Position Statement
The Hazelden Betty Ford Foundation has an important responsibility and is uniquely qualified to comment on the risks and effects of marijuana use, the consequences of which we see every day among the people we serve at our addiction treatment centers around the country.
While the Hazelden Betty Ford Foundation opposes the expansion of marijuana legalization, we support federal action to drive more research and regulation to protect against the public health consequences of current and future legalization efforts.
We know marijuana is dangerous to many users and addictive to some, and that young people are particularly vulnerable. As debates about legalizing recreational marijuana and medicinal marijuana have intensified during the past decade, many young people have come to view the drug as less risky. Not surprisingly, more of them are using marijuana (also known as cannabis). According to a study from researchers at Columbia University, the entry point for teen substance use has shifted away from cigarettes and alcohol and toward marijuana.
Early use of cannabis is especially troubling. The human brain develops throughout adolescence and well beyond. Marijuana use can harm learning, thinking and memory development, and use of the drug has been linked to mental health issues, including psychosis, as well as other physical health problems. According to one recent study, even a little cannabis consumed by a teenager can cause changes in the part of the brain involved in emotion-related processing, learning and memory formation. We also know the earlier a young person starts to use any mood- or mind-altering substance, the greater the possibility of developing a substance use disorder. Indeed, at ourbehavioral health center for adolescents and young adults in Minnesota, 89 percent of our 734 residential patients in 2017 had cannabis in their substance use history, and 84 percent were diagnosed with cannabis use disorder. Each year, we treat approximately two dozen young people who have cannabis-involved psychosis.
One of the recurring themes we hear from the youth we treat is regret—of wasted time, lost opportunities, squandered talent, impaired memory, reduced performance and disinterest in healthy activities. Since 2009, our prevention division, FCD Prevention Works, has surveyed more than 100,000 students in grades 6-12 about substance use beliefs and norms. According to our FCD Student Attitudes and Behavior Survey database, students who used cannabis in the past year, when compared with those who did not, were:
- Thirty-one percent less likely to get 'A's;
- Five times more likely to report feeling the need to also use alcohol or other drugs;
- Twice as likely to have trouble concentrating on important tasks;
- More likely to ride with an impaired driver (30 percent) than students who reported using alcohol (21 percent); and
- Two to three times more likely to engage in physically, emotionally and academically risky behaviors.
According to patients from around the country who come to our treatment centers, prices for marijuana continue to drop in the current environment, making the drug more affordable, especially for young people. We also hear that young marijuana users are shifting more rapidly than ever into using dangerous concentrates of the drug due to new vaping technology and the explosion of high-concentrate cannabis products, including edibles, brought about by commercialization.
The recognition of these risks to the health and trajectory of our young people has been lost in the fervor to legalize marijuana. Too many people—including teenagers—think, incorrectly, that cannabis is a benign or harmless substance. Many parents have told us that it has become increasingly difficult to overcome such misperceptions when talking with their children about marijuana. Public dialogue has become so distorted that some young people who develop addiction to cannabis report that their condition isn't taken seriously, even when their lives are unraveling as a result.
Minimization of the risks—through expanded legalization and misinformation, propagated by profit-minded commercial interests that began their legalization campaigns many years ago—will have long-term public health consequences that will hurt our most vulnerable, high-risk people the most.
According to the National Survey on Drug Use and Health, the number of daily cannabis users has increased from approximately three million Americans in 2005 to eight million (about one in five cannabis users) in 2017. By contrast, only one in 15 drinkers consumes alcohol daily. While ten percent of the population is most vulnerable to any substance use disorder, it is reasonable to expect that the higher rates of daily marijuana use, as a norm, will only heighten the vulnerability to addiction faced by cannabis users. Among young people, daily cannabis use is at its highest rate in 30 years. More older Americans are using cannabis, too, and it's much more potent than the cannabis of their youth. Among all ages, cannabis use in the United States doubled from 2005 to 2015.
More than ever, we believe it is paramount to educate the public, especially young people and their parents, with objective information about the risks and potentially addictive dynamics of all drugs, including cannabis, and the availability of help. Many Americans are suffering because of cannabis use disorder, and it is important they know that recovery is possible.
While we oppose the use of the word "medicine" to describe cannabis because it has not been approved by the U.S. Food and Drug Administration (FDA), we understand that some non-psychoactive constituents of the cannabis plant might have medicinal efficacy; therefore we support further research to investigate whether or not medicines can be developed and evaluated through the FDA process. The FDA's approval in 2018 of a cannabidiol-derived oral solution to treat rare, severe forms of epilepsy is a good example of how the process ought to work. The eagerness in some states to approve medical cannabis based on hopeful signs rather than rigorous scientific scrutiny and FDA approval reflects a disregard for the importance of adequate research and the known risks associated with cannabis use. For example, some states have approved cannabis as a treatment for opioid addiction. The existing scientific evidence does not support such use and, instead, points to significant risks for some patients.
With regard to decriminalization, we support sensible criminal justice reforms that reduce the penalties for marijuana possession/use and that promote recovery and redemption. We are sympathetic to social justice issues—addiction itself is one—and do not believe harsh criminal penalties for possession and use are warranted, especially given the racial disparities in our criminal justice system. Such reforms, however, do not require legalization and commercialization of marijuana. In fact, promises of social justice gains appear to be falling short in states where legal cannabis is already a big business.
Other promises have fallen short too. In California, for example, cannabis sales were down a year after legalization, tax revenues were well below forecasts and the black market was thriving. In Colorado, we have seen a concerning rise in cannabis-involved traffic fatalities and hospitalizations.
Nevertheless, popular support for cannabis legalization has surged. Heading into 2019, 10 states and the District of Columbia had legalized recreational marijuana and 23 other states had implemented medical marijuana programs. Several more states—including New York, New Jersey and Illinois—also appeared poised to consider measures to legalize recreational marijuana soon.
Unfortunately, the federal government has ceded its authority to enforce the current federal law against cannabis. Two successive Administrations—representing each of our major political parties—have chosen not to enforce it. As a result, the status of cannabis as an illegal Schedule 1 drug under the federal Controlled Substances Act means very little, and federal inaction is sending mixed messages to the public and to our youth about the known and scientifically-validated and public health impact of marijuana.
Given the confused and complex state of the nation's cannabis policy, the federal government's most pressing responsibility is to drive more research and robust regulation to protect against the public health consequences of current and future legalization efforts. It is unclear whether "rescheduling" under the Controlled Substances Act is necessary or whether other Congressional and Administration actions can accomplish the same. In either case, it is especially critical to redouble federally funded research efforts to rigorously analyze the impact of existing community-and state-level policies on a wide range of outcomes, including school attendance, employment and health impacts, among others. Doing so, and establishing timelines for the dissemination of such research, would provide a more compelling rationale for other states to delay further legalization efforts. The findings of such research should be included in a robust review of all known evidence and published in a federal public health report identifying both the risks of marijuana use and the impact of expanded availability.
In the current legal environment, private companies have generally been unwilling to subject their medicinal products to FDA scrutiny or to incur the costs of such a process, and scientifically unsubstantiated claims have gained popular acceptance. At the same time, the debates about medical marijuana and recreational marijuana have become blurred, which has worked in the favor of legalization supporters. The federal government, in the absence of enforcing its own laws against cannabis, should now assume the responsibility of funding and potentially conducting the robust research needed to determine if any of the non-psychoactive constituents in cannabis have medical value and to provide guidance into the development of pharmacy-obtainable medications that are safe and effective, with reliable dosage and known composition. Such research should also clarify the constituents of cannabis that do not have any efficacy in treating various ailments.
To protect public health and safety, the country's current patchwork of state policies also needs regulatory guardrails at the federal level. We encourage the federal government to explore creative ways to ensure more effective, consistent regulations in those states where cannabis is legal. Such regulations should include, at a minimum:
- Sufficient funding for robust, evidence-based research on the public health effects of community- and state-level policy changes;
- Educational campaigns to publicize the recent scientific findings of rigorous research studies that point to cannabis-related harms;
- Compliance checks at points of sale to prevent illegal sales to young people;
- A ban on cannabis advertising;
- Restrictions on where cannabis can be sold and used;
- Restrictions on the development of new products, especially those that target children and adolescents;
- Restrictions on cannabis outlet density to prevent concentration in some areas;
- Drugged-driving statutes and tools to implement enforcement, as difficult as this may be given limitations in the available methods for measuring THC concentration in drivers;
- More routine cannabis misuse screening and counseling interventions in primary care settings;
- Implementation of specific evaluations and treatment for youth who misuse cannabis and those who become addicted to it;
- Clear requirements and guidelines regarding potency, dosage information and labels; and
- Dedicated revenue to support the above strategies.
In today's patchwork policy landscape, taxes on legal cannabis have actually driven demand for cheaper, untaxed black-market cannabis. Therefore, while higher alcohol taxes have been shown to reduce alcohol use and related public health consequences, relying too much on cannabis taxes may be counterproductive in the current landscape. For now, it is best to fund public health strategies from multiple revenue sources.
The dialogue around cannabis legalization has been muddied by the federal government's neglect of this issue. It is time for Congress and the Administration to course-correct in a responsible, necessary and politically viable way—by driving more regulation and research. Such actions would help protect against the public health consequences of current legalization efforts, better inform the dialogue moving forward, and, ideally, slow down legalization efforts nationally—aligning with the Hazelden Betty Ford Foundation's clear and singular aim of reducing the harmful impact of addiction.
