Legal Cannabis Presents a Massive Research Deficit

​Cannabis is here and not going away for many reasons, chiefly being the tax revenue by governments.  Touted for its many health benefits throughout history and the poster child for the failed War on Drugs movement, cannabis is moving into the mainstream of American life. In addition, there is encouraging, albeit nascent, evidence for cannabis in treating a range of psychiatric disorders, including the scourges of post-traumatic stress disorder (PTSD), anxiety, and depression.  

Cannabis Status United States

Public support for legalizing marijuana use increased from 25% in 1995 to 60% in 2016, rising in lockstep with the backing for same-sex marriage. Between November 2012 and November 2016, voters in eight states passed ballot initiatives to legalize marijuana sales for nonmedical purposes—covering one-fifth of the population of the United States.

Three states – Arizona, Montana, New Jersey – passed legislation in November 2020 to legalize recreational marijuana use by adults. That, plus New York, Virginia, New Mexico, and Connecticut's 2021 initiatives, makes 18 states where adults can legally buy recreational marijuana. Thirty states have legalized medical cannabis.

Legalizing recreational cannabis has substantially reduced the price, increased its potency, and made it more available to adult users. It appears to have increased the frequency of cannabis use among adults, but not so far among youth.
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The path to legalization of recreational cannabis in the United States began with citizen-initiated referenda that legalized the medical use of cannabis, first for severe illnesses like cancer via traditional pharmacies and later by retail, commercial cannabis medical dispensaries.  Legal medical marijuana softened public opposition to the legal recreational cannabis sales, with Colorado and Washington State, in 2012.

Commercial Cannabis Packaging

Illustrative of the revenue side on cannabis is the state of Illinois, which legalized recreational cannabis starting January 2020. Illinois sold about $670 million in marijuana in 2020 and took in about $205 million in tax revenue.

Illinois has exceeded $1.3 billion in adult-use marijuana sales in 2021 as of November, the most recent data date. The Illinois Department of Financial and Professional Regulation (IDFPR) reported about $120 million in recreational cannabis purchases in October 2021.  About $82 million was by Illinois residents, but an astonishingly large amount of $39 million from out-of-state visitors. 

November 2021 was the ninth consecutive month recreational marijuana sales surpassed $100 million in Illinois.  By the end of the third quarter of 2021, Illinois had garnered more tax dollars from marijuana than alcohol.

Adjacent, more conservative states like Wisconsin, Iowa, Missouri, Kentucky, and Indiana can hear that tax revenue running into Illinois, and it is only a matter of time before they legalize recreational use of cannabis.
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For simplicity, people split cannabis into:

• Tetrahydrocannabinol (THC) is the psychoactive component of marijuana that gives the feeling of being high and is what makes the drug appealing for recreational use.
• Cannabidiol (CBD) is the non-psychoactive component of the plant that contributes to its pharmacological actions without being involved in the high; this is the component of the drug often used for the treatment of depression. CBD may offset some of the acute psychoactive effects of THC.

Vintage Anti-Cannabis Propaganda Example

Historic War on Drugs mentalities crushed research into the possible benefits of cannabis, although there was a substantial amount of research into its hazards, particularly maladaptive results.   The Diagnostic and Statistical Manual of Mental Disorders ((DSM) even devised a term called cannabis use disorder and defined it by nine pathological patterns classified under impaired control, social impairment, risky behavior, or physiological adaptation.

Institutional prejudice, researcher proclivities, and the needs of funding organizations tainted previous research. In addition, governments used the results to justify the militarization of drug control and the incarceration of the poor and minorities tainted previous research.
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This recent gold standard double-blind placebo-controlled meta-study analyses provide empirical support for medical cannabis use:

• Many studies report cannabis treatment is moderately efficacious for treating chronic pain.
• Cannabinoids, including the cannabidiol/THC buccal spray effectively treat neuropathic pain in Multiple Sclerosis.
• Cannabis is effective for chronic pain treatment, primarily for neuropathic pain patients based on limited evidence.
• The use of cannabis during pregnancy may increase adverse outcomes for women and their neonates.
• Cognitive performance in the schizophrenia group as a function of cannabis use was small to medium, denoting superior performance in cannabis-using patients.
• Nearly 20% of patients suffering from rheumatologic diseases actively consume cannabis to manage pain.
• Edible cannabis or cannabinoids results in a small improvement in pain relief, physical functioning, and sleep quality among patients with chronic pain,
• Cannabis use is no more than a minor risk factor for developing elevated anxiety symptoms in the general population.
• Cannabis was associated with significant but small-magnitude deficits in executive function, learning and memory, and global cognition, while decision making had moderate deficits.
• Cannabis, alone or even in conjunction with Antabuse, was ineffective in inducing alcoholics to enter or remain in treatment.
• A one-month trial of daily THC (up to 3 mg per day) for anxiety disorder reduced anxiety symptoms, but the effects were meager.

Medical Marijuana Product

There are general conclusions one can draw from the research.  Cannabis might be a treatment for chronic pain and anxiety, although the effects are modest. 

In 2016, about 20% of U.S. adults had chronic pain, and about 8% of adults had high-impact chronic pain. Both were more prevalent among adults living in poverty, adults with less than high school education, and adults with public health insurance.  Cannabis offers a palliative treatment, not a cure, and one might wish to consider its use and a variety of management strategies.

About 31% of U.S. adults will have an anxiety disorder at some point, and about 19% of U.S. adults had an anxiety disorder in the past year.  Past year prevalence of anxiety disorder was higher for females (about 23%) than for males (about 14%).

The anxiety effects of cannabis in clinical populations are surprisingly not well-documented. Past studies have examined the effects of cannabis on anxiety and mood symptoms in healthy people and several small studies of synthetic cannabinoid agents, but there are currently no studies that have examined the effects of the cannabis plant on anxiety and related disorders.  Given the modest effects scientists have been able to document, in this case also, one should consider cannabis as a part of a suite of management modalities.

For other chronic psychiatric conditions, there is very little authoritative research available.  Depression is a common illness worldwide, with an estimated 3.8% of the population affected, including 5.0% among adults and 5.7% among adults older than 60 years.  Depression can cause the affected person to suffer greatly, function poorly at work, school, and socially. At its worst, depression can lead to suicide, and more than 700,000 people die due to suicide every year.

There is a massive population in the United States with the referenced chronic conditions, all of which Western medicine is poor at managing.  Those people are looking for answers, and legal cannabis is one of them they are likely to explore.

The real problem is the lack of research combined with the accessibility of cannabis.  Western medicine is not adept at treating chronic conditions, particularly depression, anxiety, PTSD, and chronic pain, and the afflicted are likely to consider alternative modalities, including cannabis.  Anecdotal accounts, unreliable media advice, advertisement, and advice by untrained practitioners will drive sales to manage chronic conditions rather than unbiased and authoritative guidance.
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On the bright side, legalization provides many positives, as the sales require analysis and labeling. However, if people need cannabis, they can access it legally, keep a consistent dose, and procure it at a relatively low cost.