By Robyn Alie
Health Policy and Public Health Manager
On November 8, Massachusetts voters will decide the fate of the ballot initiative to legalize recreational marijuana. What’s at stake?
The MMS, long opposed to the use of marijuana for recreational purposes, is urging voters to cast a “no” vote on ballot question 4. If passed, Question 4 would make recreational marijuana legal in Massachusetts. The MMS is joined in opposition to the question by all members of the Campaign for a Safe and Healthy Massachusetts, including Massachusetts Governor Charlie Baker, Attorney General Maura Healey, Speaker of the House Robert A. DeLeo, the Massachusetts Hospital Association, the Association for Behavioral Healthcare, the Massachusetts Chiefs of Police, the Massachusetts Association of Superintendents, among others.
What’s at stake, the MMS believes, is the health of the people of Massachusetts, particularly its adolescents and children.
“We’re very concerned about the lack of research with regard to the individual and public health effects of marijuana,” said MMS President James S. Gessner, M.D. He added that “the studies that have been done and the experiences in Colorado and Washington state, where recreational marijuana is legal, show serious public health consequences.”
Studies have shown negative effects on cognition and brain development in youth and young adults who use marijuana. “We are very worried about how this law would affect our young people,” added Dr. Gessner.
Sharon Levy, M.D.
While the ballot question would ban sales to people under 21, “those kinds of laws have massively failed. First, kids are the group that is most interested, and second, they’re better customers,” said Sharon Levy, M.D., adding that it’s much harder to restrict kids’ exposure to the Internet advertising of today’s world. Dr. Levy is director of the Adolescent Substance Abuse Program at Boston Children’s Hospital, where marijuana use disorder is the most common reason for referral to the program.
The American Academy of Pediatrics (AAP) opposes the legalization of recreational marijuana. In a technical report published last year, the AAP wrote that “despite ongoing regulation of the tobacco and alcohol industries, youth remain common targets and ultimately consumers of these products.”
Another troubling issue is that the Massachusetts ballot question allows the sale of edibles, a point that the Supreme Judicial Court ruled in July that the ballot question must make clear after a citizens group challenged the ballot question as misleading, asserting that 45 percent of the marijuana products sold in Colorado are food and beverages.
In the year after recreational marijuana sales became legal in Colorado, calls to the area poison control center for marijuana exposure soared 70 percent. Many of these exposures are from marijuana edibles, namely, food products containing marijuana, such as brownies, chocolates, or candy.
Alan Ehrlich, M.D.
“While the absolute rate of these exposures is low, the ingestions [of marijuana edibles] have the potential to be serious, even leading to hospitalization and necessitating critical care treatment,” said Alan Ehrlich, M.D., assistant professor of family medicine at UMass Medical School and the executive deputy editor for DynaMed.
Because of the significant delay between ingestion of marijuana contained within edibles and the onset of effects, users may not perceive the desired psychoactive effect quickly enough or may consume too much, Dr. Ehrlich noted. He referenced a tragic story of a 19-year-old college student who consumed a marijuana cookie containing six times the standard amount of THC, and, experiencing acute psychosis, jumped to his death from a hotel balcony in Colorado.
Dr. Ehrlich also noted that individuals with a personal or family history of psychosis may be at increased risk for developing schizophrenia if exposed to marijuana before brain development is complete in their early 20s.
“The acute problems are easy to pick up,” said Dr. Levy. “The biggest part of the story here is what happens with exposure over time, particularly during adolescence — the effects on the brain — cognitive decline and mental health problems. There’s good data on the chronic long-term problems. Kids who start using marijuana, we’ll see a problem with mood, anxiety, drops in IQ, poorer functional outcomes, lower likelihood of establishing a family, poorer school outcomes.”
Risk for Addiction
Studies have shown other neuropsychiatric adverse effects, including cognitive effects and addiction. Marijuana is the third most common cause of drug dependence in the United States, after tobacco and alcohol. An estimated 9 percent of those who try marijuana will become addicted — 17 percent for those who start using as teenagers and as many as 25 to 50 percent in those who use marijuana daily.
Dr. Levy noted a “pretty clear link” that marijuana is a gateway drug to other substance use, including opioids. “Cannabinoid receptors and opioid receptors are on the same neurons. It appears that [marijuana use] ‘primes the pump,’ changing the cell in ways that make it more vulnerable to opioids.”
The MMS has advocated that the Drug Enforcement Agency (DEA) reschedule marijuana so that its health effects can be studied more rigorously. Marijuana is currently listed under the Controlled Substances Act as a Schedule I drug, defined by the DEA as “drugs with no currently accepted medical use and a high potential for abuse… with potentially severe psychological or physical dependence.”
The classification makes it extremely difficult to obtain the drug for research purposes.
Trend toward Liberalization
Since 2012, the national trend is tipping toward widespread liberalization of marijuana laws. Twenty-five states, including Massachusetts, have already voted in favor of medical marijuana. Four states — Colorado, Washington, Alaska, and Oregon — and the District of Columbia have legalized recreational marijuana. Four additional states — California, Nevada, Maine, and Arizona — will vote on referenda to legalize recreational marijuana this year.
Liberalization of marijuana laws has brought an increased risk of motor vehicle accidents, as marijuana can impair coordination, reaction time, and sensory perception. The AAA Foundation for Traffic Safety found the percentage of drivers involved in fatal crashes who recently used marijuana more than doubled in the year after legalization. In 2014, one in six drivers involved in fatal crashes in Washington state had recently used marijuana.
Proponents claim that legalizing marijuana in Massachusetts would make it safer by regulating it, and point to potential boons of increased tax revenue and jobs. The basis for these claims, however, is unclear, since the legislation allows for home cultivation of marijuana.
And, according to findings by the Massachusetts Legislature’s Special Senate Committee on Marijuana, the anticipated uptick in revenue may actually result in a shortfall. In a report released in March of this year highlighting the concerns and considerations of the ballot question, the senate committee stated that “revenues and fees that would be generated from legal sales may fall short of even covering the full public and social costs and should not be expected to provide a significant new funding source for other public needs.”
If passed, Massachusetts would impose a 3.75 percent tax on retail marijuana sales, and municipalities could impose an additional two percent tax. By contrast, Washington state imposes a 37 percent tax at point of sale and Colorado imposes a 15 percent excise tax on the first transfer or sale from the cultivator to the retail establishment, and a 10 percent sales tax on marijuana on top of the state sales tax, and local tax on recreational sales.
One troubling aspect of the ballot question is that no revenue from the sale of recreational marijuana is earmarked for administration and enforcement, public health, prevention, education, treatment, or research. By contrast, California’s ballot question earmarks $100 million over 10 years for research, and $50 million over five years for local programs supporting mental health and substance use disorder treatment, system navigation services, job placement assistance and other services, as well as youth education, prevention, early intervention, and treatment services.
“We’re so incredibly under-resourced in terms of helping kids with substance use disorders,” Dr. Levy said, noting there’s a push to do interventions in primary care, but then the next step up is rehabilitation. “That leaves an enormous gap, patients with marijuana addiction are all going to fall into this gap. As marijuana becomes more toxic and more concentrated, we can predict that we can see more kids with problems and families struggling with what to do.”
“This ballot question was written by and for the marijuana industry with no real consideration of public health consequences,” Dr. Gessner said, noting that MMS has developed resources and materials for physicians to help them answer patients’ questions about marijuana leading up to the vote.
“We want to make sure physicians and their patients are aware of the serious public health implications of this ballot question,” Dr. Gessner said.
Information on the health effects of marijuana, an analysis of the ballot question, a flyer for patients, links to the Report of the Special Senate Committee on Marijuana, and other resources are available on www.massmed.org/marijuana (information available on recreational marijuana on Sept. 1).