Seeking Sensible Cannabis Policy Requires "Balance," Says Beth Israel's Hill

Marijuana is now legal in some form in 29 states, including 9 states that allow recreational use. But according to psychiatrist and addiction expert Kevin P. Hill, MD, MHS, it’s not your father’s weed out there. What’s more, policy makers who fail to take an evidence-based approach when crafting laws for medical marijuana or decriminalization can leave loopholes or cause problems for their health systems.

Whether or not they agree with making cannabis legal, Hill said, it’s important that health professionals follow what’s happening so they can create policies that make sense. Hill, who recently became the director of Addiction Psychiatry at Beth Israel Deaconess Medical Center, is an assistant professor of psychiatry at Harvard Medical School and spoke Saturday at the 30th US Psychiatric and Mental Health Congress in New Orleans, Louisiana.

“You’ve heard so much about cannabis in recent years, but, unfortunately, much of what you’ve heard is distorted or flat out untrue,” said Hill. The evidence about cannabis dispels the myths that marijuana is not harmful, that it is not addictive, and that people who use it don’t suffer withdrawal, he added.

At the same time, not everyone becomes addicted, just as not everyone becomes addicted to alcohol, although about 15% of adults do. The share is less for cannabis at 9% of adults; among teenagers, it’s 17%, Hill said. There’s definitely a connection to the dose, and while marijuana does not cause anxiety, it can make it worse. In addition, regular marijuana use can boost the chances a psychosis will develop if there’s a family history.

Today’s cannabis is far more potent than what was available a generation ago, Hill said; the average tetrahydrocannabinol (THC), or psychotropic content, is 12% compared with 3% to 4% in the 1960s through the 1980s. But the perceptions about cannabis are moving in the opposite direction—as rapidly as adults are taking up the drug, the idea that it poses no risk is climbing even faster, something that worries Hill, because it’s just not true.

About 22 million people used cannabis in the past year, a number that’s doubled in the past decade. Marijuana’s connection to other drugs is evident: in substance abuse programs, Hill said, 40% of patients are being treated for alcohol, 40% for opioids, and 20% for something else.

“When you sit down with these folks and you take a careful history,” he said, “I found that about 60% of these patients would talk about a time in their lives when they were using cannabis daily for years, usually in their late teens or early 20s.”

He and other researchers are focused on several areas:

• Identifying treatments that work
• Educating other clinicians about them
• Developing medications to aid withdrawal

When talking about cannabis, whether it’s with a patient or in the policy arena, it’s essential to be balanced, Hill said. Too often the debate is dominated by voices who have “political skin in the game.” Marijuana is not completely harmless, but people who use it are not “doomed” either, he said. A young person who uses the drug, “feels it’s helping them in some way,” and it’s important for health professionals to acknowledge that.

Part of the challenge is that cannabis is viewed in extremes—to some it’s all bad, and to others it’s not harmful at all. Hill tries to compare cannabis to alcohol, which people know can be dangerous.

“There are different degrees of danger,” Hill said. “Cannabis, on the whole, is probably not as dangerous as alcohol or opioids. But just because cannabis may not be as dangerous as alcohol or opioids doesn’t mean it’s not dangerous.”

It’s important, for example, to understand the real effects of legalization. In Colorado, the first state to allow recreational use, marijuana use among youth has been relatively unchanged, a statistic consistent with national trends. By contrast, there’s been a 57% increase in visits to the emergency department and decreased work productivity. And, Hill said there’s been a rise in synthetic marijuana use among professional athletes, because users are trying to avoid getting caught—so they use a more dangerous product.

Crafting Better Marijuana Policy

Using Massachusetts as an example, Hill pointed out areas where policies fell short on science:

• Quantities. While Massachusetts waits for recreational use to take effect, it still has a law for medical marijuana, allowing 10 ounces for a 60-day supply. But Hill’s studies show that amount is 4 times what most people would need.
• Indications. Massachusetts’ law allowed doctors to add additional medical reasons for marijuana certificates beyond those spelled out in the law. A review found 90% of the certificates were for undisclosed reasons.
• Financial Incentives. Hardships granted to low-income patients allowing them to grow their own supply are an invitation for problems.
• Fraud. A low-incomes patient on MassHealth can get a permission to grow marijuana to treat migraines, but doesn’t need the entire supply and can make under-the-table income selling the rest. Hill calculated the street value of the excess at $19,200 a year.