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Cannabis Conundrums — Dissecting Policy Changes

Experts analyze the new world of weed and implications for SUD assessment and treatment, criminal justice reform, and future research challenges.

Controversy around marijuana use dates back to the 1900s. In response to an influx of Mexican immigrants and their use of the substance, a movement was underway to paint a negative picture of the minority groups crossing the border and their use of a plant known in Mexico as marihuana. The irony of the recent increased attention on cannabis policy changes (proposed and implemented) at the same time as alarming immigration policy gains traction should not be lost on those familiar with the racially based origin of criminalizing marijuana, called cannabis in the United States and at the turn of the 20th century and widely used in medicine at that time.

Using similar tactics to those employed in today’s immigration crisis, the media exaggerated the language differences and capitalized on the growing fears in the general public. Suggested to cause men of color to act violently, the Marijuana Tax Act was put in place in the 1930s, banning sale and purchase of the substance. Though overturned, the legacy of racial bias in drug policy continued. Marijuana was classified as a controlled substance through the 1970 Controlled Substances Act and listed as a schedule 1 drug, indicating it has no medicinal value and is considered dangerous. In 1996, California became the first state to legalize medical marijuana, kicking off a slow but steady wave of changes across the country (Burnett & Reiman, 2014).

Drug policy changes fall on a spectrum of criminalization, decriminalization, legalization of medical use, and legalization of adult use. In the United States, decriminalization and legalization efforts must be taken on at the state level, as cannabis use is still illegal at the federal level. Now, with a variety of states well into legalization of medical use, and swirling campaigns across the public health and private sectors pushing various platforms, where can one go for nonbiased, evidence-based information about marijuana use?

Language continues to be important, and the field is moving to replace the term “recreational use” with “adult use” to better describe the behaviors captured in those laws and efforts. The terms “cannabis” and “marijuana” continue to be used interchangeably but do hold different connotations to many in the field of drug policy and addiction treatment.

Decriminalization and Legalization
In the last two years, Advocates for Human Potential, Inc (AHP) an organization dedicated to improving behavioral health and human service systems, has convened hundreds of researchers, clinicians, and policy makers at summits and presentations for a discussion on the science and evidence base for cannabis use, decriminalization, and legalization. Linda Frazier, MA, RN, MCHES, director of addiction initiatives at AHP, describes the forums as full of energy, questions, and recommendations for filling gaps in the knowledge base around medical and adult cannabis use, while at the same time identifying and planning to eliminate barriers to furthering scientific research and right the overwhelming wrongs done to people of color during the War on Drugs and for decades prior. Frazier explains, “The reason AHP is in this space is because we looked around and said we need to have a conversation. We acknowledge different perspectives. In a circumstance where there is no federal guidance and states are legalizing, can we create a space to have a conversation and sort through what we know from the science?”

A review of states that have legalized or decriminalized cannabis use show inconsistencies in implementation strategies, protocols, and regulations. There is not enough knowledge transfer to unify and promote best practices, though there appears to be a similar path to follow: decriminalization, then medical marijuana legalization, and then a movement to adult use legalization, though the time line can be quite long.

Frazier paints the picture of “a building need for credible sources for information” and the challenge of assessing information sources’ credibility. In 2017, the National Academy of Sciences published a revision to their cannabis report. But Frazier notes that’s currently the only federal publication in circulation. “Clinicians, policy directors, and clinical treatment leaders are trying to figure out what to do. And there may not be consensus. There is a real growing hunger for trying to figure it out,” she says.

When asked to consider the current processes surrounding cannabis policy changes, many professionals question how the economic case for legalization and decriminalization has outpaced the demand for more research and more public health knowledge. Nick Szubiak, MSW, LCSW, founder of NSI Strategies, explains, “You can spend a lot of time with the range—prohibition, decriminalization, de facto decriminalization, medical legalization. Taking a step back, for a public health approach to substance use, what concerns me is the spirit of the message generated by other interested parties in the legalization of marijuana. We’re seeing the impact of the business model where there is money to be made by states through taxation, and business models that have profit through the making and distribution of marijuana. That public sector is no match for public health. The concerning message is that it’s safe.”

Considering the lessons learned from the trajectory of opioid prescribing and the subsequent opioid epidemic that we currently experience, concerns are high around the motivations for advancing marijuana policy changes now. There is inconsistency in enthusiasm for changing laws and the efforts to unwind the extreme response to marijuana use over the last 40 years.

“It can be argued that we should release those individuals who have been incarcerated for selling pot before we license the rich to do the same,” says Chad Dion Lassiter, MSW, an advocate in the field of American race relations and executive director of the Pennsylvania Human Relations Commission. “We must ask the Socratic question of why is it that the investment world is excited about marijuana legalization? Looking at this from a social justice lens, I am not so sure this is about humanity when we take a deeper look into legalization and decriminalization. Our democracy is built on capitalism, and this seems like another innovative way to feed that element of our democracy,” Lassiter says.

Many professionals reflect similar confusion about the messages offered by those on either side of the issue. Now, use is not portrayed using the legacy “this is your brain on drugs” imagery as it relates to marijuana. The pendulum is now swinging, suggesting marijuana use is not just “not bad” but that it is good. “We know that it’s not safe for developing brains of adolescents and pregnant women,” Szubiak says.

“I think health care social workers are still trying to navigate the polarization between pressure to impose the ‘abstinence-only’ approach, which has been traditionally held by the health care industry, and recognizing more current research that suggests marijuana can actually hold medicinal, therapeutic purpose,” says Noelle Ciara, DSW, LCSW. “Right now, the focus tends to be on abstinence and cessation. If and when recreational marijuana legalization occurs, I think the focus will need to shift toward more critical thinking and research on exactly how marijuana impacts health.”

Stigma, Race, and Opioids
The stigma surrounding marijuana use may be minimized in the context of the opioid epidemic. And while theoretically the comparison of the two substances shows dramatic differences, there are critical considerations for the historical and racially biased response to individuals with substance use disorders (SUDs). When asked about whether the marijuana policy changes are affected by the intensity of the opioid epidemic, Lassiter says, “I fundamentally believe they are simply because now with the opioid epidemic we see the humanity of people who are addicted. The War on Drugs was the war on black and brown and poor people. When crack hit black and brown and poor communities, we saw people as nonpersons, nonentitities. White privilege allows for demarcated catchment areas for legal injections whereas others were ‘crackheads’ and incarcerated.”

The Lessons of Alcohol Policy
Often, the cannabis conversation turns to the trajectory of alcohol policy and comparing alcohol use with marijuana use. “I remind folks that alcohol use is the third leading cause of preventable death in this country. We have normalized alcohol. We have alcohol everywhere. If you screen the primary care population [for alcohol use], about 50% [who use] will come up with not needing an intervention. A whole lot of people who just don’t use alcohol that way. Then you have the 50% that does need an intervention. We don’t have a way to assess the several drinks a day until there is an accident and then we send them to rehab,” Szubiak says.

He brings to light the opportunities that health care providers have to improve how SUDs are screened for, discussed, and ultimately treated. “Until we right the wrong of pushing addiction treatment out of health care further out into its own problem, we’ll continue to have not only marijuana problems but all drug treatment problems.” He likened the debate to changing a dangerous intersection: “We have a problem intersection where there are a few really close calls with accidents, but we wait for the third fatal car accident to put the light up. We don’t treat addiction according to what people need. We have buckets for treatment and throw people in them. We need to be able to talk about substance use along a spectrum of risk.”

Ciara echoes the concern with provider and system readiness: “This conversation is going to become more complex if marijuana becomes legal for recreational use. Patients are going to start asking a lot of tough, valid questions—questions that providers may struggle to answer. There will be a lot of conflicting information, and I suspect this incongruence is going to create confusion and put some strain on the patient/provider relationship in terms of trust and perceived knowledge of providers based on their stance.”

Implications for Criminal Justice Reform
Marijuana decriminalization reflects the same inconsistencies across states. “The decriminalization movement is so critical—[criminalization] is an antiquated and ineffective way to treat a chronic health condition. We are punishing and have been punishing people for decades because of who they are, not because we have an effective intervention. We have all this research and we haven’t changed,” Szubiak says. One of the critical considerations is whether decriminalization applies only to current use or whether legacy criminal records will be addressed.

When asked about missing elements of the conversation surrounding marijuana use and related policy changes, many point to equity, racial bias in punishment for marijuana-related crime, and the disproportionate impact criminalization has had on people of color. “The rates of arrests for the African American population for marijuana possession is off the charts compared to other populations,” Szubiak says.

“People of color continue to experience immense discrimination in the realm of marijuana law and continue to be the most adversely impacted by the criminalization of marijuana today. We need to include these points in order to avoid whitewashing the discussion and further marginalizing minority populations,” Ciara adds.

Some states have moved away from putting people in jail and have stopped pursuing probation violations for marijuana use. “A state can say we’re decriminalizing—we’re not pulling people into the legal system. This is good, but not what we really need from an equity perspective. The decision to not arrest someone does not actually expunge records or past offenses. If you just take the effort of decriminalization, it happens differently at the state or municipal level,” Frazier says. “Even when a state decriminalizes, you still see inequity in who gets arrested. It decreases arrests around cannabis. Even so, you still see the minority populations are the ones being stopped and having interactions with the criminal justice system.”

Efforts at the federal and state level to release individuals from serving long or maximum sentences for low-level drug crimes have been exceptionally visible in the media following the 2019 State of the Union address. Regarding the First Step Act, Kara Gotsch, director of strategic initiatives at The Sentencing Project, explains that though marijuana-related crime is not prevalent among the majority of those released through the First Step Act, consideration of the experience of incarcerated individuals in this context is meaningful to the marijuana decriminalization conversation. “It is important to think about those who have served long prison sentences, and ‘What has their experience been?’ is an important question to ask,” Gotsch says. “The federal prison system is not providing appropriate programs for those incarcerated. Their social and familial networks are gone. The experience of incarceration is traumatic. The psychological and emotional trauma of release has to be addressed because it affects every part of their reentry.”

Considering the well-known prevalence of SUD diagnoses across individuals with criminal justice involvement, Gotsch highlights the unfortunate reality of treatment accessed through criminal justice systems: “Drug courts have had an impact; there are many drug court programs. However, there are so many individuals with significant SUDs who do not need to be in the justice system. But that’s the only way they can get access to treatment. We don’t have to rely on the criminal justice system to be our safety net for drug treatment. For so many, the only way to get drug treatment is through the criminal justice system.”

What about drug court? Is that not the intersection of criminal justice and treatment? Drug court, however, is only an option for a small cohort of individuals involved in drug-related crime. Gotsch emphasizes that drug court needs to be more open to individuals who have significant criminal records but still also get the option to be assessed for and use drug court for their SUD-related criminal issues. Prior violent offenses should still allow for assessment in drug court. “Creating such rigid standards for drug court is bringing in those who just need treatment. We rely too much on incarceration, not enough on rehabilitation. Now we have agreement that too many individuals go to jail,” Gotsch says.

“From a strengths-based perspective, social workers can push for policy to release those who were incarcerated for low-level offenses. There were many who were incarcerated during the War on Drugs when the true crime was our inability to treat addiction without incarcerating,” Lassiter says.

The disconnect highlighted by Lassiter is evident when reflecting on the ongoing consequences of decades-old drug policy and the momentum behind legalization and decriminalization. “The promising efforts for the most part are platitudes. The War on Drugs is what led to the new Jim Crow prison system and these high rates of mass incarceration destroyed communities of color. There was no sympathy or empathy for those who in fact may have had an addiction. There has been a lack of accountability from a macro and micro level. Policy makers and the criminal justice system have to right these wrongs,” Lassiter says.

More to Come, but Research First
The classification of cannabis as a schedule 1 drug prohibits and restricts research across health and science domains. According to Frazier, you must get permission from the Drug Enforcement Agency and the National Institute of Drug Abuse. “Research that gets approved then goes through a rigorous process and the product used is the kind of cannabis used 30 years ago and nothing like the product for sale in states that have legalized,” she explains. “In order for research to be easier, cannabis would have to be rescheduled.”

One may underestimate the nuance and implications for thoughtful, informed cannabis policy based on a saturation of opinion in a particular sector, or complete lack of conversation for a variety of reasons. Regardless, change is coming. And in many states it’s already here. With interdisciplinary forums such as the North American Cannabis Summit hosted by AHP, convening around the need for more, and better, research, as well as better, and more, policy changes, the hope is the collective demand for guidance, consistency, and equity in policy changes will come to the forefront of the conversation as science and practice attempt to keep up.

— Kerianne Johnstin Guth, MSW, is a health care administrator for behavioral health and addiction medicine programs in Camden, NJ.

Reference

Burnett, M., & Reiman, A. (2014, October 8). How did marijuana become illegal in the first place? Retrieved from http://www.drugpolicy.org/blog/how-did-marijuana-become-illegal-first-place.

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