What we ought to talk about when we’re talking about decriminalizing Cannabis

A green revolution is sweeping through the social and political land­scape of the United States—a shifting tide in the way American law and society conceptualize Cannabis as a recreational and a medical substance. In light of the unprec­edented legalization of Cannabis in several states, and decriminalization campaigns in other jurisdictions—such as the nation’s capital, where we work—the topic of mari­juana has grabbed the nation’s attention and reinvigorated debate about its use.

No dearth of opinion on marijuana use
Legal and economic positions seem to be the pivot points of argument on recreational use of Cannabis—but not, surprisingly, health considerations. Even to the Cannabis non-user, the pending changes in state laws are relevant; after all, every illicit substance can lead to a pathological process and thus a public economic burden.

Articulations of marijuana’s “safety” are nothing new: Consider President Barack Obama’s recent comment that pot is no more dangerous than alcohol (the danger of alco­hol is a different argument altogether). There is another layer of Cannabis use—the drug’s psychiatric effects—that is seldom visible to the public eye but quite palpable in the field of mental health—a troubling disconnect because those psychiatric effects have been softened to inconsequence, or are not spoken of at all.

When Cannabis is juxtaposed with other illicit substances, it seems almost innocuous; dependence and withdrawal have not been detailed empirically and are continuously debated. True, consumption of marijuana is not immediately life-threatening, com­pared with the risk of stroke and myocardial infarction with cocaine use or respiratory depression with narcotic agents. Despite this facade, however, the psychiatric morbidi­ties of marijuana are real and incapacitating, ranging from extreme anxiety and dysregu­lated mood to chronic psychotic debilitation.

Even after only a few years in psychiatric residency, it has become a common experi­ence for us to observe acute and chronic psychosis in patients after they have used Cannabis. Many require hospitalization or a leave of absence from academics or employ­ment; one of our patients re-matriculated to college after 7 years of intensive care.

Every mental health professional can tell similar tales.

Beyond anecdote
Numerous publications have shown that Cannabis expedites onset of psychotic and prodromal symptoms of schizophrenia. The age range of onset of psychotic symp­toms—typically, late adolescence into early 20s—is critical, prognostically.^1,2 This epi­demiological fact is dangerously in tandem with Cannabis use patterns in America and its college culture. It is known that modifi­able risk factors are decisive in the devel­opment of psychopathology. Additionally, environmental exposures in the developing brain elicit a more ominous concern because the brain does not complete neural develop­ment until early or mid-20s.³

Another concern is the effect of Cannabis on cognition, during periods of acute intoxi­cation and after chronic use. Research on this topic is limited, but evidence suggests that heavy Cannabis use at an early age affects cognition, as measured by a diminished IQ.⁴ Regrettably, unknowns in this area of study are far more abundant than what we know. This gray area might serve to placate legisla­tors and frequent users and cool discussion.

Rx Cannabis?
Another aspect of the controversy concerns medicinal use of marijuana. Perhaps legal­ization of medical marijuana has served simply as an antecedent to recreational legal­ization, as was the case for Colorado and Washington. But under the heading of “medical marijuana” lies a poorly defined, amorphous designation—one that borders on arbitrari­ness regarding standards of use.

Cancer treatment, pain, glaucoma, HIV, multiple sclerosis are examples of condi­tions in the bucket list for discretionary use of Cannabis, yet none has a formal FDA indication.⁵ This absence of approval underscores the lack of empirical valida­tion, quality control, and standardization that are required of every other sanctioned pharmaceutical agent.

Lack of validation also might explain why the collective opinion of major medical asso­ciations, including the American Medical Association and the National Council on Alcoholism and Drug Dependence, are opposed to wide availability of smoked mari­juana. The American Society of Addiction Medicine, an interdisciplinary organization of physicians, has posted a policy statement affirming that medical marijuana should 1) be held to FDA standards and 2) not be kept under the jurisdiction of state law and regulation.⁶

Why are psychiatric morbidities of marijuana reported so timidly?
Perhaps the rarity and randomness of long-term illness associated with Cannabis use pacifies individual concerns. Psychiatry understands this reality: All people respond to stresses differently and have specific, indi­vidual vulnerabilities. The diathesis-stress model plainly explains this hypothesis— and, sometimes, Cannabis is that stressor. Perhaps a more academic hypothesis is the concept of “ecophenotypes,” which posits that our heritability is not fixed but is in con­stant calibration with our environment and our adaptability to it. Environment often is a choice that people make.