No marijuana ‘apocalypse,’ but legalization brings concerns
Impaired driving, youth use are ongoing problems
Second of two parts. Read the first part here.
WHEN MASSACHUSETTS VOTERS were considering the 2016 ballot question to legalize recreational marijuana sales, opponents, including Gov. Charlie Baker, Attorney General Maura Healey, House Speaker Robert DeLeo, and a raft of public health and safety officials, raised concerns about everything from youth use to drug trafficking to impaired driving.
So far, two years after legal marijuana shops opened, fears of violent crimes and uncontrolled diversion of pot to minors appear to be largely unfounded, and dispensaries are operating relatively smoothly.
While there are some public safety problems, they have been limited. There is evidence of slightly higher rates of impaired driving, though not a deluge of new cases. While four robberies of marijuana shops have been attempted, only two were successful, according to reports made to the state Cannabis Control Commission.
Jim Borghesani, a cannabis consultant who helped lead the pro-legalization ballot committee, said the lack of significant data on widespread harm proves legalization is working. “We’re not comparing this to some minor concerns. We’re comparing this to apocalyptic predictions by opponents of carnage on the streets,” he said.
Some marijuana proponents compare it to alcohol. “Roughly 15 percent of the population that drinks alcohol becomes addicted to it, so that’s not a good thing and we deal with that very poorly, but we also accept it in the face of having alcohol available to the other 85 percent,” said Jordan Tishler, a cannabis doctor at inhaleMD and president of the Association of Cannabis Specialists.
Northampton Police Chief Jody Kasper, who has two marijuana stores in her city, said the real test of legalization could come years from now. “What we’re seeing is a change in culture in how people feel about marijuana,” Kasper said.
She compared it to when she grew up, when alcohol was around her family’s house but marijuana was not. Kasper said the next generation is likely to view marijuana like alcohol, as something with downsides for some users, but an “acceptable substance that can be consumed by adults.”
Driving under the influence
One of the biggest safety concerns by legalization opponents and state regulators has been impaired driving. While decades of public awareness campaigns created a stigma around drunk driving, there is less awareness of the dangers of driving while high.
Recent data released by the Cannabis Control Commission, based on the International Cannabis Policy Study (ICPS), found that 16 percent of survey respondents who used marijuana had driven within two hours of using. Among all respondents, 21 percent had ridden in a car with someone who used marijuana within two hours.
Walpole Police Chief John Carmichael, a member of the Cannabis Advisory Board that advises state regulators, said few arrests for operating under the influence of marijuana result in convictions.
Since legal shops opened starting in late 2018, there appears to be a small uptick in drug-impaired driving. According to the State Police, the number of arrests for driving under the influence of drugs rose from 517 in 2018 to 590 in 2019. There were 449 arrests the first nine months of 2020, a rate similar to 2019, with fewer drivers on the road due to COVID-19.
The number of fatal motor vehicle crashes in which drugs are suspected has risen from 30 in 2017 to 48 in 2018 and 54 in 2019, according to the Executive Office of Public Safety and Security. For 2020, which has seen many fewer drivers on the road since mid-March, there were 14 as of early October.
That said, the ICPS data found no statistically significant difference in rates of dangerous driving behavior between 2018 and 2019.
At least in one community, home to one of the state’s first two recreational marijuana stores, there has been no surge in pot-impaired driving. In Northampton, there were 111 people arrested for operating under the influence in 2019, of whom six were charged with OUI-drugs and the rest with alcohol. That compared to 83 OUI arrests in 2018, four for drugs, and 120 arrests in 2017, six for drugs.
Experts warn that these numbers may be undercounts since the police are less likely to file OUI-drug charges because of the difficulty of proving marijuana impairment in court. “We definitely have officers on the street who are seeing the presence of both marijuana and alcohol, but you’ll see a charge of OUI-alcohol,” said Kasper, the Northampton police chief.
Baker introduced a bill, based on the recommendations of a special commission on impaired driving, to make it easier to prosecute drug-impaired drivers, but the Legislature has not acted on it. State officials have launched a “drive sober” campaign, and marijuana shops must distribute literature warning of the dangers of impaired driving.
Legal dispensaries are subject to strict rules governing things like age verification, surveillance cameras, marijuana storage and disposal, and employee background checks.
According to incident reports obtained from the Cannabis Control Commission through a public records request, there have been two successful break-ins: at Pure Oasis in Boston and Good Chemistry in Worcester.
The Pure Oasis break-in occurred in the early morning of June 1 amid protests over police brutality, when looters smashed the store’s window and carried out tubs of marijuana products. Media reports said the robbers stole joints and marijuana flower worth $100,000.
In February, robbers broke into Good Chemistry and stole money from an ATM.
There were attempted break-ins at Triple M in Plymouth and Temescal Wellness in Worcester, but the burglars were unable to enter the buildings.
Carmichael said he has not heard about robberies outside dispensaries, as has happened in other states. Most problems have been minor quality of life issues – traffic or people smoking outside. “We have very good and robust safety and security mechanisms built into our regulations,” Carmichael said.
Anecdotally, doctors say they are seeing more problems involving children consuming marijuana. This includes children accidentally eating edibles and adolescents using marijuana and using more potent products.
Mark Waltzman, chief of pediatrics at South Shore Hospital recalled one teenager who arrived at the South Shore Hospital emergency room difficult to arouse, with a high heart rate. He had bought THC-infused Skittles off the internet, at a strength higher than those available at legal dispensaries, and eaten five. He recovered, but Waltzman said, “In a smaller child…it could have been devastating.”
Waltzman said one problem with edibles is children are eating products meant for adults – and the same dose has a greater impact on those with lower body weight. Too much exposure to THC can lead to lethargy, rapid heart rate, blood pressure instability, dizziness, nausea, or seizures, and potentially long-term brain development problems in children.
Waltzman said while dispensaries cannot sell to minors, it is similar to adults buying alcohol and leaving it in their liquor cabinet. “Adults are buying them and leaving them around the house. That makes for easier access to children,” Waltzman said.
Sharon Levy, director of the adolescent substance use and addiction program at Boston Children’s Hospital, said since legalization, she has seen more kids using more frequently, using more potent products, and reporting more drug-related psychotic symptoms like hallucinations.
“We throw this umbrella term of marijuana over any product that has THC in it, instead of reserving the word to mean dried leaves that are indica or sativa,” Levy said, referring to different strains of marijuana plants. Concentrated oils that can be smoked or vaped have more THC than marijuana flower.
Levy worries that the commercialization of marijuana is leading to the development of more potent products. “When industries are allowed to sell psychoactive products, they manipulate the product in such a way that it becomes a better seller, but that always means it’s more addictive and more harmful,” she said.
The ICPS survey shows there is a difference in the type of products people are using post-legalization. More Massachusetts users used topical ointment, ate cannabis edibles, or took oral drops or capsules in 2019 compared to 2018. Edibles showed the largest increase, with 58 percent of past-year cannabis users eating edibles in 2019, compared to 47 percent in 2018. Simultaneously, smoking or vaping of dried herb dropped from 81 percent to 73 percent. Young adults – ages 16 to 20 – were more likely to use concentrates than older adults.
But despite anecdotal evidence, there is little concrete data indicating that youth use is increasing.
The ICPS found no significant uptick in youth use between 2018 and 2019. Among emerging adults, ages 16 to 20, the data found 47 percent had used marijuana in their life. While there were small increases in the number of young adults who used daily or weekly, none of changes were statistically significant.
The US Centers for Disease Control and Prevention conducts biennial surveys of high school youth and identified small increases in marijuana use in 2019. Its 2019 Massachusetts survey found that 26 percent of respondents used marijuana in the previous 30 days, a slight uptick from a number that had been between 24 and 25 percent each of the prior three surveys, but not a statistically significant difference.
One indication of public health problems is calls to the Regional Center for Poison Control. According to its latest report, the center has seen a steady uptick in marijuana-related calls since legalization, from an average of 21 marijuana exposure calls each quarter in Massachusetts in 2015 to an average of 62 calls quarterly in 2020. Until 2018, there was not a single quarter with more than 60 marijuana exposure calls. In 2019 and the first half of 2020, only one of the six quarters had fewer than 60 calls.
This is driven partly by an uptick in calls about children eating marijuana edibles, like chocolate and candy. In 2017, the poison control center got 32 calls about children eating edibles and 14 adult calls. In 2019, there were 65 pediatric calls and 30 adult calls, and the numbers are on track to be higher in 2020, with 74 pediatric calls about marijuana edibles in the first half of the year.
In comparison, marijuana-related calls to the regional center from Rhode Island remained steady. Rhode Island has medical marijuana stores but not recreational stores.
Cannabis Control Commissioner Jennifer Flanagan, a former state senator appointed for her public health expertise, said one unanswered question is whether there are more Poison Control calls because of more exposure, or because people feel more comfortable calling.
Flanagan said education and law enforcement are important to ensure marijuana does not get into the hands of children. The Cannabis Control Commission launched a $2 million public awareness campaign about marijuana laws in 2019, including warning about the dangers of youth use.
It is not clear whether kids are buying marijuana from illicit suppliers or from adults who purchased it legally. The Cannabis Control Commission is working on creating a product catalog, which will list every non-flower marijuana product sold legally in Massachusetts to aid law enforcement, school, and health officials in tracking products.
“If products are getting into the hands of kids from regulated entities, we want to know that,” said Cannabis Control Commissioner Britte McBride, former legal counsel to the state’s Department of Public Safety. “We want to make sure that it is nipped at the earliest point in the bud.”
Levy submitted study findings, which have not yet been published, reporting that after medical marijuana dispensaries opened, there was an increase in adolescents coming to her program after taking medical marijuana from someone else’s legal supply, as opposed to buying it illegally. Levy said data are not yet available regarding recreational marijuana.
Other health problems
Heavy use of cannabis can also cause problems in adults. According to the Cannabis Control Commission, smoking marijuana can cause lung damage, and long-term smoking can raise the risk of heart attack. Those who use marijuana at a young age or over-use marijuana are at risk of experiencing withdrawal symptoms like cravings or trouble sleeping when they quit. The science is mixed about whether marijuana use leads to mental health problems or whether those with mental health problems are more likely to use marijuana.
Kavita Babu, emergency medicine director of toxicology at UMass Memorial Medical Center, said among adolescents and adults, the hospital has seen an increase in cannabinoid hyperemesis syndrome, a marijuana side-effect characterized by intense vomiting and abdominal pain. This is mostly found in people with habitual, heavy marijuana use and goes away when someone stops using.
Flanagan said cannabis use disorder – which can include addiction — is a problem just like any other substance use disorder. She said preventing and addressing it requires public education and medical treatment, just as with addiction to tobacco, alcohol, or opioids. “You’re not singling out cannabis,” Flanagan said. “You’re adding it to a group of substances that’s mind altering enough that they can, for some people, have problems.”
Tishler, the cannabis doctor, said he does see problems, including a minority of patients who over-use. He said part of the problem is marijuana is marketed as a “do it yourself medicine.” Doctors cannot write a binding prescription, and dispensaries can sell patients more potent products. “There is a very strong commercial interest at work here that by its financial nature pushes the narrative that more is better,” Tischler said.
Alan Balsam, a former Brookline public health commissioner and member of the state’s Cannabis Advisory Board, said like alcohol, there will be people whose heavy marijuana use becomes problematic.
Balsam said there are public health benefits to legalization because it lets patients who do not want to use the state’s medical marijuana registry get relief from ailments.
While there are a wide range of health claims made about marijuana, a 2017 report by the National Academies of Sciences, Engineering, and Medicine concluded that there are three proven therapeutic benefits to medical marijuana: reduction in chronic pain, reduced muscle spasms in adults with multiple sclerosis, and prevention of nausea and vomiting in chemotherapy patients.
In other states, Balsam said there has been a correlation between medical marijuana legalization and lower opioid overdose deaths, although the evidence on whether legalization caused the drop is inconclusive. Balsam said he does see patients replacing opioid use with marijuana use.In Massachusetts, after a steady increase in opioid-related deaths between 2010 and 2016, opioid deaths began to drop from 2017 through 2019 before increasing in 2020 amid the pandemic. But the drop coincided with massive state efforts to curb opioid addiction, so it is impossible to draw any conclusion of a causal relationship with marijuana legalization.
“In general, I think the positives [of legalization] far outweigh the negatives,” Balsam said. But, he said, “The negatives are there, and they need to be addressed.”