SO what do I know about this issue? As the physician and City public health administrator tasked with the initial implementation of Proposition 215 (legalizing medical marijuana) – I learned a lot.
On the data side, I compiled every bit of published research about marijuana (positive and negative) from the previous thirty years, researching every conceivable symptom and/or adverse event. The results were published and widely cited. I also gave talks using this same information about the health implications (and the quality of the data to support or refute claims) to any group interested in hearing it.
So how’d that go? While giving the exact same talk, using the exact same slides, I received impulsive, giddy gifts from both a San Francisco medical marijuana club (an enameled marijuana pin – “finally, a physician willing to speak the truth about how safe marijuana is!”) and from the Santa Clara police department (a navy-blue district attorney mug – “finally, a physician willing to tell the truth about how dangerous this drug is!”). I had simultaneously become the unwilling darling of both ends of the spectrum. I learned from this experience two things:
1) there is a desperate need for data-based information looking at marijuana in the less-emotional context of a pharmaceutical medication, and
2) no matter how data-dry and context-bias-free you present marijuana information, passionate people will often hear what they want to hear.
Given the hazards of negotiating that landmine of reactions, and the justifiable fears of being labeled either a “pot doctor” or a “reactionary,” most physicians will not publicly get involved in a discussion of legalizing marijuana. It’s a topic they won’t touch – at all – not even with a ten-foot-stethoscope. But as we head closer to potentially legal pot, several public health issues should not be ignored (please be aware – these issues are in no way the opinion/policy of the San Francisco Department of Public Health – they are my own).
Why should you care about these public health issues? If you are in favor of legalizing pot, ignoring these issues will mean that whatever proposition may be passed is likely to die an ugly and swift death from either a) adverse publicity, or b) regulatory problems. If you are against legalizing pot, these are issues to consider as emotions run higher. If you, like most Americans, are ambivalent or slightly in favor, view this as a checklist to assess whether or not the current initiative includes appropriate public health measures.
As currently reported, the currently proposed ballot measure doesn’t include any of these common sense measures. Any taxes derived would be on a county-by-county basis (imagine how frequently one county will move to undercut another), with none of the taxes designated to help with predictable public health problems that result from legalization. Without designation of tax revenue, any taxes on marijuana will be a cash cow for politicians, and do little or nothing for the people who bear the repercussions of legalization. My thinking is, hey, if a lot of money is bankrolling this initiative, and we’re going to treat marijuana like any other pharmaceutical, then why not do this thing right the first time?
Six Crucial Public Health Issues:
1) Second-hand smoke: From the viewpoint of a pair of lungs, there is no difference between marijuana and cigarettes – with three exceptions: a) the “active” ingredient is different (nicotine for one, tetra-hydro-cannabinols, or THCs, for another), b) marijuana classically is smoked without a filter – meaning the carcinogens and tars/particulates are more concentrated (especially at the end) and c) typically people smoke many fewer joints per day than cigarettes. Using a water-pipe, or bong, has been shown to reduce particulates/tars, but to actually increase the concentration of carcinogenic vapor compounds. There is no data on the long-term bystander (second-hand) effects of water-pipe smoking. In marijuana’s favor – marijuana smokers typically smoke a much smaller daily amount than cigarette smokers. But whether it’s cigarettes or pot, second-hand smoke is still second-hand smoke.
Ignoring the issue of second-hand smoke will not make it go away. The EPA (and, now, possibly the FDA) is undoubtedly going to have a lot to say about cafes full of marijuana smoke, with the EPA recently declaring marijuana a carcinogen. In addition, cafe employees (particularly those with lung/respiratory/asthma issues) are in a prime position to bring the kind of lawsuits that have been successfully waged against the tobacco industry (yes, I’ve seen the studies about asthma and marijuana – particulates/smoke/second-hand smoke are still a major issue). What are the options? First, marijuana doesn’t have to be smoked – it can be eaten (classic: duh -brownies), dissolved in butter, or even drunk in teas (which is how Queen Victoria preferred hers). If marijuana purchasers still want to smoke (which is common – smoked marijuana gives a more rapid, peaking, and titratable high), a second option for cafes is that marijuana users who choose to smoke on site can be corralled into enclosed areas with negative air-flow and filters, in the same way cigarette smokers are at the airport. It’s socially unappealing, but effective at heading off predictable problems. Third, a well-written marijuana proposition would optimally adopt the same safeguards against second-hand smoke as those in place for tobacco.
2) Substance abuse/mental health implications: Recent, high-quality, long-term, robust research involving thousands upon thousands of people over generations of time, in several populations and countries, has shown that marijuana, especially in teen boys, leads to a measurable increase in the future development of schizophrenia – even when controlling for family and environment. These findings, very similar to unrelated alcohol research, show that risks are both dose-related, and are higher the lower the age at first exposure – all findings consistent with what we know, neurophysiologically, about the developing brain. Schizophrenia and marijuana is an issue that has gotten surprisingly little press in this country. Initial reactions to these results years ago were that a) it must be a fluke, b) it must be that the people who will get schizophrenia gravitate early to marijuana (and other drugs) in order to self-medicate – in other words a “false” association, and c) these aren’t “real” schizophrenics. Sadly, all three of those arguments have been thoroughly de-bunked by subsequent well-done studies. See published articles here, here, here and here. Short of taking a group of 11-year-olds and secretly giving half marijuana, and half placebo for twenty years, then waiting to see what happens – this is as “proven” as it can be. The effect is even dose-dependent. Frankly, researchers have moved beyond looking for an association and are now working to specifically identify the genes and neurotransmitters marijuana affects to induce schizophrenia.
Bottom line? At a minimum, increased rates of schizophrenia in a population (even if small) has to be a serious public health concern – schizophrenia can destroy entire lives, and families. Already, we, without national healthcare, have little/no resources to deal with this devastating, chronic, debilitating disease.
So what is happening? Even among reasonable clinicians, discussions around this elephant-in-the-room issue, when it comes to legalizing marijuana, are that a) for all practical purposes, marijuana is relatively easily available to teens already, and b) we don’t want this to be true, so we’ll either just say it’s not true, or we won’t talk about it at all…again, another stand that is not likely to work in the long-run. So, what to do? First, it’s unlikely that this issue will make it into the public consciousness strongly enough to block marijuana legalization. Furthermore, most people’s concerns in the area of long-term implications about widespread marijuana use are focused on addiction and crime. There is probably no good single answer, but optimally, a well-written proposition would include a fixed, permanent allocation of derived tax revenues devoted to substance abuse treatment, detox, and mental health services. Personally, I think a fixed amount of alcohol tax revenue should have been allocated to detox and substance abuse treatment when Prohibition was repealed – I’d be quite happy to have 50 cents off every bottle of Cabernet I purchase going to sobering centers and detox/rehab – our streets would look very different if it did.
First obligatory conflict of interest notice: I do not in any way receive funding from (or work for) any of these programs, although I am a medical provider to many patients suffering from mental health and substance abuse conditions – people who cannot access these scarce and underfunded resources.
3) Driving while high: Responsible propositions should include language to safeguard against, and discourage, driving while high. This is a complicated topic, clinically, because although the data is clear that people who drive while high are definitely impaired, the data on how long someone is impaired after using marijuana is highly variable to the individual. One approach would be to include in a proposition a grant-funded amount to determine how to advise, regulate against, and, frankly, prosecute users who drive-while-high, as well as an educational campaign to prevent it. Again, ignoring this issue will not make it go away, and – besides the preventable human tragedy – all it would take is a rash of high-profile disasters to get legalized marijuana reversed.
4) Childproofing: Every pharmaceutical agent has what is called a therapeutic index, which is a measure of how easy it is to overdose and die from the substance. Marijuana is, for adults, one of the safest medications ever, with no reported lethal overdoses. That, however, is NOT true for babies and toddlers, in whom coma has been reported, with risks of its corollary, death, particularly for infants. There are many reasons to formalize pot sales in classic pill-type bottles. One is that the tinted container will help prevent the breakdown of active ingredient from light exposure. The second is that optional child-proof lids will go a long ways toward preventing the potentially disastrous outcome of baby deaths post-marijuana legalization. Although some people may shriek in opposition, it is neither excessive, nor extreme – instead, just common sense – to ask adults to childproof their mind-altering and coma-inducing medications.
5) Teen protection: Again, just like with childproofing, responsible marijuana propositions should have at least the stated goal of developing (and funding from revenues) safeguards against access to marijuana by teens. Some of you may be guffawing at this idea as a laughably improbable goal. However, research in both smoking and marijuana has taught us that exposure to potentially-addictive substances at an earlier age leads to more addiction to the substance, and worse long-term outcomes (see schizophrenia, above). Legalized pot is, again, likely to be overturned if reasonable safeguards are not in place. Imagine media exposure that potentially reveals widespread easy access to legal pot by teens, and the fallout in families, and communities. The current proposed initiative states the age of 21 for legal usage, but more explicit language should be included to fund and develop monitoring mechanisms on sales, similar to tobacco and alcohol. Cigarette studies have shown that teens are very sensitive to pricing – something to consider in setting taxation levels.
6) Quality control: It’s clear that, despite widespread, serious quality and safety issues, supplements continue to sell and are popular. So why should we care if marijuana is highly variable in terms of potency and safety? First, studies have revealed the potential for widespread adulteration in a product that is usually sold by weight – including an old CDC report showing that frank dried stool was added to marijuana. Even without adverse health outcomes, one big story like that hitting the headlines will be forever damning to efforts to keep marijuana safe and legal. Second, contamination with molds and bacteria is particularly a concern for people using marijuana for medical reasons because it can lead to serious negative health outcomes. So what can be done? Probably, if marijuana goes mainstream, people will be more savvy about identifying which source provides a high-quality product. There should, however, be an industry-driven bottom “floor” for quality handling procedures – or else, like the Georgia peanut Salmonella outbreak, the FDA will come calling – potentially too late to head off massive adverse publicity, or repeal of legalization.
So are you supporting a ballot measure that lets marijuana taxes be an unrestricted cash cow for local politicians, and doesn’t include any of these public health measures? Share in the comments section. Feel free to forward this along to others you think might be interested. Keep up on the latest health issues in the news by signing up for a Doc Gurley RSS feed by clicking here. Check out Doc Gurley – and discover the weird, the wacky and the everyday symptoms you want to know about, as well as practical expert tips on staying well. Want to express your inner fan-girl/boy? Become a Doc Gurley fan on Facebook! Want to be on the inside, fast track of health news and tips? Jump on the Twitter bandwagon and follow Doc Gurley! Also check out Doc Gurley’s joyhabit and iwellth twitter feeds – so you can get topic-specific fun, effective, affordable tips on how to nurture your joy and grow your wellth this coming year.
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I would like to address every topic mentioned on your very excellent description and analysis of the general (non-smoking) public’s rationalization that somehow the effects of smoking medical marijuana are worse and more invasive than other forms of “narcotics.”
That’s basically what the opponents are saying, while at the same time they’re denying the MOST OBVIOUS reason that marijuana SHOULD BE LEGALIZED, PRESCRIBED AND TAXED: “The alternatives are deadly, and addictive, and DEADLY.
We only have to compare two (2) other narcotics and the three that are the worst, are the most commonly and frequently prescribed – and they are DEADLY.
So, would anyone like to guess what the three most deadly, widely prescribed and the most socially accepted medication are that people are taking with the encouragement of their doctors might be? Does anyone realize how many young adults, middle aged adults and older adults are under the influence while working, driving, socializing, caring for their children and “living everyday normal lives – thinking no one knows.
We KNOW. I know. I notice. You notice. WE as “a society” don’t say anything, we’re the majority – most of “us” are on medication of some type or other – we need it, and it’s legal.
Are you with me so far?
There are many facets of this issue. As many as there topics listed above. And there are more, more issues than even the issues created by “street drugs.”
The residual effects of the over use of THESE prescription drugs run deep into the fabric of our society. Our costs are more than immediate. In the future the results of overuse and misuse of these pharmaceuticals will include organ failure, dementia, violent withdrawals and long term pain that will not end. These are just the side effects that I’ve SEEN in people within my realm of opportunity, these don’t include ALL OF THE SIDE EFFECTS AS LISTED ON THE WARNING LABEL.
They get a WARNING LABEL THAT LISTS EVERYTHING but “DEATH” oh, yes, sometimes even death, as a “side effect” and some of them have already been deadly. So, what is the penalty for that?
PROTECTIONISM – they received it during the Bush Administration.
I’ve heard there are laws protecting the major pharmaceutical companies from law suits. These laws were enacted by the Bush Administration through protection by the FDA (Food and Drug Administration). How do these companies that are literally poisoning people and drugging people warrant protection from the Federal Government? I want to know if I’m wrong.
I still would like to address each topic above with the comparison to the effects of the narcotics and opiates that are being prescribed to a huge percentage of our population.
They are our young and wild, our middle aged and tired and our elderly who are aching. Every age group in our society is justifiably taking a medication that they need. They might need help, but they DON’T NEED ADDICTION – and that is what is destroying their lives.
What do you think the effects of narcotics and opiate addictions might be on the Gross National Product? What is the productivity of those who are medicated and over-medicated?
Well, you might be about ready to ask, “WHAT THE DOES THIS HAVE TO DO WITH THE LEGALIZATION OF MARIJUANA FOR MEDICAL PURPOSES?” Ask yourself that question – the answers are in the previous paragraphs.
We are always on the defensive in this battle. It is time we get on the offensive and realize who our enemies are. The billions of dollars of profits accumulated and distributed by the pharmaceutical companies to develop their infrastructure and pay their shareholders is unacceptable to society, and they must be made to pay for the addictions they have created.
They must be regulated and taxed, audited and investigated and held accountable for the millions of lives they have affected in a harmful way. In addition to coming under scrutiny for their past behaviors and manipulation of the society it has drugged, they must make compensation in the forms of financial restitution, the creation and management of detoxification centers and rehabilitation facilities – FREE TO ANYONE WHO IS ADDICTED AND WANTS TO GET OFF OF THEIR MEDICATION.
This would be a small beginning of a new behavior expected of and new standards to be held to, and the regulation of marijuana for ANY medical purpose that these pharmaceutical drugs could be prescribed for, will receive the same support, funding and research as the more expensive and more harmful opiates and barbiturates.
Now, I’ve written this very fast and didn’t give it a lot of rationalized thought. I just read some of what was written and quickly applied it to a situation my mind has been in regarding the over-use and over prescribing of addictive medication to millions of Americans.
I would like the opportunity to say more, but the time will come when I will know all that I need to say to stop “The Drugging of America” once again… and yes, ALCOHOL AND CIGARETTES are NOT TWO OF THE THREE WORST DRUGS IN THE WORLD, THEY’RE NUMBERS FOUR AND FIVE.
:>)
my best to all,
I recommend that Dr. Gurley reads the following book, Marijuana is Safer: So Why Are We Driving People to Drink?, which provides references to ample scientific studies alleviating her six public health issues.
http://www.amazon.com/o/ASIN/1603581448/
1) Second Hand Smoke – Though there may be more carcinogens in cannabis, ample studies show that long term use is not associated with cancer, rather cannabis has anti-carcinogenic properties. Also, Dr. Gurley admits that there are no studies yet that prove any harm to non-smokers from second-hand marijuana smoke. Would it make sense that second-hand marijuana smoke would cause cancer when marijuana has anti-carcinogenic properties? If marijuana WERE like tobacco (which it thankfully is not), second-hand smoke might even increase the anti-carcinogenic properties (as tobacco is the opposite and second-hand smoke can be far worse.)
2) Substance Abuse/Mental Health Issues – Yes, many people are currently enrolled in addiction treatment programs for marijuana habits. However, the majority of marijuana smokers currently in drug treatment were arrested for marijuana possession and ordered into treatment as a condition of their probation. Tobacco, alcohol, heroin, cocaine, and even caffeine are all much more addicting than cannabis. Regarding violence, an underground market fueled by prohibition causes violence between gangs and police, not from marijuana’s habit nor its chemical structure. Marijuana users are not the likely type to create violent situations, but users of alcohol, methamphetamines, cocaine, and heroin do indeed spur violence to feed one’s addiction and/or when intoxicated. Regarding mental health issues, patients predisposed to schizophrenia or other mental health disorders are best off not taking mind-altering substances as an altered state of mind is the last thing they need. One can look at this as similar to the chicken-egg scenario, and ultimately with millions of US citizens currently smoking marijuana, how many are suffering from mental health disorders? …not enough to justify a fear of mental health disorders INDUCED by marijuana alone. Alcohol is by far the winner of induced mental health disorders and violence , just to start with.
3) Driving While High – True marijuana has shown to affect driving ability. However, what Dr. Gurley fails to mention are the results of crash culpability studies and the decision to drive. The statistical incidences of motor vehicle accidents involving drivers under the influence of marijuana have proven to be no different or very little different than control groups with no medication. http://www.miqel.com/reading_library/archived_stories/feel-free-to-drive-on-weed.html – This website provides references to 12 scientific studies showing the crash culpability studies that place marijuana in a positive light of safety and show the unfortunate detriments of alcohol, the far more dangerous substance. Finally, while alcohol may induce bravado and confidence leading to the likelihood of a driving attempt, marijuana users do not feel this urge to drive while in their altered states. Most choose not to.
4) Childproofing – True, marijuana may be accidentally ingested by infants or children. The rare case of coma is unfortunate if directly attributable to cannabis. However, childproofing is a concern for a multitude of household items not limited to the many pharmaceuticals that are much more likely to cause irreparable harm to infants than cannabis: sharp objects, stairs, chemicals, etc. What this comes down to is consumer and parent responsibility, not government control.
5) Teen Protection – True, drug use among teens is an issue. However, rates of use have not dropped with prohibition, and teens report that illegal drugs are easier to acquire as dealers do not check IDs. Developing teens need to be protected, but an end to prohibition will put power into the hands of professional, responsible vendors. Education is yet another important part of teen use and abuse, and teens need to understand that if something is a gateway substance (milk and sex come to mind), alcohol is the cultural norm instituted in weddings, sports, church, and other regular activities that provides the first stepping stone for mind-altering substances. Use rates have dropped in the Netherlands after legalization, and rates have not seen significant rises in US states with legal medical cannabis. I would want my children to have the safer option of marijuana for enjoyable recreation, as the norms of alcohol and tobacco kill hundreds of thousands annually and marijuana alone (even though rare cases exist of coma development in infants) is still one of the safest substances known to humankind.
6) Quality Control – True, marijuana may vary in terms of quality and potency, but this goes with many products. Dangerous bacteria and fecal matter in our industrial meat complex is a far greater concern. Furthermore, where is the data showing that marijuana grown legally today under state laws and distributed via dispensaries does not provide quality control to the medical marijuana patient? I believe your data may come predominately from marijuana of illegal grows and Mexican “dirt weed,” being sold to uneducated recreational users. Please correct me if I’m wrong. Governmental control should be more focused on pharmaceuticals that cause ridiculous side affects and have little to no testing before wide release to the general public. Marijuana has been consumed by humans for thousands of years…and most pharmaceuticals are far more damaging.
Public health issues regarding marijuana should focus on these issues: the future negative social health of the citizen arrested every 9 seconds for marijuana possession, the negative mental and social health affects caused by incarceration in the prison system of millions of citizens for drug possession, the positive health of the medical marijuana patients, and the physical lives saved from the end of a marijuana drug war.
Please respectfully consider these related facts and educated scenarios.
Thank you.
One of the few posts on the internet that actually has real facts and addresses some of the issues no one else is bothering with.
I will state as a fact that marijuana smoke does travel, it will get into to other people’s homes and apartments if living next to someone who uses. I can also state for a fact that when people have access to a steady supply of marijuana they will smoke as much as people who smoke cigarettes.
I say this because it’s happening right next door to me.
The really scary thing is no one wants to do anything to deal with the problems and it’s only going to get worse if it’s legalized. It’s suppose to be a medicine but no medicine I know makes other people sick.
The facts are there does need to be regulation just like there is with tobacco. Unless people want kids breathing it in. Nothing like being forced to breath this when you don’t want to either.
The other fact that people are not addressing is that a good amount of the marijuana being sold now is coming from Mexico. Interesting how the number of murders and such have gone up there since it was legalized as a medication in Calif. (btw, if it is a medication why are non-pharmacies allowed to distribute it?) Nothing like knowing this “medicine” is destroying lives of others.
It’s going to be interesting to see how this goes. It’s too bad these issues are not being addressed now. I guess it’s got to get worse and be in everyone’s face before anything will even be considered.