When the COVID-19 crisis forced cities into lockdown nationwide, cannabis dispensaries ranked alongside grocery stores and pharmacies as essential businesses allowed to stay open in California, New York and other states. Yet, as the marijuana industry marches toward mainstream acceptance, policymakers are turning to USC Schaeffer Fellow Rosalie Liccardo Pacula to help ensure that its popularity does not outpace scientific understanding of its risks.
Her expertise is recognized — and called upon — worldwide, because legalized cannabis is a global concern. Marijuana decriminalization now extends beyond therapeutic applications to allow recreational sales in nations including Canada and Uruguay, as well as legal cultivation and possession in many more countries.
President of the International Society for the Study of Drug Policy, Pacula has served as a technical expert for the United Nations (U.N.) Office of Drugs and Crime and World Health Organization (WHO), as well as briefed state legislatures and the Centers for Disease Control and Prevention.
States and countries may have a variety of objectives for legalizing cannabis — from reducing the criminal justice costs and eliminating the black market to creating jobs and increasing new sources of tax revenue. “But many are moving forward without an appropriate regulatory structure in place and, thus, an insufficient system to mitigate known public health risks,” says Pacula, who is also the Elizabeth Garrett Chair in Health Policy, Economics & Law and professor of Health Policy and Management at the USC Price School of Public Policy.
After voices at the U.N. and WHO demanded that cannabis be reclassified in international drug treaties, Pacula was asked to summarize findings on the observed impacts of cannabis legalization on public health. She gave two presentations at the WHO Expert Panel Meeting in December. In the first, she described how the markets for medical marijuana in the U.S. differ from traditional pharmaceutical markets, which has led to unwanted spillover effects in the United States. In the second, Pacula offered an overview of the public health risks associated with legal cannabis as enacted in the U.S., which allows a for-profit industry, mass marketing and promotion, and very limited restrictions on the potency of products sold in these markets.
In March — at a side event to educate delegates attending the U.N. Commission on Narcotic Drugs’ annual convention who would be voting on the rescheduling of cannabis — she provided policy recommendations for nations considering cannabis legalization that prioritized public health objectives as well as human rights.
“In earlier decisions and treaties, the U.N. specified marijuana as a Schedule I drug,” she says of the categorization denoting high potential for abuse and a lack of safety for medical use. “This year, given the number of countries experimenting with medical and recreational cannabis legalization, the delegates are questioning the appropriateness of that designation and taking it to another vote,” she says.
Although a formal vote to change the U.N.’s classification of the drug was ultimately delayed until this coming December, Pacula says, “we had a full room of delegates eager to hear about lessons learned from the U.S. experience with regulating medical and recreational cannabis markets. It was important for them to hear why one should be cautious drawing lessons from the U.S. experience, as our form of cannabis regulation is much looser than that applied in other jurisdictions.”
One query Pacula repeatedly faced at the meeting was whether good guidance existed on how much cannabis should be allowed to be sold per transaction, and at what potency. The answer, she notes, is intrinsically tied to the notion of a “standardized” dose of cannabis. “But there is no research definitively defining what a standardize dose of cannabis is,” she adds. “Impairment is influenced by the individual’s body mass and use experience, as well as the potency of the product being used and how that product is being consumed — that is, whether it is smoked, vaped, eaten or dabbed.”
The challenge of setting appropriate guidelines to promote moderate consumption is compounded by the lack of set standards. “In the U.S., no states have specified a maximum potency for cannabis products in any form except edibles,” Pacula says. For example, “in Washington state, the average potency of cannabis concentrates is 69% THC, while that for a typical flower material is closer to 21% THC.”
Therefore, she adds: “It is difficult to think about equivalent levels of impairment from these two products given such a difference in potency and different modes of administration. And that assumes we believe the labels specifying the amount of THC are correct!”
Because of the federal prohibition on cannabis, testing and monitoring of the consistency of products is left to state agencies when they would usually be handled by the Food and Drug Administration (FDA). Even in terms of medical use, the FDA has only approved one non-synthetic (plant-based) cannabis therapy — Epidiolex, a treatment for seizures caused by rare forms of epilepsy and other severe syndromes.
Without federal support for establishing safe standards of products and dosing, “state regulators have a hard time pushing back against suppliers in the market,” Pacula says. “So we are allowing products that are deemed to be harmless because the industry has developed this narrative that marijuana has been around for centuries. Except the cannabis people are using today is not the cannabis that has been around for centuries. What is sold today has been reengineered to be much, much stronger.”
Still, common-sense regulation is possible, she says. Pacula observes that New Zealand, which already allows medical marijuana, plans a referendum on further legalization — but with well-advised restrictions. “It limits home cultivation to two plants and includes potency caps,” she says.
Cannabis and Criminal Justice
Even as legalized marijuana thrives, the U.S. remains a patchwork of policy confusion. Possession is still illegal at the federal level, while states offer various levels of decriminalization and allowances for medical use. One condition endures, however: Criminal penalties fall disproportionately on minorities, especially African Americans.
“While arrests of adults have declined, the differential between blacks and whites has remained the same,” notes Pacula, who has received numerous National Institutes of Health grants over the past two decades to study the variation in cannabis policies across states and their impact on criminal justice and public health outcomes. The disparity continues because, “even though simple possession is no big deal, prosecutors can use it as an extenuating circumstance,” she explains. “So even with usage rates being roughly equal, the American Civil Liberties Union found that African Americans are nearly four times more likely to be arrested for marijuana possession.”
Minors can also find themselves on the wrong end of marijuana laws. “While we have changed the rules for adults, many states have not changed the penalties for youth,” Pacula notes. Of course, underage consumption of alcohol and tobacco is also illegal but, with those substances, she says, “we didn’t proceed from a throw-people-in-jail perspective when they were prohibited for adults and nor is that how the law is interpreted for youth when it comes to these other substances.”
For marijuana, however, the situation is different, “and young people face criminal sanctions, with black youth getting overly represented again in the arrest statistics,” she says. With recreational cannabis sold as candies and other forms attractive to children, this is a vital concern that may put many futures at risk.
Meeting the challenges of legalization requires understanding and appropriate leadership, according to Pacula. “Whether or not this is a good idea really rests in the ‘how,” she says.
Informing consumers about health risks, for example, is vital. Just as alcohol and tobacco are labeled with their risks, so should cannabis be, she says. The problem is that the science identifying those risks is still in its infancy.
In this and other areas, the federal government should provide a unifying framework of standards for states to follow, Pacula says. As she testified in December before the Florida state legislature — which is considering a voter referendum on legalization — currently “states cannot regulate cannabis like alcohol or tobacco, as they do not have their federal partner to fall back on.”
Pacula’s current projects include how to better educate users about marijuana’s hazards, how to develop better measures of the entire cannabis regulatory environment, and a multisite initiative tracking the cognitive development of teens engaged in substance use.
“This is not just about intoxication,” Pacula says. “It’s about long-term effects. We need to do more research to understand the full implications of legalization.”