Evaluating the implications of legal cannabis

In Massachusetts, cannabis access is becoming increasingly simple.

Since the Commonwealth authorized recreational marijuana in 2016, dispensaries have surged, prices have plummeted by over half, and potency levels have soared. In total, the cannabis sector has flourished in Massachusetts, with the industry generating over $1.64 billion last year. Other states have reported comparable patterns.

Certain advocates of legalization imagined a new chapter of individual liberty, with straightforward access to a substance they claimed to be a healthier substitute for alcohol. Revenue from cannabis taxation would support crucial state initiatives, and legalization would relieve pressure on the justice system, they contended.

Nearly a decade later, we invited four researchers to reflect on how those aspirations measure up against the actual outcomes of marijuana legalization. Interviews have been modified for brevity and clarity.

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Legalization of marijuana has produced a substantial new income stream for the state — exceeding $920 million according to the Marijuana Policy Project. And I consider that beneficial. However, I believe that the financial gain has come at a significant cost to public health.

My colleagues and I are seeing an increasing number of individuals who have developed cannabis use disorder, a condition where cannabis consumption disrupts essential areas in one’s life, such as employment, education, or personal relationships. This is not surprising given that the frequency of daily or almost daily cannabis users has escalated 20-fold in the past thirty years.

Moreover, cannabis is considerably more potent now than in previous decades. This trend began prior to legalization, but once large corporations entered cultivation, they had the capability to significantly enhance the THC levels — the element of the plant responsible for psychoactive effects. In the 1960s, ’70s, and ’80s, average THC levels in cannabis hovered around 3 to 4 percent. Today, cannabis flower can have THC concentrations ranging from 20 to 30 percent or even higher.

In the 1960s, ’70s, and ’80s, average THC levels in cannabis were approximately 3 to 4 percent. Presently, you can find cannabis flower with THC content between 20 and 30 percent.

This increase in potency has led to a marked rise in adult users developing cannabis use disorder, climbing from 10 percent just a decade ago to about 30 percent today. It’s challenging to determine how much of this trend relates to legalization, but I suspect it has likely accelerated the process.

The issue, in my opinion, boils down to the gap between concepts and execution. We must align the rising cannabis consumption with further research to alleviate the risks associated with the substance while preserving the positive aspects of legalization. For instance, more studies are needed on how law enforcement can prevent individuals from operating vehicles under the influence of cannabis, which can result in perilous situations. Similarly, research into the medical advantages of cannabis is essential (and indeed, under certain conditions, the substance appears to offer legitimate medical benefits). Ideally, we will discover methods for individuals to benefit from these advantages while minimizing their chances of developing a substance use disorder or facing other complications arising from cannabis use.

I would like to see states and private enterprises profiting from cannabis sales allocate greater funds towards research initiatives so that cannabis science can progress in line with the burgeoning interest in cannabis.

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I believe cannabis legalization has been an outstanding achievement overall. Certainly, there are areas that could still improve, but we’ve made significant advancements in several crucial sectors.

Firstly, cannabis leads to far fewer arrests these days compared to previous decades. Arrests for possession decreased over 70 percent between 2010 and 2018. This is positive as having an arrest on your record can adversely affect your education, housing, employment, and more. It’s terrible. While conditions aren’t perfect—arrests haven’t vanished completely, and Black individuals are still apprehended at disproportionately higher rates than white individuals—the drug isn’t inundating the justice system like it once did.

Secondly, by establishing a legal market, we’ve ensured that individuals have access to secure cannabis rather than illicit products that could be tainted with pesticides, mold, or heavy metals. Of course, not everyone purchases from the legal market, and that remains an area for improvement.

Lastly, we’re producing tax revenue for the state, which is a significant triumph. Currently, the state is actually generating more tax income from cannabis than from alcohol.

No credible individuals are advocating for a return to cannabis prohibition, and I believe this reflects the overall achievements we’ve made in its legalization.

Are there still challenges to address? Yes, definitely! One of the most pressing issues is that unintentional overconsumption is increasingly common. This is due to two main factors. Firstly, products are significantly more potent than they were previously. Individuals who take the same three hits from a bong they did in college might not realize that today, that’s akin to consuming seven times what they were accustomed to.

Secondly, we foolishly produce cannabis in the form of gummies and chocolates. If left unattended, kids will consume these, which can result in emergency situations. However, it’s not just children—adults are also susceptible to overindulgence when cannabis is designed to be palatable. I strongly oppose converting cannabis into candy—or pizza sauce, hot sauce, or any other edible—and I have been advocating against this for quite some time.

Just like criminalizing cannabis, legalizing it is a societal experiment. We must monitor the situation diligently, as there may be risks we haven’t anticipated. Nonetheless, to my knowledge, no credible voices are calling for a return to cannabis prohibition, and I think that signifies the substantial success we’ve had in its legalization.

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As the leader of MGH’s pediatric injury prevention program, my interest in cannabis legalization stems from its implications for child safety. Accidental exposure to cannabis can indeed present a risk to children.

When my colleagues and I analyzed public health data to investigate how often cannabis leads to children visiting the emergency room, we discovered that these incidents increased by approximately 60 percent after the opening of recreational dispensaries. Most incidents (over 80 percent) occurred among teenagers, but the largest increases were observed in younger children. In the 0-to-5 age bracket, we witnessed roughly a fourfold surge, while in the 6-to-12 age group, the increase was sevenfold.

Because of their small size, children are more severely impacted by cannabis than adults consuming the same amount. In fact, cannabis can induce such significant drowsiness in children that they may begin to experience breathing difficulties. To complicate issues, similar reactions can occur if children consume various prescription medications or contract meningitis or encephalitis. Cannabis use is rarely fatal, but the other conditions can certainly be deadly. Unless someone witnesses the child ingest cannabis, we often lack visibility into what is happening—or the severity of the case—until we conduct extensive tests. This adds considerable pressure on the system.

It is crucial that parents securely store cannabis, and we must also call on manufacturers and retailers: Make the packaging child-proof!

Cannabis has also produced some positive outcomes in pediatric medicine. Specifically, a compound in cannabis called cannabidiol has proven successful in treating epilepsy in children who do not respond to other seizure medications. I don’t take a definitive stance on whether the benefits of cannabis legalization outweigh the drawbacks. However, as a pediatrician, my role is to advocate for children and shield them from the unintended repercussions of voters’ decisions, which currently means raising awareness about the risks associated with accidental consumption.

Young children, particularly toddlers in their exploratory stage, are especially likely to consume cannabis if it’s left exposed. It is imperative that parents keep cannabis securely stored to prevent access, and we also need to urge manufacturers and retailers to create child-proof packaging! These items should be more challenging for a child as young as 3 or 4 to open.

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One of the most peculiar features of cannabis legalization is that it is only permitted at the state level. Federally, cannabis remains illegal. Part of the reason for its illegal status is because cannabis is classified as a Schedule I substance, suggesting it is addictive and holds no medicinal value.

At this juncture, it is evident that cannabis does possess medical significance, such as alleviating specific types of pain and reducing nausea during chemotherapy. The Schedule I designation was a reaction to the societal views surrounding cannabis in the 1960s, made predominantly without robust scientific backing. Regrettably, the federal illegality of cannabis hampers researchers from exploring its legitimate medical applications due to funding restrictions. Furthermore, because cannabis is a natural substance and cannot be patented, private industry shows limited interest in investigating its uses.

Many individuals—myself included—aspire for cannabis to be reclassified as a Schedule III drug, which would eliminate some of these barriers to research.

During the Biden administration, there was interest in revising cannabis’s scheduling, but the process is complicated, and it wasn’t finalized before the new administration took over. Currently, the rescheduling seems to be on hold. The case is awaiting review by a Drug Enforcement Agency administrative law judge, who appears skeptical of its merits.