What We Ought to Talk about When We're Talking about Decriminalizing Cannabis

Agreen revolution is sweeping through the social and political landscape of the United States--a shifting tide in the way American law and society conceptual i7e Cannabis as a recreational and a medical substance. In light of the unprecedented legalization of Cannabis in several states, and decriminalization campaigns in other jurisdictions--such as the nation's capital, where we work--the topic of marijuana has grabbed the nation's attention and reinvigorated debate about its use. No dearth of opinion on marijuana use Legal and economic positions seem to be the pivot points of argument on recreational use of Cannabis--but not, surprisingly, health considerations. Even to the Cannabis nonuser, the pending changes in state laws are relevant; after all, every illicit substance can lead to a pathological process and thus a public economic burden. Articulations of marijuana's "safety" are nothing new: Consider President Barack Obama's recent comment that pot is no more dangerous than alcohol (the danger of alcohol is a different argument altogether). There is another layer of Cannabis use--the drug's psychiatric effects--that is seldom visible to the public eye but quite palpable in the field of mental health--a troubling disconnect because those psychiatric effects have been softened to inconsequence, or are not spoken of at all. When Cannabis is juxtaposed with other illicit substances, it seems almost innocuous; dependence and withdrawal have not been detailed empirically and are continuously debated. True, consumption of marijuana is not immediately life-threatening, compared with the risk of stroke and myocardial infarction with cocaine use or respiratory depression with narcotic agents. Despite this facade, however, the psychiatric morbidities of marijuana are real and incapacitating, ranging from extreme anxiety and dysregu-lated mood to chronic psychotic debilitation. [ILLUSTRATION OMITTED] [ILLUSTRATION OMITTED] Even after only a few years in psychiatric residency, it has become a common experience for us to observe acute and chronic psychosis in patients after they have used Cannabis. Many require hospitalization or a leave of absence from academics or employment; one of our patients re-matriculated to college after 7 years of intensive care. Every mental health professional can tell similar tales. Beyond anecdote Numerous publications have shown that Cannabis expedites onset of psychotic and prodromal symptoms of schizophrenia. The age range of onset of psychotic symp-toms--typically, late adolescence into early 20s--is critical, prognostically. (1), (2) This epidemiological fact is dangerously in tandem with Cannabis use patterns in America and its college culture. It is known that modifiable risk factors are decisive in the development of psychopathology Additionally, environmental exposures in the developing brain elicit a more ominous concern because the brain does not complete neural development until early or mid-20s. (3) Another concern is the effect of Cannabis on cognition, during periods of acute intoxication and after chronic use. Research on this topic is limited, but evidence suggests that heavy Cannabis use at an early age affects cognition, as measured by a diminished IQ. (4) Regrettably, unknowns in this area of study are far more abundant than what we know. This gray area might serve to placate legislators and frequent users and cool discussion. RX Cannabis? Another aspect of the controversy concerns medicinal use of marijuana. Perhaps legalization of medical marijuana has served simply as an antecedent to recreational legalization, as was the case for Colorado and Oregon. But under the heading of "medical marijuana" lies a poorly defined, amorphous designation--one that borders on arbitrariness regarding standards of use. Cancer treatment, pain, glaucoma, HIV, multiple sclerosis are examples of conditions in the bucket list for discretionary use of Cannabis, yet none has a formal FDA indication. …