The Decriminalization of Cannabis Use: Do We Have Enough Research To Back up Clinical Practice Guidelines?

Case Study: Sean Worsley was suffering from PTSD and chronic pain after serving in the Iraq War. While he and his wife were stopping to get gas while travelling in Alabama, a police officer stopped them because of their loud music. The vet had an Arizona issued Medical marijuana card but was expired. He had previously failed to appear in court for when the VA denied his application for a substance abuse program. Because it was illegal for him to possess marijuana with an expired card, and there was a fugitive warrant arrest for him, he ended up in jail. He had already been in jail for 6 months awaiting trial and could end up being sentenced for 60 months as a guest at the state prison (Moseley, 2020).

Analysis: In 2004,10% of State prisoners reported prior service in the U.S. Armed Forces, and 22% of those who were in prison were for marijuana and drug related offenses (Noonan and Mumola, 2007). This statistic is old but it raises a couple of significant issues: Veterans like Worsely (featured in the case study above) are issued medical marijuana cards by states that legalize medical marijuana use, however, when these vets travel or move to other states that have not legalize the use of medical marijuana, these vets could get arrested and punished for what the system failed to address: a lack of a Federal Bill that clearly define legal, and medical guidelines for medical marijuana use. The second issue is that among vets, untreated, undertreated PTSD and substance use have led to vets committing suicide, homicide, homelessness, violence that could have been potentially prevented with more research done with the use of medical marijuana and other adjunctive treatment modalities. With the pandemic, there is a dire need to mental health providers to advocate for veterans, nurses, and everyone who currently and or will potentially suffer from trauma as a consequence of what is happening in today’s world.

I. Introduction

The ethical, legal and moral issue of marijuana legalization has been a political debate not only for the limited research to back up cannabis medical use, the recreational use that raises challenging workplace questions related to drug testing, disability accommodation, workplace safety, hiring, and employment termination, but more so from the fact that from 2001 to 2010 over 8.2 million people have been arrested for either marijuana sales, possession, use, cultivating (Hickely, & McLaughlin, 2019). According to the Pew Research Foundation, four in 10 US drug arrests, or 650,000 people were arrested for marijuana offenses, (Gramlich,2020) in 2018, and over time, these arrests have incurred billions of tax dollars in lived lost, loss of productivity among those arrested, the cost of supporting inmates in jail while serving their time, and time, and salaries of those who are involved in the investigation, arrest, trial of those incarcerated for possession, sale or use of marijuana (Americans for Safe Access, 2013).

It was several days ago, December 4th, 2020, when the House of Representatives approved the bill to decriminalize marijuana at the Federal level. The bill creates an excise tax on cannabis sales and directs the money to be targeted to communities adversely affected by the so-called war on drugs. The bill also includes incentives for minority businesses to help them enter the cannabis market. Better yet, the More Act is the bill that proposes removing Federal penalties on marijuana, expungement of those nonviolent marijuana convictions (Walsh, 2020). As of today, 36 states have legalized the use of medical marijuana and 15 states have considered it legal to use marijuana recreationally (see Figure 1). The nature and demand for marijuana laws is fast-evolving. Despite the More bill, there will always remain a wide variance in-laws and policies from state to state. What is crucial for health care providers is to develop standards of practice that will serve as a foundation for safe medical marijuana use. The purpose of this paper is to review the history behind marijuana use and to explore how the medical community could work collaboratively with consumers, medical dispensaries and advocacy organizations to develop a tracking system that could help evaluate processes and outcomes to support evidence-based clinical practice guidelines for medical marijuana use.

Figure 1 States Where Marijuana is Legalized

II. Historical Perspective

Cannabis is one of the oldest documented plants that has over 400 chemical components and is the most widely used illicit drug in the world. Cannabis has been known to have medicinal effects on several disease processes, including mental health issues like anxiety and post-traumatic stress disorder.

Public Broadcasting Service outlined the history of marijuana in the US:

• Colonial Era: Production of hemp (the cannabis plant) was encouraged by the government in the 17th Century for the production of rope, sails, and clothing. In the late 19th Century, marijuana became a popular ingredient in many medicinal products and was sold openly in pharmacies.
• Mexican Revolution of 1910, Mexican immigrants flooded into the United States, bringing with them the recreational use of marijuana. The drug became associated with the immigrants and the fear and , in turn, prejudice about the newcomers became associated with marijuana. Anti-drug campaigners warned against the encroaching "Marijuana Menace". During the Great Depression, massive unemployment and increased public resentment and fear of Mexican immigrants escalated public and governmental concern about the potential problem of marijuana. By 1931, 29 states had outlawed marijuana.
• In 1937, Congress passed the Marijuana Tax Act, effectively criminalizing marijuana. Meanwhile the New York Academy of Medicine issued an extensive report declaring marijuana did not induce violence, or insanity, or lead to addiction or other drug use. During World War II, the U.S. Department of Agriculture turned to hemp to produce marine cordage, parachutes and other military gear. It launched a "Hemp for Victory" program and registered 375,000 acres of hemp in the United States.
• In the 1950s, federal laws which set mandatory sentences for drug-related offenses were enacted. Yet in the 1960s a cultural climate shifts led to more lenient attitudes towards marijuana. Again, reports commissioned by Presidents Kennedy and Johnson found that marijuana use did not induce violence or lead to the use of heavier drugs.
• 1970, Congress repealed mandatory penalties for drug-related offenses. In 1972, the bipartisan Shafer Commission, appointed by President Nixon at the direction of Congress, considered laws regarding marijuana and determined that personal use of marijuana should be decriminalized. Nixon rejected the recommendation, but over the course of the 1970s, eleven states decriminalized marijuana and most others reduced their penalties.
• 1976 a parent's movement against marijuana began and was instrumental in affecting public attitudes which lead to the 1980s War on Drugs. Mandatory sentences were re-enacted by President Reagan and continued on until President Bush through the "three strikes you're out" policy, required life sentences for repeat drug offenders.
• 1996 California passed Proposition 215 which allows the sale and medical use of marijuana for patients with AIDS, cancer, and other serious painful diseases.

III. The Marijuana and its Known Effects on the Human Body

• There are cannabis receptors (CB1Rs) found at the terminals of central and peripheral neurons, where they mostly mediate inhibitory action on the ongoing release of a number of excitatory and inhibitory dopaminergic, gamma-aminobutyric acid (GABA), glutamatergic, serotoninergic, noradrenalin, and acetylcholine neurotransmitter systems. Cognition, memory, motor movements, and pain perception are affected by the release of endocannabinoids, such as AEA and 2-AG, from the postsynaptic sites to the synaptic cleft occur in response to elevation of intracellular calcium. They also act as retrograde neurotransmitters on located CB1Rs to maintain homeostasis and prevent excessive neuronal activity. They are then rapidly removed from the extracellular space by cannabinoid transporters, (anandamide membrane transporters) which hastens their breakdown by internalizing the molecule and allowing access to fatty acid amide hydrolase. Despite its significance in the endocannabinoid system, little is known about the cannabinoid transporters. With cannabis, d-9-THC act as partial agonist that binds to CB1R, inhibiting the release of neurotransmitters normally modulated by endocannabinoids such as AEA and 2-AG. The process may also increase the release of dopamine, glutamate and acetylcholine in certain brain regions, possibly by inhibiting the release of an inhibitory neurotransmitter like GABA onto dopamine, glutamate or acetylcholine-releasing neurons.

Figure 1 Neurotransmitters

The functionalities of the CB1Rs are not always straightforward due to complex interactions with the other neurotransmitter systems.

The cannabis plant has two main subspecies, Cannabis indica, and Cannabis sativa.

The Indica-dominant strains are short plants with broad, dark green leaves and have higher cannabidiol content than the Sativa plants in which THC content is higher. Sativa-dominant strains are usually taller and have thin leaves with a pale green color. Due to its higher THC content, C. Sativa is the preferred choice by users. It is a complex plant with about 426 chemical entities, of which more than 60 are cannabinoid compounds. There are four major compounds found from the plant: d-9-THC, CBD, d-8-THC, and cannabinol, which have been most researched. Below is a table for marijuana strains and their known efficacy for medical issues (Carter, 2019).

IV. Clinical Practice Guidelines and the Significance of Registries

With this research, there are no specific prescription guidelines and that is specific for the treatment of PTSD. Practice recommendations were based upon a review of literature conducted by the Canadian Agency for Drugs and Technologies in Health published in 2017 (https://www.ncbi.nlm.nih.gov/books/NBK442067/; Shishiko, et.al.2018).

With this research, it was noted that medical marijuana programs by state governments in the US are the lack of established dispensary standards for monitoring the use and impact. There exist no audit standards that set practice guidelines for prescribers. Prometheus research has published a white paper emphasizing the role of site-specific registries in reducing barriers to the acceptance of medical marijuana by providers, patients, and health agencies. More specifically, the white paper states how dispensaries could provide an ideal reference point for developing provider-mediated marijuana medication management and reporting; provider real-time databases (registries) that can play in supporting much-needed studies on the long-run effects of cannabis, optimal dosing, cannabinoid ratios, and alternative administration routes and finally address concerns about the quality of evidence for support interventions in non-cancer severe pain, anxiety, PTSD and other disease processes that marijuana is indicated for (https://iqvia.prometheusresearch.com/whitepaper-outcomes-registries-and-medical-marijuana).

V. Conclusion

The issue with the legalization of medical marijuana is not just the inconsistent standards in enforcing the criminalization of the use and possession of the drug but worse off is that the medical community is not prepared to set a standardized practice protocol for the prescription and use of medical marijuana for diseases that it is supposedly indicated for and dose-specific guidelines for various age groups. With the pandemic repercussions that document anxiety, PTSD, and mental health issues, it is imperative that health care providers collaborate with various similar interest groups to maximize the use of technology to safeguard the public especially in this age of vulnerability.

References:

Carter, A. (2019). Sativa vs. Indica: What to Expect Across Cannabis Types and Strains. Accessed from https://www.healthline.com/health/sativa-vs-indica#takeaway

Gramlich, J., 2020. Four-in-ten U.S. drug arrests in 2018 were for marijuana offenses – mostly possession. Accessed from https://www.pewresearch.org/fact-tank/2020/01/22/four-in-ten- u-s-drug-arrests-in-2018-were-for-marijuana-offenses-mostly-possession/

Medical Marijuana for Post-Traumatic Stress Disorder: A Review of Clinical Effectiveness and Guidelines [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2017 Jan 11. SUMMARY OF EVIDENCE. Available from: https://www.ncbi.nlm.nih.gov/books/NBK442067/

Moseley, B. (2020). Cannabis advocates troubled by veteran’s 5-year sentence for medical marijuana. Accessed from https://www.alreporter.com/2020/07/14/cannabis-advocates- troubled-by-veterans-5-year-sentence-for-medical-marijuana/

PBS, 2020. Marijuana Timeline. Accessed from https://www.pbs.org/wgbh/pages/frontline/shows/dope/etc/cron.html

Prometheus Research, 2020. Outcomes, Registries, and Medical Marijuana: Towards Establishing Dispensary Monitoring and Reporting Standards. Accessed from https://iqvia.prometheusresearch.com/whitepaper-outcomes-registries-and-medical- marijuana

Shishko, I., Oliveira, R., Moore, T. A., & Almeida, K. (2018). A review of medical marijuana for the treatment of posttraumatic stress disorder: Real symptom re-leaf or just high hopes?. The mental health clinician, 8(2), 86–94. https://doi.org/10.9740/mhc.2018.03.086

Walsh, D. (2020). House Approves Decriminalizing Marijuana; Bill To Stall In Senate. Accessed from https://www.npr.org/2020/12/04/942949288/house-approves- decriminalizing-marijuana-bill-to-stall-in-senate