From the Editor
The controversial question of whether to legalize cannabis has emerged front and center as an important issue that deserves a serious and thoughtful dialogue. Cannabis is the general term for substances derived from the plant Cannabis sativa, with varying psychoactive and pharmacological properties that are found in 3 organic products: marijuana, hemp, and cannabinoids. With each passing year more states legalize cannabis—currently 10 states—and a much larger number of states pass legislations to decriminalize cannabis, make it legal for medical use, or both.
This creates increasing confusion across the country, as the legal ramifications of possessing and using cannabis in each state becomes increasingly complex. Thoughtful arguments can be made supporting or decrying the legalization of cannabis based on an array of issues: medical risks and benefits, psychiatric risks and benefits, the possibility of easier access by vulnerable populations, legal consequences, strong-held cultural beliefs, political ideologies, potential for tax revenue, and the fostering of outdated myths about cannabis.
In this month’s issue, Former Surgeon General Joycelyn Elders and colleagues make yet another compelling argument for the legalization of cannabis. Having cannabis classified as a Schedule 1 drug (classifying cannabis as illegal, with no clinical benefits) has stymied research into this complex portfolio of over 100 cannabinoid molecules—the 2 most common being delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD). Since cannabis is illegal under federal law, researchers face significant restrictions and regulation. As a result, research has been slow, and the endogenous presence of a cannabinoid receptor in the human brain was not confirmed until 1990.
FDA approval of cannabidiol
Significantly, in June 2018 the FDA approved one of the primary components of cannabis, CBD (brand name Epidiolex), for the treatment of seizures in Dravet syndrome and Lennox-Gastaut syndrome in children and adults. As a result of this FDA approval, the Drug Enforcement Administration reclassified CBD from a Schedule 1 drug (illegal), to a Schedule 5 “controlled substance” (in the same class as pregabalin).
A rapidly growing body of double-blind placebo-controlled studies are demonstrating clinically effective properties of CBD. It is not euphorogenic and demonstrates clinical effects that are opposite to THC. CBD has demonstrated anti- inflammatory and antioxidant effects, and findings suggest benefits of its treatment for seizures, psychosis, anxiety, multiple sclerosis, and movement disorders.
The extensive amount of information now available on cannabis is exemplified by the 2017 publication The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research.1 All relevant publications on cannabis were reviewed for this document and the document nicely describes the degree of evidence supporting the risks and benefits of cannabis use. The following possible or established benefits are listed: anti-emetic effect in chemotherapy-induced nausea/vomiting; increased appetite and decreased weight loss in individuals with HIV/AIDS; improved clinician-measured and patient-reported spasticity in multiple sclerosis; improved short-term sleep in individuals with a documented sleep disturbance; improved symptoms in some anxiety disorders; decrease in some types of chronic pain in adults; and improved symptoms in Tourette syndrome.
1. National Academies on Sciences, Engineering and Medicine. The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. 2017. http://www.nap.edu/24625. Accessed March 13, 2019.
2. ElSohly MA, Mehmedic Z, Foster S, et al. Changes in cannabis potency over the last 2 decades (1995-2014): analysis of current data in the United States. Biol Psychiatry. 2016;79:613-619.
3. Atakan Z. Cannabis, a complex plant: different compounds and different effects on individuals. Ther Adv Psychopharmacol. 2012;2:241-254.
4. Maccarrone M, Guzmán M, Mackie K, et al. Programming of neural cells by (endo) cannabinoids: from physiological rules to emerging therapies. Nature Rev. 2014;12:786-801.
5. Andrade C. Cannabis and neuropsychiatry, 2: the longitudinal risk of psychosis as an adverse outcome. J Clin Psychiatry. 2016;77:e739-e742.
6. McGuire P, Robson P, Cubala WJ, et al: Cannabidiol (CBD) as an adjunctive therapy in schizophrenia: a multicenter randomized controlled trial. Am J Psychiatry. 2018;175:225-231.
7. Harvey PD. Smoking cannabis and acquired impairments in cognition: starting early seems like a really bad idea. Am J Psychiatry. 2019;176:90-91.
8. Meier MH, Caspi A, Ambler A, et al: Persistent cannabis users show neuropsychological decline from childhood to midlife. Proc Natl Acad Sci USA. 2012;109:E2657-E2664.