How Marijuana Legalization Changed Behavioral Health in Colorado
Colorado citizens voted to amend the state constitution to legalize both medical and non-medical/retail marijuana. The Medical Marijuana Amendment 20 to the Colorado State Constitution was passed in 2000; the Colorado Marijuana Legalization Initiative, Amendment 64, was passed in November 2012. Both constitutional amendments had diverse response in terms of political perspective and reasons for support or opposition. Legalization of retail marijuana in Colorado was implemented January 2014, a little less than 14 months after voters approved constitutional Amendment 64.
In the first week of January 2014, the addiction treatment organization where I worked received national and international media calls inquiring how many individuals with marijuana addiction had been admitted for treatment. This continued for the first few months after legalization. The question demonstrated a shallow understanding of marijuana use and onset of addiction. The number of individuals admitted the first few weeks or months after legalization did not increase. Admissions to treatment don’t always reflect the incidence and prevalence in the population and it remains to be seen if and what will be the nature of future problems related to marijuana.
Creating a structure for the responsible legalization of marijuana is a huge undertaking. The multiple issues to be addressed include:
- regulation (e.g., licensing, wholesale/retail operator regulations);
- product safety (e.g., pesticides, uniform dosing, child safe packaging);
- business/industry issues (e.g. home growing, limits on numbers of plants, production safety);
- enforcement (e.g., DUI, product diversion, trafficking, preventing youth access);
- product consumption (e.g., smoked, vaporized, edibles, oil);
- prevention/harm reduction (e.g., inappropriate/risky use, adolescent use, pregnancy);
- money/taxation (e.g., state use of revenue generated, regulation/taxation/tax collection of all-cash business, issues created by federal banking laws); and
- public information/education (e.g., prevention, establishing social norms/beliefs, acculturation to the new legalized or decriminalized status of cannabis).
Having a state law in opposition to federal law also poses unique challenges. Because marijuana is illegal federally, banks see themselves at risk if they receive deposits from marijuana businesses. This includes any kind of a transaction that would go through a bank (e.g., credit card charges, deposits, transfers of funds). This means that marijuana businesses must do everything in cash, including paying employees, processing invoices from vendors, paying rent, and filing state taxes related to the sale of marijuana. This has resulted in cannabis businesses being a prime target for robberies, and subsequently needing to invest in significant structural security.
Taxes on the cannabis industry go to the state, who in turn uses that money to pay for enforcement/regulation related to cannabis, school buildings, treatment/prevention services and public information/education programs. In many states, part of legalization may include organizations being eligible to receive funds for prevention and/or treatment services from state revenue generated by marijuana sales. Under normal circumstances, forfeiture of property is often a consequence associated with exchanges of funds related to illegal drugs. It is unknown if there is risk to organizations in accepting cannabis funds in a state which has legalized marijuana when it is still illegal under federal law.
Part of what comes with legalization is the building and/or adjusting of cultural standards, norms, social values and beliefs to identify and discourage harmful use, as well as developing a community knowledge base around safe and non-harmful use. Cannabis is being introduced into a culture which has no systems, processes, structures, and collective wisdom regarding how cannabis could be used in a legal and responsible way.
One way to think about the cultural changes that come with the legalization of marijuana is to compare them to the legal use of alcohol. Similarly to cannabis, alcohol is a drug. About 30 percent of our population does not consume alcohol, and most people who do consume alcoholic beverages do not have major problems as a result of their use. Yet, alcohol has a significant relationship to violent behavior, crime, accidental deaths, homicide by vehicle, and substantial health problems.
Getting caught up in the details of the differences between alcohol and cannabis interferes with our ability to conceptualize how to manage this potential culture change. Alcohol use is influenced in part by the family/community in which one is raised, how one is mentored, taught, and has observed examples of the appropriate and/or inappropriate use of alcohol. In the process, we acquire knowledge regarding alcohol content in various products. There is some distress regarding how the potency of marijuana today is “not your parents’” marijuana. However, we also have experience dealing with high potency alcohol in our culture. We have had Everclear (190 proof/95% alcohol) for years, and there are a significant number of alcohol related injuries and overdose deaths every year. Some cannabis products are more potent than they were 40 or 50 years ago. We have also seen an increase in recreational vaporizing and inhaling alcohol (“not your parents” method to consume alcohol). It is important to note yesterday’s cannabis products also included concentrated resin (“hashish”) as well as “hash oil,” and homemade edibles. Are they the same as the cannabis products of today? No, probably not. As a culture we have managed highly potent alcohol, and I would submit that we can manage high potency cannabis products in a similar (and hopefully better) way.
We have some of the same behaviors with cannabis that we have with alcohol. This includes driving a motor vehicle while impaired and “spiking the punch” has transferred to “spiking the brownies” – both are stupid and dangerous. Addiction to alcohol is a significant health problem, and withdrawal from alcohol can be highly dangerous. It is important for states to collect baseline data prior to legalization to enable the assessment of overall impact on health and behaviors. This data may also help answer questions such as whether marijuana use was more prevalent among minors before or after legalization.
Legalization necessitates that providers have a different framework for viewing and organizing their response to cannabis. Illegality is no longer an effective prevention tool with adult marijuana use, any more than it is with adult alcohol use. Part of what is required for the sake of harm reduction is to think seriously about how learning to drink alcohol responsibly can inform and assist adults who choose to use marijuana to learn to use marijuana safely. Cultural norms, traditions, mentoring, and values related to alcohol use in some senses are templates for what we need to establish regarding legal and responsible marijuana use. Yet, alcohol templates also clearly need some improvement. Tobacco use is likely the best model regarding air pollution and the health risks of smoking marijuana. Both alcohol and marijuana use by youth have a variety of negative consequences, which include physical and cognitive impacts. Regardless of legalization for adults, we need to create and maintain strong prevention strategies and sanctions regarding cannabis and alcohol use by youth.
The legalization of marijuana creates an entirely new, yet familiar, circumstance for organizations providing substance use services. Three years later, it is clear Colorado has done well with its implementation. Not everything has been perfect, but for a “grand experiment” we have learned a lot. I have been impressed with the commitment of all levels of government to do this right.
Each state has its own character and personality, and the observations of one specialty behavioral health provider may or may not be of benefit in other states. My hope is that these comments stimulate and contribute to an expanded dialogue regarding the myriad issues pertaining to marijuana legalization. I also look forward to continuing this dialogue with you here in Denver August 28-30 at the 2017 National Cannabis Summit, where I expect to connect with leaders in a variety of roles about all of these changes and more.