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2024 Study: Medical Cannabis Legal & Regulatory Status

Updated: Jan 6

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A January 2024 study entitled "Legal and Regulatory Aspects of Medical Cannabis in the United States" that was published in the peer-reviewed journal Anesthesia & Analgesia explored the legal and regulatory status of medical cannabis in America.

A close up photo of the American flag.
Where do we stand?

"In this review, we provide a brief account of the evolution and current state of federal and state laws and regulatory agencies involved in overseeing medical cannabis use in the United States."

"The researchers credited Sir William Brooke O'Shaughnessy 'for introducing cannabis to Western medicine in 1841' when he published evidence of the herb's anticonvulsive and analgesic (pain killing) effects."

The study reported that the word "cannabis" refers to a genus of plants belonging to the family Cannabaceae and that it is comprised of the species Cannabis sativa (C sativa), with Cannabis indica and Cannabis ruderalis playing the role of either individual species or subspecies of C sativa. "The definition of marijuana (at the time, spelled 'marihuana') comes from the Controlled Substances Act (CSA) of 1970."

Brief History of Medical Cannabis

Medical Cannabis Legal & Regulatory Status. The researchers credited Sir William Brooke O'Shaughnessy "for introducing cannabis to Western medicine in 1841" when he published evidence of the herb's anticonvulsive and analgesic (pain killing) effects after having observed its use in India.

"After this introduction, cannabis was sold for a time in over-the-counter patent medicines for various ailments," reported the scientists. "Sir Russell Reynolds, eventual president of what became the British Royal Society of Medicine, published his experiences using cannabis tinctures for migraines and neuralgias in 1890," noted the study.

A sign outside Las Vegas reads: "Don't gamble with Marijuana."
Opium ruined it for cannabis.

Anti-cannabis Sentiment Emerges

Despite this progressive investigation of what has become today the most controversial plant in existence, the study's authors reported that this pro-cannabis trend slowed during the first decades of the 20th century due to a number of factors. One was a wave of opium and other opiates that spread across America, gaining such popularity that it was dubbed a public health concern. This, in turn, resulted in "greater scrutiny" and regulation of substances such as opium and morphine. And cannabis.

"Over time, public and political sentiment, fueled in part by the association of the drug with a foreign element (as seen in the replacement of the term cannabis with the slang term marijuana), turned against cannabis as well," noted the researchers. "State legislation reflected the shift, so that during the next several decades, cannabis became illegal as an over-the-counter remedy in all 50 states."

"State legislation reflected the shift, so that during the next several decades, cannabis became illegal as an over-the-counter remedy in all 50 states."

In fact, while the federal government is typically blamed for cannabis prohibition, the feds were merely following in the footsteps of the states. While modern Americans logically attribute the dismantling of pot prohibition to the States, it is these same bodies that launched the anti-cannabis crusade in the United States in the early 20th century.

"In the following years, several other states banned cannabis. Massachusetts (1911), Maine (1913), Utah, Vermont, Wyoming (1915), Texas (1919), Arkansas, Iowa, Nevada, Oregon, Washington (1923), and Montana (1927)."

Of course, this all manifested in the now infamous August 1937 federal law called the Marihuana Stamp Act (which has been replaced by the Controlled Substances Act [CSA] of 1970).

How the feds see marijuana.
How the feds see marijuana.

States Begin to End Pot Prohibition

The first state to end cannabis prohibition with a loosely worded medical program was California in 1996, followed by more than 35 other states today. The first states to enact adult-use cannabis legalization, ending decades of prohibition resulting from the Marihuana Tax Act and solidified by the CSA, were Washington and Colorado in 2012 (technically, Washington was the first).

The study explained how, as a Schedule I drug under the CSA, cannabis is considered to be completely void of medical benefit and likely to result in abuse or addiction (research shows that the addiction rate for cannabis is roughly the same as that of caffeine at about nine percent).

Wrote the study's authors: "As a schedule I substance, a physician may not, under federal law, write a prescription for marijuana. This was reiterated in United States v Oakland Cannabis Buyers’ Co-op: regardless of conflicting state law, the US Supreme Court there held that Congress intended no medical necessity exception to the CSA prohibitions on prescribing marijuana."

U.S. states both create and end pot prohibition.
U.S. states both create and end pot prohibition.

Regulatory Aspects of Cannabis

Medical Cannabis Legal & Regulatory Status. Despite the fact that federal cannabis prohibition was the culmination of a crusade led by the states from 1911 to 1937, it has been the states that have "re-legalized" marijuana for the masses.

"As of the writing of this article, 47 states have legalized medicinal marijuana in some form, and 24 states and the District of Columbia have gone so far as to legalize recreational use of marijuana," reported the study. While the idea of "required conditions" is quickly becoming a moldy artifact of the earliest days of cannabis legalization, such diseases include "cancer, human immunodeficiency virus-acquired immunodeficiency syndrome (HIV-AIDS), glaucoma, cachexia, chronic pain, nausea, seizures, muscle spasms, and multiple sclerosis."

Of these required conditions, insight is gained from the fact that the most commonly cited among all U.S. states is chronic pain. "Interestingly, in states where recreational cannabis is legal, while chronic pain is still the most commonly cited indication, others (multiple sclerosis, arthritis, and chemotherapy-induced nausea and vomiting [CINV]), are comparatively more cited than in medical-only states," wrote the scientists.

Tax Revenue Boon

"Legalization has been a tax revenue boon for states," reported the study's authors.

During 2021, the 11 states where adult-use cannabis sales were legal collected about $3 billion in excise tax. In seven of these 11 states, cannabis excise taxes surpassed both alcohol excise taxes and profits.

Despite hyperbolistic headlines and clickbait social media, cannabis legalization faced some significant setbacks during this period. "Despite legalization in some states, the Supremacy Clause of the Constitution ensures that where federal and state laws conflict, federal law takes precedence. For example, in Gonzales v Raich, the Supreme Court affirmed that any activity involving marijuana illegal under the CSA remains illegal at the federal level regardless of any state law," reported the researchers.

The study noted that the DOJ is "discouraged from prosecuting cannabis activity that is legal under state law by two precedents: The Cole memorandum and the Rohrabacher-Farr amendment."

Two Avenues to Reschedule Cannabis

"There are two avenues by which marijuana could be rescheduled in the United States," reported the study. "Legislative action through Congress or administrative action through the DEA. Legislation to reschedule or deschedule marijuana has been proposed regularly since 1981, most recently in 2021, and Congress has thus far rejected all such bills," reported the researchers.

A woman vaping cannabis.
A woman vaping cannabis.

U.S. Medical Cannabis Legal & Regulatory Status Study Conclusions

The study cautioned readers to recognize that, for cannabis and cannabis derivatives to become useful medications, "widespread clinical experience and substantial progress in research will need to occur, both of which are hindered without rescheduling or descheduling."

The study concluded the following:

"Clinical experience is limited at both the patient and prescriber levels. Because of schedule I classification of marijuana, for many years, any use has been illicit, and so, the public (including clinicians, patients, and regulators) is more likely to perceive marijuana with

presumptions tainted by this association with illegality than with the benefit of direct experience. The relative rapidity of the metamorphosis of cannabis from an illicit narcotic to a recreational and medicinal substance compounds this confusion.

"Clinicians also must contend with the recent memory of our collective descent into the current opioid crisis. At the inception of the opioid crisis, the medical community was made aware of what was portrayed as new evidence that opioids, which had previously been prescribed carefully and infrequently, were less dangerous than had been believed and could be used more liberally, even to treat pain outside of surgery and the palliative care setting. Unfortunately, much of this information has proved incorrect, and today, clinicians may justifiably be wary that the new push to liberalize the use of cannabis is another Pandora’s box, and be hesitant to prescribe lest some new epidemic be unleashed, or, through political vagaries, the use of cannabis again become criminal.

"Most physicians are currently not comfortable recommending the dose, frequency, and type of cannabis to be used. While some of this discomfort may be due to unfamiliarity and safety concerns, clinicians will also need to be reassured of the efficacy of the drug. Research will need to demonstrate which cannabis compounds, or combinations of these compounds, have clinical efficacy and which do not. While specific components of cannabis (eg, cannabidiol, tetrahydrocannabinol, and terpenes) may have clinical activity in isolation, some of the beneficial effects of cannabis are possibly due to the combination of substances in a particular cultivar, sometimes called the “entourage effect.”

"The evident effect of cannabis will differ widely depending on the dose, mode of delivery, the spectrum of compounds contained in the formulation, and the individual patient.

If marijuana were to be rescheduled from schedule I, under the CSA, it would still be incumbent upon the clinician to prescribe only for a legitimate medical need, to document appropriately, and to take all reasonable steps to mitigate the risk to personal and public health. Some controlled substances impose greater risk than others, and the recent opioid epidemic in the United States presents a cautionary tale for the potential downstream effects when medicine, the law, and public policy fail to appreciate this."

View the original study.

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