We should not allow a cannabis free-for-all – Yale ethicist

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Mental health and addiction experts should lead the development of guidelines around the use of cannabis for medicinal and recreational purposes, writes Dr Sarah C Hull, a cardiologist at Yale School of Medicine and associate director of its Program for Biomedical Ethics, in an opinion article for Medpage Today.

Harms from cannabis are real and must be recognised and mitigated, she writes, in the article published on 16 January 2021, pointing medical professionals to cannabis guidelines published in October 2020 by the American Society of Addiction Medicine. This is the op-ed article in Medpage Today, a free access health news publication:

As the new year is upon us, and vaccines have finally given us a glimmer of light at the end of the long COVID tunnel that still lies ahead, we would be wise to consider the public health implications of another health policy issue that has become increasingly salient. In November 2020, voters in several American states including New Jersey and Arizona moved to legalise recreational marijuana use, reflecting a national trend toward decriminalisation in recent years.

As there is growing consensus that the ‘war on drugs’ has been costly and ineffective, with enforcement patterns that have disproportionately penalised people of colour, decriminalising marijuana is a logical and ethical course of action. However, changes to marijuana policy should be based on science and enacted thoughtfully and judiciously in order to minimise potential harm while protecting individual liberty.

While the concept of marijuana as a ‘gateway drug’ that escalates to more dangerous substance use has been largely debunked, it would be an error to infer it is therefore harmless. Inhaling any burning substance causes lung damage and a cascade of inflammation that significantly increases the risks of cancer and cardiovascular disease.

Smoking marijuana in particular has been associated with a nearly five-fold increased risk of heart attack the hour immediately following. While vaping marijuana eliminates some of these concerns, this method of delivery has been associated with severe lung injury as well.

Hull continues in the Medpage Today op-ed:

As a cardiologist, I have seen first-hand how little the public is aware of the potential cardiovascular risk from smoking marijuana. Accordingly, when counselling patients I urge them to avoid inhalation of any substances and to opt for oral formulations if they express a strong intent to continue using marijuana.

Still, as I emphasise to patients, this is a measure of harm reduction rather than harm elimination, and more research is needed to better understand the chronic effects of marijuana itself. We already know, for example, that heavy chronic marijuana consumption in young people under the age of 25 has been associated with decreased cognitive and executive function.

In addition to risks of self-harm, marijuana may pose a risk of harm to others through inhalation of second-hand smoke or through motor vehicle accidents due to impaired judgment and motor skills.

On the other hand, marijuana derivatives may provide some therapeutic benefit for certain individuals. In patients with advanced malignancy or AIDS, tetrahydrocannabinol can help to regulate mood, suppress nausea and improve appetite.

In addition, cannabidiol has shown promise as a potential anti-epileptic agent to manage debilitating seizures in children. It has been suggested that broader populations might benefit from cannabis-related effects on mood disorders and chronic pain, but further research is needed in this area to establish whether the benefits outweigh the risks.

Hull argues in the Medpage Today op-ed:

Decriminalisation of marijuana will create significant opportunities to conduct this research, but common-sense regulation based on science must be implemented simultaneously to create an ethical policy framework.

This should aim to promote public health through comprehensive education programmes and protection of vulnerable populations such as adolescents, while recognising the right of autonomous adults to make decisions about their own health but not to act in a way that might compromise the health of others.

Mental health and addiction experts should lead the development of guidelines, such as those published by the American Society of Addiction Medicine, including an age limit of at least 21 to minimise risk of potential harm to young developing brains.

Smoking or vaping any substances in public places should be prohibited so as not to impinge upon the liberty of others who do not wish to inhale second-hand smoke, just as there should be strict legal consequences for driving under the influence of substances that may lead to impaired function and increased risk of harm to others though motor vehicle collisions.

On the contrary, possession and use of marijuana by adults that does not directly affect others should not carry significant criminal penalties, particularly as enforcement patterns in practice have only served to entrench systemic racism.

There is substantial need for more research to guide specific policy development going forward, and in the meantime, recreational use (though not medicinal use) should be generously taxed to fund research efforts as well as addiction treatment in order to enhance benefits to society.

As with so many current issues, the rhetoric regarding cannabis use has too often been subservient to political agendas, with some conservatives condemning it as dangerous and criminal, while some liberals – and aspiring marijuana entrepreneurs – want to exonerate it as completely benign.

Instead, a nuanced and fact-based approach is necessary to promote the dual moral imperatives of personal liberty and harm reduction.


American Society of Addiction Medicine – Public Policy Statement on Cannabis

Adopted by the ASAM Board of Directors October 10, 2020.

Cannabis is a plant that has been used for its intoxicating effects for at least a century in the United States and for longer in other cultures. It also has a long history of use around the world for purported medical benefits. More than 100 different cannabinoids have been identified in cannabis.

The primary intoxicating cannabinoid in cannabis is delta-9-tetrahydrocannabinol (THC). The cannabinoid cannabidiol (CBD) has received increasing public attention in recent years; preliminary findings suggest that CBD may be a useful treatment for several medical conditions and it is not reported to be associated with intoxication or addiction, unlike THC.

Between 2001-2002 and 2012-2013, the prevalence of past-year cannabis use by US adults increased from 4.1% to 9.5%, respectively, and the prevalence of cannabis use disorder (CUD) nearly doubled. Adults and adolescents increasingly view cannabis use as harmless.

A 2019 Pew Research Center survey revealed that two-thirds of American adults support cannabis legalisation, which reflects a steady increase over the past decade. However, between 9.3% and 30.6% of American adults who use cannabis have CUD as measured in the largest recent national surveys.

The document investigates the medicinal and recreational use of cannabis in America, drawing on numerous studies. Below is a short excerpt, outlining the Society’s recommendations regarding cannabis for medicinal purposes:

Cannabis and related products used for medical purposes

1- Cannabis used for medical purposes should be rescheduled from Schedule 1 of the Controlled Substances Act (CSA) to promote more clinical research and Food and Drug Administration (FDA) oversight typical of other medications.

2- Cannabis and cannabis-derived products recommended for medical indications should be subject to FDA review and approval to ensure their safety and effectiveness.

3- Healthcare professionals who recommend non-FDA-approved cannabis products under the authority of state-level medical cannabis programmes should be required to complete specific training with an emphasis on risk mitigation and the prevention, diagnosis, and management of cannabis use disorder and other substance use disorders. Such training should be evidence-based and be informed by high standards of medical professionalism.

4- Healthcare professionals who recommend or write permits for non-FDA approved cannabis should do so only within the context of a bone fide patient-clinician relationship that includes appropriate patient evaluation, creation of a medical record and follow-up visits to assess the results of use and amend the treatment plan as needed. The same amount of caution exercised when any other controlled substance is prescribed should be applied when cannabis is recommended by a healthcare professional for a medical use. Clinicians should be prepared to discontinue treatment with cannabis if it is not effective or causes harm.

5- Healthcare professionals should only recommend non-FDA-approved cannabis if there is evidence that the potential benefits outweigh the potential harms. Healthcare professionals should avoid recommending cannabis to pregnant persons, and should recommend cannabis with great caution, if at all, to those with substance use disorders or psychiatric disorders, or to children and adolescents. Healthcare professionals should screen all patients for cannabis and other substance use disorders and refer to treatment as appropriate before recommending cannabis to be used for medical purposes.

6- Healthcare professionals should not recommend cannabis use for the treatment of Opioid Use Disorder.

7-Regulation of cannabis use for medical purposes should be overseen by departments of health. Indications for cannabis used to treat medical or mental health conditions should not be specified by legislatures or public referenda.

8- Non-FDA-approved cannabis recommended by clinicians should be reported to Prescription Drug Monitoring Programs (PDMPs). Healthcare professionals who recommend cannabis should check the PDMP prior to making a recommendation.

9- Potency of non-FDA approved cannabis should be determined and clearly displayed on the label. Healthcare professionals should consider the ratio of CBD to THC with respect to the indication and minimize potential adverse effects.

10- Healthcare professionals should discourage combustion or vaporisation of cannabis as a drug delivery method.

11- Federal legislation and regulation should encourage scientific and clinical research on cannabis and its compounds, expand sources of research-grade cannabis, and facilitate the development of FDA-approved medications derived from cannabis such as CBD or other cannabis compounds. Research needs for cannabis to be used for medical purposes include basic outcomes studies for well-defined conditions using well-defined medical cannabis products.


Medpage Today article – Op-Ed: We Should Not Allow a Marijuana Free-for-All


American Society of Addiction Medicine – Public Policy Statement on Cannabis


See also from MedicalBrief’s archives:

United Nations – and United States – reclassify cannabis as less risky narcotic



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