution of legal marijuana. Like the previous section, ensure that you present these counterarguments with supporting evidence and a fair analysis, demonstrating an understanding of the complexities of the issue.

Concluding the Essay

Conclude your essay by summarizing the main points from both sides of the argument. This is your opportunity to reinforce your thesis and provide a final analysis of the issue based on the evidence presented. Reflect on the potential future of marijuana legalization, considering the current trends and policy changes. A well-crafted conclusion should provide closure to your essay and encourage the reader to continue contemplating the nuanced aspects of marijuana legalization. Your concluding remarks might also suggest areas for further research or consideration, underscoring the ongoing nature of the debate surrounding marijuana legalization.

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Understanding the evidence for medical cannabis and cannabis-based medicines for the treatment of chronic non-cancer pain

Affiliations.

• 1 National Drug and Alcohol Research Centre (NDARC), Faculty of Medicine, UNSW Sydney, 22-32 King Street, Randwick, NSW, 2031, Australia. [email protected].
• 2 National Drug and Alcohol Research Centre (NDARC), Faculty of Medicine, UNSW Sydney, 22-32 King Street, Randwick, NSW, 2031, Australia.
• 3 Monash Addiction Research Centre, Eastern Health Clinical School, Faculty of Medicine Nursing and Health Sciences, Monash University, Level 2, 5 Arnold Street, Box Hill, VIC, 3128, Australia.
• PMID: 30635715
• DOI: 10.1007/s00406-018-0960-9

The use of medical cannabis and cannabis-based medicines has received increasing interest in recent years; with a corresponding surge in the number of studies and reviews conducted in the field. Despite this growth in evidence, the findings and conclusions of these studies have been inconsistent. In this paper, we outline the current evidence for medical cannabis and cannabis-based medicines in the treatment and management of chronic non-cancer pain. We discuss limitations of the current evidence, including limitations of randomised control trials in the field, limits on generalisability of previous findings and common issues such as problems with measurements of dose and type of cannabinoids. We discuss future directions for medicinal cannabinoid research, including addressing limitations in trial design; developing frameworks to monitor for use disorder and other unintended outcomes; and considering endpoints other than 30% or 50% reductions in pain severity.

Keywords: Cannabis; Cannabis-based medicines; Chronic pain; Medical cannabis.

Publication types

• Cannabinoid Receptor Modulators / pharmacology*
• Cannabinoids / pharmacology*
• Chronic Pain / drug therapy*
• Medical Marijuana / pharmacology*
• Cannabinoid Receptor Modulators
• Cannabinoids
• Medical Marijuana

Grants and funding

• 1119992/National Health and Medical Research Council
• 1104600/National Health and Medical Research Council
• 113243/National Health and Medical Research Council

Cannabis (Marijuana) Research Report What is marijuana?

Marijuana—also called  weed, herb, pot, grass, bud, ganja, Mary Jane , and a vast number of other slang terms—is a greenish-gray mixture of the dried flowers of  Cannabis sativa . Some people smoke marijuana in hand-rolled cigarettes called joints ; in pipes, water pipes (sometimes called  bongs ), or in  blunts (marijuana rolled in cigar wraps). 1 Marijuana can also be used to brew tea and, particularly when it is sold or consumed for medicinal purposes, is frequently mixed into foods ( edibles ) such as brownies, cookies, or candies. Vaporizers are also increasingly used to consume marijuana. Stronger forms of marijuana include sinsemilla (from specially tended female plants) and concentrated resins containing high doses of marijuana’s active ingredients, including honeylike hash oil , waxy budder , and hard amberlike shatter . These resins are increasingly popular among those who use them both recreationally and medically.

The main psychoactive (mind-altering) chemical in marijuana, responsible for most of the intoxicating effects that people seek, is delta-9-tetrahydrocannabinol (THC). The chemical is found in resin produced by the leaves and buds primarily of the female cannabis plant. The plant also contains more than 500 other chemicals, including more than 100 compounds that are chemically related to THC, called cannabinoids . 2

The Reasons Why Marijuana Should be Made Legal Research Paper

Introduction, arguments against marijuana, arguments for marijuana, works cited.

Drugs that cause addiction and have negative effects health has been illegalized in most constitutions. These drugs are seen to have minimal benefits and enormous side effects. Among drugs that have been illegalized include: heroin, cocaine and marijuana among others. On the other hand those that are legalized include tobacco and alcohol. This research paper main interest is in the legalization of marijuana.

Marijuana has been illegalized because it is considered to be risk factors in people’s health and is believed to temper with the brain. It is also associated with criminal acts such as gang behavior and is discouraged. The purpose of this research paper is to address the reasons why marijuana should be made legal.

Among the reasons that support the legalization of marijuana include: the medical basis that marijuana has some benefits and that the state could gain revenue from the trade of marijuana as opposed to the costs incurred in the implementation of the laws against use the controlled drug. Furthermore, the legalization would enable the state to monitor and introduce legal outlets that would enforce the correct use of the drug (Barnes: 11).

Medical reasons against use of marijuana as medically unfit to use

In the argument against marijuana to be made illegal, Barnes (9) ascertains that marijuana should not be made legal in the medical field. There are certain cases that marijuana has negatively affected the immune system of the person taking the drug. In other cases, side effects like the damage of the brain and poisonous forms have occurred.

Testing must be done

Before marijuana is fully accepted as a medication, extensive testing of the drug must be done to establish the adverse effects as well as the benefits. This is because the state has the responsibility of ensuring that the drug is harmless before legalizing it. The state can consider thorough investigations before it is legalized. They may also consider what other institutions have assessed and made conclusions about the use of the drug (Barnes 11).

Measurements of elements contained in marijuana

Another reason against the use of marijuana in the medical field is the inability to have power over the purity of the drug. Marijuana is not a synthetic drug and hence it may be difficult to establish control over the natural growing marijuana. It may also develop other challenges concerned with the way productions and distribution of the drug.

However, this argument is challenged with the tobacco industry where it has been established and seems to be doing well. This is because the manufacturers of tobacco have been able to follow directives as by the government and controlled it. So, if the same measures are employed with marijuana the control may be successful.

Marijuana should not be prescribed

In his argument against marijuana to be prescribed in medical institutions Barnes (12) disputes that the state will be able to uphold its uprightness in the testing of the drug. This is because it may not be able to follow keenly the patients under testing of marijuana for medical purposes and therefore may fail to accurately get the right assessment. This is because monitoring the marijuana consumers may be difficult, thus paralyzing the testing of the drug.

Marijuana is replaceable

Barnes (11) states that the medical field does consider the use of marijuana as unnecessary as there are other drugs that could replace it and have fewer side effects. Therefore, marijuana can be avoided and the alternative drugs be used in its place. Despite some medical practitioners ignoring the use of marijuana for cancer cases like vomiting, patients have proffered marijuana to the synthetic drugs. In other cases marijuana has been argued to be of benefit to cancer patients as well as other diseases (Cervantes: 6).

Marijuana may be misinterpreted to be safe on human health

Barnes (15) mentions that if marijuana is legalized for medical reasons it may be misinterpreted by the public. This is because they may consider use of marijuana safe for their health following the states approval for medical use. As a result, marijuana would be used for leisure hence create more health problem among the public especially if excessively smoked.

Illegal businesses will be encouraged

If legalized, businesses will be set up to sell marijuana. The traders will sell it assuming that it helps cancer patients whereas just a few may benefit. This is because the people selling may be unauthorized to sell. This implies that those taking the drug may lack monitoring from a professional in the medical field hence the treatment may be inadequate or in excess or even wrong. Consequently, the state may welcome more harm instead of good.

Marijuana is different from alcohol

Smith (8) argues against marijuana saying that marijuana is harmful to health just like cigarettes. When smoked after a long time the person may develop lung problems. For expecting mothers smoking may lead to death of the fetus or cause births with deformities.

Marijuana be used only when necessary

Despite the fact that legalized marijuana may bring more evil than good, the state can consider the use of marijuana for medical situations that require the specific intervention of the drug. The use of the drug will purely be made possible by a qualified professional who by careful consideration of all options recommends the use of marijuana. Therefore, the government should not abolish the use marijuana even for medical reasons.

Marijuana does not cause health problems

Marijuana rarely causes biological problem. The persons using marijuana cannot be affected in the mind destroy the immune system or transfer effects to through inheritance. However, persistence use of marijuana can make one suffer from bronchitis if they smoke it.

This is a preventable cause because marijuana can be consumed in food for instance baked products. Additional marijuana is not known to cause serious illnesses like those caused by other drugs like cocaine. Marijuana cannot cause death if simply taken in large quantities (Legalization of marijuana.com Para 8).

On the contrary Stimson says that “the scientific knowledge is clear that marijuana is addictive and that its use significantly impairs bodily and mental functions. Marijuana use is associated with memory loss, cancer, immune system deficiencies, heart disease and birth defects, among other conditions. Even where decriminalized, marijuana trafficking remain a source of violence, crime and social integration” (p. 1)

Marijuana is a source of revenue

Another reason why marijuana should be legalized is that it is a source of revenue for the government and a source of income for the individual. Those trading marijuana gain profits that can support the family besides paying all the taxes. When the breadwinner is arrested for being in possession of the illegal drug, the family suffers. Children are transferred to children’s home separating them from their parent (Legalization of marijuana.com Para 5).

The other concern that is raised as a source of income is the spread of drug network in the name of legalized trade. Stimson (2) notes that legalization of marijuana may lead to expansion of the drug associations that sell drugs under ground. This may be an opportunity for them to sell other drugs that have much worse adverse effect. In addition, the groups selling drugs may end up selling it to underage children who should be protected from taking the drug.

Marijuana has medical benefits

As Barnes (8) point out, marijuana can be used for medical treatment of some illnesses and therefore should be legalized. Marijuana may have fewer side effects when compared to other drugs in the medical field when used to treat a certain illness. As a matter of fact, marijuana as a medical drug would work effectively and be the best drug for particular patients. For instance, marijuana is very effective in managing nausea in patients and the side effects can be tolerated to treat this symptom.

Marijuana get equal treatment as alcohol and tobacco

Gieringe (2) supports the legalization marijuana just like other drugs that have been legalized like the prominent tobacco and the consumption of alcohol. Like other drugs it has benefits and short comings which in most cases may be equal to those of the legalized drugs.

Furthermore, the use of marijuana hardly encourages the use of much superior drugs and therefore should be considered safe for the users. Another consideration is that the consumers of marijuana are not involved in unlawful behaviors and thus it is unfair to consider those consuming it to be criminals.

Stimson (3) argues against the treatment of marijuana as being similar to alcohol. In his article, he makes it clear that although both marijuana and alcohol have similar side effects, alcohol have adverse effects that are less acute as those of marijuana. On further considerations, alcohol is more widely accepted in many cultures of the world and accepted by many. Legalizing the drug would therefore go against many cultures and societies.

Report findings from the COMPAS (2) reveal that most people believe that crime will increase if marijuana is legalized. Others strongly believe that it will increase consumption behavior and some people will develop dependency. The results of being dependent will be an increase in people with deteriorating health.

Crime is believed to increase because the people who have developed dependency must keep taking the drug. Since the drug is costly, they look for more money after they have used whatever they had. Consequently, the persons may neglect their obligations perhaps in the family or at work to acquire the drug. This is undesired in the society because it affects the economy of an individual negatively.

Retractions lead to increased consumption

The individuals who are use marijuana controllably remain capable of driving as well as remain not addicted. Driver’s judgment on the road is not affected and therefore those under the influence of the drug can drive safely. For this reason, Gieringe (2) argues that restricting the marijuana will lead to increased consumption. This is because it is impossible to eradicate societal vices as they tend to increase when prohibited. Therefore, it is appropriate to legalize marijuana.

Illegal measures have failed

Punishments given for being in possession or using marijuana are futile. Regardless of whatever measures the state puts to control the use of prohibited drugs like marijuana, the public continues the consumption. Gieringe (4) indicates that strict punitive measures do not deter the users from using it.

In most cases they have secretive ways of producing and selling the same as well as consume it without being noticed. It is necessary to consider that consumption of the drug is an individual choice hence limiting or availing the drug may not be the factors to consider but rather it is an individual choice.

An example of the case of California

According to Gieringe (5) the law against the use of marijuana turned to be ineffective. The law was introduced with an aim to stop the broadening of the consumption as was introduced by a group of people. Following prohibition, the drug gained prominence as many learned to use. Apart from the consequences illegal marijuana on the people, the government used a lot of funds to curb the problem of illegal drugs.

When the public is introduced to prominent drug use Stimson (6) insists that a majority become addicted. Accordingly, the brain is affected making them unable to perform like other members of society, who do not use the drug. As a result, the affected at times have little ability to learn as before and so students who take drugs discontinue education for failure or inability to concentrate. The people who work and have jobs most often fail to perform well and are relieved from work.

Legalizing marijuana would contradict the law. Most governments have prohibited the production, distribution and consumption of illegal drugs. A law that would legalize one of the controlled drugs would send a message that with time even other drugs can be made legal. The argument is that the law would contradict itself since some of the other illegal drugs posses same adverse effects as those of marijuana (Stimson: 8). Instead the law should remain constant so that such laws do not fail as Rosenthal & Kubby (174) notes.

The budget after legalization of marijuana

Legalizing marijuana not only has advantages in the decrease in unlawful activities but also bring economic benefits in the budget of the state. Miron (2) indicates that the budget drastically incur large expenditure in the implementation of laws against marijuana.

This is opposed to the fact that, if legalized, marijuana such costs would not be realized and the state would therefore gain revenue for transactions involved in marijuana. Caputo and Brian (480) also point out that the sales made in the illegal sale of marijuana are not taxed. If the government would implement taxation, then the state would have increased revenue.

Some of the costs are as follows: The police are funded by the state budget to conduct arrests of those found with marijuana. Other cost is spent in the justice system. After the sent the criminal to prison another cost is incurred. This cost can be scraped off and the government would gain instead (Miron: 2).

Control Measures by the state

Upon legalization there should be restrictions that the state can enforce to monitor the production distribution and consumption of marijuana. First, it can consider making the any individuals who is concerned with marijuana trade to obtain a license given the state. Additionally, the concerned people must surrender the marijuana before selling for inspection of its contents and grading.

This will make it possible for the state to standardize the product assess whether there are harmful contents and allow only the safe product to be sold. Upon the assessment for the elements, the trader will then be taxed. Selling will also be done by authorized persons through specific channels. As with the use of other tobacco, it can be sold to adults in specific areas at a particular time.

Obtaining of a licenses should not be made difficult by the state or remain within the reach of a few. Those who wish for a medium scale business can be allowed to have such licenses. It may also be relevant to consider allowing individuals to plant some marijuana for own consumption although in small quantities as allowed by the state. This is similar to the home made wine made for own use and is also in line with individual liberties.

The challenged face with implementing the home grown marijuana is the control of the plant in terms of production. Another challenge is to be able to discourage children from accessing and using the drug before they are of the legal age Stimson (2). Punitive measures can also be made similar to those of the tobacco trade where the trader forfeits the license and risks being fined if they fail to adhere to rules.

Benefits of legalizing marijuana

The state will have reduced expenditure concerned with the unlawful trade of marijuana. This implies that, there will be fewer criminals the laws against will have been withdrawn. Therefore, the responsibility of taking the drug will be left upon individual judgment and for medical interventions.

More individuals will conform to the regulations about the consumption and encourage legal trade as opposed to illegal trade. The monitored distributers will make it impossible for people bellow the recommended age to obtain the drug. In addition, the quality and elements in the plant will be assessed and thus individuals will obtain safe marijuana. Lastly, the distributors will pay levy just like other businesses (Gieringer: 10).

Gieringe (7) notes that marijuana can be made legal and most problems associated with the consumption would be eliminated. If licensed individuals would be allowed to produce the crop and sell it through controlled channels of adults then the problems of misuse would decline.

There would be revenue generated and some individuals would support their families without fear of separation due to arrests. The drug can be categorized in the same group as alcohol and tobacco and receive equal treatment. With time, the sale will decline and be similar to that of tobacco. The production will also decline with the increase in production and lowering of prices. Consequently, the government will gain taxes from the sale as it loses in the illegal trade of marijuana.

The use of marijuana has adverse effects that are undesirable. The negative effects they have on human health when used for a long time are to be avoided by moderate use of the substance. Criminals are known to be drug users of among others marijuana hence it bring social evils. Since it damages the brain, students suffer and drop from school while those working fail to keep up to the task.

Although, those who are associated with marijuana are thought to be criminals the society can view them differently and legalize the use of the drug while monitoring its use. Marijuana has medical benefits and should be considered. The state also benefit from the taxes collected from the legal sale of marijuana.

Barnes, Eric. Reefer madness: Legal and moral issues surrounding the medical Prescription of marijuana , 2000. Web.

Caputo, Michael and Brian, Ostrom. “Potential Tax Revenue from a Regulated Marijuana Market: A Meaningful Revenue Source.” American Journal of Economics and Sociology , 1994, 53, 475-490.

Cervantes, Jorge. Marijuana horticulture: the Indoor/Outdoor Medical grower’s bible. North America: Van Patten Publishing, 2006.

COMPAS. Legalization of marijuana: A Compass Report for the National Post, 2004. Web.

Gieringer, Dale. Testimony of the legalization of Marijuana , 2009. Web.

Legalization of marijuana.com. Legalizing marijuana , 2010. Web.

Miron, Jeffrey. The budgetary implications of marijuana legalization in Massachusetts, 2003. Web.

Rosenthal, Ed & Kubby, Steve. Why marijuana should be legal. New York: Thunder Mouth press, 2003.

Smith, Sandra . Lee Marijuana . New York: The rasen publishing group, 1995. Web.

Stimson, Charles. Legalizing marijuana: why citizens should just say no , 2010. Web.

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Bibliography

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The Legalization of Marijuana, Research Paper Example

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The Legalization of Marijuana and the Effects on the Criminal Justice System

Introduction

No democracy deals without the burning issues that split the society and fall under different categories of perception according to their morality and acceptability. Such issues in the USA include euthanasia, death penalty, legalization of marijuana etc. The problem with such issues is that they are ethically perceived from different points of view and can find both proponents and opponents who may justify their position from legal, moral and philosophic points of view. The federal government usually adopts a position cardinally different from that of the public, and the only way out is to track the change in public thinking, to conduct thorough research on all issues related to the problem to identify the true outcomes of any decision taken in their respect, either positive or negative.

As an example, one can consider the debates over legalization of marijuana that have been overwhelming the USA for more than ten years since the adoption of the Compassionate Use Act in California. The revolutionary effect of that law was that it legitimated the cultivation and usage of marijuana for medical purposes. Since then a large number of states have passed similar laws that allowed distribution and cultivation of marijuana for medical purposes, which caused outrageous resistance from federal bodies of power.

Such a decision was caused by the long-term research of medical properties of marijuana. This substance scientifically called tetrohydrocannabinoid has proved to have a profound pain-relieving power for seriously ill patients with cancer, glaucoma or neuritis. It is also a recognized substance for appetite-increasing activities for patients with appetite loss and is widely applied for medical purposes in cases of epilepsy. However, the main problem with the application of marijuana in the medical field is the unclear margin between the positive therapeutic effect and the uncontrolled effect on the CNS that patients experience because of wrong dosing or inappropriate usage.

The question is still open for the majority of the US states and even those states that have more loyal legislation on access to marijuana for medical purposes can become the subject of legal prosecution and sanction. Such incongruence is caused by the unchangeable position of marijuana in the list of dangerous drugs that has not been changed yet even with the proper consideration of all recognized medical effects that were found out as properties for this substance. As a result, the USA experience a set of scandalous lawsuits from marijuana users for medical purposes and proponents of fundamental freedoms stipulated in the US Constitution; it is still not clear which outcome awaits the US in the process of that fight for free access to cannabis for medical application. But what remains obvious is that the possible outcomes of marijuana legalization have to be thoroughly considered and analyzed to predict the changes that it will cause in the state system of law enforcement, prosecution, investigations and criminal punishment.

One can predict assume that the legalization process will inevitably cause the changes in the law enforcement structure and will require a more comprehensive approach from law enforcement agencies on the provision of safe access to marijuana for qualified patients and to restrict its usage for non-medical purposes. The danger of marijuana abuse still remains extremely high, so an adequate criminal justice system response is necessary to ensure the proper fulfillment of legalization law observation and compliance with all its provisions.

Study of California and New Jersey Marijuana Legalization

Medical Applications of Marijuana

Nowadays the debate over propriety of marijuana medical usage is gaining force under the conditions that different US states experience different attitudes and legislative measures concerning the medical substance. Alongside with marijuana’s status of a forbidden drug, its tremendous therapeutic effect has been recognized and proven, causing the necessity for further action in the legislative sphere. As a proof for positive tendencies in the issue of legalization one can check the assumptions of the National Institutes of Health meeting on the subject of marijuana application in medicine:

“Central to the current debate about the therapeutic uses of marijuana is the claim that smoked marijuana offers therapeutic advantages over the currently available oral form (dronabinol capsules) of its most active ingredient, delta-9-tetrahydrocannabinol (9-THC), for a wide variety of conditions” (NIH, 1997).

The first factor that initiated research of cannabinoid receptors was the recognition of their positive functional roles in treatment of particular disorders such as analgesia, neurological and movement disorders, nausea and vomiting associated with cancer chemotherapy, glaucoma, and appetite stimulation/cachexia. Thus, compiling the views of the Expert group, a series of the following conclusions has been made on the range of cannabis applications in medicine (NIH, 1997).

The study with patients experiencing pain, cancer pain included, showed that there was a vague margin between the positive analgesia and the adverse CNS effects that are highly negative and undesirable. Research with patients with neurological and movement disorders turned out to be paradoxical: help of marijuana in spasticity release in cases of multiple sclerosis, partial spinal cord injury as well as Parkinson’s disease and Huntington’s chorea was not proven (NIH, 1997). However, assistance of cannabinoid substances in treatment of epilepsy, tonic-clonic seizures in particular, was found evident, though not understood in full. Some more positive results from application of marijuana occurred in cases of dystonic states, neuritis and experimental allergic encephalomyelitis (EAE) (NIH, 1997).

Marijuana application in cases of nausea and vomiting connected with chemotherapy is widely recognized despite the fact that many anti-emetics have been developed to eliminate these symptoms. Treatment of glaucoma showed efficiency of cannabis application – it proved to “lower intraocular pressure (IOP) in subjects with normal IOP and patients with glaucoma” (NIH, 1997). Appetite stimulation is also a widely known effect of cannabinoid consumption – it proves not to change the biological mechanisms of taste and normal satiety, thus becoming a valuable medication in appetite-related cases (NIH, 1997).

Drawing a conclusion from the NIH report assumptions, it is possible to understand how widely cannabis can be applied in medicine. Ways of consumption are different, and consequences as well as side effects are diverse and not completely known; however, the positive effect overwhelms the negative side of cannabis application, making debates about its legalization more and more intense. In some cases marijuana has proven to have a stronger clinical effect than strong medications do; all this evidence speaks in favor of legalization of this doubtable drug with so many applications, both in medicine and for evil purposes (as a narcotic). Such diversity of applications and effects caused by cannabis is causing various attitudes in law enforcement agencies across the country, causing legalization in some states that are more liberal and legislative prosecution in states with stricter legislation.

The Status of Legalization in the USA

Legalization of marijuana in the USA has several dimensions for consideration; this is largely determined by the fact that power in the country is distributed on several levels including federal government, state agencies and the strong impact that public opinion produces on shaping the US legislation. The main turning point in the legalization process occurred in 2005 with the decision of the Supreme Court to prosecute patients consuming the marijuana for medical purposes even in states with compassionate use laws (Medical Marijuana, 2010). This decision seriously aggravated the situation with cannabis consumption, since the public opinion on the subject is directly the opposite.

The federal opinion on marijuana legalization is highly negative – however, positive tendencies are evident in the Congress position concerning the issue. The recent proportion of votes for legalization constitutes 161 instead of 94 in 1998 (Medical Marijuana, 2010). The history of marijuana treatment started in 1978 when federal government started to sponsor access to medical marijuana for serious, terminal diseases. The program had to be conserved 14 years later because of the extreme growth of applications for treatment from AIDS patients, so now there are less than a dozen patients who still receive federal support with access to marijuana (Medical Marijuana, 2010).

One more aggravating circumstance can be seen in the fact that cannabis is still considered a Schedule I substance – having a high potential for abuse and no medical value. The fight for reconsideration of the role of cannabis lasts for 30 years already and has led to the establishment of the Coalition of Rescheduling Cannabis in 2002 (Medical Marijuana, 2010).

Nonetheless, the federal disapproval of marijuana use finds little state support, which can be witnessed from statistics of marijuana arrests – 99% occur at the state or local level. The distribution of tolerance towards marijuana across the USA looks as follows:

• The most loyal states that remove penalties for cannabis-related activities are Alaska, California, Colorado, Hawaii, Maine, Michigan, Montana, Nevada, New Mexico, Oregon, Rhode Island, Vermont and Washington
• Ten states virtually provide citizens with the right to use but do not provide support and protection before the law
• Thirteen states have medical research laws
• Fifteen states haven’t ever had protective marijuana use laws (Medical Marijuana, 2010).

Finally, public opinion in the USA is exceedingly pro-marijuana: since the extensive medical usefulness has been recognized, more and more Americans vote for legalization in search of elimination of pain and sufferings. The recent research showed that more than 70% of US citizens would agree to use and approve of the use of marijuana if prescribed or recommended by the doctor (Medical Marijuana, 2010).

California Medical Marijuana Laws

The state of California is in the list of states exercising loyalty towards marijuana usage. A set of legislative provisions have been taken to ensure softer requirements for marijuana access in medicine. Among the most powerful ones it is necessary to note California Proposition 215 (titled “The Compassionate Use Act”) passed in 1996 and the Bill No. SB420 passed in 2003 to stipulate the provisions of Prop 215 (California’s Medical Marijuana Laws, 2010).

The California Proposition 215 was passed by 56% of votes and made California the first state to legalize marijuana usage for medical purposes. It introduced changes in the California Health and Safety Code as under its provisions, Californians obtained the right to get and use marijuana in the following cases:

“seriously ill Californians have the right to obtain and use marijuana  for medical purposes where that medical use is deemed appropriate and has been recommended by a physician who has determined that the persons health would benefit from the use of marijuana in the treatment of cancer, anorexia, AIDS, chronic pain, spasticity, glaucoma, arthritis, migraine or any other illness for which marijuana provides relief” (The California Proposition 215, 1996).

More than that, the Proposition allowed Californians who used marijuana for medical purposes to be not subject to criminal prosecution and outlined recommendations to ensure “safe and affordable distribution” of marijuana (The California Proposition 215, 1996). Physicians who recommend marijuana use are also not subject to prosecution of any kind. Thus, possession and cultivation of cannabis has become subject to a set of guidelines that became the margin between lawful and unlawful treatment of marijuana, stipulating the acceptable amounts for marijuana users for medical purposes only (California’s Medical Marijuana Laws, 2010).

The second major legislative act that promoted marijuana usage in California for medical purposes is the Bill No. SB420. This Bill established certain limits for the usage of Proposition 215, offering the establishment of identification cards that would be issued to qualified patients allowing usage of marijuana. The initial purpose of this document’s adoption was the growing number of irregularities concerning application of Proposition 215 – many problems and uncertainties caused the inability of law enforcement officers to provide adequate protection for qualified patients and designated primary caregivers. For this reason the act pursued the following set of purposes:

• To clarify the provisions of the act
• To promote its correct application
• To enhance access to marijuana for authorized individuals according to the provisions of the act (Bill No. SB420, 2003).

The State Department of Health Services plays the key role in provision of ID cards, development of protocols and application forms, renewal fees for the program etc. The Bill also enables the Attorney General to establish limits for cannabis possession and cultivation as well as to establish security and non-diversion of marijuana grown under the Proposition 215 for medical purposes (Bill No. SB420, 2003).

New Jersey Medical Marijuana Laws

The beginning of 2010 witnessed a democratic decision on legalization of marijuana usage for medical purposes in New Jersey, making it the 14 th state in the USA to adopt suchlike legislative provisions. The most striking fact is that legislation took place in the East Coast state – the region is famous for anti-legislation attitudes and statistically has no states where marijuana would be allowed (Kocieniewski, 2010). However, this democratic step was made by the state government:

“The measure — which would allow patients diagnosed with severe illnesses like cancer, AIDS, Lou Gehrig’s disease, muscular dystrophy and multiple sclerosis to have access to marijuana grown and distributed through state-monitored dispensaries — was passed by the General Assembly and State Senate on the final day of the legislative session” (Kocieniewski, 2010).

The newly passed legislative act is recognized as the most restrictive medical marijuana law because it enables physicians to prescribe marijuana only for a limited set of highly serious, chronic diseases. Besides, in contrast to other states, patients will be forbidden to grow marijuana on their own, will be unable to use it in public and will have to act according to a set of guidelines controlling consumption limits and distribution specifics (Kocieniewski, 2010).

Surely, adoption of legalization laws in such a conservative state as New Jersey could not help causing an agitated protest and debates around an easier access to marijuana that resulted from the decision made. First of all, the New Jersey public is concerned by the potential threat of marijuana becoming available for recreational usage and the increase of marijuana usage by teenagers. More than that, the main loophole seen by opponents in the law was “a list of ailments so unrestricted that it might have allowed patients to seek marijuana to treat minor or nonexistent ailments” (Kocieniewski, 2010). Luckily, that black spot was successfully eliminated.

At least, the stricter approach to medical marijuana legislation turned out to be decisive for the growing concern of patients left behind the legalization provisions in New Jersey. On the example of O’Brien born without fingers and toes as well as experiencing awful neuropathic pain, James (2010) shows how many patients with serious illnesses have still remained unable to receive medical marijuana for medical purposes. The initially reasonable wish to adopt a more restrictive law on medical marijuana that would leave no chance for drug abuse turned out to be an unlawful restriction and unequal access to medical marijuana for those in pain (James, 2010).

Figure 1. O’Brien’s in-born defect causing neuralgic pain

Note: From James, S.D. (2010). N.J. Medical Marijuana Law Overlooks Many in Pain. The ABC News Online . Retrieved February 17, 2010, from http://abcnews.go.com/ Health/Wellness/nj-medical-marijuana-law-ignores-chronic-pain-sufferers/ story?id=9574509&page=1

Surely, the overwhelming majority of medical marijuana proponents are sure that the legalization of law is a good start of the process of access to marijuana provision for all those needing it. The law will come into force within half a year and the list of diseases that are subject to recommended marijuana treatment will be reviewed in two years. Thus, there is still hope that in the near future much more will be done to provide a wider and more equal access to marijuana for medical purposes.

Criminal and Social Justice Issues Application to the Marijuana Legalization Process

The issue discussed in the present report cannot be unanimously assessed because of the overlapping spheres of philosophy, ethics and criminal justice that can be applied to marijuana legalization. When speaking about whether cannabis should be allowed for free medical use or not one should consider such theory as the criminal justice one that dictates punishment for wrongdoing according to the commonly accepted standards. Drug use, cultivation and sale are crimes according to the Criminal Code of any country, so distribution and use of marijuana should be punished according to the law. However, in connection with the possibilities for the medical application of marijuana one should also think about the social justice theory that dictates equality of opportunity and outcome. This theory protects human rights and fights for the equal access to their enjoyment. This is why the cannabis legalization issue is highly controversial – many assumptions of both theories come into conflict in this sphere, so they have to be considered extremely thoroughly.

US Constitution and US Homeland Security Act

The US Constitution is the main law governing the lives of US citizens and formulating democratic provisions for their enjoyment of equal opportunities, freedoms and rights. The USA have been fighting for democracy and independence hard, so there is no surprise that the Constitution of the US represents a highly democratic document allowing the nation to enjoy the rights inherent in every person in the world. The USA is fairly regarded as the most democratic country in the modern world; one cannot find any other country where the human rights are so eagerly protected in the courts of all levels. For this reason it is necessary to get a deeper look into the provisions of the US Constitution that may aid both proponents and opponents of marijuana legalization.

The first constitutional provision that is used by proponents of marijuana legalization is the Fifth Amendment that states that the US citizen cannot be “compelled in any criminal case to be a witness against himself, nor be deprived of life, liberty, or property, without due process of law” (U.S. Const. am. 5, 1787). The second most powerful argument can be found in the Ninth Amendment stating that ” the enumeration in the Constitution, of certain rights, shall not be construed to deny or disparage others retained by the people” (U.S. Const. am. 9, 1787). These two amendments dictate the protection of inherent human rights to seek a normal life for themselves and to look for ways to eliminate pain and sufferings that they experience. This is the reason why so many fighters for freedom of marijuana usage apply these provisions for the protection of their right to equal usage of medical substances that have proven to ensure the needed therapeutic effect for them.

However, the protection of basic freedoms for all US citizens dictated by the Constitution comes into conflict with the provisions of the Homeland Security Act adopted in 2002. As it is known, the Homeland Security Act was a natural reaction of the US to the series of inhuman terrorist attacks on the 9 th of September 2001; after the tragedy was understood, the federal government recognized the urgent necessity of composing a document in which it would formulate the major directions in which action should be taken and would list the threats that await the country in the modern world. Thus, drug interdiction and control over drug dissemination and illegal drug trafficking in the USA were recognized as several number one priorities alongside with the possible measures of terrorist attacks prevention (The Homeland Security Act, 2002).

This fact speaks about the seriousness of attitude to drugs taken by the US government, which makes the attitude to marijuana legalization understandable. When discussing marijuana-related issues one should remember that the cannabinoid substance is still considered a drug of the first degree with the high potential for abuse. This is why the Homeland Security Act of 2002 is often used by opponents of marijuana legalization to make their argument stand to reason.

Looking at the situation with marijuana legalization from a legislative point of view one can see that the debate has many implications interwoven; the issues where the principles of social justice and criminal justice contradict each other it is highly complicated to find the unified way out that would satisfy both the law enforcement authorities and the common public. As soon as the social justice requirements are satisfied, a great number of people will get the relief from pain they desire and will obtain an opportunity to get this relief on a legal basis. It is hard to imagine that all people refuse from pain relief and do not use cannabis only because it is forbidden by the law – the majority of terminally, chronically ill people confess in a confidential manner that they smoke marijuana being in the constant fear of legal prosecution.

But with the fulfillment of social justice principles there is a high threat of marijuana abuse and the increase of criminal prosecution cases that are likely to emerge in the state with legalized marijuana. Remembering that marijuana is highly necessary for thousands of people in horrible pain, one should still take into consideration the whole scope of outcomes that will result from legalization, both good and bad. The outlook on the problem from the side of the Homeland Security Act supposes that extended use of cannabis, no matter for what purposes, is already a federal crime that threatens the motherland’s security; it is equaled to terrorism or human trafficking, so it has to be eliminated in all its revelations no matter how much suffering and prosecution for terminally ill people it will cause.

CSI Applications in Legalization: Traditional Marijuana-Related Law Enforcement Measures

Even despite the fact that New Jersey and California have absolutely different attitudes and legislative provisions concerning marijuana possession, cultivation and sale, there are still criminal measures that govern the legal part of marijuana-related issues. Californian laws are surely more loyal and soft concerning the amount of marijuana to be held and cultivated; they also allow Californians to cultivate marijuana for medical purposes in their own households. Detailed legal penalties concerning marijuana in California look as follows:

Note: From California (2010). The NORML Site . Retrieved February 17, 2010, from http://norml.org/index.cfm?Group_ID=4525&wtm_view=penalties

California as a state with the 14-year-old experience of marijuana legalization has much softer laws concerning cannabis possession, use, transportation, selling and distribution. Possession of up to an ounce of marijuana is not a punishable misdemeanor at all. In case individuals were caught with the described amount of marijuana and have an identification card of a qualified patient, they will not have to do anything and will not pay a fine. In case the right for possession has not been proven in court, the fine of $100 will be imposed. Possession of a greater amount of marijuana is penalized by up to $500 (California, 2010).

Possession of about an ounce of marijuana at school grounds presupposes the penalty of $500 and 10 days in jail. Larger amounts presuppose 6 months of imprisonment and a $500 fine. Cultivation of marijuana also has some legal limitations but they are not imposed on qualified patients. Those who consume marijuana upon a medical prescription or recommendation are not subject to any legal penalties except cases of marijuana sale (California, 2010).

Sale of marijuana in any amount is punishable by law – it takes from 2 to 4 years of imprisonment. However, passing a small amount of marijuana (less than one ounce) is not a serious misdemeanor and is punished by up to a $100 fine. Sale of marijuana to a minor is a graver offense and presupposes criminal prosecution and imprisonment for up to 5 years. It is also necessary to note that using marijuana for industrial purposes is also popular – this is called hemp industry and specializes in producing textiles, paper, paints etc. (California, 2010).

In comparison with New Jersey one can see that the penalties are much softer. The New Jersey list of penalties and fines related to marijuana possession, cultivation and dissemination is as follows:

Note: From New Jersey (2010). The NORML Site . Retrieved February 17, 2010, from http://norml.org/index.cfm?Group_ID=4552&wtm_view=penalties

New Jersey imposes much stricter rules on the possession of marijuana (about 50 grams is considered an offense and is punished by imprisonment up to 6 months). Possession of greater amounts of marijuana supposes imprisonment for up to 1,5 years. The jail sentences are also accompanied by considerable fines ($1,000 in the first case and $25,000 in the second). In addition, the New Jersey government is highly obsessed by the potential threat of marijuana usage by teenagers, so possession of marijuana near schools is considered a graver crime and is additionally punished by 100 hours of community service (New Jersey, 2010).

Manufacture and distribution of marijuana are also considered grave crimes and are punished by means of imprisonment from 1,5 to 20 years and a fine from $10,000 to $300,000 depending on the amount of marijuana detected. The starting point is about one ounce. Growing marijuana (about 10 plants found) is already considered an illegal narcotics manufacturing activity that is severely punished – from 10 to 20 years of imprisonment (New Jersey, 2010).

Detected sale of marijuana is also considered a crime, even for doses less than an ounce. The sentence usually depends on the place where the sale has been detected – sale in public places as well as near schools is additionally punished. There is a complementary provision about sale to under-aged and pregnant females that presupposes double sentence (New Jersey, 2010).

Changes in Criminal and Social Justice Systems Caused by Legalization of Marijuana

As it comes from the legal information on attitude to marijuana-related issues in such states as New Jersey and California, one can see that the legalization process has reached different stages in various parts of the country. The Western Coast is considered a more loyal territory where the majority of states have already legalized marijuana for medical purposes more or less recently. However, the change in the criminal justice system that California has already undergone and that is awaiting New Jersey is evident – it is enough to have a look at the statistics of penalties for marijuana-related issues and to compare the amount and gravity of penalties for them.

At the present moment, before the enactment of the marijuana legalization process, New Jersey has a wide variety of penalties for marijuana possession, sale and cultivation – law enforcement officers are guided by those regulations in case they detect carriers or sellers of marijuana and severely punish them by law. At the present moment of site, as soon as the medical marijuana law is enacted, the infrastructure of law enforcement agencies in New Jersey will inevitably be changed. First of all, the change pertains to the identification cards issuing and management. The set of new roles and responsibilities is generated for the authorities in the state, for the Department of Health and Safety. These agencies will take the main burden of issuing identification cards to qualified patients, of prolonging the term of their power, of collecting the fees for taking part in the medical marijuana access program etc.

In addition, the role of police officers who used to detect marijuana users will have to be re-considered. Surely, the law about medical marijuana is much stricter in New Jersey and only usage will be punished less severely – in all other aspects such as selling or cultivation the role of police will remain the same. Thus, it becomes possible to assume that the change in New Jersey is not as grand as it is in California, but it may be a matter of time – it is hard to suppose that the loyalty towards marijuana in the first state that adopted legalization happened within a short period of time. The state has stepped on the way of change, and the review of diseases that will enable patients to apply for access to marijuana will be done in two years. Maybe this will be a turning point for further softening of possession, cultivation and obtaining procedures.

Social justice principles are gradually coming into force in New Jersey, which can be seen on the law about legalization recently passed by the state government; however, the common fears concerning this process of establishing social justice are intermingled with the inevitable abuse cases that will intrude in the criminal justice principles that worked well in New Jersey. Many opponents of medical marijuana legalization have used the situation in California as an argument against legalization – it is evident that too much abuse can be detected in this state as a result of too soft legislative measures both for authorized and unauthorized usage of marijuana. However, there is still some hope that some legal action will be taken to achieve a consensus between the social and criminal justice values that should be kept to in every society.

As it has been found in the present report, much incongruence is inescapable in any society obsessed by such controversial issues as marijuana legalization – these problems will always find both proponents and opponents, and the arguments each group will find will be justifiable. Each point of view stands to reason and each party of suchlike debates has the right for preservation either of indispensible human rights to eliminate pain by all possible means or to sustain law and order in the society by eliminating the chance for drug abuse or easy access to drugs in the community where their children exist.

The government can understand both sides of the debate, which is seen in the decisions of varying loyalty in different states. However, no equilibrium in the correlation of law, ethics and morality has been yet found, and both negative and positive decisions about marijuana legalization have proven to cause negative consequences that will hardly be eliminated unless the problem is approached in a more reasonable, balanced and grounded way from the side of the government and the public.

Bill Number: SB 420 — Bill Text (2003). Retrieved February 17, 2010, from http://www.chrisconrad.com/expert.witness/sb420-03.htm#text

California (2010). The NORML Site. Retrieved February 17, 2010, from http://norml.org/index.cfm?Group_ID=4525&wtm_view=penalties

California Proposition 215 (1996). Retrieved February 17, 2010, from http://www.chrisconrad.com/expert.witness/Prop215.html#215text

California’s Medical Marijuana Laws (2010). Americans for Safe Access Site. Retrieved February 17, 2010, from http://www.safeaccessnow.org/ section.php?id=189

James, S.D. (2010). N.J. Medical Marijuana Law Overlooks Many in Pain. The ABC News Online . Retrieved February 17, 2010, from http://abcnews.go.com/ Health/Wellness/nj-medical-marijuana-law-ignores-chronic-pain-sufferers/ story?id=9574509&page=1

Kocieniewski, D. (2010). New Jersey Vote Backs Marijuana for Severely Ill. The New York Times Online . Retrieved February 17, 2010, from http://www.nytimes.c om/2010/01/12/nyregion/12marijuana.html

Medical Marijuana (2010). Drug Policy Alliance Network . Retrieved February 17, 2010, from http://www.drugpolicy.org/marijuana/medical/

New Jersey (2010). The NORML Site . Retrieved February 17, 2010, from http://norml.org/index.cfm?Group_ID=4552&wtm_view=penalties

The Constitution of the United States , 1787.

The Homeland Security Act, 2002.

The Medical Uses of Marijuana (1997). The National Institutes of Health . Retrieved February 17, 2010, from http://www.a1b2c3.com/drugs/mj022.htm

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A Mapping Literature Review of Medical Cannabis Clinical Outcomes and Quality of Evidence in Approved Conditions in the USA from 2016 to 2019

Sebastian jugl.

a Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida, USA

b Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA

Aimalohi Okpeku

Brianna costales, earl j. morris, golnoosh alipour-haris, juan m. hincapie-castillo, nichole e. stetten.

c Occupational Therapy, University of Florida, Gainesville, Florida, USA

Ruba Sajdeya

d Epidemiology, University of Florida, Gainesville, Florida, USA

Shailina Keshwani

Verlin joseph, yahan zhang, lauren adkins.

e Health Sciences Center Libraries, University of Florida, Gainesville, Florida, USA

Almut G. Winterstein

Amie goodin, associated data.

In 2017, a National Academies of Sciences, Engineering, and Medicine (NASEM) report comprehensively evaluated the body of evidence regarding cannabis health effects through the year 2016. The objectives of this study are to identify and map the most recently (2016–2019) published literature across approved conditions for medical cannabis and to evaluate the quality of identified recent systematic reviews, published following the NASEM report. Following the literature search from 5 databases and consultation with experts, 11 conditions were identified for evidence compilation and evaluation: amyotrophic lateral sclerosis, autism, cancer, chronic noncancer pain, Crohn's disease, epilepsy, glaucoma, human immunodeficiency virus/AIDS, multiple sclerosis (MS), Parkinson's disease, and posttraumatic stress disorder. A total of 198 studies were included after screening for condition-specific relevance and after imposing the following exclusion criteria: preclinical focus, non-English language, abstracts only, editorials/commentary, case studies/series, and non-U.S. study setting. Data extracted from studies included: study design type, outcome definition, intervention definition, sample size, study setting, and reported effect size. Few completed randomized controlled trials (RCTs) were identified. Studies classified as systematic reviews were graded using the Assessing the Methodological Quality of Systematic Reviews-2 tool to evaluate the quality of evidence. Few high-quality systematic reviews were available for most conditions, with the exceptions of MS (9 of 9 graded moderate/high quality; evidence for 2/9 indicating cannabis improved outcomes; evidence for 7/9 indicating cannabis inconclusive), epilepsy (3 of 4 graded moderate/high quality; 3 indicating cannabis improved outcomes; 1 indicating cannabis inconclusive), and chronic noncancer pain (12 of 13 graded moderate/high quality; evidence for 7/13 indicating cannabis improved outcomes; evidence from 6/7 indicating cannabis inconclusive). Among RCTs, we identified few studies of substantial rigor and quality to contribute to the evidence base. However, there are some conditions for which significant evidence suggests that select dosage forms and routes of administration likely have favorable risk-benefit ratios (i.e., epilepsy and chronic noncancer pain). The body of evidence for medical cannabis requires more rigorous evaluation before consideration as a treatment option for many conditions, and evidence necessary to inform policy and treatment guidelines is currently insufficient for many conditions.

Introduction

Medical cannabis is available to patients by physician order in 33 states and territories in the USA as of 2020. However, at the federal level, cannabis remains classified as a schedule I controlled substance, which limits efficacy and safety investigations [ 1 ]. Collectively, “medical cannabis” encompasses various terms used in reference to medical marijuana, cannabis-derived products from the cannabis plant (including cannabinoids), and synthetic cannabinoids (e.g., synthetic delta-9-tetrahydrocannabinol (THC) or dronabinol). States that permit physician-ordered medical cannabis typically require a diagnosed medical condition that is considered qualifying by respective state law permitting its use as treatment or adjuvant. Currently, over 50 medical conditions have been granted a qualifying medical condition status by individual state laws, though there is significant variation between each state's approved conditions [ 2 ]. The most frequent medical conditions for approved medical cannabis use nationally are chronic noncancer pain, multiple sclerosis (MS) and other motor neuron disorders, epilepsy, cancer and cancer symptoms, mental health disorders (primarily anxiety disorders such as posttraumatic stress disorder [PTSD]), glaucoma, and symptoms related to irritable bowel diseases [ 3 , 4 ].

Approximately 12.9% of Americans report past-year cannabis use, with 90.2% using for nonmedical purposes only, 6.2% for medical purposes only, and 3.6% for both purposes [ 5 ]. The amount of medical-only cannabis users is higher in states that have enacted medical marijuana laws, where around 17% of cannabis users consumed cannabis for medical reasons in those states [ 6 ]. The most common routes of administration of cannabis use in the USA are oral/peroral (e.g., edibles), pulmonary (e.g., smoking, or vaping), and topical [ 7 ].

In 2017, the National Academies of Sciences, Engineering, and Medicine (NASEM) published a comprehensive scientific review on the effects of cannabis and cannabinoids in the treatment of medical conditions frequently cited for medical cannabis use [ 8 ]. The NASEM report included an evidence review of studies evaluating the efficacy and safety of cannabis for selected conditions based on the frequency of use, hypothesized effectiveness, and/or eligibility of the condition for medical cannabis certification across several states. The NASEM report evaluated the body of evidence published in the literature through the year 2016, and the objective of this study is to further expand this work by examining the most recently available evidence. Therefore, the objectives of this review are to (1) identify and map the most recently published clinical and scientific evidence across approved conditions for medical cannabis and (2) evaluate the quality of identified recent systematic reviews.

Topic Selection

Clinical conditions were selected based on inclusion within the NASEM report, relevance to current trends in medical cannabis-eligible diagnoses, and consultation with subject matter experts and relevant stakeholders (e.g., physicians, patients, and community input). Relevant stakeholders perceived needs in research priorities, and evidence gaps as related to clinical outcomes were assessed via preliminary surveys, interviews, and open-ended discussion. Stakeholders recommended including medical conditions approved in the US state jurisdiction of the study team, in addition to emerging trends in use of medical cannabis applications based on discussion with physicians who were certified to order medical cannabis in this locale. Based on this process, the clinical conditions determined for inclusion for this review were amyotrophic lateral sclerosis (ALS), autism, cancer, chronic noncancer pain, Crohn's disease, epilepsy, glaucoma, human immunodeficiency virus (HIV)/AIDS, MS, Parkinson's disease, and PTSD.

Literature Search and Identification

The search strategy was developed in collaboration with the University of Florida Health Sciences Center Library. For this mapping review, we conducted a systematic search using the following databases: PubMed, Embase, Web of Science, the Cochrane Library, and clinicaltrials.gov . We restricted our search to studies that were published after the NASEM report's inclusion period, between May 2016 and October 2019. Search strings from the NASEM report were replicated, and additional keywords and Medical Subject Headings terms were identified in collaboration with subject matter experts and through literature cross-referencing. Since autism was the only included condition that was not evaluated by NASEM, we employed rapid review strategies and adjusted our date restriction inclusion period from the year 2000 to October 2019 for this condition. We limited our search to English language literature only. Complete search strings are available for all conditions in the see online suppl. files. (For all online suppl. material, see www.karger.com/doi/10.1159/000515069 .)

Literature Screening

Screening for eligible studies was conducted in 2 phases. In each phase, publications were either classified as include, exclude, or uncertain. In the first phase, for each clinical indication, one reviewer screened the identified abstracts for eligibility. Abstracts that were classified as “uncertain” were then screened by a second reviewer. If the second abstract reviewer also classified the abstract as uncertain, the publication was advanced for full-text screening. In the second phase, full-text publications were screened for eligibility for each clinical indication. Publications classified as “uncertain” during full-text screening were then screened by a second reviewer. If the publication was still classified as “uncertain” following a second full-text screening, group review and discussion were required until consensus regarding eligibility was achieved. Other discrepancies between reviewers were resolved via discussion and by a third reviewer, when necessary. Publications were included in qualitative synthesis if they were published between 27 May 2016 and 22 September 2019 and investigated the therapeutic effect, a patient or provider perspective, or utilization of medical cannabis in any form in one of the identified 11 indications or conditions. Additionally, the study had to be conducted in humans. Publications were excluded if they included only preclinical data, if the primary research was conducted exclusively outside the USA, clinical case studies, abstracts-only, letters to the editors, opinion pieces, or editorials.

Data Extraction

The study team created a standardized data extraction tool in Microsoft Excel to capture elements from all included studies. An initial pilot run with the underlying data extraction table was performed in a group setting for training purposes and to ensure consistency. Afterward, for each condition, one reviewer extracted the following data from the eligible studies into the tool: study design, study setting, cannabis intervention type, study period, inclusion and exclusion criteria, indicators for whether special populations were included (e.g., pediatrics and geriatrics), outcomes assessed, outcome definition, change in outcome, and summary of findings. Reviewers presented uncertainties in data extraction in a group discussion meeting for resolution. In instances where a single study was identified as eligible for data extraction for multiple conditions, data were independently extracted as relevant for each condition covered within the study; however, these studies were not counted more than once in overall counts of assessed studies.

Quality of Evidence Assessment

Studies that were classified as systematic reviews with or without meta-analysis were evaluated using the Assessing the Methodological Quality of Systematic Reviews-2 (AMSTAR-2) instrument. The Assessing the Methodological Quality of Systematic Reviews-2 tool was developed to grade the quality of evidence reviewed, organized, and presented within systematic reviews [ 9 ]. It consists of 16 items that evaluate the methodological quality of systematic reviews and the risk of bias via a checklist, and each item can be answered with “yes,” “partial yes,” “no,” or “no meta-analysis conducted.” Based on weaknesses in critical domains, systematic reviews are then rated as a high-, moderate-, low-, or critically low-quality review. Two reviewers for each condition conducted the evidence grading independently. Disagreements were resolved by a third reviewer, and when necessary, classifications of study design were re-evaluated. Additional reviewers examined studies when needed until the majority consensus on both study design classification and quality of evidence rating was achieved.

Evidence Synthesis

Findings from identified studies were reported in accordance with PRISMA guidelines. Search, screening, and evaluation were conducted in accordance with systematic literature review best practices; however, the structure of this review is more appropriately classified as a mapping review to allow for its broad scope [ 10 ].

Studies in each condition were classified according to whether they assessed efficacy and/or safety outcomes. (See online suppl. Tables for outcome definitions.) Studies assessing relevant efficacy outcomes were classified into 1 of 5 categories based on the following classification scheme. Studies were classified as “outcome improved” when the condition improved following medical cannabis treatment; as “outcome worsened” when the condition worsened; as “none” when there was no significant observable change; as “inconclusive” if they specifically indicated that results were inconclusive in their results and discussion section and/or there were multiple outcomes assessed but not all reported in findings; or as “mixed” in cases where multiple outcomes were assessed, but some indicated improvement and others indicated no change or worsening. Study outcome definitions for efficacy by condition were summarized (online suppl. Table 1 ).

Studies reporting safety outcomes were classified into 4 different categories. Studies were classified as “worsening” when an increase in adverse events as compared to placebo, active comparator, or both groups were reported, or single-arm studies reported side effects or adverse events that might be associated with exposure; as “mixed” when different safety outcomes were assessed, but some indicated no change, while others indicated worsening; as “no change” when no significant changes in safety outcomes when measured against the comparator group were reported, or in the case of single-arm studies, studies not reporting any side effects that might be associated with exposure; or as “inconclusive” when studies specifically described results as inconclusive in the results and discussion section and/or if there were multiple outcomes assessed, but not all reported in findings were classified analogous to the efficacy outcome.

Studies that did not fit into the presented classification scheme assessed outcomes unrelated to efficacy and safety, employed a cross-sectional design, or were utilization studies, all of which were summarized separately. Cross-sectional studies were not included in the classification scheme due to their lack of longitudinal assessment, thus limiting the interpretability of findings for quantifying the evidence base in regard to efficacy and safety. Studies that were classified as “other nonsystematic reviews” (e.g., clinical, narrative, scoping, or undefined) were captured in our search strategy but were not evaluated using the classification schemes described herein.

For visualization purposes, all systematic reviews assessing safety or efficacy outcomes were compiled into an evidence map figure consisting of 5 different dimensions (Fig. ​ (Fig.1). 1 ). The bubble size is proportional to the number of included studies within each condition topic area. The bubble color represents the underlying medical condition. The x -axis describes the effect of cannabis in each condition. The y -axis represents the quality of evidence assessment score, and notations within the bubbles indicate whether the systematic reviews included meta-analysis. For a more comprehensive insight into the efficacy and safety-related findings of eligible studies, studies were finally organized by the condition-specific outcome, study design type, and directions of findings.

Quality of evidence among systematic reviews assessing medical cannabis efficacy, effectiveness, and safety outcomes in selected conditions. MS, multiple sclerosis; ALS, amyotrophic lateral sclerosis; PTSD, posttraumatic stress disorder; HIV, human immunodeficiency virus.

A total of 15,917 studies were identified across all searched databases during the study period, where searches were conducted for each of the included clinical conditions. Following stratification by clinical condition relevance and screening for eligibility, 438 studies remained (see online suppl. materials for PRISMA flow diagrams for individual clinical conditions). We then further restricted qualitative synthesis to studies that reported primary results or systematically reviewed prior work ( n = 198), meaning that 240 studies were narrative reviews or other types of nonsystematic reviews. Table ​ Table1 1 summarizes efficacy findings as stratified by study design type and condition, and Table ​ Table2 2 summarizes the same for safety findings. Table ​ Table3 3 summarizes cannabis agents administered or observed in randomized controlled trials (RCTs) and observational studies by agent and route of administration for each condition. Below, we summarize condition-specific findings.

Medical cannabis study efficacy outcome findings, 1 by condition and study design type

ALS, amyotrophic lateral sclerosis; HIV, human immunodeficiency virus; PTSD, posttraumatic stress disorder; RCT, randomized controlled trial; MS, multiple sclerosis. 1 Findings for efficacy outcomes were classified for cannabis/cannabinoid treatment relative to placebo or active comparator according to the following: “improvement” if outcome improved, “worsening” if outcome worsened, “mixed” if multiple efficacy outcomes were assessed with divergent findings for each, “no change” if no change observed, and “inconclusive” if outcomes were unable to be assessed.

Medical cannabis safety outcome findings, 1 by condition and study design type

ALS, amyotrophic lateral sclerosis; HIV, human immunodeficiency virus; PTSD, posttraumatic stress disorder; RCT, randomized controlled trial; MS, multiple sclerosis. 1 Safety outcomes were defined in all studies as proportion of adverse events relative to placebo/active comparator, frequency of adverse events, or severity of adverse events relative to placebo/active comparator. Findings for safety outcomes were classified for cannabis/cannabinoid treatment according to the following: “worsening” if outcome worsened, “mixed” if multiple safety outcomes were assessed with divergent findings for each, “no change” if no change observed, and “inconclusive” if outcomes were unable to be assessed. 2 A secondary endpoint from one RCT, was deemed appropriate for inclusion in safety outcomes [ 136 ].

Counts of agents in reviewed studies by routes of administration and condition

No studies were eligible in the area of ALS, glaucoma, and MS. THCA, tetrahydrocannabinolic acid; ALS, amyotrophic lateral sclerosis; HIV, human immunodeficiency virus; PTSD, posttraumatic stress disorder; THC, tetrahydrocannabinol. 1 Buccal, tincture, oromucosal, rectal, and other not specified. 2 When more than one agent was investigated, but the route of administration was not distinguished between the agents. 3 THCA oil.

Amyotrophic Lateral Sclerosis

As depicted in the flow diagrams (online suppl. files), the use of medical cannabis in patients with ALS was investigated in 9 eligible publications. Among those were 2 systematic reviews without meta-analysis, 2 observational/quasi-experimental studies, and 5 other types of reviews. Of all studies investigating medical cannabis and ALS, 2 studies used cramp intensity/frequency as the primary outcome [ 11 , 12 ] and 2 investigated other outcomes or used a cross-sectional design [ 13 , 14 ]. Among those studies that investigated cramp intensity/frequency, one indicated no change [ 11 ] and one study indicated inconclusive findings [ 11 , 12 ]. (More detailed information about each study type and summary of findings can be found in Tables ​ Tables1 1 and ​ and2 2 and in the online suppl. files.) Other outcomes assessed in this condition included an examination of trajectories of ALS cases [ 13 ], and one cross-sectional study assessed patient characteristics in a dispensary and dispensary staff recommendations [ 14 ].

Medical cannabis in patients with autism was investigated in 17 eligible publications. Among those were one systematic review with meta-analysis, 8 observational/quasi-experimental studies, and 8 other types of reviews. Of all studies investigating medical cannabis and autism, 3 studies used symptom mitigation (see online suppl. Table 1 for outcome definitions) as the primary outcome [ 15 , 16 , 17 ] and 6 investigated other outcomes or used a cross-sectional design [ 18 , 19 , 20 , 21 , 22 , 23 ]. The latter studies and other types of reviews are summarized in the online suppl. files. Among those studies that investigated symptom mitigation, 2 indicated an improvement [ 16 , 17 ] and one study indicated no change in symptoms [ 15 ]. Other outcomes assessed in this condition were assessed in 6 studies, of which one used a cross-sectional study design. Among those outcomes that were assessed by more than 1 study, 2 studies assessed the brain activity in response to CBD with functional magnetic resonance imaging and magnetic resonance spectroscopy [ 22 , 23 ].

Medical cannabis in patients with cancer was investigated in 138 eligible publications. Among those were 6 systematic reviews with meta-analysis, 10 systematic reviews without meta-analysis, 4 RCTs, 31 observational/quasi-experimental studies, and 86 other types of reviews. Of all studies investigating medical cannabis and cancer, 13 studies investigated cancer-related pain reduction as the primary outcome [ 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 ]; 2 studies investigated cancer-related nausea and vomiting [ 27 , 36 ]; 3 studies investigated weight change, appetite increase, or caloric intake [ 27 , 37 ]; 17 studies investigated safety outcomes [ 24 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 34 , 35 , 36 , 38 , 39 , 40 , 41 , 42 , 43 ]; and 31 studies investigated other outcomes or used a cross-sectional design [ 3 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 ]. Among studies that investigated cancer-related pain, 5 indicated an improvement [ 24 , 25 , 28 , 29 , 36 ], 2 studies indicated no change [ 34 , 35 ], and 6 were inconclusive [ 26 , 27 , 30 , 32 , 74 , 75 ]. Among studies that investigated cancer-related nausea and vomiting, one indicated an improvement [ 36 ] and one was inconclusive [ 27 ]. In studies that investigated weight change, appetite increase, or caloric intake, one indicated an improvement [ 36 ] and 2 were inconclusive [ 27 , 37 ]. Of the 17 studies assessing safety outcomes of medical cannabis in cancer patients, 11 studies indicated worsening [ 24 , 26 , 28 , 29 , 34 , 35 , 36 , 38 , 39 , 40 , 43 ], one indicated mixed findings [ 41 ], and 5 studies were inconclusive [ 27 , 30 , 32 , 42 , 74 ]. For 2 RCTs, results are still pending at this time [ 76 , 77 ]. Other outcomes assessed in this condition were assessed in 31 studies, of which 24 used a cross-sectional study design. Among those outcomes that were assessed by more than one study, 10 studies investigated patients or provider perceptions of cannabis benefits and side effects [ 47 , 52 , 53 , 56 , 60 , 62 , 64 , 67 , 68 , 69 ] and 7 investigated patterns of cannabis consumption [ 48 , 49 , 55 , 57 , 63 , 71 , 72 ].

Chronic Noncancer Pain

Medical cannabis in patients with chronic noncancer pain was investigated in 120 publications. Among those were 8 systematic reviews with meta-analysis, 8 systematic reviews without meta-analysis, 3 RCTs, 36 observational/quasi-experimental studies, and 63 other types of reviews. Of all studies investigating medical cannabis and chronic noncancer pain, 17 studies investigated pain reduction or quality of life as the primary outcome, 9 studies investigated safety outcomes, and 35 investigated other outcomes or used a cross-sectional design [ 14 , 68 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 , 105 , 106 , 107 , 108 , 109 , 110 ]. Among those studies that investigated pain reduction or quality of life, 10 indicated an improvement [ 25 , 111 , 112 , 113 , 114 , 115 ], one study indicated mixed findings [ 42 ], 3 studies indicated no change [ 116 , 117 , 118 ], and 3 were inconclusive [ 30 , 119 , 120 ]. Of the 9 studies investigating safety outcomes of medical cannabis in patients with chronic noncancer pain, 6 studies indicated a worsening [ 111 , 112 , 117 , 119 , 121 , 122 ], 1 indicated mixed findings [ 25 ], and 2 were inconclusive [ 30 , 114 ]. For 3 RCTs, results are still pending (see online suppl. Table 2 ) [ 123 , 124 , 125 ]. Thirty-five eligible studies, including 27 cross-sectional studies, investigated other outcomes. Among those outcomes that were assessed by more than 1 study, 9 studies investigated patients or provider perceptions of cannabis benefits and side effects [ 84 , 85 , 88 , 92 , 100 , 102 , 103 , 106 , 107 ], 8 studies investigated different relationships between cannabis use and opioid use [ 79 , 81 , 87 , 96 , 101 , 105 , 108 , 109 ], 6 studies investigated cannabis use patterns [ 78 , 82 , 83 , 90 , 97 , 110 ], 2 examined consumer characteristics [ 89 , 93 ], and 2 explored reasons for medical cannabis use [ 68 , 99 ].

Crohn's Disease

Twenty-five publications investigated medical cannabis in patients with Crohn's disease. Among those were 2 systematic reviews without meta-analysis, 1 RCT, and 8 observational/quasi-experimental studies. Of all studies investigating medical cannabis in patients with Crohn's disease, 3 studies investigated symptom mitigation as the primary outcome, 1 study investigated safety outcomes, and 6 investigated other outcomes or used a cross-sectional design [ 14 , 116 , 126 , 127 , 128 , 129 ]. In studies that investigated symptom mitigation, 1 study indicated an improvement [ 130 ], 1 study indicated mixed findings [ 61 ], and one was inconclusive [ 131 ]. Safety outcomes were reported by one study, which indicated worsening safety outcomes [ 132 ]. The RCT has recently been withdrawn due to inadequate funding [ 133 ]. Six eligible studies, including 3 cross-sectional studies, investigated other outcomes. Outcomes that were assessed by more than one study included patient perceptions of cannabis benefits and side effects, which was assessed by 2 studies [ 127 , 128 ], and cannabis use patterns, which was investigated by 2 studies [ 126 , 129 ].

Medical cannabis in patients with epilepsy was investigated in 72 eligible publications. Among those were 3 systematic reviews with meta-analysis, 2 systematic reviews without meta-analysis, 3 RCTs, 17 observational/quasi-experimental studies, and 47 other types of reviews. Of all studies investigating medical cannabis and epilepsy, 19 studies investigated the effect on seizures (i.e., reductions in number of seizures and seizure frequency) as the primary outcome, 2 studies assessed health-related quality of life, 18 studies investigated safety outcomes, and 3 studies investigated other outcomes or used a cross-sectional design. Among those studies that investigated the effect on seizures as outcomes, 13 studies indicated an improvement [ 116 , 134 , 135 , 136 , 137 , 138 , 139 , 140 , 141 , 142 , 143 , 144 , 145 ], 4 studies indicated no change [ 144 , 146 , 147 , 148 ], and 2 studies were inconclusive [ 149 , 150 ]. In those studies that investigated health-related quality of life or quality of life as the primary outcome, both studies indicated an improvement [ 144 , 146 ] and one study indicated no change [ 146 ]. Among those 18 studies that investigated safety outcomes, 10 studies indicated worsening [ 134 , 136 , 138 , 140 , 142 , 145 , 151 , 152 , 153 , 154 ], 1 indicated mixed findings [ 155 ], 5 indicated no change [ 135 , 141 , 144 , 156 ], and 2 were inconclusive [ 149 , 150 ]. Three eligible studies, including 1 cross-sectional study, investigated other outcomes. One study assessed potential pharmacokinetic interactions [ 157 ], one investigated perception about cannabis use and benefits [ 158 ], and the third assessed doses of cannabidiol [ 116 ].

Medical cannabis in patients with glaucoma was investigated in 14 eligible publications, including one systematic review without meta-analysis and one book section. (Detailed information about the latter and the 12 other types of reviews can be found in the online suppl. files.) Of all studies, one investigated the effect of medical cannabis on intraocular pressure, and this study indicated no change in the outcome [ 116 ].

Human Immunodeficiency Virus/AIDS

Medical cannabis in patients with HIV/AIDS was investigated in 25 eligible publications, among those were 3 systematic reviews with meta-analysis, 19 observational/quasi-experimental studies, and 3 other types of reviews. Of all studies within this section, 2 studies investigated symptom mitigation (see online suppl. material) as the primary outcome, 4 studies investigated the effect on adherence to antiretroviral therapy, 2 studies investigated the effect on viral suppression, 5 studies investigated safety outcomes, and 12 studies investigated other outcomes or used a cross-sectional design [ 159 , 160 , 161 , 162 , 163 , 164 , 165 , 166 , 167 , 168 , 169 , 170 ]. Among the 2 studies that investigated symptom mitigation, one indicated an improvement [ 120 ] and one was inconclusive [ 115 ]. Among the 5 studies examining the effect of cannabis use on adherence to antiretroviral therapy, 2 indicated worsening [ 171 , 172 ], 2 reported no change [ 160 , 173 ], and 1 reported inconclusive findings [ 174 ]. One study examining the effect on viral suppression indicated no change [ 173 ], and 1 study indicated inconclusive findings [ 174 ]. Of the 5 studies investigating safety outcomes, 3 studies indicated worsening [ 120 , 175 , 176 ] and 2 studies indicated no change [ 176 , 177 ]. Twelve eligible studies, including 6 cross-sectional studies, investigated other outcomes. Among those outcomes that were assessed by more than one study, 5 studies assessed aspects of HIV care continuum measures [ 160 , 161 , 162 , 163 , 168 ] and 2 studies assessed the prevalence and correlates of substance use [ 165 , 178 ].

Multiple Sclerosis

Medical cannabis in patients with MS or related motor neuron disorders was investigated in 25 eligible publications. Among those were 5 systematic reviews with meta-analysis, 4 systematic reviews without meta-analysis, and 16 other types of reviews. Of all studies within this section, 6 studies investigated spasticity and spasm as the primary outcome, 4 studies investigated efficacy on MS-related pain, 3 studies investigated bladder function, 1 study examined the effect on gait function, and 6 studies investigated safety outcomes. (More information about the 17 other types of reviews can be found in the online suppl. files.) Among the 6 studies investigating spasticity and spasm, 3 indicated an improvement [ 179 , 180 , 181 ], one indicated mixed findings [ 182 ], one study reported no change [ 183 ], and one was inconclusive [ 30 ]. Among the 4 studies examining MS-related pain, one indicated improvement [ 180 ], one reported no change [ 183 ], and 2 reported inconclusive findings [ 30 , 115 ]. Of studies examining the effect on bladder function, 2 indicated improvement [ 180 , 184 ] and one reported no change [ 183 ]. One study investigating gait function reported inconclusive findings [ 185 ]. In studies investigating safety outcomes, 3 studies indicated worsening [ 180 , 183 , 184 ], 2 studies indicated no change [ 181 , 182 ], and 1 study reported inconclusive findings [ 30 ].

Parkinson's Disease

Medical cannabis in patients with Parkinson's disease was investigated in 17 eligible publications. Among those were one RCT and 4 observational/quasi-experimental studies. Of all studies, one study investigated the effect of medical cannabis on safety outcomes and indicated no change in the outcome [ 186 ]. For one RCT, results are still forthcoming [ 187 ]. Other outcomes were investigated by 3 cross-sectional studies. All of these studies investigated physicians or patient expectations or perceived benefits of cannabis on Parkinson's disease-related symptoms [ 83 , 188 , 189 ]. (More information about the studies that assessed other outcomes and the 12 other types of reviews can be found in the online suppl. files.)

Posttraumatic Stress Disorder

Medical cannabis in patients with PTSD was investigated in 50 eligible publications. Among those were 10 systematic reviews without meta-analysis, 5 RCTs, 3 observational/quasi-experimental studies, and 31 other types of reviews. Of all studies investigating medical cannabis in patients with PTSD, 8 studies investigated symptom mitigation (e.g., sleep disturbances, dissociative reactions or flashbacks, and hyperarousal) as the primary outcome, 3 studies investigated safety outcomes, and 3 assessed other outcomes or used a cross-sectional design [ 14 , 190 , 191 ]. Among those studies that investigated symptom mitigation, 2 indicated mixed findings [ 192 , 193 ] and 6 were inconclusive [ 12 , 122 , 194 , 195 , 196 , 197 ]. One study investigating safety outcomes indicated mixed findings [ 198 ], and 2 studies reported inconclusive findings [ 195 , 199 ]. Among those 5 RCTs, 1 study has been terminated, 2 were completed, but publications were not available at the time of literature search, and for 2, results are still pending. For 5 RCTs, results are still pending [ 200 , 201 , 202 , 203 , 204 ]. Three eligible studies, including 2 cross-sectional studies, investigated other outcomes. Two of 3 investigated cannabis dispensary staff or healthcare provider practices [ 14 , 191 ] and 1 study investigated cannabis use patterns and associated problems [ 190 ].

Cannabis Agents

The vast majority of RCTs and observational studies (including cross-sectional studies) that investigated the safety or efficacy of cannabis did not further specify the type of cannabis product that was investigated. A specific route of administration was also often not reported. Among those publications that specified the cannabis product, CBD was the most frequent investigated agent and mostly for investigations related to epilepsy or other seizure disorders. Whole plant cannabis was the least investigated drug. With respect to route of administration, studies investigating THC, CBD, or THC and CBD combinations typically employed oral/peroral, buccal, or sublingual administration. This is in contrast to those studies assessing unspecified agents, in which pulmonary and oral/peroral administrations were most common. We encountered only one study that assessed minor cannabinoids, namely, tetrahydrocannabinolic acid.

Evidence Map

The majority of identified systematic reviews were conducted on the topic areas of chronic noncancer pain, cancer, MS, epilepsy, and PTSD. The evidence map includes indications for conditions that were determined to have scarce recent evidence available. The quality of evidence varied widely among all eligible systematic reviews and differed between each condition. Reviews graded as either critically low or low quality, indicating serious risks of biases and/or methodological limitations, were mainly conducted in the areas of cancer, PTSD, and HIV/AIDS. Moderate-quality systematic reviews were represented in all conditions. Only the areas of chronic noncancer pain, epilepsy, and MS included systematic reviews graded as high quality. In terms of safety and efficacy outcomes, only a few systematic reviews in the area of ALS, cancer, chronic noncancer pain, Crohn's disease, glaucoma, and MS indicated worsening or no difference. The majority of included reviews reported inconclusive or mixed results, and only publications in the area of chronic noncancer pain, cancer, epilepsy, and MS reported improved outcomes. Furthermore, among high-quality reviews, only chronic noncancer pain and epilepsy reported improved outcomes (see Fig. ​ Fig.1 1 ).

Referring to the 11 investigated conditions, the NASEM report in 2017 concluded that there is conclusive or substantial evidence for cannabis in treating chronic noncancer pain, chemotherapy-induced nausea and vomiting (oral cannabinoids), and MS spasticity symptoms (via oral cannabinoids). In addition, limited evidence was reported for the efficacy of cannabis and cannabinoids for the purposes of increasing appetite and decreasing weight loss in patients with HIV/AIDS, improving clinician measures of MS spasticity symptoms (specifically, via oral cannabinoids), and improving symptoms of PTSD (specifically, with nabilone). NASEM also concluded that limited evidence was available that cannabis and cannabinoids were ineffective in improving intraocular pressure associated with glaucoma (specifically via cannabinoids). Furthermore, insufficient or no evidence existed to support or refute the effectiveness of cannabis or cannabinoids for a majority of examined indications. Those indications included cancer (cannabinoids), cancer-associated anorexia-cachexia syndrome and anorexia nervosa (cannabinoids), symptoms of irritable bowel syndrome (dronabinol), epilepsy (cannabinoids), symptoms associated with ALS, or Parkinson's disease-related symptoms or levodopa-induced dyskinesia (cannabinoids).

In the 4 years since the NASEM report, much has been published in the clinical and scientific literature regarding the safety and efficacy of cannabis and cannabinoids, but we identified few recent studies conducted within US populations and were of substantial rigor and quality to move the evidence base forward for many clinical conditions. In fact, across all condition topic areas, the most frequently identified study design was clinical/narrative review with a nonsystematic approach, and these reviews only recounted and compiled previous RCT and observational study findings. Many other identified studies, particularly observational studies, also had significant limitations when assessing the safety and efficacy of cannabis that potentially affected validity. Detailed information about the history of cannabis use, other substance use, concomitant medications, comorbidities, types of cannabis product (THC, CBD, THC/CBD, and whole plant), route of administration, and dosage was not captured in the majority of observational studies due to unavailable data or limited subject knowledge. Thus, confounding was a recurring threat to validity in many identified studies. Several observational studies, for example, suggest that cancer patients using medical cannabis tend to have more severe symptoms than those who did not consume medical or recreational cannabis [ 57 , 60 , 71 ]. However, it is unclear if cannabis is contributing to more severe symptoms or if the presence of severe symptoms prompted increases in cannabis utilization. In addition, patient-reported outcomes and behaviors may be more susceptible to recall bias and/or inaccurate reporting of dosage, duration, and frequency of use [ 205 , 206 ]. Patients also might not report nonmedical cannabis use due to perceived social norms.

Quality of Evidence

Our assessment of the quality of systematic reviews determined that high-quality systematic reviews were conducted only among the conditions of chronic noncancer pain, epilepsy, and MS. In the area of chronic noncancer pain, the most recent systematic reviews are in alignment with findings of the NASEM report, which reported substantial evidence for the use of cannabis as a treatment for chronic pain in adults.

In the area of epilepsy, one recently published high-quality systematic review included several newly published RCTs focusing on pediatrics and found significantly reduced seizure frequency with adjunctive CBD use in pediatric drug-resistant Dravet and Lennox-Gastaut syndromes, aligning with the FDA approval of Epidiolex. High-quality systematic reviews in the field of MS did not include any RCT results following the publication of the NASEM report and are, therefore, not expanding the evidence base.

Only 7 systematic reviews were graded as high quality, whereas almost one-third were graded as low- or critically low-quality systematic reviews. Common reasons for being rated as a moderate- or low-quality review were due to the absence of a prior established protocol, lack of a comprehensive literature search strategy, failing to report the source of funding of included studies, missing an adequate detailed description of excluded studies, inadequate accounting for the risk of bias assessment within result interpretation and discussion, absence of adequate discussion of heterogeneity, and absence of a quantitative synthesis or meta-analysis. In addition to these limitations, many identified systematic reviews also consisted of few RCTs.

Despite the limited evidence available from recent high-quality systematic reviews, it is promising that we identified 12 RCTs with registered protocols and trial registrations. The studies are covering the field of Crohn's disease, chronic noncancer pain, cancer, Parkinson's disease, and PTSD [ 76 , 77 , 123 , 124 , 125 , 133 , 187 , 200 , 201 , 202 , 203 , 204 ], and 2 of them have recently been withdrawn or terminated [ 133 , 202 ]. However, the remaining 10 RCTs have the potential to expand the evidence base. In addition, our review identified many studies that reported an increase in adverse events relative to placebo or an active comparator, which was consistent across most of the assessed medical conditions. Nevertheless, the vast majority of the reviewed studies reported that adverse event severity ranged from mild to moderate, and most adverse events were reversible with dose reduction or discontinuation. Medical cannabis was often referred to as “generally well tolerated.” However, information about long-term safety outcomes was scarce.

Gaps in Literature

We identified several persistent gaps in the literature during this review. Recent observational studies often lacked specific information about the route of administration, dosage, frequency, and cannabis product used. Clinical trials were mainly limited to peroral, oral, or sublingual administration and represented few formulations of available cannabis products. Studies investigating whole-plant cannabis products are needed to better understand the risks and benefits of cannabis in real-world settings as patients receiving medical cannabis in practice are typically receiving whole-plant products. In order to provide valuable information about the effectiveness and safety of medical cannabis, real-world studies must define cannabis products, the route of administration, and dosage precisely. In addition, it is unclear whether or not standardized products provided in RCTs are comparable to those products offered by dispensaries, where consistency in product dosing, concentrations, and even routes of administration offered are not necessarily guaranteed and are subject to variations in state regulations [ 207 ]. Furthermore, there remain other questions about the generalizability of existing evidence raised. For example, patients with substance use disorder histories were often excluded from randomized studies across several conditions, even though use by patients with these or similar underlying conditions is common (e.g., PTSD and chronic noncancer pain) [ 208 ].

Implications for Research, Clinicians, and Policy

The prevalence of medical cannabis and cannabis use for nonmedical reasons is increasing [ 209 ], while perceived risks associated with cannabis use are decreasing, particularly among younger persons [ 210 ]. Therefore, it is important to evaluate and disseminate the evidence widely to both clinicians and patients. Interestingly, there is also some evidence suggesting that the legalization of cannabis might not necessarily affect the compliance rate of primary therapies in patients with chronic noncancer pain under opioid therapy [ 211 ], so it is unclear whether the changing availability of licit nonmedical cannabis will impact clinical outcomes in patients receiving medical cannabis.

There remains a need for well-designed and conducted RCTs for most of the assessed medical conditions. However, there are several methodological and practical challenges in conducting RCTs specific to investigating efficacy and safety of cannabis and cannabinoids, including placebo effects, practical limitations in conducting blinding for cannabis products, and regulatory barriers. Expense and complicated implementation, meanwhile, render it difficult to design and perform high-quality RCTs even in the absence of cannabis-related regulatory barriers [ 212 , 213 ]. Studies assessing cannabis efficacy and safety for these conditions, or any condition, must consider the effect that different routes of administration can have on systemic exposure and ultimately on study outcomes. Studies must also clearly and precisely quantify active metabolites and ratio of metabolites (i.e., THC:CBD) with the same rigor as applied to other medication studies.

Questions also remain about medical cannabis safety, especially in terms of rare adverse drug events, long-term effects, the effects on patients with comorbidities (e.g., people with history of substance abuse), and the potential for interactions with prescription medications and other substances, particularly among patients most susceptible to adverse events from drug-drug interactions (e.g., geriatric populations). Future research will require the utilization of a combination of approaches and techniques to overcome the barriers associated with capturing these rare or long-term outcomes, including the use of real-world data and sophisticated pharmacoepidemiologic methods to overcome current limitations in reported studies for ascertaining exposures and outcomes.

The evolving and challenging legal status of cannabis remains a significant obstacle to the expansion of cannabis research in the USA. The schedule I controlled substance designation of whole-plant cannabis restricts research in this area due to regulatory barriers and limited feasibility, along with scarce federal research funding allocated to the investigation of constituent compounds [ 214 ]. Furthermore, only a minority of the National Institute of Health's budget is earmarked for therapeutic cannabis research, while more is available for investigations of problematic uses and/or abuse potential, making it challenging to get US funding for investigation of therapeutic potential [ 215 , 216 ]. The complicated legal status of cannabis in the USA restricts cultivation and production to a single federally permitted institution; thus, a narrow amount of cannabis products can be tested, and these may not mirror constituents and concentrations of products available to consumers on the market [ 217 , 218 ]. Thus, policies would need revision to permit handling or production of dispensary-available cannabis products for research purposes and expand funding mechanism to support urgently needed research on clinical outcomes of medical cannabis.

Limitations and Strengths

Our review has several limitations that should be considered in the interpretation of the findings. First, we restricted our search strategy to studies published between July 2016 and October 2019 and for our rapid review to studies published between 2000 and October 2019. Therefore, we assessed only a narrow period of the most recently available literature. Second, we excluded articles reporting primary research conducted exclusively outside the USA, in order to account for differences in cannabis product availability internationally as well as differences in regulatory barriers and access. We, therefore, have excluded potentially relevant recent literature conducted in countries with robust scientific and clinical research programs evaluating cannabis efficacy and safety. However, studies originating from the USA accounted for almost 2/3 of all publications between 2000 and 2017 [ 219 ]. Third, even though we conducted pilot runs and training with reviewers on the use of the data extraction tool, the data extraction step was only conducted by one reviewer with review by a second reviewer in cases of uncertainty. In addition, the screening process for each topic area was only conducted by a second reviewer for those articles categorized as “uncertain”; thus, selection bias might have been introduced during both stages. However, weekly meetings throughout the review process were used to clarify any questions and uncertainties throughout the screening and extraction process. Fourth, systematic reviews and meta-analyses were not excluded if they partially included studies that were not matching our criteria (e.g., a systematic review consisting of studies that were conducted between 2016 and 2019 but also prior to 2016 was still considered as eligible, since it was not feasible to disentangle the evidence synthesis without examining the underlying primary study). Therefore, our findings based on systematic reviews and meta-analyses might not be restricted to our country and time criteria. In order to account for this limitation, we stratified our findings by study design and also restricted our summary of cannabis agents to RCTs and observational studies. Fifth, we did not assess whether medical cannabis was used as adjuvant treatment or primary therapy. Subsequently, different directions of findings might be based on variation in co-medications. However, the regulatory environment in the US mainly restricts the use of medical cannabis products to adjuvants, and the objective of this study was not to assess safety and efficacy of medical cannabis. Last, although a standardized classification scheme was applied to categorize the outcomes, inter-rater variability might have introduced misclassification of the outcomes.

There are also several strengths of this review to consider, including the broad scope of assessed medical conditions, comprehensive search strategy that extended beyond RCTs, and adherence to the PRISMA statement for gathering and reporting findings. Furthermore, this review highlights recent research efforts by medical condition, and directions of findings, thus creating a comprehensive picture of the scientific landscape of clinical studies about cannabis. Moreover, we also identified several literature gaps that could be addressed in future research, and we assessed the quality of evidence available, which is essential information for policymaking. Additionally, input from an external expert panel ensured a wide range in scope of the literature covered, and this review gives an up-to-date overview about the current state of evidence quality in a readily interpretable map.

The large body of the literature recently published regarding medical cannabis masks a paucity of evidence related to efficacy and safety as treatment options for several conditions for which it is commonly prescribed. Across 11 conditions, we identified few studies of substantial rigor and quality to contribute to the evidence base. However, there are some conditions for which significant evidence suggests that certain dosage forms and routes of medical cannabis products likely have favorable risk-benefit ratios (i.e., epilepsy and chronic noncancer pain). Gaps in the evidence remain significant for most examined conditions, but the identification of several registered forthcoming RCTs suggests that improved evidence will be available in the coming years.

Conflict of Interest Statement

The Consortium for Medical Marijuana Clinical Outcomes Research provided funding support for 4 contributors to this study, where S.J. and B.C. received graduate student stipend support in 2019–2020, and A.G., J.H.C., and A.W. received salary offset for serving as University of Florida faculty leads in 2019–2020. No other authors have conflicts of interest to declare.

Funding Sources

The consortium (described above) provided material support for 4 authors during the period of study completion (2019–2020). The funder did not have a role in decisions related to the preparation of data or the contents of this manuscript.

Author Contributions

S.J. prepared protocols for literature search, screening, and data extraction and drafted the manuscript. A.G. designed the study, supervised contributors, and critically revised the manuscript. L.A. performed literature searches and curated the reference library. The following contributors were topic lead reviewers for the following conditions: A.G. in amyotrophic lateral sclerosis, A.O. in human immunodeficiency virus (HIV)/AIDS, B.C. in Crohn's disease and posttraumatic stress disorder, E.J.M. in Parkinson's disease, G.A.H. in epilepsy, S.K. and S.J. in cancer, S.J. in chronic noncancer pain, Y.S. in autism and multiple sclerosis, and Y.Z. in glaucoma. R.S. developed figures. All other contributors were positioned in various roles as screeners, in data extraction, in reviewer resolutions, and in qualitative synthesis. All contributors critically revised and approved the manuscript.

Supplementary Material

Supplementary data

Acknowledgement

We thank and acknowledge the panel of scientific and clinical subject matter experts who provided comments on the protocols for topic selection, literature identification search strategies, literature screening, and data extraction procedures. Expert panelists were recruited as part of the Consortium for Medical Marijuana Clinical Outcomes Research activities, but the panelists have not contributed to the interpretation of the review findings.