Recreational cannabis legalization presents an opportunity to reduce the harms of the US medical cannabis industry
Authors: Keith Humphreys, Chelsea L. Shover
Journal: World Psychiatry (2020)

Hall and Lynskey's masterful essay1 provides a comprehensive assessment of the public health consequences of recreational cannabis legalization, which wise policy-makers will consider as they design regulatory systems. We urge US policy-makers to recognize that recreational cannabis legalization changes the political environment in a way that creates an important public health opportunity: cleaning up the under-regulated and frequently harmful US medical cannabis industry. Medical cannabis legalization initially emerged as a political cause in California in the mid-1990s. The explicit goal of many of its advocates was to pave the way for recreational legalization by exploiting both the public's compassion for seriously ill individuals and the public's trust in medicine. Of course, some individuals with serious diseases did access legalized medical cannabis and some of them may well have benefited from it. But the bulk of the "medical" customer base were young adult males with a long history of consuming cannabis along with a range of other drugs2. From a regulatory viewpoint, the system was med­ical in name only, functioning instead as an aggressively commercialized, quasi-recreational cannabis industry. California was not unique in this respect: in many states implementing or planning to implement recreational cannabis, "medi­cal" providers operate both lines of busi­ness. Most of the states with legalized recreational cannabis thus have a pre-existent medical industry that could be likened to a vestigial organ, except that it does significant harm, including but not limited to the following. First, unlike a truly medical industry, the "medical" cannabis industry develops, promotes and sells drug products without submitting them to the Food and Drug Administration (FDA) for approval. So, physicians are in the awkward position of discussing drug products with patients without any reassurance that they are safe or effective. Lack of FDA approval and stan­dardization for all but a few cannabis-based products also means that physician recommendation letters cannot specify dose, frequency, route of administration, strength, or any other attribute. This means that vulnerable patients are being sent out to try drugs under the false belief that the normal protections they expect from the health care system are in place. Second, the public may view cannabis dispensaries as analogous to pharmacies, but they are not subject to the regulation that make pharmacies beneficial. Any written advice from a physician in no way constrains what putatively medical cannabis products are dispensed to customers. Point-of-sale advice comes from "budtenders" who have no medical training. In this role, they sometimes give unsound advice, such as encouraging pregnant women to smoke cannabis3. Such potentially harmful advice is probably more likely to be followed than it would be in a strictly retail setting, because it comes wrapped in medical trappings. Third, unlike in real medicine, individuals harmed by the "medical" cannabis industry have no right to redress. If following the medical advice of a physician caused a birth defect in a woman's newborn, she would have grounds to sue or petition for removal of the physician's license. But bud­tenders have no medical license to remove and are not responsible as physicians are for the advice they give. Similarly, in an industry that sells non-FDA approved drug products, there is no way for a regulator to pull from all shelves a product that is discovered to cause detrimental side effects. Fourth, medical cannabis product label­ling, unlike FDA-approved drug label­ling, is loosely regulated and minimally enforced. Audit studies show that the dose and contents reported on medical cannabis industry product labels are frequently incorrect4, which can lead to undesired effects, including acute poisoning. Fifth, medical cannabis products with no evidence of effectiveness compete with life-saving treatments, potentially causing needless deaths. Multiple companies promote using cannabis to replace buprenorphine for opioid addiction treatment, de­spite zero evidence of the benefits of the former and multiple clinical trials for the benefits of the latter5. Other for-profit com­panies publically claim that medical cannabis legalization will reverse the opioid overdose epidemic as a promotional strat­egy, despite the evidence that no such pop­ulation-level benefit exists6. Just as tragic are reports from oncologists that some cancer patients drop out of care because they have heard that medical cannabis can cure their disease7. Finally, because heavy cannabis use now has the cultural imprimatur of medicine, physicians (particularly psychiatrists) often struggle to persuade patients whose illness is exacerbated by cannabis use to reduce or cease use. Prior to recreational cannabis legalization, policy-makers who attempted to address problems such as the above through tightened regulation faced the opposition of deep-pocketed for-profit "medical" can­nabis providers, as well as risked being painted as cutting off legions of desperately sick individuals from their medicine. However, with recreational legalization in place, neither of those concerns are politically relevant, allowing steps such as the following to be taken by regulators. First, medical cannabis programs should be folded into the recreational industry (as the State of Washington recently did). To facilitate this, states can automatically con­vert licensed medical dispensaries to licensed recreational dispensaries. This pre­vents recreational customers from using the medical cannabis system to evade taxes (medical cannabis is often taxed at a lower rate). Combining systems preserves access to medical cannabis for genuinely sick individuals without subjecting them to a potentially dangerous false promise of medical-level regulation and consumer protection8. It also protects public trust in genuine medicine by not labelling an under-regulated and frequently unsafe industry as medical. Second, state health commissions which – to their discredit – have endorsed indications for medical cannabis with no evidence (e.g., for opioid use disorder treatment5) should withdraw all such recommendations immediately. No further such recom­mendations should be made without the FDA-level evidence required for health com­missions to make recommendations for any other drug. Third, the FDA should become substan­tially more engaged with removing misleading advertisements, withdrawing licenses from fraudulent sellers, and recalling dangerous and mislabeled products just as they do for genuinely medical industries. Though the FDA has the authority to regulate claims by medical cannabis operators, to date that action has been limited to a few companies among hundreds making unfounded and harmful medical claims. In 2019, the FDA sent warning letters to 22 companies over unsupported medical claims about their products (e.g., treating breast cancer, depression, Alzheimer's disease, anxiety) and illegally selling cannabidiol products9. These letters, which provide instructions to voluntarily correct a violation, are a good start, but they must be built upon rapidly with industry-wide standards and consequences. Finally, coverage of cannabis in medical school curricula should be updated to reflect how legalization may impact a patient's health – from reducing some social consequences of use, to making decisions and having conversations analogous to those about alcohol and tobacco during pregnancy. None of these regulatory steps would threaten genuinely sick individuals' access to cannabis. Indeed, they would better protect such individuals by subjecting cannabis-based treatments to the same safety and effectiveness standards as all other medications. Some elements in the US medical cannabis industry will adopt the rules and standards of the rest of medicine. Such ethical actors should be welcomed, licensed, and allowed to provide services. But the rest of the industry should no longer be granted the status and trust of medicine without the ethical, scientific and professional standards from which that status and trust are derived.