Marijuana, aka Cannabis, Ganja, Ma, or Weed

States and cities that have opted to legally regulate adult social use and/or medical use of marijuana:

Marijuana Legalization
(24): Alaska, Arizona, California, Colorado, Connecticut, Delaware, Illinois, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Montana, Nevada, New Jersey, New Mexico, New York, Ohio, Oregon, Rhode Island, Vermont, Virginia, Washington.
*Note: Marijuana is also legal in Washington, DC, Guam, and the Marshall Islands, however these are not states.

Marijuana Decriminalization
(14): Connecticut, Delaware, Maryland, Hawaii, Minnesota, Mississippi, Missouri, Nebraska, New Hampshire, North Carolina, North Dakota, Ohio, Rhode Island

Medical Marijuana Legalization
(38): Alabama, Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Hawaii, Illinois, Kentucky*, Louisiana*, Maine, Maryland, Massachusetts, Michigan, Minnesota*, Mississippi, Missouri, Montana, Nevada, New Hampshire, New Jersey, New Mexico, New York*, North Dakota, Ohio*, Oklahoma, Oregon, Pennsylvania*, Rhode Island, South Dakota, Utah, Vermont, Virginia, Washington, West Virginia* (also, Washington, DC)

*no smoking allowed

Medical Marijuana Legalization - CBD Oil Only
(14): Alabama, Georgia, Indiana, Iowa, Kansas, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee, Texas, Virginia, Wisconsin, Wyoming

Hemp Legalization*
Hemp is now federally legal. Only two states in the country - Idaho and Mississippi - do not allow cultivation of hemp for commercial, research or pilot programs.

Cities That Have Legalized Marijuana
(5): Breckenridge, CO; Denver, CO; Portland, ME; South Portland, ME; Washington, DC

Cities That Have Decriminalized or Depenalized Marijuana
(57): Albuquerque, NM; Allentown, PA; Ann Arbor, MI; Athens, OH; Atlanta, GA; Austin, TX; Bellaire, OH; Berkeley, CA; Berkley, MI; Chicago, IL; Cincinnati, OH; Cocoa Beach, FL; Columbia, MO; Dayton, OH; Daytona Beach, FL; Detroit, MI; East Lansing, MI; Eau Claire, WI; Ferndale, MI; Flint, MI; Fremont, OH; Grand Rapids, MI; Houston, TX; Huntington Woods, MI; Jackson, MI; Jersey City, NJ; Kansas City, MO; Keego Harbor, MI; Lancaster, PA; Logan, OH; Madison, WI; Miami, FL; Milwaukee, WI; Monona, WI; Mount Pleasant, MI; New Orleans, LA; Newark, OH; Norfolk, VA; Norwood, OH; New York, NY; Oregon, OH; Orlando, FL; Philadelphia, PA; Pittsburgh, PA; Pleasant Ridge, MI; Portage, MI; Port Huron, MI; Roseville, OH; Saginaw, MI; State College, PA; Santa Fe, NM; St. Louis, MO; Tampa, FL; Toledo, OH; Wichita, KS; Windham, OH; York, PA

Cities That Have Made Marijuana Arrests the Lowest Priority
(12): Eureka Springs, AR; Fayetteville, AR; Hailey; ID; Kalamazoo, MI; Oakland, CA; San Francisco, CA; Santa Barbara, CA; Santa Cruz, CA; Santa Monica, CA; Seattle, WA; Tacoma, WA; Tampa, FL; West Hollywood, CA

States That Have Decriminalized Entheogenic Plants (including psilocybin)
(3): Colorado, New Jersey*, Oregon

*for possessing an ounce or less of mushrooms from a third-degree crime to a disorderly-persons offense

Cities That Have Decriminalized Entheogenic Plants (including psilocybin)
(8): Ann Arbor, MI; Cambridge, MA; Denver, CO; Oakland, CA; Santa Cruz, CA; Somerville, MA; Vancouver, BC; Washington, DC

Nations That Have Decriminalized Possession of Marijuana
Brazil

Nations That Have Legalized Marijuana
(4): Canada, Uruguay, Malta, Germany

Nations That Have Decriminalized Possession of Controlled Substances
(2): Portugal, Czechia

"The gateway effect, if it exists, has at least two potential and quite different sources (MacCoun, 1998). One interpretation is that it is an effect of the drug use itself (e.g., trying marijuana increases the taste for other drugs or leads users to believe that other substances are more pleasurable or less risky than previously supposed). A second interpretation stresses peer groups and social interactions. Acquiring and using marijuana regularly may lead to differentially associating with peers who have attitudes and behaviors that are prodrug generally, not only with respect to marijuana. One version of this is the possibility that those peers will include people who sell other drugs, reducing the difficulty of locating potential supplies. If the latter is the explanation, then legalization might reduce the likelihood of moving on to harder drugs compared to the current situation."

"Marijuana is the illicit drug most frequently found in the blood of drivers who have been involved in vehicle crashes, including fatal ones.¹⁰ Two large European studies found that drivers with THC in their blood were roughly twice as likely to be culpable for a fatal crash than drivers who had not used drugs or alcohol.^11,12 However, the role played by marijuana in crashes is often unclear because it can be detected in body fluids for days or even weeks after intoxication and because people frequently combine it with alcohol. Those involved in vehicle crashes with THC in their blood, particularly higher levels, are three to seven times more likely to be responsible for the incident than drivers who had not used drugs or alcohol. The risk associated with marijuana in combination with alcohol appears to be greater than that for either drug by itself.⁸

"Several meta-analyses of multiple studies found that the risk of being involved in a crash significantly increased after marijuana use¹³—in a few cases, the risk doubled or more than doubled.^14–16 However, a large case-control study conducted by the National Highway Traffic Safety Administration found no significant increased crash risk attributable to cannabis after controlling for drivers’ age, gender, race, and presence of alcohol.¹⁷"

"This study of crash risk found a statistically significant increase in unadjusted crash risk for drivers who tested positive for use of illegal drugs (1.21 times), and THC specifically (1.25 times). However, analyses incorporating adjustments for age, gender, ethnicity, and alcohol concentration level did not show a significant increase in levels of crash risk associated with the presence of drugs. This finding indicates that these other variables (age, gender, ethnicity and alcohol use) were highly correlated with drug use and account for much of the increased risk associated with the use of illegal drugs and with THC.

"This study found a statistically significant association between driver alcohol level and crash risk both before and after adjustment for demographic factors. These findings were generally consistent with similar analyses conducted in prior crash risk studies. Findings from this study indicate that crash risk grows exponentially with increasing BrAC. The study shows that at low levels of alcohol (e.g., 0.03 BrAC) the risk of crashing is increased by 20 percent, at moderate alcohol levels (0.05 BrAC) risk increases to double that of sober drivers, and at a higher level (0.10 BrAC) the risk increases to five and a half times. At a BrAC of 0.15, the risk is 12 times, and by BrACs of 0.20+ the risk is over 23 times higher."

Although the intent of a 'War on Drugs' may have been to target drug smugglers and 'King Pins,' of the 1,558,862 arrests for drug law violations in 2019, 86.7% (1,351,533) were for mere possession of a controlled substance. Only 13.3% (207,329) were for the sale or manufacturing of a drug. Further, 35.0% of drug arrests in 2019 were for marijuana offenses -- a total of 545,602. Of those, an estimated 500,395 arrests (32.1% of all drug arrests) were for marijuana possession alone. By contrast in 2000, a total of 734,497 Americans were arrested for marijuana offenses, of which 646,042 (40.9%) were for possession alone.

Table: Total Annual Arrests in the US by Year and Type of Offense, 1996-2019

"Preliminary look at racial disparities in select counties of Washington

"The Crime, Cannabis & Police Research Group at Washington State University used preliminary data from a Department of Justice funded study to compare white vs. Black arrests.¹¹ Latinos were not included in the analysis, because of difficulties measuring ethnicity in arrest data. Their main preliminary findings are that after legalization in Washington, African Americans/Blacks continue to be disproportionally arrested for the possession and selling of marijuana when compared to whites. Though the disparity in marijuana possession between African American/Blacks and whites was reduced slightly after legalization, the disparity for selling marijuana has more than doubled since legalization.

"Local trends

"While statewide studies have the ability to control for individual law enforcement agencies or police departments, monitoring trends in marijuana-related crimes within a local police department can provide details of violations that statewide data systems do not. For example, violations for public consumption of marijuana cannot be directly queried from state-derived data; however, local law enforcement agencies and municipal courts maintain details on the nature of the crime that would indicate whether someone was ticketed for public consumption vs. possession or a different drug-related charge. One example of the potential of local data to explore issues of criminal justice can be made using data from the Seattle Police Department (SPD). A 2015 report for the Seattle Community Police Commission showed a disproportionate number of citations for marijuana public consumption issued to African Americans/Blacks in Seattle.¹² Using local police department data is key to understanding differences in the implementation and enforcement of polices pertaining to the legalization of marijuana."

"Compelling evidence in other states suggest racial disparities persist or have become worse after legalization and the opening of a licensed marijuana market, even while total marijuana-related criminal justice incidents have decreased.

"In Colorado, marijuana court filings decreased by 85% from 2010 to 2014 after legalizing marijuana in 2012. During the same time frame the rate of arrests for marijuana possession among African Americans/Blacks remained 2.4 times higher compared to the arrest rate for whites. The disparities for African American/Blacks were even larger for arrests for marijuana cultivation (2.5 times the arrest rate for whites) and distribution of marijuana (5.4 times the arrest rate for whites).¹³

"Results from Oregon are consistent with findings in Colorado. The Oregon Public Health Division examined changes in the age-adjusted rates of marijuana arrests by racial groups.¹⁴ The age adjusted rate of marijuana arrests for African Americans/Blacks was 2 to 3 times the rate of whites during 2010–2014. Oregon legalized marijuana in 2014 and in the following year the disparity between African Americans/Blacks and whites persisted. Specifically, the rate of arrest was 77% higher among African Americans/Blacks in 2015 when compared to whites.

"Preliminary results suggest that legalization of marijuana for adults has greatly reduced the number of people arrested and convicted for marijuana-related crimes, yet racial disparities persist in Washington and in other states. Other factors may contribute to sustaining the racial disparities, such as over-policing in low-income neighborhoods, racial profiling, and other racially biased police practices.¹⁵ These inequitable practices may minimize the potential positive impacts of I-502 and marijuana legalization on all communities."

"In these initial investigations, we found no evidence that I-502 enactment, on the whole, affected cannabis abuse treatment admissions. Further, within Washington State, we found no evidence that the amount of legal cannabis sales affected cannabis abuse treatment admissions.

"The bulk of outcome analyses in this report used the within-state approach to focus on identifying effects of the amount of legal cannabis sales. We found no evidence that the amount of legal cannabis sales affected youth substance use or attitudes about cannabis or drug-related criminal convictions.

"We did find evidence that higher levels of retail cannabis sales affected adult cannabis use in certain subgroups of the population. BRFSS respondents 21 and older who lived in counties with higher levels of retail cannabis sales were more likely to report using cannabis in the past 30 days and heavy use of cannabis in the past 30 days.

"We also found two effects that are difficult to interpret. Among the portion of the population aged 18 to 21, BRFSS respondents living in counties with higher sales were less likely to report using cannabis in the past 30 days, in some analyses. It may be that legal cannabis sales have made cannabis more difficult to access by persons below the legal age, for instance, by reducing black market supply through competition.

"We also found that in the portion of the BRFSS sample who smoked cigarettes, respondents living in counties with higher levels of legal cannabis sales were less likely to report past-month cannabis use. It is particularly difficult to explain why increased sales would lead to lower cannabis use among cigarette smokers."

"The public health burden of cannabis use is probably modest compared with that of alcohol, tobacco, and other illicit drugs. A recent Australian study⁹⁶ estimated that cannabis use caused 0·2% of total disease burden in Australia—a country with one of the highest reported rates of cannabis use. Cannabis accounted for 10% of the burden attributable to all illicit drugs (including heroin, cocaine, and amphetamines). It also accounted for around 10% of the proportion of disease burden attributed to alcohol (2·3%), but only 2·5% of that attributable to tobacco (7·8%)."

"As noted in the illicit drug use section, an estimated 26.0 million Americans aged 12 or older in 2017 were current users of marijuana (Figure 11). This number of past month marijuana users corresponds to 9.6 percent of the population aged 12 or older (Figure 13). The percentage of people aged 12 or older who were current marijuana users in 2017 was higher than the percentages from 2002 to 2016. This increase in marijuana use among people aged 12 or older reflects increases in marijuana use among both young adults aged 18 to 25 and adults aged 26 or older."

"Moving marijuana from Schedule I to Schedule III, without other legal changes, would not bring the state-legal medical or recreational marijuana industry into compliance with federal controlled substances law. With respect to medical marijuana, a key difference between placement in Schedule I and Schedule III is that substances in Schedule III have an accepted medical use and may lawfully be dispensed by prescription, while Substances in Schedule I cannot. However, prescription drugs must be approved by the Food and Drug Administration (FDA). Although FDA has approved some drugs derived from or related to cannabis, marijuana itself is not an FDA-approved drug. Moreover, if one or more marijuana products obtained FDA approval, manufacturers and distributors would need to register with DEA and comply with regulatory requirements that apply to Schedule III substances in order to handle those products. Users of medical marijuana would need to obtain valid prescriptions for the substance from medical providers, subject to federal legal requirements that differ from existing state regulatory requirements for medical marijuana. 

"Rescheduling marijuana would not affect the medical marijuana appropriations rider. Thus, so long as the current rider remains in effect, participants in the state-legal medical marijuana industry who comply with state law would be shielded from federal prosecution. If the rider were to lapse or be repealed, these persons would again be subject to prosecution at the discretion of DOJ. 

"With respect to the manufacture, distribution, and possession of recreational marijuana, if marijuana were moved to Schedule III, such activities would remain illegal under federal law and potentially subject to federal prosecution regardless of their status under state law. 

"Some criminal penalties for CSA violations depend on the schedule in which a substance is classified. If marijuana were moved to Schedule III, applicable penalties for some offenses would be reduced. However, CSA penalties that apply to activities involving marijuana specifically, such as the quantity-based mandatory minimum sentences discussed above, would not change as a result of rescheduling. DEA is not required to set annual production quotas for Schedule III controlled substances. 

"The prohibition on business deductions in Section 280E of the Internal Revenue Code applies to any trade or business that “consists of trafficking in controlled substances (within the meaning of schedule I and II of the Controlled Substances Act) which is prohibited by Federal law or the law of any State in which such trade or business is conducted.” Because the provision applies only to activities involving substances in Schedule I or II, moving marijuana from Schedule I to Schedule III would allow marijuana businesses to deduct business expenses on federal tax filings. Other collateral legal consequences would continue to attach to unauthorized marijuana-related activities."

"There is a large body of literature describing the diagnosis, pathophysiology, and treatment of CHS [Cannabinoid Hyperemesis Syndrome]. However, most of the evidence is considered low quality because it is in the form of case reports and case series. When these reports are combined, a larger and more robust set of diagnostic characteristics, evaluation of pathophysiology, and determination of effective treatments can be generated. Based on our knowledge of 211 unique CHS patients, the following characteristics are associated with the syndrome: (1) severe cyclic vomiting that is usually accompanied with abdominal pain, (2) symptom onset preceded by at least weekly cannabis use, (3) temporary relief of symptoms with compulsive hot baths/showers, (4) resolution of symptoms with cessation of cannabis use, (5) onset of cannabis use in the teenage years, and (6) symptom onset in the third decade of life. While not all these criteria must be met to make the diagnosis, of 133 cases for which raw data were available, 85 met at least four criteria (75.2%) and 104 (92%) met at least three criteria. Secondary to incomplete and inconsistent reporting of the proposed diagnostic characteristics in the case report literature, the aforementioned data may be an underestimate of the actual occurrence of these symptoms in CHS patients.

"CHS shares many clinical similarities with cyclic vomiting syndrome (CVS), a functional gastrointestinal disorder. A diagnostic dilemma arises when CVS patients concurrently use cannabis, as it can be difficult to discern if the true underlying disorder is CHS or CVS that is being symptomatically managed with cannabis."

"Assessing both CUD [Cannabis Use Disorder] and cannabis use status and their associations with suicidal ideation, plan, and attempt, we found that suicidality trends varied by sex, depression, and both CUD and cannabis use status. Our results suggest that CUD, daily cannabis use, and even nondaily cannabis use were associated with a higher prevalence of suicidal ideation, plan, and attempt more significantly in women than in men. Specifically, the adjusted prevalence of past-year suicidal ideation was higher among women with CUD regardless of MDE [Major Depressive Episode] status and among women without MDE but with daily or nondaily cannabis use compared with their male counterparts. We found upward trends in suicidal ideation among women (rather than men) with MDE and CUD or daily and nondaily cannabis use. Compared with their male counterparts, the adjusted prevalence of suicide plan and attempt were higher among women with MDE and CUD or daily cannabis use and among women without MDE but with CUD or daily and nondaily cannabis use. Similarly, from 2008 to 2019, we found an upward trend in suicide plan among women (rather than men) with MDE and daily cannabis use and an upward trend in suicide attempt among women (rather than men) with MDE and CUD. By contrast, among individuals with neither MDE nor cannabis use, the adjusted prevalence of suicidal ideation, plan, and attempt were similar between men and women, and the adjusted prevalence of suicidal ideation was lower among women with MDE without CUD or cannabis use compared with their male counterparts."

"Our results, along with those from a recent study,⁴⁸ suggest that adults with MDE [Major Depressive Episode] may be particularly vulnerable to cannabis use as beliefs in its therapeutic potential become more widespread and products become more accessible. Moreover, even after adjusting for depression, CUD, cannabis use status, and other potential confounding factors, we found that from 2008 to 2019 among adults aged 18 to 34 years, the adjusted prevalence of suicidal ideation increased 1.4-fold; suicide plan, 1.6-fold; and suicide attempt, 1.4-fold. Furthermore, even for those with neither MDE nor cannabis use, we found upward trends in suicidal ideation and plan among both men and women and in suicide attempt among men. Our results indicate that depression and cannabis use are associated with suicidality but do not appear to be the only causes for the upward trends in suicide among young adults."

"Among the more common adverse effects is the cannabinoid hyperemesis syndrome (CHS), first reported in 2004 [6]. CHS is a syndrome of cyclic vomiting in the setting of chronic, high-dose cannabis use that is frequently associated with compulsive hot baths/showers, used in attempt to control symptoms.

"Patients with CHS present frequently to various health care settings with intractable nausea and vomiting. These patients often undergo expensive medical testing, may require hospital admission for symptom management, and often experience significant delays in diagnosis [7]. CHS is under-recognized due to a combination of factors including the paradoxical use for treatment of nausea and vomiting, the stigma associated with cannabis use, and the illegal status of cannabis in many regions leading to under-reporting of use. The frequency of emergency department visits and high rates of hospital admission for CHS exemplify the difficulty in symptom management. The lack of knowledge and treatment recommendations regarding CHS compounds this issue. Subsequently, CHS is a costly illness to manage. In an observational study of CHS patients followed over 2 years, the median charge for ED visits and hospital admissions was $95,023 (IQR = $62,420–$268,110) [7]."

"Cannabinoid agonist treatment is unlikely to be an approach relevant to all cannabis users seeking treatment, as evidenced by the large numbers of individuals who did not complete the study screening process, and the modest 12-week treatment retention rates. Whereas nicotine-agonist and opioid-agonist treatments are considered front-line therapies, our findings suggest a more cautious approach for cannabinoid agonist treatment at this time. The control group demonstrated some benefits from treatment, confirming previous research that psychosocial interventions (CBT and case management) without medication can be effective for some patients. Although further research is required to replicate our findings and to refine how cannabinoid agonist treatment is delivered, our study suggests cannabinoid agonist treatment to be a promising approach for treating patients with cannabis dependence, particularly for those who cannot sustain reductions in illicit cannabis use with counseling-only interventions, in a stepped care approach."

"Among 207,781 national YRBS [Youth Risk Behavioral Survey] respondents (mean [SD] age, 16.04 [1.23] years; 50.90% male), 13.35% were Black or African American, 17.09% were Hispanic, and 60.13% were non-Hispanic White. Among 1 549 075 state YRBS respondents (mean [SD] age, 16.01 [1.23] years; 50.20% male), 16.53% were Black or African American, 17.78% were Hispanic, and 58.09% were non-Hispanic White.

"Based on the national YRBS, RML [Recreational Marijuana Laws] adoption was not associated with current marijuana use (odds ratio, 0.97; 95% CI, 0.85-1.10) or frequent marijuana use (odds ratio, 0.98; 95% CI, 0.83-1.16) (Table). Estimates based on the state YRBS and estimates of the association between the first dispensary opening and marijuana use were qualitatively similar (Table). Interaction-weighted estimates were similar to their logistic regression counterparts (Table).

"Based on the national YRBS and using lead and lag indicators in place of the RML indicators, there was no association between RMLs and marijuana use during the prelegalization period (Figure), suggesting the parallel-trends assumption held. After legalization, there was no evidence of an increase in marijuana use.

"The primary care sample of patients who used cannabis (n = 1463 patient respondents weighted to primary care population who used cannabis) was predominantly middle-aged (weighted mean [SD] age, 47.4 [16.8] years); female (748 [weighted proportion, 61.9%] vs 715 male [weighted proportion, 38.1%]), and commercially insured (935 [61.1%]) (Table 1). By self-report, 12 patients (weighted proportion, 0.2%) were American Indian or Alaska Native, 56 (weighted proportion, 2.4%) were Asian, 120 (weighted proportion, 4.9%) were Black, 10 (weighted proportion, 0.2%) were Native Hawaiian or Other Pacific Islander, 1029 (weighted proportion, 78.6%) were White, 95 (weighted proportion, 5.3%) reported multiple races, and 141 (weighted proportion, 8.3%) were of another or unknown race; 151 (weighted proportion, 3.5%) reported Hispanic ethnicity and 1239 (weighted proportion, 9.3%) non-Hispanic ethnicity.

"Among patients who used cannabis, the prevalence of patient reasons for cannabis use included 42.4% (95% CI, 31.2%-54.3%) reporting medical use only, 25.1% (95% CI, 17.8%-34.2%) reporting nonmedical use only, and 32.5% (95% CI, 25.3%-40.8%) reporting both reasons for use. Patients reporting medical use only tended to be older (mean [SD] age, 53.6 [14.6] years), were mostly female (142 [76.5%]), retired (67 [33.6%]), and mostly had Medicare (84 [33.7%]). The prevalence of patients who reported any medical cannabis use (ie, medical use only or both reasons for use) was 74.7% (95% CI, 65.7%-82.1%), while the prevalence of any reported nonmedical cannabis use (ie, nonmedical use only or both reasons for use) was 57.5% (95% CI, 45.6%-68.6%).

"The prevalence of any CUD was 21.3% (95% CI, 15.4%-28.6%) and did not differ depending on patient reasons for use (Table 2). The prevalence of moderate to severe CUD was 6.5% (95% CI, 5.0%-8.6%) and differed across groups: 1.3% (95% CI, 0.0%-2.8%) for medical use only; 7.2% (95% CI, 3.9%-10.4%) for nonmedical use only; and 7.5% (95% CI, 5.7%-9.4%) both reasons for use (P = .01). For all groups, the most prevalent CUD symptoms were tolerance, uncontrolled escalation of use and craving. Compared with patients with medical use only, patients with nonmedical use only or both reasons for use were more likely to report withdrawal, use in hazardous situations, continue use despite consequences, time spent on use, interference with obligations, and activities given up."

"In this cross-sectional study of primary care patients in a state with legal recreational cannabis use, CUD was common among patients who used cannabis, with 21% having CUD and 6% having moderate to severe CUD. Patients who used cannabis for medical reasons only were mostly older and likely to use applied products. Patients who reported any nonmedical use were at greatest risk of moderate to severe CUD (7.2% to 7.5%). While the prevalence of moderate to severe CUD was lowest among patients who reported medical use only (1.3%), 13.4% met criteria for mild, moderate, or severe CUD.

"The prevalence of CUD among patients who use cannabis found here is comparable to recent studies of patients who use cannabis in states with legal medical and recreational use.^12,27 Moreover, comparable to the study by Browne et al,¹² the prevalence of moderate to severe CUD in this study was significantly lower for patients reporting medical use only.

"The finding that CUD was common among primary care patients in a state with legal recreational use, where more than 20% of the population reports cannabis use,¹³ underscores the importance of assessing patient cannabis use in clinical settings. Population-based screening with a validated single-item screen can identify patients who use cannabis and may be at risk of CUD.²² Knowledge of patient use provides an opportunity to discuss risks and limited benefits of cannabis use and potentially safer treatment alternatives for those using cannabis for medical reasons.²⁸ For patients with higher risk cannabis use (eg, daily), psychometrically valid brief assessments for DSM-5 symptoms of CUD can identify and gauge CUD severity.²⁹ Such knowledge can support engagement around symptoms, shared decision-making, and offering of treatment if desired, especially for patients with moderate to severe CUD who may benefit most from treatment. Yet research is needed on how best to assess and document patient reasons for cannabis use and to engage individuals with CUD in treatment."

"Positivity rates for marijuana in the general US workforce based on more than 6 million urine tests continued an upward climb, increasing 8.3% (3.6% in 2020 versus 3.9% in 2021), the highest positivity rate ever reported in the DTI. Over 5 years, positivity for marijuana in the general US workforce increased 50% (2.6% in 2017 versus 3.9% in 2021).

"Overall positivity in the federally mandated, safety-sensitive workforce based on nearly 2.7 million urine drug tests stayed even year over year (2.2% in 2020 and 2021) and was 4.8% higher than 2017 (2.1% in 2017 versus 2.2% in 2021). In the general US workforce, positivity increased 1.8% (5.5% in 2020 versus 5.6% in 2021) and was 12% higher than in 2017 (5.0% in 2017 versus 5.6% in 2021) and up each of the last 5 years."

"Globally, some recent changes in cannabis policies have experimented with different ways of regulating the sale and use of cannabis. Evolving cannabis policies raise numerous potential concerns about negative side-effects. These include increased commercialisation of legal cannabis; increased influence of the cannabis industry (similar to ‘big pharma’); possible increased use or more harmful patterns of use; complexities for regulatory approaches for the cannabis markets between countries that do not adopt the same policy; and tensions with UN international system for drug control and multi-national cooperation. There are also concerns related to the increased availability of products containing high levels of THC that may increase the risk of acute intoxication. There are also broader policy issues that may grow in importance should commercialised cannabis markets become established, such as what are the appropriate regulatory frameworks for addressing cannabis-impaired driving or restricting commercial availability to minors. Additionally, it was observed by some participants that an increased supply of the commercially available CBD products in some Europe countries raised concerns about possible negative effects on the consumers (EMCDDA, 2020). Possible emerging needs identified in the policy workshop included how to monitor quality assurance of cannabis-based products being produced legally in the European Union and how to identify and report on any potential risks associated with new policies and products.

"The debates about shifts in cannabis policies may also require us to make a clearer distinction between legalisation of cannabis for medical purposes and for recreational use. This is likely to require reliable information and timely monitoring of the health effects of cannabis use (medical and recreational) from the countries or regions where cannabis regulations have been changed."

"Tetrahydrocannabinol is a very safe drug. Laboratory animals (rats, mice, dogs, monkeys) can tolerate doses of up to 1,000 mg/kg (milligrams per kilogram). This would be equivalent to a 70 kg person swallowing 70 grams of the drug—about 5,000 times more than is required to produce a high. Despite the widespread illicit use of cannabis there are very few if any instances of people dying from an overdose. In Britain, official government statistics listed five deaths from cannabis in the period 1993-1995 but on closer examination these proved to have been deaths due to inhalation of vomit that could not be directly attributed to cannabis (House of Lords Report, 1998). By comparison with other commonly used recreational drugs these statistics are impressive."

In 2020, law enforcement agencies in the US made an estimated 7,632,473 arrests for all offenses, of which 1,155,610 were drug arrests.

Although the intent of a 'War on Drugs' may have been to target drug smugglers and 'King Pins,' of the 1,155,610 arrests for drug law violations in 2020, 86.7% (1,001,914) were for mere possession of a controlled substance. Only 13.3% (153,696) were for the sale or manufacturing of a drug. Further, 30.3% of drug arrests in 2020 were for marijuana offenses -- a total of 350,150. Of those, an estimated 317,793 arrests (27.5% of all drug arrests) were for marijuana possession alone. By contrast in 2000, a total of 734,497 Americans were arrested for marijuana offenses, of which 646,042 (40.9%) were for possession alone.

Table: Total Annual Arrests in the US by Year and Type of Offense, 1996-2020

"A total of 11 articles met the inclusion criteria for the metaanalysis (Figure 1): 7 for depression^{10,16,34,38,44-46}; 3 for anxiety,^16,38,44 3 for suicidal ideation,^41,47,57 and 3 for suicide attempts.^10,54,57 To estimate the extent to which cannabis use
during adolescence was associated with increased odds of developing depression in young adulthood, we pooled results from 7 studies.^{10,16,34,38,44-46} The pooled OR [Odds Ratio] for depression during young adulthood among cannabis users compared with nonusers was 1.37 (95% CI, 1.16-1.62; I2 = 0%; Figure 2). Cannabis use during adolescence was associated with increased odds of developing anxiety in young adulthood when pooling 3 studies^16,38,44 (OR, 1.18; 95% CI, 0.84-1.67; I2 = 42.0%; Figure 2). Suicidal ideation is a symptom of depression, while suicide represents one of the most severe sequelae of mental illness. Results from 3 studies that had measured the association of cannabis use during adolescence with subsequent suicidal ideation within adolescence^41,57 and in young adulthood⁴⁷ were pooled with a resultant OR of 1.50 (95% CI, 1.11-2.03; I2: 0%; Figure 3). For the number of suicide attempt outcomes within adolescence^54,57 or during young adulthood,¹⁰ the results were pooled with a resultant OR of 3.46 (95% CI, 1.53-7.84; I2 = 61.3%; Figure 3)."

"Based on NSDUH estimates, rates of cannabis abuse and dependence remained relatively stable from 2002 to 2019, with the highest rates of abuse and dependence among young adults (aged 18–25) (Figure 3-27). For 2020, except for youth (aged 12–17), for whom the data suggest a slight decline in rates of cannabis abuse and dependence, the data are generally consistent with the longer-term trends for the other age groups. In 2021, the NSDUH introduced the diagnostic category of cannabis use disorder to better accord with DSM-V criteria for classifying substance use disorders. The frequency of the disorder is higher than previous estimates of cannabis use and dependence (online Appendix E). Given that cannabis use disorder has only been measured for two years using the new DSM-V criteria, it is challenging to determine how this has changed over the full 20-year time period. It follows a similar pattern as that of cannabis use and dependence, with the highest rates of the disorder among young adults (aged 18–25), males, non-Hispanic American Indians/Alaska Natives, people living in poverty, and people with some college education. In 2022, cannabis use disorder was less common in pregnant persons than in the general population but was increasing in both populations (Figure 3-28, online Appendix E)."

"Two things are needed to move beyond policy-biased appraisals of the evidence on cannabis and psychosis.

"First, we need to use explicit criteria to assess the evidence for contributory causal relationships and apply them in an even-handed and consistent way. We should avoid the example of the tobacco industry in setting such a high standard of evidence for a causal inference that no evidence can satisfy it (30). We should also avoid accepting weaker evidence in support of causal explanations, for example accepting observational evidence that persons with psychosis who use cannabis have better social adjustment than those who do not as evidence of the cognitive benefits of cannabis use [e.g., (31)].

"Second, we need more nuanced analyses of the relationships between evidence and policy than those often implicitly assumed [e.g., (32, 33)]. For example, accepting that regular cannabis use may play a contributory causal role in psychosis does not entail support for cannabis prohibition. There is experimental evidence, for example, that heavy alcohol use is a contributory cause of the psychosis delirium tremens (34). There is also observational evidence that sustained heavy alcohol use can produce psychoses that persist beyond alcohol withdrawal (35, 36). This evidence does not justify alcohol prohibition because policy makers have to consider the social and economic consequences of the policy, as revealed during national alcohol prohibition in the USA from 1920 to 1933 (37).

"Ideally democratic pluralist societies should decide on an appropriate cannabis policy by weighing the costs and benefits of cannabis use and cannabis control policies (38, 39). Policy makers need to weigh the harms that may arise from cannabis prohibition, such as, criminal records for cannabis users, production of a large illicit market, police corruption and discriminatory enforcement of the criminal law (38). The costs of cannabis prohibition and the potential benefits of regulating and taxing cannabis have led a majority of US citizens to support the legalization of adult cannabis use (40).

"If a government decides to legalize cannabis, however, the evidence on cannabis and psychosis is relevant in making decisions as to how cannabis should be regulated. Experience with alcohol (41), for example, suggests that we should discourage the use of high potency cannabis by basing taxes on the THC content of cannabis products or setting a cap on their THC content (42). The availability of cannabis retail outlets could also be limited and restrictions on the legal age of purchase enforced to reduce adolescent access (41, 43)."

"It has long been postulated that ongoing neurodevelopmental processes during adolescence may impart heightened vulnerability to cannabis exposure and increase the likelihood of long-term associations with cognition and behavior. Many animal studies have reported enduring effects of adolescent exposure to tetrahydrocannabinol (THC), the primary psychoactive substance in cannabis. Specifically, adolescent exposure to THC has been shown to decrease social behavior in adult rats^46,47 as well as alter motivational processes.⁴⁸ Rodent and primate studies have also demonstrated that adolescent exposure to THC results in working memory deficits in adulthood.^49-52 Several rodent studies have also found that adolescent THC exposure results in lasting alterations in glutamatergic and γ-aminobutyric acidergic functioning.^53,54 In humans, adolescent-onset cannabis users exhibit greater use-associated problems in adulthood relative to late-onset cannabis users.^55,56 Findings from the present study may help to elucidate heightened vulnerability to the effects of cannabis use among adolescents. We found that the statistical map of age-related cortical change was significantly correlated with statistical maps of the time × cannabis interaction on cortical thickness as well as the main association of cannabis use with cortical thickness at 5-year followup. Taken together, these results suggest that, on average, cannabis use tended to qualify cortical thickness change within areas already undergoing the greatest degree of age-related change (from baseline to 5-year follow-up). This finding provides support for the association of cannabis use with ongoing maturational processes in the brain and a possible explanation for the heightened vulnerability to the cognitive outcomes of cannabis use among adolescents. More important, our imaging findings are consistent with recent animal research on adolescent THC exposure and prefrontal cortical maturation. Miller et al¹⁵ examined the association of adolescent THC exposure with prefrontal cortical maturation using a rat model. Researchers injected male rats with THC during the period of their adolescence, spanning 4 to 7 weeks of age. They found that adolescent THC exposure resulted in distinct proximate and long-term alterations of dendritic architecture. Specifically, THC exposure disrupted normal neurodevelopmental processes by inducing premature pruning of dendritic spines and atrophy of dendritic arbors in early adulthood. We hypothesize that the MR imaging (MRI)–assessed cannabis-related thinning revealed in our human study is underpinned by the same neurobiological phenomenon."

"Several limitations of the present study should also be addressed. The PET data used in this study were collected on a separate sample of young adults, not the 799 youths who underwent longitudinal neuroimaging. Given the invasive nature of PET imaging and its associated risks, it is not ethical to collect PET data on minors. We cannot state definitively that, in our sample of 799 participants, the areas exhibiting cannabis-related thinning in longitudinal MRI analysis were, in fact, high in CB1 receptor availability. Our present findings are also limited by the self-report nature of our cannabis use measure. As with any self-report measure, it is possible that participants were not honest regarding their cannabis use or that their estimates of past cannabis use were inaccurate. We also did not have information pertaining to the types of cannabis products used (eg, cannabis oil concentrates and other formulations). As in other longitudinal MRI studies, there is uncertainty with regard to the exact neurobiological mechanisms associated with MRI-assessed cortical thinning. Research suggests that MRI-assessed, age-related cortical thinning may reflect increased myelination of lower cortical layers as opposed to synaptic pruning and/or neuronal cell loss.⁵⁷ Natu et al⁵⁷ found good correspondence between MRI-assessed cortical thickness and histologic measurements of cortical thickness among young adults. This latter finding is critical given that we detected cannabis-related differences in cortical thickness at age 19 years and not at 14 years, suggesting that our MRI-assessed cortical thickness findings are associated with reduced cortical gray matter rather than increased myelination. The present study focused on cortical thickness development and did not examine potential cannabis-related outcomes within subcortical structures. Future studies may benefit from conducting similar analyses on subcortical regions, particularly those rich in CB1 receptors. Most important, given the observational nature of the present study, it is possible that the apparent association between cortical thinning and cannabis use reflects preexisting trajectories of brain maturation that were not caused by cannabis use. We cannot rule out the possibility that preexisting cognitive and/or behavioral differences are associated with neurodevelopmental trajectories from adolescence to early adulthood and that cannabis use is not causally related to cerebral cortical thickness development."

"CUD [Cannabis Use Disorder] is defined in the DSM-5 as a problematic pattern of cannabis use leading to clinically significant impairment or distress occurring within a 12-month period as manifested by cannabinoid tolerance and withdrawal; increasing amounts of cannabis use over time; inability to control consumption; craving; and recurrent cannabis use having negative implications on social, professional and educational life [3]. Withdrawal symptoms usually appear approximately 24 hours after abstinence initiation, peak within two to six days and remit within two weeks [4]. Symptoms may include irritability, anger or aggression; nervousness or anxiety; sleep difficulty (insomnia, disturbing dreams); decreased appetite or weight loss; restlessness; depressed mood; or physical discomforts (abdominal pain, shakiness/tremors, fever, chills or headache) [5, 6, 7•]. Withdrawal is diagnosed if at least three of these symptoms develop. A week after cessation of use, additional symptoms may appear such as fatigue, yawning, difficulty in concentration, and rebound periods of increased appetite or hypersomnia [3]."

"Some 4.3 percent of Americans have been dependent on marijuana, as defined in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR; American Psychiatric Association, 2000), at some time in their lives. Marijuana produces dependence less readily than most other illicit drugs. Some 9 percent of those who try marijuana develop dependence compared to, for example, 15 percent of people who try cocaine and 24 percent of those who try heroin. However, because so many people use marijuana, cannabis dependence is twice as prevalent as dependence on any other illicit psychoactive substance (cocaine, 1.8 percent; heroin, 0.7 percent; Anthony and Helzer, 1991; Anthony, Warner, and Kessler, 1994)."

"Alcohol and marijuana are the two most commonly used substances by teenagers to get high, and a question that is often asked is to what extent does change in one lead to a change in the other. If the substances co-vary negatively (an increase in one is accompanied by a decrease in the other) they are said to be substitutes; if they co-vary positively, they are said to be complements.

"Interestingly, the answer may differ by historical era. Before 2007 patterns of use for the two substances suggested they acted as complements. When marijuana use increased in the late 1970s, so too did alcohol use. Between 1979 and 1992 marijuana use declined and a parallel decline took place in annual, monthly, and daily alcohol use, as well as in binge drinking among 12th graders. As marijuana use increased again in the 1990s, alcohol use again increased with it, although not as sharply. In sum, before 2007 there was little evidence from MTF to support what we have termed “the displacement hypothesis,” which asserts that an increase in marijuana use will lead to a decline in alcohol use, or vice versa.8

"However, since 2007 a new trend has emerged that would be consistent with the “displacement” hypothesis. From 2007 through 2019 alcohol use declined markedly, reaching historic lows in the life of the study. Meanwhile, for most of this time period marijuana use has stayed steady or increased for all age groups. For the first time trends in alcohol and marijuana use are substantially diverging, suggesting that the historical relationship between these two drugs may have changed."

"In summary, this study showed little, if any, effect of marijuana use on non-AIDS mortality in men and on total mortality in women. The increased risk of AIDS mortality in male marijuana users probably did not reflect a causal relationship, but most likely represented uncontrolled confounding by male homosexual behavior. The risk of mortality associated with marijuana use was lower than that associated with tobacco cigarette smoking."

According to the Substance Abuse and Mental Health Service's Treatment Episode Data Set, in 2020 in the US there were 139,481 admissions to treatment with marijuana reported as the primary substance out of the total 1,416,357 admissions to treatment in the US for those aged 12 and older for all substances that year.

By comparison, in 2010 in the US there were 358,034 admissions to treatment with marijuana reported as the primary substance out of the total 1,928,013 admissions to treatment in the US for those aged 12 and older for all substances that year.

"Marijuana essentially became illegal in 1937 pursuant to the Marijuana Tax Act.³⁹ The use of marijuana required the payment of a tax for usage; failure to pay the tax resulted in a large fine or stiff prison time for tax evasion.⁴⁰ Drug prohibition was elevated to another level by targeting 'marijuana,' a plant that had never demonstrated any harm to anyone.⁴¹

"Anslinger’s [Harry J. Anslinger, the first Commissioner of the Federal Bureau of Narcotics] efforts to eradicate marijuana continued when Anslinger sought similar anti-narcotic laws against marijuana at the state level.⁴² Guided by Anslinger’s policy direction, states began passing their own laws or adopting more strident versions of federal laws.⁴³ By 1952, nearly all states had anti-narcotic laws in place.⁴⁴"

"Our results indicate a moderate relation between early teen marijuana use and young adult abuse of other illicit substances; however, this association fades from statistical significance with adjustments for stress and life-course variables. Likewise, our findings show that any causal influence of teen marijuana use on other illicit substance use is contingent upon employment status and is short-term, subsiding entirely by the age of 21. In light of these findings, we urge U.S. drug control policymakers to consider stress and life-course approaches in their pursuit of solutions to the 'drug problem.'"

"It was not until 1951, when Congress again took up the issue, that a reputable researcher was called to testify. Dr. Harris Isbell, director of research at the Public Health Service Hospital in Lexington, Ky., disputed the insanity, crime and addiction theories, telling Congress that 'smoking marijuana has no unpleasant aftereffects, no dependence is developed on the drug, and the practice can easily be stopped at any time.'

"Despite Dr. Isbell’s testimony, Congress ratcheted up penalties on users. The states followed the federal example; Louisiana, for instance, created sentences ranging from five to 99 years, without parole or probation, for sale, possession or administration of narcotic drugs. The rationale was not that marijuana itself was addictive — that argument was suddenly relinquished — but that it was a 'steppingstone' to heroin addiction. This passed largely without comment at the time.

"The country accepted a senselessly punitive approach to sentencing as long as minorities and the poor paid the price. But, by the late 1960s, weed had been taken up by white college students from the middle and upper classes. Seeing white lives ruined by marijuana laws altered public attitudes about harsh sentencing, and, in 1972, the National Commission on Marihuana and Drug Abuse released a report challenging the approach."

"The law enforcement view of marijuana was indelibly shaped by the fact that it was initially connected to brown people from Mexico and subsequently with black and poor communities in this country. Police in Texas border towns demonized the plant in racial terms as the drug of 'immoral' populations who were promptly labeled 'fiends.'

"As the legal scholars Richard Bonnie and Charles Whitebread explain in their authoritative history, 'The Marihuana Conviction,' the drug’s popularity among minorities and other groups practically ensured that it would be classified as a 'narcotic,' attributed with addictive qualities it did not have, and set alongside far more dangerous drugs like heroin and morphine.

"By the early 1930s, more than 30 states had prohibited the use of marijuana for nonmedical purposes. The federal push was yet to come.

"The stage for federal suppression of marijuana was set in New Orleans, where a prominent doctor blamed 'muggle-heads' — as pot smokers were called — for an outbreak of robberies. The city was awash in sensationalistic newspaper articles that depicted pushers hovering by the schoolhouse door turning children into 'addicts.' These stories popularized spurious notions about the drug that lingered for decades. Law enforcement officials, too, trafficked in the 'assassin' theory, under in which killers were said to have smoked cannabis to ready themselves for murder and mayhem."

"Hemp fields, in fact, could be a deterrent to marijuana growers. A strong case can be made that the best way to reduce the THC level of marijuana grown outdoors would be to grow industrial hemp near it. An experiment in Russia found that hemp pollen could travel 12 kilometers. This would mean that a hemp field would create a zone with a 12-kilometer radius within which no marijuana grower would want to establish a crop.

"The reciprocal also applies. Growers of hemp seed would not want Cannabis of an 'off type' (i.e., not the intended genetic type) mixing its pollen with their flowers. The isolation of genotypes is a common procedure used by the seed industry to preserve the genetic integrity of varieties. Valued strains are created by plant breeding, at substantial expense. Marijuana pollen would destroy this value."

"Clemson University Professor John Huffman is credited with first synthesizing some of the cannabinoids, such as JWH-018, now used in 'fake pot' substances such as K2. The effects of JWH-018 can be 10 times stronger than those of THC. Dr. Huffman is quoted as saying, 'These things are dangerous—anybody who uses them is playing Russian roulette. They have profound psychological effects. We never intended them for human consumption.'²³ While synthetic cannabinoids may be used with the intention of getting a marijuana-like high, their actual effects are not yet known. Some reported effects of synthetic cannabinoids, such as relaxation and reduced blood pressure, are consistent with effects of marijuana. Other reported effects, such as nausea, increased agitation, elevated blood pressure, and racing heart rates, are not.²⁴ The Centers for Disease Control and Prevention (CDC) has noted epidemiological links between synthetic cannabinoid use and acute kidney injury.²⁵ In at least one case, synthetic cannabinoid use has been blamed for a fatality when an Iowa teen committed suicide reportedly following a K2-induced panic attack.²⁶ In the summer of 2014, the New York City (NYC) Department of Health issued a warning to the public regarding the dangers of synthetic cannabinoid use after 15 people experienced “severe adverse reactions after suspected ingestion of synthetic cannabinoids” over a period of three days.²⁷ In 2015, following a “tenfold increase in medical emergencies from synthetic marijuana” in New York State (NYS) in the summer of 2015 compared to the summer of 2014, Governor Cuomo announced passage of emergency NYS Health Department regulations to combat the sale of these drugs—these emergency regulations included the addition of two classes of chemical compounds to the banned substances list.²⁸"

"Breeders and producers of sweet corn go to great lengths to isolate their crops from the pollen of field corn. The same applies to hemp and marijuana. People who grow strains of Cannabis for smoking try to avoid pollination of the flowers. The superior quality material is obtained from seedless plants, the so-called “sinsemilla.”

"Hemp fields, in fact, could be a deterrent to marijuana growers. A strong case can be made that the best way to reduce the THC level of marijuana grown outdoors would be to grow industrial hemp near it. An experiment in Russia found that hemp pollen could travel 12 kilometers. This would mean that a hemp field would create a zone with a 12-kilometer radius within which no marijuana grower would want to establish a crop.

"The reciprocal also applies. Growers of hemp seed would not want Cannabis of an “off type” (i.e., not the intended genetic type) mixing its pollen with their flowers. The isolation of genotypes is a common procedure used by the seed industry to preserve the genetic integrity of varieties. Valued strains are created by plant breeding, at substantial expense. Marijuana pollen would destroy this value."

"The 2021 review of cannabis policy found that states also have limits on ingredients that can be contained in cannabis products. Many states have banned or are testing for vitamin E acetate because of the 2019 outbreak of e-cigarette or vaping product–associated lung injury (EVALI) (Schauer, 2021). Colorado has banned medium-chain triglycerides oil and polyethylene glycol oil entirely. Similarly, Oregon has prohibited squalane, propylene glycol, and all triglycerides, substances that lack established safety data for aerosols. Nevada limits the added terpene content in vape oils to 10 percent, which aligns with the upper range of naturally occurring terpenes in the cannabis plant. Vermont takes the strictest approach, permitting only natural cannabis-derived flavors in its upcoming adult-use market. States that regulate cannabis and cannabis-derived products do not have uniform testing procedures or regulatory approaches to ensure product integrity, safety, and labeling (Schauer, 2021)."

"Worldwide, there were an estimated 192 million past-year users of cannabis in 2018, corresponding to 3.9 per cent of the global population aged 15–64. The past-year use of cannabis is substantially higher than the global average in North America (14.6 per cent), Australia and New Zealand (10.6 per cent) and West and Central Africa (9.3 per cent).

"In 2009, cannabis use was reported to be stabilizing or declining in countries with established cannabis markets, such as in Western and Central Europe, North America and Australia and New Zealand, but that trend was offset by increasing use in many countries in Africa and Asia.²¹ A decade later, cannabis use in Western and Central Europe has remained stable overall and has increased considerably in North America, Africa and Asia.²²"

"The THC levels in industrial hemp are so low that no one can get high from smoking it. Moreover, industrial hemp, while low in THC, is high in another kind of cannabinoid, CBD, which counteracts THC’s psychoactivity.

"As William M. Pierce Jr., Ph.D., Associate Professor of Pharmacology and Toxicology at the University of Louisville School of Medicine notes, “Industrial hemp does in fact contain a psychoactive substance, tetrahydrocannabinol (THC) and thus the question appears at first reading to be a reasonable one. Upon closer consideration, however, using the most fundamental principles of pharmacology, it can be shown that it is absurd, in practical terms, to consider industrial hemp useful as a drug.”²⁷

"According to Professor Pierce, to obtain a psychoactive effect with even 1 percent THC hemp (industrial hemp and feral hemp, the wild hemp the DEA aggressively harvests and burns²⁸, contain less than 0.5% percent THC29 ), would require the user to smoke 10-12 cigarettes containing hemp in a “very short period of time. . . . This large volume (and) high temperature inhalation of vapor, gas, and smoke would be difficult for a person to withstand, much less enjoy.” Professor Pierce goes on to note that anyone who ate hemp hoping to get “high” would be consuming the fiber equivalent of several doses of a high-fiber laxative. In other words, the very unpleasant side effects would dissuade anyone from trying to use industrial hemp as a drug.

"Dr. Pierce points out that beer sold as “nonalcohol” contains measurable alcohol. So does mouthwash. Even nutmeg contains a psychoactive substance. But the authorities are not aggressively concerned about the abuse of these products because the side effects are so severe as to discourage such abuse.

"Critics have alleged that the marijuana of the sixties had THC levels comparable to those of industrial hemp. But when Lynn Zimmer, Ph.D., and John Morgan, M.D., examined this assertion they found it lacked substance."

"Among 50-year-old high school graduates in 2012, we estimate that about three quarters (74%) have tried marijuana, and that about two thirds (64%) have tried an illicit drug other than marijuana. (These estimates are adjusted to correct for panel attrition, as described in chapter 4 of Volume II.)
"Their current behavior is far less extreme than those statistics might suggest, but it is not by any means negligible. One in eight (12%) indicates using marijuana in the last 12 months, and one in ten (10%) indicates using any other illicit drug in the same period. Their past-month prevalence rates are lower—7.3% and 6.2%, respectively, for marijuana and any other illicit drug. About 1 in 43 (2.3%) is a current daily marijuana user, though substantially more indicate that they have used marijuana daily at some time in the past."

"Daily marijuana use held steady at 6.8% in 2015 among young adults, but that is triple the rate in 1992 (2.3%), the low point since estimates for this age group first became available in 1986. The 2014 and 2015 rates are the highest levels of daily use ever observed in this young adult population since tracking of their use began 29 years ago."

Click here for complete datatable of Thirty-Day Prevalence of Daily Marijuana, Alcohol, and Tobacco Use Among 19-30 Year Olds in the US

"People who develop problems with marijuana may indeed be different from those who do not, but this phenomenon has been observed with other substances of abuse. A comparison with alcohol use and dependence provides a case in point. The great majority of Americans have tried alcohol and continue to drink alcoholic beverages regularly. However, only an estimated 10 to 15 percent of alcohol drinkers develop problems, and only some of these problem drinkers seek treatment. This is also true of those who have tried cocaine or heroin (Anthony, Warner, and Kessler, 1994).

"That said, the experience of dependence on marijuana tends to be less severe than that observed with cocaine, opiates, and alcohol (Budney, 2006; Budney et al., 1998). On average, individuals with marijuana dependence meet fewer DSM dependence criteria; the withdrawal experience is not as dramatic; and the severity of the associated consequences is not as extreme. However, the apparently less severe nature of marijuana dependence does not necessarily mean that marijuana addiction is easier to overcome. Many factors besides a drug’s physiological effects -- including availability, frequency and pattern of use, perception of harm, and cost -- can contribute to cessation outcomes and the strength of addiction. The low cost of marijuana, the typical pattern of multiple daily use by those addicted, the less dramatic consequences, and ambivalence may increase the difficulty of quitting. Although determining the relative difficulty of quitting various substances of abuse is complex, the treatment literature reviewed here suggests that the experience of marijuana abusers rivals that of those addicted to other substances."

"In 2009-2010, past month marijuana use was reported by 6.8 percent of the U.S. population aged 12 years or older, an increase from 6.4 percent in 2008-2009 (Table C.3). Nine States that were in the top fifth for past month illicit drug use among persons aged 12 or older also were ranked in the top fifth for past month marijuana use: Alaska, Colorado, District of Columbia, Maine, Massachusetts, New Hampshire, Oregon, Rhode Island, and Vermont (Figures 2.1 and 2.9).

"Seven States were ranked in the top fifth for past month marijuana use in age groups 12 to 17, 18 to 25, 26 or older, and 12 or older: Colorado, Maine, Massachusetts, New Hampshire, Oregon, Rhode Island, and Vermont (Figures 2.9 to 2.12). The rate of past month marijuana use in the 12 or older population ranged from 3.1 percent in Utah to 11.8 percent in Alaska (Table B.3). Utah had the lowest rate in all age groups. Between 2008-2009 and 2009-2010, past month marijuana use among persons 12 or older increased in 10 States: Colorado, District of Columbia, Idaho, Illinois, Massachusetts, Michigan, New Mexico, Oklahoma, Texas, and Washington (Table C.3). During the same time period, past month marijuana use increased in one State among 12 to 17 year olds (District of Columbia), eight States among 18 to 25 year olds (Florida, Illinois, Iowa, New Mexico, North Carolina, Oklahoma, Pennsylvania, and Washington), and four States among persons aged 26 or older (District of Columbia, Idaho, Michigan, and Texas). Decreases only occurred in two States: Tennessee, among persons aged 12 or older, and Utah, among youths aged 12 to 17. All four census regions had higher rates of past month marijuana use among persons aged 12 or older in 2009-2010 compared with 2008-2009."

"The costs of this national obsession, in both money and time, are astonishing. Each year, enforcing laws on possession costs more than $3.6 billion, according to the American Civil Liberties Union. It can take a police officer many hours to arrest and book a suspect. That person will often spend a night or more in the local jail, and be in court multiple times to resolve the case. The public-safety payoff for all this effort is meager at best: According to a 2012 Human Rights Watch report that tracked 30,000 New Yorkers with no prior convictions when they were arrested for marijuana possession, 90 percent had no subsequent felony convictions. Only 3.1 percent committed a violent offense."

"For Michele Leonhart, the administrator of the Drug Enforcement Administration, there is no difference between the health effects of marijuana and those of any other illegal drug. 'All illegal drugs are bad for people,' she told Congress in 2012, refusing to say whether crack, methamphetamines or prescription painkillers are more addictive or physically harmful than marijuana.

"Her testimony neatly illustrates the vast gap between antiquated federal law enforcement policies and the clear consensus of science that marijuana is far less harmful to human health than most other banned drugs and is less dangerous than the highly addictive but perfectly legal substances known as alcohol and tobacco. Marijuana cannot lead to a fatal overdose. There is little evidence that it causes cancer. Its addictive properties, while present, are low, and the myth that it leads users to more powerful drugs has long since been disproved.

"That doesn’t mean marijuana is harmless; in fact, the potency of current strains may shock those who haven’t tried it for decades, particularly when ingested as food. It can produce a serious dependency, and constant use would interfere with job and school performance. It needs to be kept out of the hands of minors. But, on balance, its downsides are not reasons to impose criminal penalties on its possession, particularly not in a society that permits nicotine use and celebrates drinking."

In 2015:
an estimated 117,865,000 people aged 12 or older in the US had tried marijuana at least once in their lifetimes.
an estimated 36,043,000 people aged 12 or older in the US had tried marijuana at least once in the past year.
an estimated 22,226,000 people aged 12 or older in the US had tried marijuana at least once in the past month.

Table: Marijuana Use in Lifetime, Past Year, and Past Month among Persons in the US Aged 12 or Older, by Demographic Characteristics: Number in Thousands

"• Table 8-8 lists the proportions of 12th graders in 2015 who favor various legal consequences for marijuana use: making it entirely legal (42%), a minor violation like a parking ticket but not a crime (27%), or a crime (15%). The remaining 15% said they 'don’t know.' It is noteworthy just how variable attitudes about this contentious issue are. 

"• Asked whether they thought it should be legal to sell marijuana if it were legal to use it, about three in five (64%) said “yes.” However, about 86% of those answering 'yes' (55% of all respondents) would permit sale only to adults. A small minority (9%) favored the sale to anyone, regardless of age, while 23% said that sale should not be legal even if use were made legal, and 13% said they 'don’t know.' Thus, while the majority subscribe to the idea of legal sale, if use is allowed, the great majority agree with the notion that sale to underage people should not be legal. 

"• Most 12th graders felt that they would be little affected personally by the legalization of either the sale or the use of marijuana. Over half (53%) of the respondents said that they would not use the drug even if it were legal to buy and use, while others indicated that they would use it about as often as they do now (14%) or less often (1%). Only 9% said they would use it more often than they do at present, while 13% thought they would try it. Another 11% said they did not know how their behavior would be affected if marijuana were legalized. Still, this amounts to 22% of all 12th graders, or about one in five, who thought that they would try marijuana, or that their use would increase, if marijuana were legalized."

"Although the mean annual opioid analgesic overdose mortality rate was lower in states with medical cannabis laws compared with states without such laws, the findings of our secondary analyses deserve further consideration. State-specific characteristics, such as trends in attitudes or health behaviors, may explain variation in medical cannabis laws and opioid analgesic overdose mortality, and we found some evidence that differences in these characteristics contributed to our findings. When including state-specific linear time trends in regression models, which are used to adjust for hard-to-measure confounders that change over time, the association between laws and opioid analgesic overdose mortality weakened. In contrast, we did not find evidence that states that passed medical cannabis laws had different overdose mortality rates in years prior to law passage, providing a temporal link between laws and changes in opioid analgesic overdose mortality. In addition, we did not find evidence that laws were associated with differences in mortality rates for unrelated conditions (heart disease and septicemia), suggesting that differences in opioid analgesic overdose mortality cannot be explained by broader changes in health. In summary, although we found a lower mean annual rate of opioid analgesic mortality in states with medical cannabis laws, a direct causal link cannot be established."

"Although individual lifetime risk of chronic psychotic disorders such as schizophrenia, even in people who use cannabis regularly, is likely to be low (less than 3%), cannabis use can be expected to have a substantial effect on psychotic disorders at a population level because exposure to this drug is so common."

"• Marijuana was the illicit drug with the largest number of persons with past year dependence or abuse in 2013, followed by pain relievers, then by cocaine. Of the 6.9 million persons aged 12 or older who were classified with illicit drug dependence or abuse in 2013, 4.2 million persons had marijuana dependence or abuse (representing 1.6 percent of the total population aged 12 or older, and 61.4 percent of all those classified with illicit drug dependence or abuse), 1.9 million persons had pain reliever dependence or abuse, and 855,000 persons had cocaine dependence or abuse (Figure 7.2)."
"• The number of persons who had marijuana dependence or abuse in 2013 (4.2 million) was similar to the number in 2012 (4.3 million) and in each year from 2002 through 2011 (ranging from 3.9 million to 4.5 million) (Figure 7.3). The rate of marijuana dependence or abuse in 2013 (1.6 percent) was lower than the rates in 2002 (1.8 percent) and 2004 (1.9 percent). Otherwise, the rate in 2013 was similar to the rates in prior years (ranging from 1.6 to 1.8 percent).
"• The number of persons who had pain reliever dependence or abuse in 2013 (1.9 million) was similar to the number in 2012 (2.1 million) and in each year from 2006 through 2011 (ranging from 1.6 million to 1.9 million) (Figure 7.3). However, the number in 2013 was higher than the numbers in 2002 to 2005 (ranging from 1.4 million to 1.5 million)."

"First, the use of cannabis and rates of psychotic symptoms were related to each other, independently of observed/non-observed fixed covariates and observed time dynamic factors (Table 2). Secondly, the results of structural equation modeling suggest that the direction of causation is that the use of cannabis leads to increases in levels of psychotic symptoms rather than psychotic symptoms increasing the use of cannabis. Indeed, there is a suggestion from the model results that increases in psychotic symptoms may inhibit the use of cannabis."

"In terms of the model set out in the Introduction, the expected rise in diagnoses of schizophrenia and psychoses did not occur over a 10 year period. This study does not therefore support the specific causal link between cannabis use and the incidence of psychotic disorders based on the 3 assumptions described in the Introduction. This concurs with other reports indicating that increases in population cannabis use have not been followed by increases in psychotic incidence (Macleod et al., 2006; Arsenault et al., 2004; Rey and Tennant, 2002). However, it is not in line with findings of a rise in first admission rates for psychotic disorders among young people in Zurich following increases in cannabis availability and consumption (Ajdacic-Gross et al., 2007). One factor involved in this discrepancy may be the potency of the cannabis consumed, which varies considerably within Europe (EMCDDA, 2008). In addition, a Netherlands study found that high-potency cannabis obtained from ‘coffee shops’ led to higher levels of tetrahydrocannabinol (THC) in the blood, with young males aged 18–45 at particular risk for excessive consumption (Mensinga et al., 2006)."

"A review of the literature suggests that the majority of cannabis users, who use the drug occasionally rather than on a daily basis, will not suffer any lasting physical or mental harm. Conversely, as with other 'recreational' drugs, there will be some who suffer adverse consequences from their use of cannabis. Some individuals who have psychotic thought tendencies might risk precipitating psychotic illness. Those who consume large doses of the drug on a regular basis are likely to have lower educational achievement and lower income, and may suffer physical damage to the airways. They also run a significant risk of becoming dependent upon continuing use of the drug. There is little evidence, however, that these adverse effects persist after drug use stops or that any direct cause and effect relationships are involved."

"The issues of measurement and conceptualization described above in relation to efforts to screen for problematic or harmful cannabis use highlight the shortcomings of ‘one-size-fits-all’ approaches to screening. Our examination of the existing literature and of cannabis users from a general population study and from a mixed-methods study of adult, stable, socially integrated users suggests that many cannabis users who may otherwise meet the criteria for being at moderate risk for problematic use are nonetheless able to successfully integrate cannabis use into everyday life with few associated problems. Indeed, our findings advocate that regular use of small amounts of cannabis does not appear to increase an individual’s likelihood of experiencing problems, and it does not threaten one’s ability to function well and perform expected roles. Even so, the tools used to assess potentially harmful cannabis use invariably serve to classify almost all ‘regular’ users as problematic users."

"• In 2011, an estimated 16.7 percent of past year marijuana users aged 12 or older used marijuana on 300 or more days within the past 12 months. This translates into nearly 5.0 million persons using marijuana on a daily or almost daily basis over a 12-month period.

"• In 2011, an estimated 39.1 percent (7.1 million) of current marijuana users aged 12 or older used marijuana on 20 or more days in the past month. This was similar to the 2010 estimate of 39.8 percent or 6.9 million users."

"One area representative, from New York City, reported the continuing predominance in indicators and serious consequences of marijuana (as well as heroin and cocaine) and changes in marijuana trends as a key finding in that area for this reporting period. Marijuana indicator levels continued to be reported as high relative to other drugs, however, across all CEWG areas, based on treatment admissions and reports identified as marijuana/cannabis among drug items seized and analyzed. New marijuana/cannabis laws legalizing both medical and recreational marijuana use were expected by area representatives to be influencing indicators in several areas currently and in the future. Representatives from Texas and Chicago reported a shift in trafficking and marketing away from Mexican marijuana (due to a drought and poor quality Mexican marijuana) to local markets and local 'grow' operations."

"Police departments deploy most patrol and narcotics police to certain neighborhoods, usually designated "high crime." These are disproportionately low-income, and disproportionately African-American and Latino neighborhoods. It is in these neighborhoods where the police make most patrols, and where they stop and search the most vehicles and individuals, looking for "contraband" of any type in order to make an arrest. The item that young people in any neighborhood are most likely to possess, which can get them arrested, is a small amount of marijuana. In short, the arrests are racially-biased mainly because the police are systematically "fishing" for arrests in only some neighborhoods, and methodically searching only some "fish."⁵ This produces what has been termed "racism without racists."⁶"

"The lead researcher in the Christchurch study, Professor David Fergusson, said the role of cannabis in psychosis was not sufficient on its own to guide legislation. 'The result suggests heavy use can result in adverse side-effects,' he said. 'That can occur with ( heavy use of ) any substance. It can occur with milk.' Fergusson's research, released this month, concluded that heavy cannabis smokers were 1.5 times more likely to suffer symptoms of psychosis that non-users. The study was the latest in several reports based on a cohort of about 1000 people born in Christchurch over a four-month period in 1977. An effective way to deal with cannabis use would be to incrementally reduce penalties and carefully evaluate its impact, Fergusson said. 'Reduce the penalty, like a parking fine. You could then monitor ( the impact ) after five or six years. If it did not change, you might want to take another step.'

"In 1990, half of California’s marijuana possession arrestees were African-American, Latino, Asian, or other nonwhite and 35% were under age 20. In 2010, 64% were nonwhite and 52% were under age 20. Marijuana possession arrests of teenagers of color rose from 3,100 in 1990 to 16,400 in 2010 – an arrest surge 300% greater than population growth in that group."

Total Number of Sentenced People In Federal Prisons, 2004 = 153,776
Total Number of Sentenced People In State Prisons, 2004 = 1,274,600

Total Number of Sentenced People In Federal Prisons In The US For Whom a Drug Charge Was Their Most Serious Offense, 2004: 85,300 (55.5%)
Total Number of Sentenced People In State Prisons In The US For Whom a Drug Charge Was Their Most Serious Offense, 2004: 249,400 (19.6%)

Percent of sentenced people serving time in federal prisons whose most serious drug charges were marijuana/hashish offenses: 2004 = 12.4%
Percent of sentenced people serving time in state prisons whose most serious drug charges were marijuana/hashish, 2004 = 12.7%

(Sentenced people with drug offenses as their most serious charge) * (percent marijuana) = sentenced people serving time for marijuana offenses

Sentenced people serving time in federal prison on marijuana charges, 2004 = 10,577
Sentenced people serving time in state prisons on marijuana charges, 2004 = 31,674
Total sentenced people serving time on marijuana charges, state and federal prisons combined, 2004 = 42,251

Note: These data only address people in prisons and thus exclude everyone serving time in local jails because of a marijuana conviction.

"Synthetic cannabinoids are substances chemically produced to mimic tetrahydrocannabinol (THC), the active ingredient in marijuana. When these substances are sprayed onto dried herbs and then consumed through smoking or oral ingestion, they can produce psychoactive effects similar to those of marijuana.²⁰ Synthetic cannabinoids were first produced for research purposes to study the effects of cannabinoids on brain functioning and their efficacy in treating pain.

"The DEA has indicated that the primary users of these synthetic substances are youth who purchase the substances online or in gas stations, convenience stores, smoke shops, and head shops.²¹ The substances are often sold as herbal incense, and common brand names under which synthetic cannabinoids are marketed are 'Spice' and 'K2.' Other names include 'Blaze,' 'Red X Dawn,' 'Genie,' and 'Zohai,' among others.²²

"Clemson University Professor John Huffman is credited with first synthesizing some of the cannabinoids, such as JWH-018, now used in 'fake pot' substances such as K2. The effects of JWH-018 can be 10 times stronger than those of THC. Dr. Huffman is quoted as saying, 'These things are dangerous—anybody who uses them is playing Russian roulette. They have profound psychological effects. We never intended them for human consumption.'²³ While synthetic cannabinoids may be used with the intention of getting a marijuana-like high, their actual effects are not yet known. Some reported effects of synthetic cannabinoids, such as relaxation and reduced blood pressure, are consistent with effects of marijuana. Other reported effects, such as nausea, increased agitation, elevated blood pressure, and racing heart rates, are not.²⁴ The Centers for Disease Control and Prevention (CDC) has noted epidemiological links between synthetic cannabinoid use and acute kidney injury.²⁵ In at least one case, synthetic cannabinoid use has been blamed for a fatality when an Iowa teen committed suicide reportedly following a K2- induced panic attack.²⁶ In the summer of 2014, the New York City (NYC) Department of Health issued a warning to the public regarding the dangers of synthetic cannabinoid use after 15 people experienced 'severe adverse reactions after suspected ingestion of synthetic cannabinoids' over a period of three days.²⁷ In 2015, following a 'tenfold increase in medical emergencies from synthetic marijuana' in New York State (NYS) in the summer of 2015 compared to the summer of 2014, Governor Cuomo announced passage of emergency NYS Health Department regulations to combat the sale of these drugs—these emergency regulations included the addition of two classes of chemical compounds to the banned substances list.²⁸"

"To provide a sense of the intensity of enforcement, we calculated the risk a marijuana user faces of being arrested for possession. If calculated per joint consumed, the figure nationally is trivial—perhaps one arrest for every 11,000–12,000 joints.⁴ However, the relevant risk may be the probability of being arrested during a year of normal consumption. Since marijuana is mostly consumed by individuals who use it at least once a month,⁵ we estimated the risk that such individuals face. We know from prior studies (e.g., Reuter, Hirschfield, and Davies, 2001) that these risks are higher for youth. Table 2.2 presents separate estimates for those aged 12–17 and for the entire population 12 and over. We observe that the annual risk of misdemeanor arrest for those 12–17 (6.6 percent) is more than twice the rate for the full population (3.0 percent)."

"The central finding gleaned from the present study was that MML [Medical Marijuana Legalization] is not predictive of higher crime rates and may be related to reductions in rates of homicide and assault. Interestingly, robbery and burglary rates were unaffected by medicinal marijuana legislation, which runs counter to the claim that dispensaries and grow houses lead to an increase in victimization due to the opportunity structures linked to the amount of drugs and cash that are present. Although, this is in line with prior research suggesting that medical marijuana dispensaries may actually reduce crime in the immediate vicinity [8]."

"In sum, these findings run counter to arguments suggesting the legalization of marijuana for medical purposes poses a danger to public health in terms of exposure to violent crime and property crimes. To be sure, medical marijuana laws were not found to have a crime exacerbating effect on any of the seven crime types. On the contrary, our findings indicated that MML precedes a reduction in homicide and assault. While it is important to remain cautious when interpreting these findings as evidence that MML reduces crime, these results do fall in line with recent evidence [29] and they conform to the longstanding notion that marijuana legalization may lead to a reduction in alcohol use due to individuals substituting marijuana for alcohol [see generally 29, 30]. Given the relationship between alcohol and violent crime [31], it may turn out that substituting marijuana for alcohol leads to minor reductions in violent crimes that can be detected at the state level. That said, it also remains possible that these associations are statistical artifacts (recall that only the homicide effect holds up when a Bonferroni correction is made)."

"Given that the current results failed to uncover a crime exacerbating effect attributable to MML [Medical Marijuana Legalization], it is important to examine the findings with a critical eye. While we report no positive association between MML and any crime type, this does not prove MML has no effect on crime (or even that it reduces crime). It may be the case that an omitted variable, or set of variables, has confounded the associations and masked the true positive effect of MML on crime. If this were the case, such a variable would need to be something that was restricted to the states that have passed MML, it would need to have emerged in close temporal proximity to the passage of MML in all of those states (all of which had different dates of passage for the marijuana law), and it would need to be something that decreased crime to such an extent that it ‘‘masked’’ the true positive effect of MML (i.e., it must be something that has an opposite sign effect between MML [e.g., a positive correlation] and crime [e.g., a negative correlation]). Perhaps the more likely explanation of the current findings is that MML laws reflect behaviors and attitudes that have been established in the local communities. If these attitudes and behaviors reflect a more tolerant approach to one another’s personal rights, we are unlikely to expect an increase in crime and might even anticipate a slight reduction in personal crimes."

" A recent issue of The DASIS Report² examined marijuana treatment admissions between 1992 and 2002 and found that between these years [1992 and 2002] the rate of substance abuse treatment admissions reporting marijuana as their primary substance of abuse³ per 100,000 population increased 162 percent. Similarly, the proportion of marijuana admissions increased from 6 percent of all admissions in 1992 to 15 percent of all admissions reported to the Treatment Episode Data Set (TEDS) in 2002.
"During this time period, the percentage of marijuana treatment admissions that were referred from the criminal justice system increased from 48 percent of all marijuana admissions in 1992 to 58 percent of all marijuana admissions in 2002."

"The withdrawal syndrome associated with dronabinol, the API [Active Pharmaceutical Ingredient] in Marinol®, produces symptoms in humans such as restlessness, irritability, mild agitation, anxiety, anger, insomnia, sleep EEG disturbances, nausea, decreased appetite, and decreased weight. Since a withdrawal syndrome is indicative of physical dependence, it is reasonable to conclude that generic dronabinol products (both naturally-derived [from the cannabis plant] or synthetically produced, and in hard or soft gelatin capsules) in sesame oil, will also produce physical dependence similar to those produced by Marinol®."

"• Marijuana/hashish was reported as the primary substance of abuse by 15 percent of TEDS admissions aged 12 and older in 2014 [Table 1.1b].
"• The average age at admission for primary marijuana/hashish admissions was 26 years [Table 2.1b], although the peak age at admission for both genders in all race/ethnicities was about 16 to 17 years [Figure 12]. Thirty-two percent of marijuana/hashish admissions were under age 20 (vs. 8 percent of all admissions combined), and primary marijuana/hashish abuse accounted for 78 percent of admissions aged 12 to 14 and 76 percent of admissions aged 15 to 17 years [Table 2.1c].
"• Non-Hispanic Whites accounted for 44 percent of primary marijuana/hashish admissions (30 percent were males and 14 percent were females), and non-Hispanic Blacks accounted for 31 percent (24 percent were males and 8 percent were females) [Table 2.3b].
"• Twenty-four percent of primary marijuana/hashish admissions had first used marijuana/hashish by age 12 and another 30 percent had first used it by age 14 [Table 2.5b].
"• Primary marijuana/hashish admissions were most likely to be referred by the court/criminal justice system (52 percent). Primary marijuana/hashish admissions were less likely than all admis-sions combined to be self- or individually referred to treatment (18 vs. 37 percent) [Table 2.6b].
"• More than 4 in 5 marijuana/hashish admissions (86 percent) received ambulatory treatment; among all admissions combined, 3 in 5 (61 percent) received ambulatory treatment [Table 2.7b].
"• Sixty-three percent of primary marijuana/hashish admissions reported abuse of additional sub-stances. Alcohol was reported by 37 percent [Table 3.8]."

"In conclusion, our results suggest that participation in the use of both licit and illicit drugs is price sensitive. Participation is sensitive to own prices and the price of the other drugs. In particular, we conclude that cannabis and cigarettes are complements, and there is some evidence to suggest that cannabis and alcohol are substitutes, although decriminalization of cannabis corresponds with higher alcohol use. Alcohol and cigarettes are found to be complements."

"Although marijuana grown in the United States was once considered inferior because of a low concentration of THC, advancements in plant selection and cultivation have resulted in higher THC-containing domestic marijuana. In 1974, the average THC content of illicit marijuana was less than one percent. Today most commercial grade marijuana from Mexico/Columbia and domestic outdoor cultivated marijuana has an average THC content of about 4 to 6 percent. Between 1998 and 2002, NIDA-sponsored Marijuana Potency Monitoring System (MPMP) analyzed 4,603 domestic samples. Of those samples, 379 tested over 15 percent THC, 69 samples tested between 20 and 25 percent THC and four samples tested over 25 percent THC."

"California, Hawaii, Kentucky, Oregon, Tennessee, Washington, and West Virginia are the primary marijuana cultivation states (M7 states). Domestic Cannabis Eradication/Suppression Program (DCE/SP) data show that more than 8 million plants were eradicated in 2008, 89 percent (7,136,133 plants of 8,013,308 plants) of which were eradicated in the M7 States."

Click here for the complete datatable of Average Tetrahydrocannabinol (THC), Cannabidiol (CBD), and Cannabinol (CBN) Levels of Seized Samples of Domestic Cannabis in the US, 1995-2015

Click here for complete datatable of THC Potency of Tested Cannabis from Federal Seizure and State and Local Eradication Samples, by Type, 1985-2014.

"• Twenty-three Police Forces in England and Wales participated in the study. Forces were requested to submit samples confiscated from street-level users. In early 2008, they submitted 2,921 samples for analysis to either the Forensic Science Service Ltd (FSS) or LGC Forensics at Culham (LGC F).
"• Initial laboratory examination showed that 80.8% were herbal cannabis and 15.3% were cannabis resin. The remaining 3.9% were either indeterminate or not cannabis.
"• Microscopic examination of around two-thirds of the samples showed that over 97% of the herbal cannabis had been grown by intensive methods (sinsemilla). The remainder was classed as traditional imported herbal cannabis.
"• Regional variations were found in the market share of herbal cannabis. Thus North Wales, South Wales, Cleveland and Devon and Cornwall submitted proportionately fewer herbal cannabis samples, whereas Essex, Metropolitan and Avon and Somerset submitted proportionately more. These differences were statistically significant at the 0.1% confidence interval.
"• The mean THC concentration (potency) of the sinsemilla samples was 16.2% (range = 4.1 to 46%). The median potency was 15.0%, close to values reported by others in the past few years.
"• The mean THC concentration (potency) of the traditional imported herbal cannabis samples was 8.4% (range = 0.3 to 22%); median = 9.0%. Only a very small number of samples were received and analysed.
"• The mean potency of cannabis resin was 5.9% (range = 1.3 to 27.8%). The median = 5.0% was typical of values reported by others over many years.
"• Cannabis resin had a mean CBD content of 3.5% (range = 0.1 to 7.3%), but the CBD content of herbal cannabis was less than 0.1% in nearly all cases.
"• There was a weak, but statistically-significant, correlation (r = 0.48; N = 112; P < 0.001) between the THC and the CBD content of resin."

"Data on the THC content of cannabis products in the USA have been collected by ElSohly et al. (1984, 2000) for many years as part of the University of Mississippi Potency Monitoring Project. Samples were submitted by law enforcement agencies and it has to be assumed that they were representative of the market. Mean THC values are shown in Figure 16 for normal herbal cannabis, sinsemilla and resin. The anomalously high value for resin in 1997 (19.24 %) has been excluded; it was based on only five values and is over nine standard deviations above the mean potency for the period 1980–1996. Although there has been an increase in the potency of herbal cannabis over the twenty-five-year period, cannabis resin (and hash oil) showed no long-term trends since 1980 when data were first collected. Although the potency of sinsemilla showed a clear upward trend in the final three years of the study, no such trend was obvious when the longer period of 1980–1995 is examined, particularly in view of the wide variations in potency that occurred from year to year (ElSohly et al., 2000). The THC content of herbal cannabis increased from around 1% before 1980 to around 4% in 1997. This increase, when seen in the European context, is deceptive. Before 1980, all mean herbal cannabis THC levels in the ElSohly study were less than 2.4%. By contrast, and as shown in Figure 10, comparable levels at that time in the United Kingdom were twice as great. In other words, it must be assumed that the quality of herbal cannabis consumed in the USA more than twenty years ago was unusually poor, but that in recent years it has risen to levels typical of Europe. So even the modest increase found by ElSohly et al. (2000) may be less significant than it seems. A recent analysis of cannabis seized in Florida in 2002 (Newell, 2003) showed amounts of THC found in samples ranging from 1.41% to 12.62%; the average THC content was 6.20%, which is almost identical to the 2002 value reported by the University of Mississippi Potency Monitoring Project."

"Statements in the popular media that the potency of cannabis has increased by ten times or more in recent decades are not support by the data from either the USA or Europe. As discussed in the body of this report, systematic data are not available in Europe on long-term trends and analytical and methodological issues complicate the interpretation of the information that is available. Data are stronger for medium and short-term trends where no major differences are apparent in Europe, although some modest increases are found in some countries. The greatest long-term changes in potency appear to have occurred in the USA. It should be noted here that before 1980 herbal cannabis potency in the USA was, according to the available data, very low by European standards."

"Despite continuing increases in the amount of cannabis produced domestically, much of the marijuana available within the United States is foreign-produced. The two primary foreign source areas for marijuana distributed within the United States are Canada and Mexico. Mexican drug trafficking organizations (DTOs) have relocated many of their outdoor cannabis cultivation operations in Mexico from traditional growing areas to more remote locations in central and northern Mexico, primarily to reduce the risk of eradication and gain easier access to U.S. drug markets. Asian criminal groups are the primary producers of high-potency marijuana in Canada."

"Tetrahydrocannabinol is a very safe drug. Laboratory animals (rats, mice, dogs, monkeys) can tolerate doses of up to 1000 mg/kg (milligrams per kilogram). This would be equivalent to a 70 kg person swallowing 70 grams of the drug —about 5,000 times more than is required to produce a high. Despite the widespread illicit use of cannabis there are very few if any instances of people dying from an overdose."

"The identification of cannabis as a potentially dangerous psychoactive substance did not, however, prevent a substantial number of these enquiries to explore the issue of whether current legislation reflected the real dangers posed by cannabis. Already in 1944, the La Guardia Committee Report on Marihuana concluded that ‘the practice of smoking marihuana does not lead to addiction in the medical sense of the word’ and that ‘the use of marihuana does not lead to morphine or heroin or cocaine addiction’ (Zimmer and Morgan, 1997). In 1968 the Wootton Report stated that ‘the dangers of cannabis use as commonly accepted in the past and the risk of progression to opiates have been overstated’ and ‘cannabis is less harmful than other substances (amphetamines, barbiturates, codeine-like compounds)’. A similar conclusion was arrived at 34 years later in 2002 when the Advisory Committee on Drug Dependence proposed the reclassification of cannabis from Class B to Class C (enforced by law in 2004 and confirmed in 2005). These views were reiterated by other enquiries, such as the Baan Committee in the Netherlands, which affirmed in 1971 that ‘cannabis use does not lead directly to other drug use’ (¹⁶) or by the US National Commission on Marihuana and Drug Abuse, which in 1973 stated that ‘the existing social and legal policy is out of proportion to the individual and social harm engendered by the use of the drug [cannabis]’ (¹⁷). The Canadian Le Dain Commission saw ‘the UN Single Convention of 1961 as responsible’ for such a situation which ‘might have reinforced the erroneous impression that cannabis is to be assimilated to the opiate narcotics’. The same commission, however, suggested that the UN Convention did ‘not prevent domestic legislation from correcting this impression’ (¹⁸)."

An exhaustive search of the literature finds no deaths induced by marijuana. The US Drug Abuse Warning Network (DAWN) records instances of drug mentions in medical examiners' reports, and though marijuana is mentioned, it is usually in combination with alcohol or other drugs. Marijuana alone has not been shown to cause an overdose death.

"The public health burden of cannabis use is probably modest compared with that of alcohol, tobacco, and other illicit drugs. A recent Australian study⁹⁶ estimated that cannabis use caused 0·2% of total disease burden in Australia—a country with one of the highest reported rates of cannabis use. Cannabis accounted for 10% of the burden attributable to all illicit drugs (including heroin, cocaine, and amphetamines). It also accounted for around 10% of the proportion of disease burden attributed to alcohol (2·3%), but only 2·5% of that attributable to tobacco (7·8%)."

"There are health risks of cannabis use, most particularly when it is used daily over a period of years or decades. Considerable uncertainty remains about whether these effects are attributable to cannabis use alone, and about what the quantitative relationship is between frequency, quantity and duration of cannabis use and the risk of experiencing these effects.
"On existing patterns of use, cannabis poses a much less serious public health problem than is currently posed by alcohol and tobacco in Western societies."

In 1988, the DEA's Administrative Law Judge, Francis Young, concluded: "In strict medical terms marijuana is far safer than many foods we commonly consume. For example, eating 10 raw potatoes can result in a toxic response. By comparison, it is physically impossible to eat enough marijuana to induce death. Marijuana in its natural form is one of the safest therapeutically active substances known to man. By any measure of rational analysis marijuana can be safely used within the supervised routine of medical care."

"A careful search of the literature and testimony of the nation's health officials has not revealed a single human fatality in the United States proven to have resulted solely from ingestion of marihuana. Experiments with the drug in monkeys demonstrated that the dose required for overdose death was enormous and for all practical purposes unachievable by humans smoking marihuana. This is in marked contrast to other substances in common use, most notably alcohol and barbiturate sleeping pills."

"Of the approximately 2.5 million drug misuse or abuse ED visits that occurred during 2011, a total of 1,252,500, or just over half (50.9%), involved illicit drugs (Table 4). A majority (56.3%) of illicit drug ED visits involved multiple drugs. Overall, 27.9 percent of visits involving illicit drugs also involved alcohol.
"Cocaine and marijuana were the most commonly involved drugs, with 505,224 ED visits (40.3%) and 455,668 ED visits (36.4%), respectively. Cocaine and marijuana were followed by heroin, at 258,482 ED visits, or 20.6 percent, and then by amphetamines/methamphetamine, at 159,840 visits, or 12.8 percent."

Note: According to the DAWN report, "DAWN captures drugs that are explicitly named in the medical record as being involved in the ED visit. The relationship between the ED visit and the drug use need not be causal. That is, an implicated drug may or may not have directly caused the condition generating the ED visit; the ED staff simply named it as being involved." (p. 15)

"For physiological and pharmacological reasons,⁶¹ smoking cannabinoid herbals does not seem to have a similar health hazard profile as tobacco smoking, aside from the potential for bronchial irritation and bronchitis. Smoking cannabis was not associated with an increased risk of developing chronic obstructive pulmonary disease ..."

"In this 20-year study of marijuana and pulmonary function, we confirmed the expected reductions in FEV1 [Forced expiratory volume in the first second of expiration] and FVC [forced vital capacity] from tobacco use. In contrast, marijuana use was associated with higher FEV1 and FVC at the low levels of exposure typical for most marijuana users. With up to 7 joint-years of lifetime exposure (eg, 1 joint/d for 7 years or 1 joint/wk for 49 years), we found no evidence that increasing exposure to marijuana adversely affects pulmonary function. This association, however, was nonlinear: at higher exposure levels, we found a leveling off or even a reversal in this association, especially for FEV1. Although our sample contained insufficient numbers of heavy users to confirm a detrimental effect of very heavy marijuana use on pulmonary function, our findings suggest this possibility."

"Despite these findings, the small number of observational studies fail to demonstrate a clear association between marijuana smoking and diagnoses of lung cancer. Therefore, we must conclude that no convincing evidence exists for an association between marijuana smoking and lung cancer based on existing data. Nonetheless, certain logistic properties of marijuana smoking may increase the risk of carcinogenic exposure compared with conventional tobacco smoking, raising questions as to why observational studies have not demonstrated an association with lung cancer."

"Nonetheless, and contrary to our expectations, we found no positive associations between marijuana use and lung or UAT cancers. Although we observed positive dose-response relations of marijuana use to oral and laryngeal cancers in the crude analyses, the trend was no longer observed when adjusting for potential confounders, especially cigarette smoking. In fact, we observed ORs <1 for all cancers except for oral cancer, and a consistent monotonic association was not apparent for any outcome. Similar findings were found when the analyses were restricted to subjects who never smoked cigarettes. The 95% confidence intervals for the adjusted ORs did not extend far above 1 (e.g., were under 2 for marijuana and lung cancer), which suggests that associations of marijuana use with the study cancers are not strong and may be below detectable limits for this type of study."

"We found that moderate marijuana use was significantly associated with reduced risk of HNSCC [head and neck squamous cell carcinoma]. This association was consistent across different measures of marijuana use (marijuana use status, duration, and frequency of use). Diminished risk of HNSCC did not differ across tumor sites, or by HPV [human papillomavirus] 16 antibody status. Further, we observed that marijuana use modified the interaction between alcohol and cigarette smoking, resulting in a decreased HNSCC risk among moderate smokers and light drinkers, and attenuated risk among the heaviest smokers and drinkers."

"Despite several lines of evidence suggesting the biological plausibility of marijuana use being carcinogenic (1), it is possible that marijuana use does not increase cancer risk, as suggested in the recent commentary by Melamede (26). Although the adjusted ORs <1 may be chance findings, they were observed for all non-reference exposure categories with all outcomes except oral cancer. Although purely speculative, it is possible that such inverse associations may reflect a protective effect of marijuana. There is recent evidence from cell culture systems and animal models that 9-tetrahydrocannabinol, the principal psychoactive ingredient in marijuana, and other cannabinoids may inhibit the growth of some tumors by modulating key signaling pathways leading to growth arrest and cell death, as well as by inhibiting tumor angiogenesis (27-29). These antitumoral associations have been observed for several types of malignancies including brain, prostate, thyroid, lung, and breast."

"In the current study, we demonstrated that chronic cannabis smokers had relative visceral adiposity and adipose tissue insulin resistance but not hepatic steatosis, glucose insulin insensitivity, impaired pancreatic b-cell function, glucose intolerance, or dyslipidemia compared with age-, sex-, ethnicity-, and BMI-matched control individuals. Our study results suggest that chronic, daily cannabis use may have differential tissue-specific effects on insulin sensitivity, but these effects appear to have minimal impact on glucose or lipid metabolism."

"Our analyses of adults aged 20-59 years in the NHANES [National Health and Nutrition Examination Survey] III database showed that participants who used marijuana had lower prevalence of DM [Diabetes Mellitus] and had lower odds of DM relative to non-marijuana users. We did not find an association between the use of marijuana and other chronic diseases, such as hypertension, stroke, myocardial infarction and heart failure. This could be due to the smaller prevalence of stroke, myocardial infarction and heart failure in the examined age group.
"We noted the lowest prevalence of DM in current light marijuana users, with current heavy marijuana users and past users also having a lower prevalence of DM than non-marijuana users. The finding that past marijuana users had lower odds of prevalent DM than non-users suggests that early exposure to marijuana may affect the development of DM and a window of time of marijuana exposure earlier in life could be a factor to study. Similarly, our findings of a significant association between marijuana use and DM was only found in those aged $40 years suggest that the possibility of some protection from marijuana use may require many years before they become manifested. By contrast, it could reflect the increased prevalence of DM with age and the ability to detect an association with a lesser sample size when there is a greater cohort at risk for DM. The possible association of light marijuana use with decreased DM is similar to that of alcohol on DM and the metabolic syndrome, in which mild alcohol use was associated with lower prevalence of DM and the metabolic syndrome,^{14 15} and higher alcohol use associated with higher prevalence of DM and the metabolic syndrome.^{14 16}"

Marijuana use is associated with higher daily caloric intake. In the NHANES III and CARDIA study, heavy cannabis users had ;20% higher calorie intake than nonusers (25,26). The increase in calories was from higher intake of all macronutrients. Specifically, the frequency and amount of consumption of soda, cheese, salty snacks, pork, and alcohol was higher in cannabis users. Consistent with other studies, the quality of diets consumed by cannabis users was poor (27). Furthermore, the percent of daily calories derived from carbohydrates relatively rich in simple sugars was significantly higher in marijuana smokers. These findings are consistent with human and animal studies demonstrating that cannabinoids stimulate food intake, specifically highly palatable sweet-tasting foods (28). Cannabis smokers in our study exhibited characteristics typically observed in marijuana smokers in the general population."

"People who develop problems with marijuana may indeed be different from those who do not, but this phenomenon has been observed with other substances of abuse. A comparison with alcohol use and dependence provides a case in point. The great majority of Americans have tried alcohol and continue to drink alcoholic beverages regularly. However, only an estimated 10 to 15 percent of alcohol drinkers develop problems, and only some of these problem drinkers seek treatment. This is also true of those who have tried cocaine or heroin (Anthony, Warner, and Kessler, 1994).

"That said, the experience of dependence on marijuana tends to be less severe than that observed with cocaine, opiates, and alcohol (Budney, 2006; Budney et al., 1998). On average, individuals with marijuana dependence meet fewer DSM dependence criteria; the withdrawal experience is not as dramatic; and the severity of the associated consequences is not as extreme. However, the apparently less severe nature of marijuana dependence does not necessarily mean that marijuana addiction is easier to overcome. Many factors besides a drug’s physiological effects—including availability, frequency and pattern of use, perception of harm, and cost—can contribute to cessation outcomes and the strength of addiction. The low cost of marijuana, the typical pattern of multiple daily use by those addicted, the less dramatic consequences, and ambivalence may increase the difficulty of quitting. Although determining the relative difficulty of quitting various substances of abuse is complex, the treatment literature reviewed here suggests that the experience of marijuana abusers rivals that of those addicted to other substances."

"As research on pharmacological treatments for CUD continues, a few key findings are of note. First, cannabinoid agonists (nabilone, dronabinol in combination with lofexidine, and lofexidine alone), were the only drugs that decreased drug-taking in a human laboratory model of relapse, supporting the notion that agonist replacement and attenuation of noradrenergic activity show promise for relapse prevention. Although dronabinol alone failed to clinically reduce cannabis use, a higher dose might have been more effective. Further, that study was designed to evaluate the initiation of abstinence; dronabinol or the more bioavailable agonist nabilone, might have greater utility in the prevention of relapse [25•]. These studies also support further testing of lofexidine in combination with other drugs, and generally illustrate the utility that can be gained from combining medications.
"Second, gabapentin and NAC were the only drugs tested in placebo-controlled clinical trials that decreased cannabis use (abstinence induction). Third, the ability of a drug to reduce cannabis withdrawal symptoms is not predictive of its ability to alter drug-taking behaviors (reduce use or prevent relapse). However, all the studies that reported positive changes in drug use also reported a reduction in withdrawal during early abstinence, suggesting that this feature is an important component of an efficacious medication."

"Analysis of the demographic and social characteristics of a large sample of applicants seeking approval to use marijuana medically in California supports an interpretation of long term non problematic use by many who had first tried it as adolescents, and then either continued to use it or later resumed its use as adults. In general, they have used it at modest levels and in consistent patterns which anecdotally-often assisted their educational achievement, employment performance, and establishment of a more stable life-style. These data suggest that rather than acting as a gateway to other drugs, (which many had also tried), cannabis has been exerting a beneficial influence on most."

"Differences in cannabis smoking behaviour may also represent different risks for cannabis dependence independently of total THC exposure. Similar to cigarette smokers [16,21–24], cannabis smokers typically gradually decrease the puff volume and puff duration during the course of one joint, whereas puff velocity and interpuff interval gradually increase [20]. Interestingly, in a 2-year prospective study, nicotine dependence has been shown to develop more rapidly in tobacco smokers who smoke with stable or increasing puff volume and increasing puff duration ('atypical' smoking) [16]. One interpretation of this finding is that the risk of becoming nicotine-dependent is lower in smokers who reach nicotine saturation before the cigarette is finished and decrease their pace of smoking. If this mechanism also applies to cannabis smoking, one may expect that the risk for and the severity of cannabis dependence is associated with 'atypical' cannabis smoking."

"This study among 98 experienced cannabis smokers is the first naturalistic study to examine whether users of cannabis with high THC concentration titrate the psychoactive effects by using lower doses and/or by reduced inhalation, and whether cannabis smoking behaviour (topography) predicts cannabis dependence severity independently of total THC exposure.
"In contrast to our hypothesis, there was a positive association between cannabis THC concentration and cannabis dose, indicating that users of stronger cannabis generally used larger amounts of cannabis to prepare their regular joint. However, in line with our hypothesis, the negative association between THC concentration of joints and total inhaled smoke volume indicates that users of stronger joints inhaled smaller smoke volumes, thus resulting in partial titration of the total THC exposure. Overall, as exemplified by the comparison of the average user with the user with the maximum THC concentration, users of high-potency cannabis will generally be exposed to higher total doses of THC (at least in this sample). This is in line with Cappell et al.’s observations through a one-way mirror experiment in 1973 where users only partly adapted their intake [14]. Indeed, increased THC concentrations of cannabis have recently been linked to increased internal THC exposure assessed in blood [28]."

"Although experienced young adult cannabis users with a preference for stronger joints titrated their THC exposure to some extent by inhaling less smoke, in general more potent cannabis was used in higher dosages leading to a higher THC exposure compared to users preferring lower potency cannabis. None the less, in our population of frequent cannabis users, total THC exposure was only a weak predictor of dependence severity, and did not remain significant after adjustment for baseline dependence severity. However, cannabis smoking behaviours predicted cannabis dependence severity independently of baseline THC exposure and baseline cannabis dependence severity. As the amount of explained variance was low, due possibly to the multifactorial aetiology of dependence, future studies should include other predictors, such as genetic variations, early traumatic experiences and — most importantly — time-dependent variables representing the dynamic nature of personal and dependence development. Meanwhile, smoking variables, such as smoking topography and completely finishing high-dose/high-potent joints in one smoking session, may be helpful to identify people at risk of escalating cannabis dependence severity."

"An abstinence syndrome has been reported after the abrupt discontinuation of dronabinol [Marinol®] in volunteers receiving dosages of 210 mg/day for 12 to 16 consecutive days. Within 12 hours after discontinuation, these volunteers manifested symptoms such as irritability, insomnia, and restlessness. By approximately 24 hours post-dronabinol discontinuation, withdrawal symptoms intensified to include 'hot flashes', sweating, rhinorrhea, loose stools, hiccoughs and anorexia.
"These withdrawal symptoms gradually dissipated over the next 48 hours. Electroencephalographic changes consistent with the effects of drug withdrawal (hyperexcitation) were recorded in patients after abrupt dechallenge. Patients also complained of disturbed sleep for several weeks after discontinuing therapy with high dosages of dronabinol."

"There is no conclusive evidence that the drug effects of marijuana are causally linked to the subsequent abuse of other illicit drugs."

"Patterns in progression of drug use from adolescence to adulthood are strikingly regular. Because it is the most widely used illicit drug, marijuana is predictably the first illicit drug most people encounter. Not surprisingly, most users of other illicit drugs have used marijuana first. In fact, most drug users begin with alcohol and nicotine before marijuana, usually before they are of legal age."

"In line with previous work, we found that cannabis users had lower teenage IQ scores and poorer educational performance than teenagers who had never used cannabis. At the same time, cannabis users also had higher rates of childhood behavioural problems, childhood depressive symptoms, other substance use (including use of cigarettes and alcohol) and maternal use of cannabis during pregnancy. After adjustment to account for these group differences, cannabis use by the age of 15 did not predict either lower teenage IQ scores or poorer educational performance. These findings therefore suggest that cannabis use at the modest levels used by this sample of teenagers is not by itself causally related to cognitive impairment. Instead, our findings imply that previously reported associations between adolescent cannabis use and poorer intellectual and educational outcomes may be confounded to a significant degree by related factors."

"In summary, the notion that cannabis use itself is causally related to lower IQ and poorer educational performance was not supported in this large teenage sample. However, this study indeed has limitations, in particular the young age of outcome assessment. While we have demonstrated that confounding may be an explanation for links between cannabis use and poorer outcomes, large prospective cohorts tracking young people prior to, during and after stopping cannabis use, using more objective measures of drug use (e.g. the new NIH-funded ‘ABCD study’ in the United States; National Institute on Drug Abuse, 2015) are required before we can make strong conclusions. Cigarette smoking in particular has once again (Hooper et al., 2014; McCaffrey et al., 2010; Silins et al., 2014; Stiby et al., 2014) been highlighted as an important factor in adolescent outcomes, as well as a robust independent predictor of educational performance, and the reasons for this need to be elucidated."

"Compared with those in our sample who had never tried cannabis, teenagers who had used cannabis at least 50 times were 17 times more likely (84% vs. 5%) to have smoked cigarettes more than 20 times in their lifetime. Accounting for group differences in cigarette smoking dramatically attenuated the associations between cannabis use and both IQ and educational performance. Further, even after excluding those who had never tried cannabis, cigarette users were found to have lower educational performance (adjusted performance 2.9 percentage points lower, approximately equivalent to dropping two grades on one subject taken at GCSE) relative to those who had never tried cigarettes. A relationship between cigarette use and poorer cognitive (Chamberlain et al., 2012; Hooper et al., 2014; Weiser et al., 2010; Whalley et al., 2005) and educational (McCaffrey et al., 2010; Silins et al., 2014; Stiby et al., 2014) outcomes has been noted previously, and may have a number of explanations. Cigarette use may have a negative impact on cognitive ability. However, this is not supported by the experimental psychopharmacology literature, which robustly shows that acute nicotine administration results in transient cognitive enhancement (Heishman et al., 2010). Alternatively, reverse causality may contribute to this relationship, for example performing poorly at school may lead to increased engagement in risky behaviours such as cigarette smoking. Further, residual confounding may contribute to this link: cigarette smoking may be a marker of unmeasured factors, for example social adversity during adolescence, that influence both IQ and educational attainment."

"In the present study, the most persistent adolescent-onset cannabis users evidenced an average 8-point IQ decline from childhood to adulthood. Quitting, however, may have beneficial effects, preventing additional impairment for adolescent-onset users. Prevention and policy efforts should focus on delivering to the public the message that cannabis use during adolescence can have harmful effects on neuropsychological functioning, delaying the onset of cannabis use at least until adulthood, and encouraging cessation of cannabis use particularly for those who began using cannabis in adolescence."

"Although the heavy current users experienced a decrease in IQ score, their scores were still above average at the young adult assessment (mean 105.1). If we had not assessed preteen IQ, these subjects would have appeared to be functioning normally. Only with knowledge of the change in IQ score does the negative impact of current heavy use become apparent."

"The results of our meta-analytic study failed to reveal a substantial, systematic effect of long-term, regular cannabis consumption on the neurocognitive functioning of users who were not acutely intoxicated. For six of the eight neurocognitive ability areas that were surveyed. the confidence intervals for the average effect sizes across studies overlapped zero in each instance, indicating that the effect size could not be distinguished from zero. The two exceptions were in the domains of learning and forgetting."

"In conclusion, our meta-analysis of studies that have attempted to address the question of longer term neurocognitive disturbance in moderate and heavy cannabis users has failed to demonstrate a substantial, systematic, and detrimental effect of cannabis use on neuropsychological performance. It was surprising to find such few and small effects given that most of the potential biases inherent in our analyses actually increased the likelihood of finding a cannabis effect."

"Our findings suggest that regular cannabis use before age 18 y predicts impairment, but others have found effects only for younger ages ^{(10, 15)}. Given that the brain undergoes dynamic changes from the onset of puberty through early adulthood ^{(37, 38)}, this developmental period should be the focus of future research on the age(s) at which harm occurs."

"Nevertheless, when considering all 15 studies (i.e., those that met both strict and more relaxed criteria) we only noted that regular cannabis users performed worse on memory tests, but that the magnitude of the effect was very small. The small magnitude of effect sizes from observations of chronic users of cannabis suggests that cannabis compounds, if found to have therapeutic value, should have a good margin of safety from a neurocognitive standpoint under the more limited conditions of exposure that would likely obtain in a medical setting."

"Current marijuana use had a negative effect on global IQ score only in subjects who smoked 5 or more joints per week. A negative effect was not observed among subjects who had previously been heavy users but were no longer using the substance. We conclude that marijuana does not have a long-term negative impact on global intelligence. Whether the absence of a residual marijuana effect would also be evident in more specific cognitive domains such as memory and attention remains to be ascertained."

"Other studies have found short term residual effects of cannabis use on memory and cognition (34, 35) that are more severe among women (36) and heavy users (37). However, our data suggest that over the long term cannabis use is not associated with greater declines in cognition among men, women, or heavy users. The study design we used included several of the features proposed by Pope et al. (34) as critical to addressing the long term effects of cannabis on cognition: naturalistic follow-up, a large sample size, a population basis, comparison of light cannabis use with heavy use, and the construction of models accounting for the effects of gender and use of illicit drugs, alcohol, and tobacco. Therefore, these results would seem to provide strong evidence of the absence of a long term residual effect of cannabis use on cognition."

"These results can be interpreted in several ways. A statistically reliable negative effect was observed in the domain of learning and forgetting, suggesting that chronic long-term cannabis use results in a selective memory defect. While the results are compatible with this conclusion, the effect size for both domains was of a very small magnitude. The "real life" impact of such a small and selective effect is questionable. In addition, it is important to note that most users across studies had histories of heavy longterm cannabis consumption. Therefore, these findings are not likely to generalize to more limited administration of cannabis compounds, as would be seen in a medical setting."

"The [endo] cannabinoids produce psychological states that closely parallel several experiences described as being related to the runner’s high. Compared with the opioid analgesics, the analgesia produced by the endocannabinoid system is more consistent with exercise induced analgesia. Activation of the endocannabinoid system also produces sedation, anxiolysis, a sense of wellbeing, reduced attentional capacity, impaired working memory ability, and difficulty in time estimation. This behavioural profile is similar to the psychological experiences reported by long distance runners."

"One of the major concerns about the psychological effects of chronic heavy cannabis use has been that it impairs adult motivation. The evidence for an 'amotivational syndrome' among adults consists largely of case histories and observational reports (e.g. Kolansky and Moore, 1971; Millman and Sbriglio, 1986). The small number of controlled field and laboratory studies have not found compelling evidence for such a syndrome (Dornbush, 1974; Negrete, 1983; Hollister, 1986). The evidential value of the field studies is limited by their small sample sizes, and the limited sociodemographic characteristics of their samples, while the evidential value of the laboratory studies is limited by the short periods of drug use, the youthful good health of the volunteers, and minimal demands made on volunteers in the laboratory (Cohen, 1982). Some regular cannabis users report a loss of ambition and impaired school and occupational performance as adverse effects of their use (e.g. Hendin et al, 1987) and that some ex-cannabis users give impaired occupational performance as a reason for stopping (Jones, 1984). Nonetheless, it is doubtful that cannabis use produces a well defined amotivational syndrome. It may be more parsimonious to regard the symptoms of impaired motivation as symptoms of chronic cannabis intoxication rather than inventing a new psychiatric syndrome."

"This 10 year follow-up study showed that incident cannabis use significantly increased the risk of incident psychotic experiences. The association was independent of age, sex, socioeconomic status, use of other drugs, urban/rural environment, and childhood trauma; additional adjustment for other psychiatric diagnoses similarly did not change the results. There was no evidence for self medication effects as psychotic experiences did not predict later cannabis use. The results thus help to clarify the temporal association between cannabis use and psychotic experiences by systematically addressing the issue of reverse causality, given that the long follow-up period allowed exclusion of all individuals with pre-existing psychotic experiences or pre-existing cannabis use. In addition, cannabis use was confirmed as an environmental risk factor impacting on the risk of persistence of psychotic experiences (fig 3)."

"Laboratory studies also find no link between THC intoxication and violence. Most people who ingest THC before performing a competitive task in the laboratory do not show more aggression than people who receive placebos; occasionally they show decreased hostility. Numerous scientific panels sponsored by various governments invariably report that marijuana does not lead to violence.(751)"

"The younger and more often teens use marijuana, the more likely they are to engage in other substance use and the higher their risk of developing a substance use disorder. Among high school students, 7.5 percent used marijuana for the first time before the age of 13. CASA’s analysis of national data finds that the average age of initiation of marijuana use among high school students is 14.3 years old. Compared to those who began using marijuana after age 21, those who first used it before age 15 are:
• More likely to have ever smoked a cigarette (93.3 percent vs. 86.4 percent);
• More than twice as likely to have ever misused controlled prescription drugs (56.5 percent vs. 22.9 percent); and
• Two and a half times as likely to have ever used other illicit drugs (70.2 percent vs. 27.8 percent)."

"Annual marijuana prevalence peaked among 12th graders in 1979 at 51%, following a rise that began during the 1960s. Then use declined fairly steadily for 13 years, bottoming at 22% in 1992—a decline of more than half. The 1990s, however, saw a resurgence of use. After a considerable increase (one that actually began among 8th graders a year earlier than among 10th and 12th graders), annual prevalence rates peaked in 1996 at 8th grade and in 1997 at 10th and 12th grades. After these peak years, use declined among all three grades through 2007 or 2008. After these declines, an upturn occurred in use in all three grades, lasting for three years in the lower grades and longer in grade 12. Annual marijuana prevalence among 8th graders increased in use from 2007 to 2010, decreased slightly from 2010 to 2012, and then declined significantly in 2016. Among 10th graders, use increased somewhat from 2008 to 2013 and then declined after that. Among 12th graders, use increased from 2006 to 2011 and then held level through 2016. As shown in Table 8, daily use increased in all three grades after 2007, reaching peaks in 2011 (at 1.3% in 8th), 2013 (at 4.0% in 10th), and 2011 (at 6.6% in 12th), before declining slightly since. Daily prevalence rates in 2016 were 0.7%, 2.5%, and 6.0%, respectively, with one in seventeen 12th graders smoking daily."

"High school students are more likely to use marijuana than to smoke cigarettes. High school students are:
"• More likely to have tried marijuana than tobacco (24 percent vs. 15 percent); and
"• More likely to say their close friends use marijuana than smoke cigarettes (51 percent vs. 39 percent)."

"Teens also say they are seeing more peers in school smoking marijuana and more teens (73 percent) report having friends who smoke marijuana regularly (71 percent) – significantly higher than four years ago. Since 2008, there have also been significant declines in teen perceptions that they will lose respect, harm themselves, or mess up their lives if they use marijuana."

"The proportion of students seeing great risk from using marijuana regularly fell during the rise in use in the 1970s, and again during the subsequent rise in the 1990s. Indeed, at 10th and 12th grades, perceived risk declined a year before use rose in the upturn of the 1990s, making perceived risk a leading indicator of change in use. (The same may have happened at 8th grade as well, but we lack data starting early enough to know.) The decline in perceived risk halted in 1996 in 8th and 10th grades; the increases in use ended a year or two later, again making perceived risk a leading indicator. From 1996 to 2000, perceived risk held fairly steady and the decline in use in the upper grades stalled. After some decline prior to 2002, perceived risk increased in all grades through 2004 as use decreased. Perceived risk fell after 2004 and 2005 in 8th and 12th grades respectively, (and since 2008 in 10th grade) presaging the more recent increase in use. In 2011 perceived risk continued to decline in grades 10 and 12 and leveled in grade 8."

"Asked whether they thought it should be legal to sell marijuana if it were legal to use it, about three in five (62%) said 'yes.' However, about 80% of those answering 'yes' (51% of all respondents) would permit sale only to adults. A small minority (11%) favored the sale to anyone, regardless of age, while 28% said that sale should not be legal even if use were made legal, and 10% said they 'don’t know.'"

"The apparent strength of these relationships in cross-sectional studies (e.g. Kandel, 1984) has been exaggerated because those adolescents who are most likely to use cannabis have lower academic aspirations and poorer high school performance prior to using cannabis than their peers who do not (Newcombe and Bentler, 1988). It remains possible that factors other than the marijuana use account for apparent causal relations. To the extent they may exist, these adverse effects of cannabis and other drug use upon development over and above the effect of pre-existing nonconformity may cascade throughout young adult life, affecting choice of occupation, level of income, choice of mate, and the quality of life of the user and his or her children."

"Risk thresholds could be formulated only for THC which was the most prevalent illicit drug in the general driving population and in injured/killed drivers. The prevalence of THC across all countries that participated in DRUID is 1.37%. This is about one third of the alcohol prevalence. The epidemiological, the experimental and the meta-analytical approaches result in rather low risk estimations. Epidemiological case-control studies assess at maximum a 2.4-fold risk for injury, experimental studies and meta-analysis rank the risk between 0.5 and 2 times than that of sober driving. So THC seems to be much less impairing and risky than most of the other examined substances. Although a relationship between THC concentration and accident risk was found in the epidemiological studies, it was only possible to set an exact THC cut-off by a meta-analysis of experimental studies. Thereby it was found that the serum concentration of 3.8ng/mL THC (?2ng/mL in whole blood) causes the same amount of impairment as 0.5g/L alcohol. This value could be an empirical basis for a threshold discussion. The meta-analysis could also be used to define limits comparable to lower BAC levels."

"As with cannabis, alcohol use increased variability in lane position and headway (Casswell, 1979; Ramaekers et al., 2000; Smiley et al., 1981; Stein et al., 1983) but caused faster speeds (Casswell, 1977; Krueger & Vollrath, 2000; Peck et al., 1986; Smiley et al., 1987; Stein et al., 1983). Some studies also showed that alcohol use alone and in combination with cannabis affected visual search behavior (Lamers & Ramaekers, 2001; Moskowitz, Ziedman, & Sharma, 1976). Alcohol consumption combined with cannabis use also worsened driver performance relative to use of either substance alone. Lane position and headway variability were more exaggerated (Attwood et al., 1981; Ramaekers et al., 2000; Robbe, 1998) and speeds were faster (Peck et al., 1986).
"Both simulator and road studies showed that relative to alcohol use alone, participants who used cannabis alone or in combination with alcohol were more aware of their intoxication. Robbe (1998) found that participants who consumed 100 g/kg of cannabis rated their performance worse and the amount of effort required greater compared to those who consumed alcohol (0.05 BAC). Ramaekers et al. (2000) showed that cannabis use alone and in combination with alcohol consumption increased self-ratings of intoxication and decreased self-ratings of performance. Lamers and Ramaekers (2001) found that cannabis use alone (100 g/kg) and in combination with alcohol consumption resulted in lower ratings of alertness, greater perceptions of effort, and worse ratings of performance."

"Our primary analysis looked at the risk of a motor vehicle collision while under the influence of cannabis and included all nine studies (relating to 49 411 participants). The pooled risk of a motor vehicle collision while driving under the influence of cannabis was almost twice the risk while driving unimpaired (odds ratio 1.92 (95% confidence interval 1.35 to 2.73); P=0.0003); we noted heterogeneity among the individual study effects (I2=81%).
"We also assessed culpability and non-culpability studies separately and explored differences between motor vehicle collisions resulting in deaths and non-fatal injuries. Meta-analyses on subgroups of studies explored the potential effect of specific features related to study design and potential biases: case-control studies versus culpability studies, fatal collisions versus non-fatal collisions, and high quality studies versus medium quality studies (fig 3?).
"High quality studies had a pooled odds ratio that was higher than that for medium quality studies, although both results showed a significant association at the 0.05 level. Furthermore, case-control studies (2.79 (1.23 to 6.33); P=0.01) estimated the effect of cannabis use on crash risk to be higher than that estimated by culpability studies (1.65 (1.11 to 2.46); P=0.07). Studies of fatal collisions (2.10 (1.31 to 3.36); P=0.002) had a pooled odds ratio that was statistically significant, but studies of non-fatal collisions (1.74 (0.88 to 3.46); P=0.11) did not show significant results.
"In all studies assessing cannabis use in conjunction with alcohol, the estimated odds ratio for cannabis and alcohol combined was higher than for cannabis use alone, suggesting the presence of a synergistic effect."

"Overall, 23,591 (90.9%) of the 25,951 drivers who died within 1 hour of a crash in these 6 states underwent toxicological testing. Drivers who were tested for drugs were similar in crash circumstances to those who were not tested, but they appeared to be slightly younger (mean age = 39.4 (standard deviation, 19.4) years vs. 43.4 (standard deviation, 27.7) years), more likely to be male (77.7% vs. 75.8%), more likely to be involved in nighttime crashes (51.4% vs. 47.0%), and more likely to have been involved in a crash in the previous 3 years (15.7% vs. 13.9%) than those who were not tested.
"Of the 23,591 drivers tested, 39.7% were positive for alcohol, and 24.8% tested positive for other drugs. The prevalence of alcohol involvement was stable at approximately 39% from 1999 to 2010 (Z = ?1.4, P = 0.16). Alcohol involvement was more prevalent in men (43.6%) than in women (26.1%), but trends were stable for both sexes (Table 1). In contrast, the prevalence of nonalcohol drugs showed a statistically significant increasing trend over the study period, rising from 16.6% (95% confidence interval (CI): 14.8, 18.4) in 1999 to 28.3% (95% CI: 26.0, 30.7) in 2010 (Z = ?10.19, P < 0.0001). The prevalence rates of non-alcohol drugs and 2 or more nonalcohol drugs increased significantly over the study period in both sexes (Table 1). The prevalence of nonalcohol drug use increased significantly across all age groups (Figure 1)."

"Although for the mobile phone conversation and cannabis studies the reaction times were slightly different, they were still comparable. The same visual stimulus was used and was presented in the same visual scene. When reaction times under each condition were compared with the baseline reaction times measured, alcohol gave a 12.5% increase in reaction times, cannabis a 21% increase, a hands-free mobile phone conversation increased reaction times by 26.5%, texting by 37.4%, using a smartphone for social networking by 37.6% and using a mobile phone for a hand-held mobile phone conversation increased reaction times by 45.9% compared to the baseline condition. Thus, using a smartphone for social networking resulted in a greater impairment to reaction times than alcohol, cannabis, hand held mobile phone conversations and texting, but less than a hand held mobile conversation."

"The prevalence of drugs detected in cases was higher than in controls across the drug categories (Table 3). Marijuana, narcotics, stimulants, and depressants were each associated with a significantly increased risk of fatal crash involvement, with estimated odds ratios ranging from 1.83 for marijuana to 4.83 for depressants (Table 3). Polydrug use, defined as use of two or more non-alcohol drugs, was associated with a 3.4-fold increased risk of fatal crash involvement (Table 3).
"About one-fifth (20.5%) of the cases tested positive for alcohol and one or more drugs, compared with 2.2% of the controls. Relative to drivers who tested positive for neither alcohol nor drugs, the estimated odds of fatal crash involvement increased over 13 folds for those who were alcohol-positive but drug-negative, more than two folds for those who were alcohol-negative but drug-positive, and 23 folds for those who were positive for both alcohol and drugs (Table 4)."

"We found only limited evidence to support the claim that cannabis use increases accident risk. Participants who had driven under the influence of cannabis in the previous year appeared to be no more likely than drug-free drivers to report that they had had an accident in the previous 12 months. Prima facie, this would seem to suggest that cannabis-intoxicated driving is not a risk factor for non-fatal accidents. In this sense, the results would support those of Longo et al. (2000b) who found no relationship between recent cannabis use and driver culpability for non-fatal accidents."

"Absorption is slower following the oral route of administration with lower, more delayed peak THC levels. Bioavailability is reduced following oral ingestion due to extensive first pass metabolism. Smoking marijuana results in rapid absorption with peak THC plasma concentrations occurring prior to the end of smoking. Concentrations vary depending on the potency of marijuana and the manner in which the drug is smoked, however, peak plasma concentrations of 100-200 ng/mL are routinely encountered. Plasma THC concentrations generally fall below 5 ng/mL less than 3 hours after smoking. THC is highly lipid soluble, and plasma and urinary elimination half-lives are best estimated at 3-4 days, where the rate-limiting step is the slow redistribution to plasma of THC sequestered in the tissues. Shorter half-lives are generally reported due to limited collection intervals and less sensitive analytical methods. Plasma THC concentrations in occasional users rapidly fall below limits of quantitation within 8 to 12 h. THC is rapidly and extensively metabolized with very little THC being excreted unchanged from the body. THC is primarily metabolized to 11-hydroxy-THC which has equipotent psychoactivity. The 11-hydroxy-THC is then rapidly metabolized to the 11-nor-9-carboxy-THC (THC-COOH) which is not psychoactive. A majority of THC is excreted via the feces (~65%) with approximately 30% of the THC being eliminated in the urine as conjugated glucuronic acids and free THC hydroxylated metabolites."

"THC is the major psychoactive constituent of cannabis. Potency is dependent on THC concentration and is usually expressed as %THC per dry weight of material. Average THC concentration in marijuana is 1-5%, hashish 5-15%, and hashish oil ³ 20%. The form of marijuana known as sinsemilla is derived from the unpollinated female cannabis plant and is preferred for its high THC content (up to 17% THC). Recreational doses are highly variable and users often titer their own dose. A single intake of smoke from a pipe or joint is called a hit (approximately 1/20th of a gram). The lower the potency or THC content the more hits are needed to achieve the desired effects; 1-3 hits of high potency sinsemilla is typically enough to produce the desired effects. In terms of its psychoactive effect, a drop or two of hash oil on a cigarette is equal to a single “joint” of marijuana. Medicinally, the initial starting dose of Marinol® is 2.5 mg, twice daily."

"Cannabis use impairs cognitive, memory and psycho-motor performance in ways that may impair driving.¹⁰ Recent data suggest that approximately 5% of Canadian drivers/adults report driving after cannabis use in the past year.³⁹ Large-scale epidemiological studies using different methodologies (e.g., retrospective epidemiological and case control studies) have found that cannabis use acutely increases the risk of motor vehicle accident (MVA) involvement and fatal crashes among drivers.^40,41 Recent reviews have found the increase in risk to be approximately 1.5-3.0, an increase which is substantially lower, however, than that in alcohol-impaired drivers. The impairment from concurrent alcohol and cannabis use may be multiplicative, so individuals who drive under the influence of both drugs may be at higher risk for MVAs.⁴² An expert consensus view was that a THC concentration of 7-10 nanograms per millilitre in serum would produce impairment equivalent to that of 0.05% blood alcohol content (BAC). It was suggested that this level could serve as a 'per se' limit to define cannabis-impaired driving.⁴³ Current research suggests that acute impairment from cannabis typically clears 3-4 hours after use.⁴⁴
"This time span could be recommended to users as a minimum wait period before driving. The required wait before driving would need to be longer for higher doses, and would also vary on the basis of individual variation."

"A review of over a dozen of these [laboratory] experiments reveals three findings. First, after using marijuana, people drive more slowly. In addition, they increase the distance between their cars and the car in front of them. Third, they are less likely to attempt to pass other vehicles on the road. All of these practices can decrease the chance of crashes and certainly limit the probability of injury or death if an accident does occur. These three habits may explain the slightly lower risk of accidents that appears in the epidemiological studies. These results contrast dramatically to those found for alcohol. Alcohol intoxication often increases speed and passing while decreasing following distance, and markedly raises the chance of crashes.(632)"

"There is considerable evidence from laboratory studies that cannabis (marijuana) impairs reaction time, attention, tracking, hand-eye coordination, and concentration, although not all of these impairments were equally detected by all studies (Couper & Logan, 2004a; Heishman, Stitzer, & Yingling, 1989; Gieringer, 1988; Moskowitz, 1985). In reviewing the literature on marijuana, Smiley (1998) concluded that marijuana impairs performance in divided attention tasks (i.e., a poorer performance on subsidiary tasks). Jones et al. (2003) adds that Smiley’s finding is relevant to the multitasking essence of driving, in particular by making marijuana impaired drivers perhaps less able to handle unexpected events. Interestingly, there is also evidence showing that, unlike alcohol, marijuana enhances rather than mitigates the individual’s perception of impairment (Lamers & Ramaekers, 1999; Robbe & O'Hanlon, 1993; Perez-Reyes, Hicks, Bumberry, Jeffcoat, & Cook, 1988). Robbe and O'Hanlon (1993) reported that in laboratory conditions, drivers under the influence of marijuana were aware of their impairment, which led them to decrease speed, avoid passing other vehicles, and reduce other risk-taking behaviors. Such was not the case with alcohol; for the authors reported that alcohol-impaired drivers were generally not aware of impairment, and therefore did not adjust their driving accordingly."

"Cannabis is only considered a risk factor for traffic accidents if drivers operate vehicles after consuming the drug. Robbe (1994) found that 30% to 90% of his participants were willing to drive after consuming a typical dose of cannabis. This is consistent with a recent Australian survey in which more than 50% of users drove after consuming cannabis (Lenne, Fry, Dietze, & Rumbold, 2000). A self administered questionnaire given to 508 students in grades 10 to 13 in Ontario, Canada, found that 19.7% reported driving within an hour after using cannabis (Adlaf, Mann, & Paglia, 2003)."

"Participants receiving active marijuana decreased their speed more so than those receiving the placebo cigarette during a distracted section of the drive, An overall effect of marijuana was seen for the mean speed during the distracted driving (PASAT [Paced Auditory Serial-Addition Test] section), While no other changes in driving performance were found, marijuana appeared to hinder practice effects on the PASAT task, suggesting individuals may not be able to adequately use information and experience previously acquired while under the influence of marijuana, While only minimal differences in driving performance were found, this failure to benefit from prior practice may be detrimental to driving performance. Research has shown that graduated driver's licensing programs in which participants receive more on the road training results in a decrease in fatal crashes in 16-year-olds (Baker, Chen & Li 2006), If marijuana indeed impairs one's ability to use prior experience to improve performance, this will likely impair driving under pretrained conditions (e,g,, steering into a skid, allowing increased stopping time on slippery roads, etc)."

"The present study's subtle finding of decreased speed under the influence of acute marijuana is generally consistent with the literature, which has found that marijuana's effects on driving can be subtle. In Berghaus's review of the literature prior to 1995, 45% of driving simulator studies showed no impairment from marijuana within the first hour after use (Berghaus, Scheer & Schmidt 1995), More cautious driving behaviors were found in several studies (Lamers & Ramaekers 2001; Stein et al, 1983; Ellingstad, McFarling & Struckman 1973; Rafaelsen, Bech & Rafaelsen 1973; Dott 1972), while an increased reaction time for stopping was the most common finding (Liguori, Gatto & Robinson 1998; Rafaelsen, Bech & Rafaelsen 1973), Moskowitz, Ziedman and Sharma (1976) also found slowed reaction times for a visual choice-reaction time task administered while driving and Smiley, Moskowitz and Zeidman (1981) found increased variability in velocity and lateral position while following curves and while controlling the car in gusts of wind with a high dose of marijuana (200 mcg/kg THC) but not with a lower dose (100 mcg/kg THC), They also found an increase in variability of headway and lateral position while following other cars."

"The decreased speed during the simulated drive could be interpreted as an attempt to compensate for perceived cognitive impairment, Alternatively, marijuana may not have affected decision making and judgment and the reduction in speed would improve safety margins, While the clinical significance of a 3% to 5% decrease in speed may be questioned, previous research suggests such a decrease will result in approximately a 7% decrease in all injuries and a 15% decrease in fatalities (Nilsson 1981), Use of an alternate task design in which subjects are requested to drive as quickly and as safely as possible rather than following a posted speed limit may provide more insight into compensatory strategies employed while driving under the influence of marijuana, Use of a more challenging road paradigm (e.g., icy or gravel roads) which capitalizes on the use of practice effects may aid in identifying differences in driving performance under the influence of marijuana, There was significant between-subject variability in driving measures and future studies would be further strengthened by using a within-subjects design."

"Epidemiological studies have been inconclusive regarding whether cannabis use causes an increased risk of motor vehicle accidents; in contrast, unanimity exists that alcohol use increases crash risk.³⁰ In tests using driving simulation, neurocognitive impairment varies in a dose-related fashion, and symptoms are more pronounced with highly automatic driving functions than with more complex tasks that require conscious control.³¹ Cannabis smokers tend to over-estimate their impairment and compensate effectively while driving by utilizing a variety of behavioral strategies."

"When compared to alcohol, cannabis is detected far less often in accident-involved drivers. Drummer et al. (2003) cited several studies and found that alcohol was detected in 12.5% to 79% of drivers involved in accidents. With regard to crash risk, a large study conducted by Borkenstein, Crowther, Shumate, Zeil and Zylman (1964) compared BAC in approximately 6,000 accident-involved drivers and 7,600 nonaccident controls. They determined the crash risk for each BAC by comparing the number of accident-involved drivers with detected levels of alcohol at each BAC to the number of nonaccident control drivers with the same BAC. They found that crash risk increased sharply as BAC increased. More specifically, at a BAC of 0.10, drivers were approximately five times more likely to be involved in an accident.
"Similar crash risk results were obtained when data for culpable drivers were evaluated. Drummer (1995) found that drivers with detected levels of alcohol were 7.6 times more likely to be culpable. Longo et al. (2000) showed that drivers who tested positive for alcohol were 8.0 times more culpable, and alcohol consumption in combination with cannabis use produced an odds ratio of 5.4. Similar results were also noted by Swann (2000) and Drummer et al. (2003)."

"Another paradigm used to assess crash risk is to use cross-sectional surveys of reported nonfatal accidents that can be related to the presence of risk factors, such as alcohol and cannabis consumption. Such a methodology was employed in a provocative dissertation by Laixuthai (1994). This study used data from two large surveys that were nationally representative of high school students in the United States during 1982 and 1989. Results showed that cannabis use was negatively correlated with nonfatal accidents, but these results can be attributed to changes in the amount of alcohol consumed. More specifically, the decriminalization of cannabis and the subsequent reduction in penalty cost, as well as a reduced purchase price of cannabis, made cannabis more appealing and affordable for young consumers. This resulted in more cannabis use, which substituted for alcohol consumption, leading to less frequent and less heavy drinking. The reduction in the amount of alcohol consumed resulted in fewer nonfatal accidents."

"Most of the research on cannabis use has been conducted under laboratory conditions. The literature reviews by Robbe (1994), Hall, Solowij, and Lemon (1994), Border and Norton (1996), and Solowij (1998) agreed that the most extensive effect of cannabis is to impair memory and attention. Additional deficits include problems with temporal processing, (complex) reaction times, and dynamic tracking. These conclusions are generally consistent with the psychopharmacological effects of cannabis mentioned above, including problems with attention, memory, motor coordination, and alertness.
"A meta-analysis by Krüger and Berghaus (1995) profiled the effects of cannabis and alcohol. They reviewed 197 published studies of alcohol and 60 studies of cannabis. Their analysis showed that 50% of the reported effects were significant at a BAC of 0.073 g/dl and a THC level of 11 ng/ml. This implies that if the legal BAC threshold for alcohol is 0.08 g/dl, the corresponding level of THC that would impair the same percentage of tests would be approximately 11 ng/ml."

"Several studies have examined cannabis use in driving simulator and on-road situations. The most comprehensive review was done by Smiley in 1986 and then again in 1999. Several trends are evident and can be described by three general performance characteristics:

"1. Cannabis increased variability of speed and headway as well as lane position (Attwood, Williams, McBurney, & Frecker, 1981; Ramaekers, Robbe, & O'Hanlon, 2000; Robbe, 1998; Sexton et al., 2000; Smiley, Moskowitz, & Zeidman, 1981; Smiley, Noy, & Tostowaryk, 1987). This was more pronounced under high workload and unexpected conditions, such as curves and wind gusts.

"2. Cannabis increased the time needed to overtake another vehicle (Dott, 1972 [as cited in Smiley, 1986]) and delayed responses to both secondary and tracking tasks (Casswell, 1977; Moskowitz, Hulbert, & McGlothlin,
1976; Sexton et al., 2000; Smiley et al., 1981).

"3. Cannabis resulted in fewer attempts to overtake another vehicle(Dott, 1972) and larger distances required to pass (Ellingstad et al., 1973 [as cited in Smiley, 1986]). Evidence of increased caution also included slower speeds (Casswell, 1977; Hansteen, Miller, Lonero, Reid, & Jones, 1976; Krueger & Vollrath, 2000; Peck, Biasotti, Boland, Mallory, & Reeve, 1986; Sexton et al., 2000; Smiley et al., 1981; Stein, Allen, Cook, & Karl, 1983) and larger headways (Robbe, 1998; Smiley et al., 1987)."

"Both simulator and road studies showed that relative to alcohol use alone, participants who used cannabis alone or in combination with alcohol were more aware of their intoxication. Robbe (1998) found that participants who consumed 100 g/kg of cannabis rated their performance worse and the amount of effort required greater compared to those who consumed alcohol (0.05 BAC). Ramaekers et al. (2000) showed that cannabis use alone and in combination with alcohol consumption increased self-ratings of intoxication and decreased self-ratings of performance. Lamers and Ramaekers (2001) found that cannabis use alone (100 g/kg) and in combination with alcohol consumption resulted in lower ratings of alertness, greater perceptions of effort, and worse ratings of performance."

"Both Australian studies suggest cannabis may actually reduce the responsibility rate and lower crash risk. Put another way, cannabis consumption either increases driving ability or, more likely, drivers who use cannabis make adjustments in driving style to compensate for any loss of skill (Drummer, 1995). This is consistent with simulator and road studies that show drivers who consumed cannabis slowed down and drove more cautiously (see Ward & Dye, 1999; Smiley, 1999. This compensation could help reduce the probability of being at fault in a motor vehicle accident since drivers have more time to respond and avoid a collision. However, it must be noted that any behavioral compensation may not be sufficient to cope with the reduced safety margin resulting from the impairment of driver functioning and capacity."

"In 1937, Congress passed the first federal law to discourage cannabis production for marijuana while still permitting industrial uses of the crop (the Marihuana Tax Act; 50 Stat. 551). Under this statute, the government actively encouraged farmers to grow hemp for fiber and oil during World War II. After the war, competition from synthetic fibers, the Marihuana Tax Act, and increasing public anti-drug sentiment resulted in fewer and fewer acres of hemp being planted and none at all after 1958. The Controlled Substances Act of 1970 (CSA, 21 U.S.C. §801 et. seq.) placed the control of select plants, drugs, and chemical substances under federal jurisdiction and was enacted, in part, to replace previous federal drug laws with a single comprehensive statute.⁴³

"The CSA adopted the same definition of Cannabis sativa that appeared in the 1937 Marihuana Tax Act. The definition of “marihuana” (21 U.S.C. §802(16)) reads:

"The term marihuana means all parts of the plant Cannabis sativa L., whether growing or not; the seeds thereof; the resin extracted from any part of such plant; and every compound, manufacture, salt, derivative, mixture, or preparation of such plant, its seeds or resin. Such term does not include the mature stalks of such plant, fiber produced from such stalks, oil or cake made from the seeds of such plant, any other compound ... or preparation of such mature stalks (except the resin extracted therefrom), fiber, oil, or cake, or the sterilized seed of such plant which is incapable of germination."

"The statute thus retains control over all varieties of the cannabis plant by virtue of including them under the term marihuana and does not distinguish between low- and high-THC varieties. The language exempts from control the parts of mature plants—stalks, fiber, oil, cake, etc.—intended for industrial uses. Some have argued that the CSA definition exempts industrial hemp under its term exclusions for stalks, fiber, oil, cake, and seeds.⁴⁴ DEA refutes this interpretation.⁴⁵

"Strictly speaking, CSA does not make growing cannabis illegal; rather, it places strict controls on its production, making it illegal to grow the crop without a DEA permit. Regarding industrial hemp, however, growers that comply with the 2014 farm bill provision (discussed in the next section) do not need DEA approval."

"Based on the research to date, the harms associated with the actual use of cannabis likely pale in comparison with the widely observed harms attributable to cannabis prohibition. As such, policymakers should integrate the scientific research conducted on the likely impacts of current prohibitive approaches to cannabis use into the process of optimising cannabis policy."

The U.S. Penal Code violations for marijuana and possible sentences:
Violation: "1000 kilograms or more of a mixture or substance containing a detectable amount of marihuana, or 1,000 or more marihuana plants regardless of weight."
Sentence: not "less than 10 years or more than life" "No person sentenced under this subparagraph shall be eligible for parole during the term of imprisonment imposed therein."
Violation: "100 kilograms or more of a mixture or substance containing a detectable amount of marihuana, or 100 or more marihuana plants regardless of weight."
Sentence: not "less than 5 years and not more than 40 years" "No person sentenced under this subparagraph shall be eligible for parole during the term of imprisonment imposed therein."
Violation: "less than 50 kilograms of marihuana, except in the case of 50 or more marihuana plants regardless of weight, 10 kilograms of hashish, or one kilogram of hashish oil"
Sentence: "not more than 5 years, a fine not to exceed the greater of that authorized in accordance with the provisions of title 18 or $250,000 if the defendant is an individual or $1,000,000 if the defendant is other than an individual, or both."

"RECOMMENDATIONS
"1. The severity of punishment for a cannabis possession charge should be reduced. Specifically, cannabis possession should be converted to a civil violation under the Contraventions Act.
"The current law involves considerable enforcement and other criminal justice costs, as well as adverse consequences to individual drug offenders, with little evidence of a substantial deterrent impact on cannabis use, and at best marginal benefits to the public health and safety of Canadians. As a minimal measure, jail should be removed as a sentencing option for cannabis possession. The available evidence indicates that removal of jail as a sentencing option would lead to considerable cost savings without leading to increases in rates of cannabis use. Punishing cannabis possession with a fine only would be consistent with current practices and prevailing public opinion."

"It is also important to point out that in no Western country is a user at much risk of being criminally penalized for using marijuana. The rates of arrest for past-year marijuana users in Western countries are typically less than or equal to 3 percent (Kilmer, 2002; Room et al., 2010). More important, almost none of those convicted of simple possession is incarcerated or receives a fine exceeding $1,000 (Pacula, MacCoun, et al., 2005)."

"There is no evidence that the depenalization component of the 1976 policy, per se, increased levels of cannabis use. On the other hand, the later growth in commercial access to cannabis, after de facto legalization, was accompanied by steep increases in use, even among youth. In interpreting that association, three points deserve emphasis. First, the association may not be causal; we have already seen that recent increases occurred in the United States and Oslo despite very different policies. Second, throughout most of the first two decades of the 1976 policy, Dutch use levels have remained at or below those in the United States. And third, it remains to be seen whether prevalence levels will drop again in response to the reduction to a 5-g limit, and to recent government efforts to close down coffee shops and more aggressively enforce the regulations."

"In California and Ohio, surveys before and after decriminalisation showed that cannabis use increased, but not at a greater rate than in US states which had not decriminalised cannabis. Single (1989) also reviewed data from two large US national surveys of drug use in the 1970s that compared rates of cannabis use in states which had and had not decriminalised cannabis. He found that the prevalence of cannabis use increased in all states, with a larger increase in those states which had not decriminalised (Single, 1989)."

"In 1968, the National Institute of Mental Health began funding a Drug Supply Program to provide researchers with compounds necessary to conduct biomedical research. Initially, the program focused on THC and other naturally occurring cannabinoids, and then gradually expanded to a wide range of compounds. (Since its beginning, the program has synthesized or obtained over 1,500 different compounds that have been supplied to over 2,500 researchers.) Cannabis was among the first substances to be made available through the Drug Supply Program for use by scientists conducting both nonhuman research and human research under a variety of investigational new drug protocols. It was grown through a contract with the University of Mississippi. With its establishment in 1974, NIDA became the successor to NIMH as the administrator of the cannabis contract and the sole U.S. source for legal cannabis."

"... the Government of Canada amend the Controlled Drugs and Substances Act to create a criminal exemption scheme. This legislation should stipulate the conditions for obtaining licenses as well as for producing and selling cannabis; criminal penalties for illegal trafficking and export; and the preservation of criminal penalties for all activities falling outside the scope of the exemption scheme."

"Our conclusion is that the present law on cannabis produces more harm than it prevents. It is very expensive of the time and resources of the criminal justice system and especially of the police. It inevitably bears more heavily on young people in the streets of inner cities, who are also more likely to be from minority ethnic communities, and as such is inimical to police-community relations. It criminalizes large numbers of otherwise law-abiding, mainly young, people to the detriment of their futures. It has become a proxy for the control of public order; and it inhibits accurate education about the relative risks of different drugs including the risks of cannabis itself."

"Rather than inducing violent or aggressive behavior through its purported effects of lowering inhibitions, weakening impulse control and heightening aggressive tendencies, marihuana was usually found to inhibit the expression of aggressive impulses by pacifying the user, interfering with muscular coordination, reducing psychomotor activities and generally producing states of drowsiness lethargy, timidity and passivity."

"Proponents of criminalization attribute to their preferred drug-control regime a special power to affect user behavior. Our findings cast doubt on such attributions. Despite widespread lawful availability of cannabis in Amsterdam, there were no differences between the 2 cities [Amsterdam and San Francisco] in age at onset of use, age at first regular use, or age at the start of maximum use."
"Our findings do not support claims that criminalization reduces cannabis use and that decriminalization increases cannabis use."

"Only orally given THC and, to a lesser extent, nefazodone have shown promise [in treating marijuana dependence]. THC reduced craving and ratings of anxiety, feelings of misery, difficulty sleeping, and chills (Haney et al., 2004). In addition, participants could not distinguish active THC from placebo. These findings were replicated in an outpatient study, which found that a moderate oral dosage of THC (10 mg, three times daily) suppressed many marijuana withdrawal symptoms and that a higher dosage (30 mg, three times daily) almost completely abolished withdrawal symptoms (Budney et al., 2007)."

"Marihuana's relative potential for harm to the vast majority of individual users and its actual impact on society does not justify a social policy designed to seek out and firmly punish those who use it. This judgment is based on prevalent use patterns, on behavior exhibited by the vast majority of users and on our interpretations of existing medical and scientific data. This position also is consistent with the estimate by law enforcement personnel that the elimination of use is unattainable."

"Under the current contract with the University of Mississippi for any given year NIDA [National Institute on Drug Abuse] has the option to grow either 1.5 or 6.5 acres of cannabis, or to not grow any at all, depending on research demand. Generally, 1.5 acres are grown in alternate years. The number of cannabis cigarettes produced from 1.5 acres is about 50,000-60,000, although it can be higher. Cigarettes are produced in three potencies: strength 1 - 3-4 %; strength 2 - 1.8-2.2 %; and strength 3 - placebo, as close to 0% as possible. During the past three years, the following quantities have been shipped: 1994 - 24,000 cigarettes; 1995 - 23, 100 - cigarettes; and 1996 17,700 cigarettes. Virtually all of the cigarettes shipped in the last three years have been for single patient INDs. As of March 1997 there were 278, 100 cigarettes in stock. The cigarettes are maintained in frozen storage and have a useful life of approximately five years."

"Synthetic cannabinoids are functionally similar to delta9-tetrahydrocannabinol (THC), the psychoactive principle of cannabis, and bind to the same cannabinoid receptors in the brain and peripheral organs."

"Much of our understanding of cannabinoid tolerance, dependence, and withdrawal has been based on studies involving ∆⁹-THC, a relatively weak partial agonist at CB1 and CB2 receptors. However, the SCBs [Synthetic Cannabinoids] commonly found in quasi-legal commercial products, such as K2 and Spice, are typically full cannabinoid receptor agonists. Importantly, a drug’s efficacy determines how “powerful” its maximal effects may be in biological systems. A low efficacy cannabinoid like ∆⁹-THC will have a less pronounced maximal effect than a higher efficacy cannabinoid, such as the SCBs present in commercial products, and this difference in maximal effects cannot be overcome simply by increasing the dose of ∆⁹-THC. In other words, no amount of ∆⁹-THC can stimulate cannabinoid receptors to the same degree as the SCBs currently emerging as drugs of abuse. This has left researchers working with these high efficacy SCBs in the unusual position of having to determine whether their effects are related to the unprecedented degree of cannabinoid receptor stimulation elicited by these compounds, or whether they are produced by interactions with other, noncannabinoid receptor systems."

"Increased funding for cannabis prohibition has increased cannabis seizures and arrests, but the assumption that this reduces cannabis potency, increases price or meaningfully reduces availability or use is inconsistent with surveillance data the US federal government has itself collected."

"There are indications that cannabis was used as early as 4000 B.C. in Central Asia and north-western China, with written evidence going back to 2700 B.C. in the pharmacopeia of emperor Chen-Nong. It then gradually spread across the globe, to India (some 1500 B.C., also mentioned in Altharva Veda, one of four holy books about 1400 B.C.¹), the Near and Middle East (some 900 B.C.), Europe (some 800 B.C.), various parts of South-East Asia (2nd century A.D.), Africa (as of the 11th century A.D.) to the Americas (19th century) and the rest of the world.²"

"The biological (reproductive) definition of a species states that all specimens of a population are of a single species if they are naturally able to sexually reproduce, generating fertile offspring. This is the case throughout the genus Cannabis, and by this definition, therefore, there are no clear biological grounds to separate it into different species.However, within the species Cannabis sativa L., several subspecies are sometimes identified (Small and Cronquist, 1976).

"Despite this, modern Cannabis taxonomy remains confused, as a scientific minority prefers to define species according to their typological or morphological characteristics. In 1974, Schultes et al. described three putative species, Cannabis sativa L. (a typically tall species used for fibre, seed or psychoactive use), Cannabis indica Lam. (a short, wide-leafed plant from Afghanistan, used to produce resin) and Cannabis ruderalis Jan. (a short unbranched roadside plant with minimal drug content)."

"Prohibition has two effects: on one hand it raises supplier costs, disrupts market functioning and prevents open promotion of the product; on the other, it sacrifices the authorities’ ability to tax transactions and regulate operation of the market, product characteristics and promotional activity of suppliers. The cannabis prevalence rates presented in Figure 1 show clearly that prohibition has failed to prevent widespread use of the drug and leaves open the possibility that it might be easier to control the harmful use of cannabis by regulation of a legal market than to control illicit consumption under prohibition. The contrast between the general welcome for tobacco regulation (including bans on smoking in public places) and the deep suspicion of prohibition policy on cannabis is striking and suggests that a middle course of legalised but limited consumption may find a public consensus."