Protecting the public is a challenge in the new era of legal cannabis
October 4, 2019

With cultivation and sale of recreational marijuana becoming legal in Illinois, many questions have arisen concerning health and use by adolescents.

By Eva Hofmann

Legalizing cannabis is more complicated than large tax revenues and being able to buy an ounce of marijuana. Now that Illinois is making recreational marijuana legal, many questions arise: What public health issues will develop now that we can study the drug’s impact? How will the state prevent access and availability to adolescents? How will law enforcement handle driving impairment?

Like tobacco, commercial marijuana likely will have public health consequences that will not become apparent for decades. Legalization enables research, but some public health data is available from states where recreational cannabis already is legal.

Hospitalization increases

In Colorado, hospitalization rates from possible marijuana exposures increased from 803 per 100,000 before commercialization (2001-2009) to 2,696 per 100,000 after commercialization (January 2014-September 2015), according to the state’s Department of Public Safety.

In Nevada, recreational cannabis became legal in January 2017. That year, the Nevada Department of Health registered a 67% increase from 2016 in youth 14 years and younger reporting marijuana poisoning symptoms. Meanwhile, adults between 25 and 64 saw a 125% increase in marijuana poisoning during that period. According to the Centers for Disease Control (CDC), symptoms of marijuana poisoning include extreme confusion, anxiety, paranoia, panic, fast heart rate, delusions or hallucinations, increased blood pressure, and severe nausea or vomiting.

The American Society of Addiction Medicine (ASAM) advocates limiting cannabis sales to state operated outlets to preserve public access while limiting broad commercialization. Mayor Lori Lightfoot’s proposed zoning rules would block cannabis dispensaries from doing business in most of downtown Chicago when sale of recreational marijuana becomes legal in January. The mayor’s plan could face opposition, however, from cannabis interests wanting dispensaries in the central business corridor.

The Illinois Department of Public Health (IDPH) is working on public education campaigns in coordination with local health departments and community organizations to inform people about health risks. “IDPH will convene the Adult Use Cannabis Health Advisory Committee, which will monitor changes in drug-use data in Illinois and the emerging science and medical information relevant to the health effects associated with cannabis use,” said Melaney Arnold, IDPH public information officer. “Additionally, IDPH will monitor for any cannabis-infused products that pose a health hazard.”

Vaping cannabis

At this writing, 36 states, including Illinois, have reported a combined 380 cases of vaping-related respiratory illness since April, according to a September 12 CDC update.

The disease likely stems from an unknown chemical exposure, as researchers have not linked a single product or substance conclusively to the disease. “The severity of illness that people are experiencing is alarming, and we must get the word out that using e-cigarettes and vaping can be dangerous,” said IDPH spokesperson Cristobal Martinez.

E-cigarettes also can be used to deliver tetrahydrocannabinol (THC), the principal psychoactive component of cannabis. “According to the patients themselves, some cases used products that contained THC,” said Martinez. “People who experience any type of chest pain or difficulty breathing after using e-cigarettes or vaping should seek immediate medical attention. Health care providers caring for patients with unexpected serious respiratory illness should ask about a history of vaping or e-cigarette use.”

IDPH has requested a CDC team to help investigate these cases.

Photo courtesy Rand Corp.
Demonstrators advocate for legalizing medical marijuana. Opinions are mixed on cannabis’s health benefits.

Adolescent use

The national Monitoring the Future study, an annual survey conducted by researchers at the University of Michigan in Ann Arbor, has shown consistently that about 80% of 12th graders, 70% of 10th graders, and 40% of eighth graders in the United States report that marijuana is either “fairly easy” or “very easy” to obtain. Some worry commercial legalization will increase availability to adolescents.

“In states where marijuana has been legalized, young people in grammar school and high school have a much greater access to the drug,” said Irene O’Neill, MD, a physician and Bridgeport resident. “Our kids have enough problems growing up in our society today, without giving them more chances to destroy their lives.”

ASAM cites a relationship between cannabis use during adolescence and impairments in subsequent academic achievement and education, employment and income, and social relationships.

The good news is that actual use among adolescents has not been increasing, according to the late economist Mark A.R. Kleiman, one of the country’s pre-eminent experts on drug and crime policy. In his spring 2019 National Affairs article, The Public-Health Case for Legalizing Marijuana, Kleiman wrote that the big rise in cannabis use has occurred among people older than 25. “Since early initiation of use is a significant risk factor for having drug problems later, preventing a rise in adolescent use remains an important policy objective,” he said.

White knight or new opioid?

The IDPH launched the Opioid Alternative Pilot Program on Jan. 31, 2019, providing access to medical cannabis for those who qualify for an opioid prescription by an Illinois licensed physician. As of July 31, 2019, 2,156 patients registered and 931 patients awaited certifications.

Critics argue not enough evidence exists to promote marijuana as an effective treatment for opioid addiction, as no randomized controlled trials have evaluated cannabis for this type of therapy, according to Scientific American. What’s more, substituting cannabis for tried and true treatments such as methadone and buprenorphine could be harmful and even life-threatening.

A recent review in Cannabis and Cannabinoid Research, however, presents emerging evidence that cannabis might help with opioid addiction symptoms such as withdrawal and cravings. This finding shows promise for developing cannabis based medicines to treat opioid addiction.

Crime

A September 2018 study by the Reason Foundation reported that legalization tends to diminish dramatically the illegal production, distribution, and sale of cannabis. This factor relieves the burden on courts, law enforcement, and prisons, allowing greater focus on violent crime.

In Washington State, which legalized marijuana for recreational use in 2013, the number of adults older than 21 convicted of misdemeanor possession fell from 297 in January 2012 to zero in January 2013 and has remained at zero ever since. The number of those younger than 21 convicted for possession fell by about 50% between 2012 and 2013.

In Colorado, the number of cases brought against people for cultivating, distributing, and possessing marijuana fell by 85% in the first full year of legal sales (2014) compared to the average in the three years preceding legalization (2010-2012).

Similar declines in charges and convictions were seen in jurisdictions that subsequently legalized recreational cannabis, including Oregon, Alaska, and Washington, DC.

“People have been getting marijuana on the black market for decades, and the government and law enforcement are powerless to stop it,” said Jonathan Loiterman, an attorney, Oregon-based cannabis entrepreneur, and former chair of the Illinois State Bar Association Health Law section.

“Cannabis possession has often been used as a pretext for arresting minorities, and I hope you’d see less of that,” said Loiterman. “I think having fewer cannabis folks in prison will lead to stronger families. The social and economic consequences of dropping a few IQ points,” a possible effect of cannabis use, “are preferable to spending years in prison.”

The late economist and drug-policy guru Kleiman, who died in July, pointed out in that, since the early 1990s, as marijuana usage in America has increased dramatically, violent crime has decreased significantly.

“Cannabis prohibition is no longer enforceable,” he wrote in his 2019 National Affairs article. “The black market is too large to successfully repress,” he said, adding that the market’s sheer size would make any effective toughening of laws very expensive and compete with the “resource demands of enforcement against the harder drugs (especially opioids) and against violent crime.”

Safe travels

A recent study conducted by the Insurance Institute for Highway Safety and Highway Loss Data Institute found that motor vehicle crashes are up 6% in four states (Colorado, Nevada, Oregon, and Washington) that have legalized recreational marijuana, compared with four neighboring states where cannabis remains restricted or illegal. The study’s sponsors cautioned that the results indicate only a correlation between marijuana legalization and a higher number of crashes and that officials need more research to determine whether marijuana use caused the increase.

Last year, Colorado’s Centennial Institute reported that 69% of users admitted to driving under the influence of marijuana at least once, and 27% said they did so daily.

With no meaningful test to detect drugs other than alcohol, the Colorado Department of Public Safety advocates training peace officers to identify drugged driving impairment. For example, cannabis impaired driving commonly exhibits “standard deviation of lane position,” or weaving within a lane.

To lead training efforts in Illinois, the Illinois State Police (ISP) are heading the DUI Cannabis Task Force. Created under the Cannabis Regulation and Tax Act, the group’s aims to improve enforcement and education regarding driving under the influence of cannabis. Composed of public safety partners, subject matter experts, and stakeholders, the task force will make recommendations to policy makers to protect public safety.

A large number of state police personnel are certified in Advanced Roadside Impaired Driving Enforcement (ARIDE) training, and the ISP is working to increase the number of ARIDE-certified and Drug Recognition Expert-certified employees currently on patrol.

In addition, the ISP is gathering and reviewing feedback from other states that have legalized recreational cannabis and are conducting oral fluid testing. Several states have implemented technology that has shown promise and could be effective in Illinois. The ISP is working to implement this technology as soon as possible.

Courtesy California Defense Lawyers
Those opposing legalized cannabis are concerned about marijuana smokers behind the wheel, making driving more dangerous.

Environmental impacts

Cannabis is becoming a robust industry and likely will leave a hefty environmental footprint. Cannabis production has led to a host of issues ranging from water theft and degradation of public lands to wildlife deaths and potential ozone effects.

Marijuana plants can consume about a billion liters of water per square mile over a growing season. Some estimates suggest they soak up six gallons of water per day per plant over the summer. For reference, it takes about four gallons of water to run an energy-efficient dishwasher once.

Researchers have estimated that indoor growing operations account for 1% of total U.S. electricity use annually, about the same amount of electricity consumed by every computer in every home and apartment in the country. The culprits are the high-intensity lightbulbs cannabis plants need to thrive when grown indoors. To power all those fixtures, as well as dehumidifiers and heating and ventilation systems, indoor growing operations use about eight times the amount of energy per square foot as a normal commercial building.

While growing cannabis outdoors naturally is more energy efficient than indoor cultivation, getting a patch of land ready for farming can mean cutting down forests, diverting rivers, and destabilizing ecosystems.

According to Colorado’s Centennial Institute report, the marijuana industry used enough electricity to power 32,355 homes in 2016. Also in 2016, Colorado’s marijuana industry was responsible for approximately 393,053 pounds of CO2 emissions, and marijuana packaging yielded more than 18.78 million pieces of plastic.

Making it work

Goals of a policy friendly to public health, according to Kleiman, should be eliminating or nearly eliminating the illicit market and replacing it with a legal market that delivers a product of certified purity and known chemical composition. It also should minimize the increase in heavy or hazardous use and use by minors. The U.S. could attain these goals with national legalization of marijuana, Kleiman wrote.

“We need national legalization now, as a measure to protect public health,” Kleiman explained. He warned of substantial public health costs with the continued process of what he called “state by state, quasi-legalization under inadequate controls,” which would increase the political power of cannabis vendors. “It’s time for Congress to bite the bullet and try to craft a cannabis policy that eliminates the illicit market without letting problem use explode,” he said.

For ASAM, log on to www.asam.org. Learn more from the CDC at www.cdc.gov. For the IDPH, go to www.dph.illinois.gov. Learn more from the IIHS at www.iihs.org. Log on to https://reason.org for the Reason Foundation.

Editor’s note: This is the third in a Gazette Chicago three-part series of articles on the advantages and disadvantages of legalized cannabis in Illinois.