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Marijuana is the most commonly used illicit drug in the United States. In 1 month in 2014, as reported by the Substance Abuse and Mental Health Services Administration (SAMHSA), more than 22 million people aged 12 years and older used marijuana. According to the 2014 survey, 4.2 million people had disorders related to the use of marijuana. Among adolescents aged 12 to 17, 2.7%, or 667,000, were found to have marijuana use disorder (SAMHSA, 2015).
Now that the use of marijuana is becoming legal in many states (30 at the time of publication), healthcare professionals are well positioned to affect the choices communities make about the supply, distribution, prescription, and care of people using marijuana, as well as the regulatory developments surrounding marijuana’s future, its use, and abuse. Worldwide, the growing development of marijuana-based medicines has led to greater discussion among prescribers, the public, and policy makers. Ethical principles in health care mandate a degree of separation between the prescribing of a drug and its supply, thus necessitating the need for independent channels of distribution. In the case of marijuana, growers are engaged in distribution and quality control of supply, and marijuana dispensaries are being established in states where marijuana is legal. Should the federal prohibition on marijuana be lifted and medical marijuana be legalized, pharmacists may also be responsible for the handling, supply, counsel, and oversight of the safe use of the plant as well as its related products and drugs.
The line between medicinal and recreational use of marijuana is often blurred. Greater awareness and education can clarify distinctions between these two purposes for using marijuana (Isaac, Saini, & Chaar, 2016). The first part of this module provided insight into the cultural and historical context of both medicinal and recreational uses. Marijuana’s legal status has often been contrasted with that of legal opioids, which have killed thousands more people than marijuana. (States that have legalized marijuana have reported a substantial decline in opiate and pain medication prescription overdose rates; Schepker, 2017). Use of both illicit and prescription opioids has reached the status of a “public health emergency” (U.S. Department of Health and Human Services, 2017). This is not to say that there are not significant potential risks in the legalization of marijuana. A published review of drug policy publications suggests that it is plausible that legalizing recreational marijuana use in the United States could substantially reduce its price and increase heavy use and marijuana-related problems such as dependence and substance misuse among those who already use the drug. In the longer term, legalization may also increase the number of new users (Hall & Lynskey, 2016).
To provide background to the issue of legalization of marijuana, the following is a brief outline of the history:
1850: In the United States, marijuana was sold over the counter and was commonly used as treatment for such diseases as cholera, alcoholism, opiate addiction, and convulsive disorders.
1906: Congress passed the Pure Food and Drug Act, a piece of legislation designed to restrain abuses in the patent-medicine industry. It was also the first piece of legislation in the United States to mention marijuana. Until this time, there was no concerted effort on the part of the government to regulate psychoactive substances. Cocaine was still in Coca-Cola; heroin kits were available for sale at Sears. No drug was illegal.
1930: The Federal Bureau of Narcotics (FBN) was formed in Washington, DC.
1936: Every state then in the union passed a law restricting possession of marijuana and eliminating its availability as an over-the-counter drug.
1937: Although opposed by the American Medical Association, the Marihuana Tax Act of 1937 was passed to prohibit all nonmedical use of marijuana in the United States. However, the law also limited medical use with fees and regulatory restrictions that imposed a significant burden on physicians prescribing marijuana.
1970: On October 27, 1970, the Comprehensive Drug Abuse Prevention and Control Act was enacted. Title II of the act – The Controlled Substances Act – established categories varying from Schedule I (the strictest classification) to Schedule V (the least strict). Marijuana was placed in the Schedule I category, thereby prohibiting its use for any purpose.
1996: California voters approved Proposition 215 to legalize medical marijuana. However, the Clinton Administration opposed the proposition and threatened to revoke the prescription-writing privileges of doctors who prescribed the drug. Since the passage of Proposition 215, marijuana use among youth in California has declined significantly (Lee, 2012).
Although the federal government of the United States currently prohibits the sale and use of marijuana, thirty U.S. states and the nation’s capital have made marijuana legal for all adults, and most states allow for some use of medicinal marijuana. A total of 29 states, the District of Columbia, Guam, and Puerto Rico allow for comprehensive public medicinal marijuana programs. The Marijuana Policy Project (2018) and the National Conference of State Legislatures (2017) provide web-based resources that detail each state’s legalization status for medicinal marijuana. Contained within the federal budget are provisions to protect a state’s right to responsibly regulate medical marijuana programs. Since December 2014, the Rohrabacher-Farr amendment has prohibited the Justice Department from spending funds to interfere with the implementation of state medical marijuana laws. This amendment must be renewed each fiscal year to remain in effect and was included in a series of spending bills approved in 2016 and 2017, with the most recent extension being approved with the passage of the budget on February 9, 2018. Several states and the District of Columbia have stopped jailing individuals for possession of small amounts of marijuana (Marijuana Policy Project, 2017).
Despite concerns that legalization of marijuana could increase crime risk, several studies have shown that instating laws allowing for medical marijuana and dispensaries is not associated with increased crime. In 2012, a study published in the Journal of Studies on Alcohol and Drugs found that the density of medical marijuana dispensaries was not associated with violent or property crime rates (Kepple & Freisthler, 2012). In 1914, the Harrison Act placed narcotics under the regulatory control of the federal government, restricting access to nonmedical consumers. The Harrison Act made the first legal distinction between recreational and medical use of drugs. That year, undercover sting operations led to the arrest of 25,000 physicians on narcotics charges. Three thousand were given prison sentences and “thousands had their licenses revoked for giving out opiates” (Lee, 2012, p. 41). The pharmaceutical industry’s lobby did, however, keep marijuana from being covered by the Harrison Act. Few people were smoking marijuana at the time, although some were still eating hashish. Prohibition of marijuana began in California, where it was outlawed in 1915. The political rationale was control of Mexicans in the labor force. “Arrests and convictions of ‘Mexican’ workers for marijuana possession were most concentrated during the years of, and in the areas with, the highest levels of labor organization and action” (Lee, 2012, p. 42). During most of the Prohibition era, marijuana was exempt from national crime legislation; however, in 1929 Congress passed the Narcotic Farms Act (later repealed in 1944), which misclassified Indian hemp as a habit-forming narcotic (Lee, 2012) and authorized construction of two hospitals in the prison system for treating drug addicts, including non-medical marijuana users deemed addicts (Lee, 2012). As a social upside, marijuana was at the center of the jazz culture that brought together Black and White Americans interested in the emerging music genre. By 1931, when the FBN was formed in Washington, D.C., many states had banned marijuana.
Marijuana is currently listed as a Schedule I substance under the Controlled Substances Act of 1970, the highest classification under the legislation, and remains illegal at the federal level. The Controlled Substances Act regulates the manufacture, importation, possession, use, and distribution of substances such as marijuana. A Schedule I drug, as defined by the U.S. Drug Enforcement Administration (DEA), is a substance that has a high potential of being abused by its users and has no acceptable medical use (DEA, n.d.). Recently, however, legislation has been rapidly changing at the state level. Health professionals, along with the public and legislators, are reviewing the evidence resulting from marijuana prohibition. Some evidence suggests that marijuana laws have contributed to increased prevalence of illicit marijuana use and marijuana use disorders (Hasin et al., 2017). States recognize (make the policy for) medical use, limited medical use, no access laws, or some recreational use.
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