Reflections from the trenches of a recent statewide debate on legal marijuana.

By David Rettew M.D.

Recently, my home state of Vermont became the latest state to legalize possession of smaller amounts of marijuana, and the first to do so through a legislative process rather than a voter referendum. Our Republican governor somewhat reluctantly signed the bill after several years of legislative debate. He did so mainly on libertarian grounds and the belief that adults have the right to do what they want to do as long as it doesn’t hurt others.

I was active during this debate, testifying three times to various legislative committee, helping to organize messages from various medical organizations, and speaking at press conferences and other venues. While I was and remain sympathetic to an individual’s right to personal freedoms, my principal message was that legalization will be a net negative for public health, leading to increases in mental health problems, substance abuse, traffic fatalities, and other problems, and we shouldn’t sugarcoat that reality in trying to figure out what to do. 

This position came from both my clinical experience as a child psychiatrist and from a careful reading of a huge quantity of scientific data. Now at this particular crossroads, I hope to offer a view observations on the process that occurred here and the direction our state and country may be taking in the near future.

Like many individual issues, marijuana legalization was another great example of how quickly people are willing to abandon their broad political principles for the right cause. During this debate, we saw many liberals with long histories of being very skeptical of big business cozying up with complete trust to the multi-billion dollar cannabis industry. We saw adamant opponents of the current administration prodding our attorney general and the Trump administration to follow through and enforce federal law. We also did not hear concern from many outspoken critics of “mind-altering” psychiatric medications who somehow seem to have no problem at all about people self-administering unlimited amounts of THC. These examples should be a reminder to all of us how easily we can succumb to hypocrisy. 

One of the surprising and, frankly, disheartening aspects about this debate was where it mainly was focused. Initially, I had perhaps naïvely expected the debate to center around a classic personal freedom versus public safety balance with legalization advocates putting forth the position that issues of fairness with regards to alcohol and personal freedoms for the many people who use cannabis responsibly outweigh the downsides that will inevitably be caused by increased use. That argument was barely heard, and instead much of the advocacy for cannabis legalization, over and above the decriminalization that is already present here, was made in the name of public health. People with straight faces really stood up and predicted that legalized marijuana will result in roads being safer, minds being sharper, and crime rates falling despite the preponderance of scientific evidence that suggests otherwise. It was hard to tell the degree to which people were intentionally trying to manipulate the data versus actually believing what they said, but in the end, enough people believed them. How could this happen? Because scientific data is rarely completely consistent, especially at first.  And just like the case of global warming, there is initially enough inconsistency in the science for people to cherry pick studies that support what they want to believe. Over time, this gets more and more difficult to do.

Medical and public health organizations vigorously tried to educate the public and our lawmakers otherwise but to a significant degree were unsuccessful. Here, what was most startling was the realization of how much of a hit the medical community has taken to its credibility through its ties to the pharmaceutical industry. Over and I over, I heard that the opinions of doctors were not to be trusted because we were in cahoots with the makers of opiate medications. This perception was extremely hard to shake, despite the profoundly ironic twist that it was the paid marijuana lobby that was promoting the message. The charge was also simply untrue for me (I haven’t written a prescription for an opiate in 15 years) and for the many medical professionals who weren’t getting a dime from anyone to speak about their concerns. 

Indeed, it was astonishing to see how intolerant any comment at all about the dangers of cannabis use engendered accusations of fear mongering and “reefer madness!” Hearing the pro-legalization position, you would think that the vast majority of marijuana using Vermonters were 80-year-old grandmothers with cancer and chronic pain. Miraculously, the one word you never heard from supporters was about getting “high.” 

In all this, the elephant in the room that nobody wanted to look at was the issue of personal and financial conflicts of interests. The latest National Survey on Drug and Use and Health found that a whopping 48 percent of young Vermonters used marijuana in the past month and you can bet that among them are elected officials and many of the individuals who suddenly became public health experts as they testified about their interpretation of the data and statistics regarding cannabis.  When medical professionals give talks, we are required to disclose any financial ties that might cloud our ability to offer an informed and objective opinion on a subject.  Sadly, no such requirement existed during the marijuana debate so people with personal and/or financial stakes didn’t need to say anything about them as they voiced their views about the virtues of cannabis. This needs to change, in my view. While it certainly may be a little uncomfortable at first, there is a growing need for medical journals, legislative committees, and other groups that are charged with uncovering the “truth” about complicated topics to require those offering data and opinions on the subject to disclose possible conflicts of interest. To be fair, this should probably also be true for alcohol-related research and legislation, among others.

Aside from the recreational use debate, our state also has been discussing expanding the indications for “medical” marijuana. One of those newly blessed indications from our legislature was for Post-Traumatic Stress Disorder (PTSD), and the process that lead to this was quite amazing. Our country already has a system through the Food and Drug Administration or FDA to evaluate products based on science to deem them safe and effective as medications. Legislatures across the country, however, think that it is okay to create their own system that bypasses this process and to do so only for marijuana. If a state legislature insists on becoming its own FDA and being the judge of what should be defined as medicinal, it absolutely has the responsibility to do this right, which means relying on scientific evidence and not personal anecdotes. When it comes to PTSD, not only is there no systematic data at this point that smoking marijuana is effective for PTSD, there is data showing that for most people it makes things worse rather than better, including an important study conducted with veterans. Regrettably, we are already hearing of horrible stories of veterans suffering from PTSD who decide to stop taking their prescribed medications and begin using cannabis instead, only to become psychotic, paranoid and violent. Moving forward, you also have to wonder if the “it’s no different than alcohol” argument the pro-legalization lobby loves to bring up will be taken to its logical conclusions. I’m sure makers of beer and liquor would not have to work that hard to find people willing to testify that drinking has helped their level of anxiety or mood swings and that therefore we should require medical insurance companies to cover their booze.

Since I broke my crystal ball a few years ago, it is hard to predict exactly what happens next. It seems possible that this movement may begin to fizzle out, especially as statistics on things like homelessness, crime, mental health crises, and traffic fatalities become so compelling that even a skilled spinmaster no longer can argue against them. If things move in that direction, the legalizing states may find themselves more and more as islands that increasingly draw in or repel people based on their views and habits about marijuana. 

It also seems possible that there will continue to be momentum for more and more states to join the bandwagon and legalize, especially as the number of marijuana users continues to grow. Should this happen, one silver lining might hopefully be that, with their legal victory in hand, there will be less of a need for people to continue to pretend that cannabis is free of potential harms or that the cannabis industry actually cares about our welfare. States that legalize cannabis have real work to do to mitigate the negative impacts as much as possible, and time is of the essence.  It’s not going to be productive for people like me who have expressed real concern about legal marijuana to simply say, “I told you so.” We also need to resist the temptation to describe the harms related to legal marijuana in apocalyptic terms or to deny the fact that some benefits to legalization also exist. If we are really going to do this, it is time for everyone to take off the rose-colored glasses and think seriously about things like increasing the capacity of emergency departments to handle mental health crises, expanding the number of psychiatric beds equipped to help people with psychotic illness, and delivering honest public messages to adolescents that using marijuana is really not a good idea.

Welcome to the new era of cannabis.