research paper on marijuana in india

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A Review of Historical Context and Current Research on Cannabis Use in India

Affiliation.

• 1 Dept. of Psychology, CHRIST (Deemed to be University), Bangalore, Karnataka, India.
• PMID: 36925496
• PMCID: PMC10011848
• DOI: 10.1177/02537176221109272

Background: The cultivation and use of cannabis is historically rooted in the Indian subcontinent and this rich heritage of cannabis use dates back to at least two thousand years. Cannabis remains an illicit substance in India despite its changing status globally with many countries legalizing cannabis use in recent years. Scientific research on cannabis use in India has also been sparse.

Method: Extensive search of online databases resulted in the identification of 29 original research studies pertaining to one of three areas of cannabis research; a) prevalence of cannabis use b) psychological correlates of cannabis use, c) cannabis use in substance use treatment settings.

Findings: We found that most Indian studies used very basic quantitative research designs and had poor scientific rigor. Samples were small, region specific and included only males. Data analyses were limited to descriptive methods. The criteria for cannabis use in most of the reviewed studies were not rigorous and prone to biases.

Conclusion & implications: With changing attitudes and loosening of restrictions on cannabis use, the prevalence of new users is rising dramatically particularly in the college going population. This presents a strong need for research on motivations and attitudes to cannabis use and how those can influence patterns of use, and also the short- and long-term effects of use. More studies with stronger research designs (both cross sectional and longitudinal) are required for the study of cannabis use and this knowledge will be critical for managing the growing substance epidemic, generating public health solutions as well as formulating effective policy frameworks.

Keywords: Cannabis use; Cannabis use research; India; marijuana.

© 2022 The Author(s).

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Conflict of interest statement

The author declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

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Legalization of Recreational Cannabis: Is India Ready for it?

Chithra, Nellai K.; Bojappen, Nandhini; Vajawat, Bhavika; Pai, Naveen Manohar; Gowda, Guru S.; Moirangthem, Sydney; Kumar, Channaveerachari Naveen; Math, Suresh Bada

Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India

Address for correspondence: Dr. Guru S. Gowda, Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Hosur Road, Bengaluru - 560 029, Karnataka, India. E-mail: [email protected]

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

Cannabis is one of the oldest psychoactive substances in India and worldwide. Many developed countries like Canada, Netherlands and few states of the USA have legalized the use of recreational cannabis. However, In India, the recreational use of cannabis and its various forms such as ganja, charas, hashish, and its combination is legally prohibited. There have been several discussions and public interest litigations in India regarding the legalization of recreational cannabis use and its benefits. With this background, this article addresses the various implications of legalizing recreational use of cannabis, a multibillion dollar market and its impact on mental health, physical health, social, cultural, economic, and legal aspects with the lessons learnt from other countries that have already legalized recreational cannabis use. It also discusses whether India is prepared for the legalization of recreational cannabis, given the current criminal justice and healthcare systems. The authors conclude that, India is perhaps not enough prepared to legalize cannabis for recreational use. India's existing criminal justice and healthcare systems are overburdened, finding it challenging to control medicinal use, which is often the first contact point for cannabis-related concerns.

Introduction

Cannabis sativa is one of the world's oldest and widely used psychoactive substances. [ 1 ] The 1961 Single Convention on Narcotic Drugs (CNDs) classify cannabis as Schedule IV alongside heroin and cocaine, prohibiting recreational use, even excluding its use for medicinal or research purposes. In December 2020, 27 of the CNDs, 53 member states, including India, the United States, and most European nations voted “Yes” on the motion to delete cannabis and cannabis resin from Schedule IV and reclassify it as Schedule I drug. [ 2 ] This marks a historic step towards recognizing the therapeutic benefits of cannabis.

In India, cannabis (hemp) is classified as a “narcotic drug” as per Section 2 (xiv) of the Narcotic Drugs and Psychotropic Substances Act (NDPSA), 1985. [ 3 ] The recreational use of cannabis and its various forms, such as ganja, charas, hashish, and any mixture of the above preparation, is legally prohibited in India. Section 8 (c) of NDPSA further prohibits the cultivation, production, possession, use, consumption, purchase, sale, transport, warehousing, import, and export of ganja for any purpose other than medical and scientific purpose. However, bhang (a preparation exclusively made out of the leaves of cannabis) is excluded from this definition in NDPSA.

According to the Magnitude of Substance Use report, 2019, in India, approximately 2.2-crore persons (2%) use bhang and 1.3-crore persons (1.2%) use ganja and charas. Cannabis is the most abused illicit drug in India. [ 4 ] There are about 72 lakh problem users and 25 lakh dependent users of cannabis in India. The highest prevalence of cannabis has been found in the states of Uttar Pradesh, Punjab, Sikkim, Chhattisgarh, and Delhi. “Bhang,” a socioculturally and legally acceptable form of cannabis, is the highest used form of cannabis across India. The sale of Bhang is legally permitted in government-licensed retail shops. Bhang is used in various forms that include mixing with drinks and eateries. It can also be smoked. It was also used for vaping, but later vaping itself got banned in India.

The term medical marijuana is used to denote different forms of marijuana which are mixtures of tetrahydrocannabinol (THC) and CBD which are produced in the laboratory. [ 5 ] Dronabinol and nabilone are the two prototypes of the synthetic forms of THC which have been approved by the US FDA for treatment of chemotherapy-induced nausea and vomiting. [ 6 ] Whereas, the term recreational use refers to the use of marijuana for a sense of euphoria, altered perception, and relaxation, along with increased intensity of normal experiences such as eating food. [ 7 ] Recreational use of marijuana would involve untitrated concentrations usually taken in inhalational or any other form for its psychotropic effects.

Decriminalization is the reduction of penalties/punishment for cannabis use while maintaining the penalties for cannabis supply. Legalization is the permission to use and supply oneself through home growing or controlled sale. [ 8 ] Research into medical use of cannabis in India was only legalized for the first time in the year 2017, with the realization that this important step might curb the problem of drug addiction and facilitate research for better pain medications in palliative care for cancer patients. There have been several discussions in India regarding the legalization of recreational use of cannabis.

Public Interest Litigation on Legalizing the Recreational use of Cannabis

The Bombay high court in 2015 dismissed a Public Interest Litigation (PIL) questioning the scientific and logical reasons behind including cannabis under Schedule I of NDPS. [ 9 ] The PIL also asked for clarification regarding how consumption of cannabis is harmful to the human body and justification for its illegality. Similarly, the Great Legalization movement India Trust in 2017 filed a PIL in Delhi high court, whether criminalizing the cultivation, possession, and use of cannabis violated the right to life enshrined in article 21 of the constitution since the existing laws failed to consider its medicinal use. [ 10 ] This PIL also mentions raising awareness concerning the medical, industrial, ecological, economic, and other benefits related to cannabis.

With this background, this article addresses the various implications of legalizing recreational use of cannabis, a Multibillion dollar market, and its impact on mental health, physical health, social, cultural, economic, and legal aspects and the lessons learned from other countries which have already legalized recreational cannabis use.

Legalization of Recreational use of Cannabis – Learning from Other Countries

This section highlights the impact of legalization of recreational use of cannabis in various domains. It summarizes important findings from the countries that have legalized the recreational use of cannabis.

Impact on the prevalence of use

Worldwide, 15 states in the USA, Canada, and Uruguay have permitted the medical use, recreational use, and sale of cannabis. [ 11 ] Around 8 states in the USA, namely Alaska, California, Colorado, Maine, Massachusetts, Nevada, Oregon, and Washington showed an increase in the cannabis use ranging from 5% to 8% increase from 2014 to 2017 postlegalization. Interestingly, the rate of cannabis users in young teens has either remained stable or decreased in the states of the USA. [ 12 ] In Uruguay, studies have reported that noncommercial model of cannabis legalization had not led to an increase in adolescent cannabis prevalence rate in short term. [ 13 ] In Canada, the 3-month prevalence of cannabis use increased from 16% in the first quarter of 2018 to 22% in the first quarter of 2019. [ 14 ] Overall, this shows that there has been a significant increase in the rates of cannabis users. However, in several countries, the use has remained stable among teenagers.

Impact on mental and physical health

The mental health consequences of cannabis use include behavioral disturbances under intoxication, precipitating or worsening of schizophrenia, negative symptoms, cognitive impairment, mood disorders, violence related to substance use, and suicide. [ 15-19 ] The use of cannabis is also considered to pave way for various substance use disorders as it is one of the gateway drugs. [ 20 ] The psychoactive component responsible for mental health effects is Δ 9 - THC. As the level of THC increases, its effects on mental health also increases. Over the past few decades, it has been noted that there has been an increase in the THC content of cannabis from 5% to 15% in several states in the USA and Europe. [ 21 ] The risk of dependence syndrome is around 40.9% with daily use of cannabis. [ 22 ] All these can lead to an impairment in daily functioning and an increase in health-related costs. [ 23 ] There has been an increase in the rate of suicides (from 12.1 in 2012 to 16.5 per 100,000 in 2018) in the states that have legalized cannabis in the USA except for Washington, D.C. [ 24 ] Legalization of recreational use cannabis has also affected the concurrent use of other substances in several ways. In certain states of the USA and Canada, studies have found that the increase in the opioid use seems to be less marked with the concurrent use of cannabis. [ 25 , 26 ] However, the study done in 2018 in the USA has found that cannabis use does not reduce opioid use. [ 27 ] Nonalcoholic THC beers have become popular in the USA clubs. Cannabis-related admissions in rehabilitation facilities have increased in most of the states in the USA. About 40% of these admissions include teenagers of age 12–19 years. [ 28 ]

The physical health consequences include lung cancer, [ 29 ] chronic bronchitis, elevated systolic blood pressure, [ 30 ] cerebrovascular accidents, [ 31 ] impairment in memory, motor coordination and can lead to motor vehicle accidents. [ 7 ] There has been an annual increase of cannabis-associated emergency department visits in the USA by 7%. [ 32 ] Review by Zvonarev et al . showed that the rise in the emergency department visits was because of cannabis overdose. [ 28 ] The rate of deaths related to cannabis overdose has increased postlegalization, as reported by the Center for Disease Control. [ 24 ] Using cannabis for recreational purposes has increased deaths because of road traffic accidents by 92% in Colorado and 28% in Washington. However, as per the review by Zvonarev et al ., cannabis-related crash rates have not shown a significant increase in postlegalization when compared to states that have not legalized. [ 28 ] It is noteworthy that, most of the studies have used the level of THC in the blood as a marker. However, the presence of THC indicates the use of cannabis in the recent weeks and hence cannot be concluded to be proximally related to death. There has been a significant increase in the emergency department visits related to cannabis use in the form of a drug overdose, traffic accidents, etc. However, the proximal association of cannabis use and these events is quite unclear and needs further research.

Social, cultural, and economic impact

Children exposed to cannabis may engage in early initiation of cannabis use, poor academic performance, drop out from school, may face challenges in social adjustment, and vocational success. [ 33 , 34 ] In Uruguay, public views toward cannabis liberalization were associated with concerns about public security that it will open the gate to heavier drugs such as amphetamines or opioids. [ 35 ] Attitudes toward cannabis in the USA have changed over a period as the perceived harmfulness of its use has reduced to almost nil or slight harm in using cannabis once or twice a week in adolescents aged 12–17 years. [ 36 ] In the National Survey on Drug Use and Health, the prevalence of perceived risk decreased in all age groups and other demographic groups between 2002 and 2012. [ 37 ] For instance, the prevalence of perceived high risk of cannabis use has decreased from 58.8% to 46.7% among women and from 43.2% to 33.5% among men from 2002 to 2012. Overall, the perceived risk of harmfulness had decreased significantly with cannabis legalization.

The concept of legalizing recreational use of cannabis had emerged with certain economic benefits such as reduction in law enforcement costs and additional tax revenue that could be generated. [ 38 ] THC is the main psychoactive component, and there is a dose-dependent relationship with the adverse events depending on the content of THC. [ 39 ] Legalization can give power to the government to control the level of THC in the products. The other concerns included a reduction in the black market sale of cannabis and the high costs spent on it which can be diverted toward the government with reasonable costs and good quality cannabis. [ 40 ] This benefits the government to generate revenue and reduces the cost spent on the substance, thereby benefiting the consumer.

In the USA, the legalization of cannabis has been able to curb unemployment and sustain the economy. [ 28 ] In Australia, the cost-benefit analysis of two policy options of the status quo and legalization of cannabis did not show any significant difference between the two. [ 41 ] Although the benefit of the generation of tax revenue and the decrease in the black market have been highlighted in the objectives of legalization of cannabis, its true impact yet needs to be established clearly. Besides, studies regarding long-term impact of cannabis on social and family relationships, academic decline and dropout, sexually transmitted diseases, and unwanted pregnancies may be required.

Impact on cannabis use and conflict with law

Uruguay has been a forerunner in cannabis legalization. It witnessed a reduction in drug-related crime and improvement in the health of users. These have been the recurring themes in favor of legalization of cannabis. In Oregon, arrests of underage youth decreased by 80% between 2012 and 2015. [ 42 ] Cannabis-related criminal arrests in Washington had decreased from 5531 in 2012 to 120 in 2013, which allowed for more police resource allocation to other divisions. [ 43 ] The reported rapes, property crimes, and thefts have all decreased by 15%–30%, 10%–20%, and 13%–22%, respectively, after legalization in Washington, when a retrospective analysis compared crime data in neighboring American states. [ 44 ] In California, certain sources report that illegal markets have decreased after the legalization of cannabis. [ 45 ] Driving under the influence-related arrests have decreased in Alaska, Oregon, Washington postlegalization. [ 28 ]

However, another set of reports have found an increase in legal issues postlegalization of cannabis. The homicide rates have increased in Columbia, Denver, Seattle. [ 46 , 47 ] This can be related to the low cost of marijuana and being less afraid of arrests. [ 28 ] Uruguay in 2017 had the homicide rate of 8.1 per 100,000 inhabitants which was the second-highest recorded rate in the past 30 years. [ 48 ] In 2018, the drug-related violence was responsible for 59% of homicides, about twice the proportion in 2012 in Uruguay. [ 49 ] Contrary to this, there has been another study reporting that there has been no significant change in crime trends in Uruguay. [ 50 ] Illegally grown cannabis had increased from 700,000 pounds in 2017 to 1.6 million pounds in 2018 despite legalization in California. [ 28 ] Although legalization was implemented to reduce illicit cannabis sales, the black market for cannabis in Canada had increased with legalization rather than the expected decrease. [ 51 ] They hypothesize that this might have occurred because more cannabis is available from legal sources to sell illegally. Therefore, the legal issues mainly include crimes which are either directly or indirectly related to cannabis use. The studies depict a mixed picture of cannabis-related legal impact. There is a need for further prospective observational studies examining the direct association between cannabis and crime.

Is India Ready for Legalization of Recreational Cannabis?

Legalization of recreational use of cannabis may lead to the generation of revenue for the country, accountability of its use, reduce law enforcement on the punishment of illegal use, support individual autonomy to choose, reduce the black-market sales and crime rates. The use of cannabis products during certain festivals in India is culturally acceptable, and hence, the resistance associated with its recreational legalization might not be high. As cannabis is already used as a herbal treatment in several parts of India, its acceptability might be higher than expected among various age groups. However, legalization would require an increase in the resources to handle the situation to control illegal cultivation, production, sale, quality control, and marketing. Control of a naturally growing weed is difficult, though quality control and marketing control are possible as shown for alcohol and tobacco.

Despite these regulations, higher tax slabs, alcohol, and tobacco are the most common substances abused in India. [ 52 ] Further, just by legalization, the supposition that grey markets will come down is not guaranteed as there is a mixed picture from other countries. [ 53 , 54 ] There are only around 122 government deaddiction centers along with 4 central institutes with deaddiction facilities. [ 55 ] Legalization of cannabis can lead to a decrease in the perceived harm and an increase in its use. It is proven beyond doubt that cannabis brings forward the onset of psychosis among vulnerable population. [ 56 , 57 ] Furthermore, cannabis use in persons with mental illnesses worsen the prognosis. [ 58 ] Long-term effects (behavioral, academic achievement, and personality development) of cannabis use in adolescents are not clearly known. Introducing another substance might need more facilities to manage these consequences. Besides that, according to the National Mental Health Survey 2015–2016, the treatment gap for mental disorders in India ranges from 70% to 85%. [ 52 ] The treatment gap represents the percentage of individuals who require care but do not receive treatment. [ 59 ] The treatment gap is already high, and legalization of cannabis can potentially increase the burden as more people might use the substance and thereby the increase in physical, mental health, and crime-related consequences. Furthermore, it has been noted that treatment seeking in patients using cannabis is less in India. [ 60 ] This can further widen the treatment gap. Finally, chronic use of cannabis can be associated with as a single word with a capital A: Amotivational syndrome characterized by apathy, withdrawal, poor judgment, and failure to achieve. [ 61 , 62 ] This can be one of the challenges in legalization of recreational cannabis and may affect the largely on gross domestic product of the country.

In India, policymakers need to consider the above-mentioned studies and experiences before legalizing the recreational use of cannabis. Making an informed decision to use or not use a substance is of utmost importance. Therefore, introducing cannabis into society would require adequate education and awareness programs about the risk and benefits of the substance. Table 1 summarizes the debate on whether or not should the recreational use of cannabis be legalized.

What is the Way Forward in India?

The existing judicial system in India prohibits recreational use of cannabis except bhang. Before considering legalization of recreational use of cannabis, one of the most important steps would be for policymakers, health planners and other stakeholders to have a debate and draft a clear and rational policy related to recreational use of cannabis appropriate for India. This requires a paradigm shift of public health systems in its approach towards cannabis use. Already, the existing criminal justice system and health-care systems are overburdened and are finding it difficult to regulate the medicinal use often the first to come in contact with cannabis-related problems. Stringent laws and regulations need to be in place before legalization of recreational use of cannabis. These could be in the form of having a strict legal age for procuring cannabis, regulation of the amount of THC in the available cannabis for recreational use, regulating the growth of cannabis, etc.

The legal age of procuring cannabis is 21 years and 18 years in the USA and Canada, respectively. [ 63 ] Majority of these policies are derived from the policies of alcohol which are difficult to implement even in developed nations. Driving under the influence of cannabis is prohibited in all the states of the USA. [ 22 , 64 ] However, the ground reality is that the number of accidents (under the influence of cannabis) is increasing. Hence, these regulations are very unlikely to work in India. [ 63 ] Thus, the authors believe that India is perhaps not yet ready to legalize the recreational use of cannabis.

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Traditional, Cultural, and Nutraceutical Aspects of Cannabis in India

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Historically, India has continued to produce and use Cannabis for medicinal, nutritional, spiritual-religious, and socio-cultural purposes, as documented in ancient Indian literature. Furthermore, various indigenous medicinal practices unique to India, such as the Ayurveda, Siddha, and Unani, indicate wide use of Cannabis in treating various disorders. Cannabis has had a very long unbroken tradition of cultivation and application in India for ages till the present. Various parts of the plant ( Cannabis sativa Linn.), such as the flowers, leaves (and the resinous matter derived from there), fruit, young twigs, and stalk/stem, are commonly used in India and other parts of the world for different purposes. This book chapter gives an overview of the broad applicability of Cannabis in India, including cultural, medicinal, agricultural, commercial, and recreational uses.

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Abbreviations.

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Legalization of Marijuana in India

17 Pages Posted: 11 May 2013

Shayan Dasgupta

Independent

Date Written: May 6, 2013

Marijuana has been used since the Pre-Historic period of Man’s existence and is closely integrated with the history of the most Ancient civilizations known to have existed. In India, it is association with religious customs and traditions that date back to the period of thriving gods and goddesses. Legalization of marijuana has always been a debatable topic after the enforcement of Narcotic Drugs and Psychotropic Substances Act, 1985 illegalising sale and possession of marijuana all over India. Despite its use in the medical field no positive step has been taken. In the wake of the recent events in which two US states have voted to legalize recreational use of marijuana, a wave of liberal thoughts have up-roared in this country. This paper aims at drawing a strict analysis of usage of marijuana followed with a comparative study with the rest of the world pin-pointing whether India should legalize marijuana or not.

Keywords: Addict, Cannabis, Marijuana, Recreational use

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India Law eJournal

Legalization Of Marijuana And An Outlook Into The NDPS Act: Research And Analysis

• Author(s): Rahul Ranjan
• Publication Date: December 18, 2021

Contents of this Post

Marijuana has been one of the primitive psychotropic drugs used since the Pre-Historic period of Man’s existence and is closely integrated with the history of most ancient civilizations in terms of their religious practices, known to have existed throughout the world. In India, Marijuana mostly has an association with religious customs and traditions that date back to the period of flourishing gods and goddesses. Decriminalization of marijuana has always been a questionable topic after the execution of the Narcotic Drugs and Psychotropic Substances Act, (NDPS Act) 1985, interdicting the sale and possession of marijuana all over India. In the wake of the recent events in which ten states in the United States have voted to legalize the recreational use of marijuana, a surge of liberal thoughts has outraged this country. This paper aims at drawing a strict analysis on the usage of marijuana, legalization of the same in India followed by arguments related to alcohol and tobacco regulation and the ineffectiveness of the NDPS Act in relation to the prohibition of Marijuana.

Consumption of marijuana and other cannabis spinoffs such as bhang date back hundreds of years with strong roots in Indian religion and culture. From being the indulgence of Baul singers of Bengal to the festival of Holi, Marijuana use has rarely been seen as aberrant social behaviour in Indian society. In fact, till 1985, marijuana and other cannabis by-products were legally sold in the country through approved retail shops. However, the enactment of the Narcotic Drugs and Psychotropic Substances (NDPS) Act in that year killed the marijuana trade in India.

Research Objective

Aim and objective.

This project aims to provide evidence as to why Marijuana should be made legal in a country like India. The objective is to find evidence and loopholes in the various statutes regarding mild intoxicants and come up with arguments as to why such mild drugs can /should be regulated in government authorised stores rather than being banned.

Scope and Limitations

The research paper attempts to figure why Marijuana is illegal in India, how the NDPS Act came into existence and whether it had been serving its purpose or not, if it is possible to make Marijuana legal because the NDPS Act is ineffective and also as more than half the population is already smoking it.

As a researcher there were a few constraints that I faced during the progress of my paper, the primary being the lack of material when viewed in the context of India. The secondary is that some of the sources (mostly the internet) that I have relied on may require further verification on certain grounds.

The majority of this paper has been done using secondary sources. There has also been the application of very few primary sources in certain areas. My research has mostly been around blogs, online newspapers, videos, articles, journal articles, e-books, etc.

Research Questions

• Is the outlawing of Marijuana beneficial to the Indian subcontinent? What is the ‘mischief’ that is sought to be addressed/prevented by criminalizing marijuana?
• Is there a legal basis in banning Marijuana and or does the basis lie in non-legal cultural/moral norms?
• Is there a case for decriminalizing marijuana use considering the ineffective enforcement of (NDPS) Act?

Concept and Content of Cannabis

Cannabis, also known as marijuana (from the Mexican Spanish marihuana), and by other names such as Weed, Hemp, Hashish/hash, Ganja, Strawberry Diesel etc. is a blend of the Hemp [1] plant intended for use as a psychotropic drug as well as for its medicinal [2] values. Cannabis has more than two hundred street names amongst which hashish (also known as hash), ganja, weed, pot, grass etc. are the popular ones. Marijuana contains THC (delta-9-tetrahydrocannabinol), the main active chemical in marijuana. It also contains 400 other chemicals. Marijuana’s effects on the user depend on the strength or potency of the THC it contains. THC is a chemical that increases the tolerance of the user towards the drug where more quantities of the drug need to be taken in order to achieve the same ‘HIGH’ effect as before. The mind-altering effect caused by this active chemical changes the way the brain works and functions. It has been argued for years now whether the cannabis plant/hemp is a drug or simply a natural herb like any other with stronger side effects and hence many people are considering both herb and drug to be the most logical answer.

What Is the ‘Mischief’ That Is Sought to Be Prevented by Criminalizing Marijuana in India?

In 2004, the United Nations (UN) estimated that the global consumption of cannabis throughout the world to be approximately 4% of the adult world population (162 million people) who used cannabis annually and approximately 0.6% (22.5 million) of people who used cannabis [3] daily.  Since the early 20th-century cannabis has been subject to legal restrictions with the possession and use and abuse, and the sale of cannabis preparations containing psychoactive ingredients is currently illegal in most countries of the world especially in India; the United Nations has said that cannabis is the most-used illicit drug in the world.

Aside from a subjective change in perception and, most notably, mood, the most common short-term physical and neurological effects include increased heart rate, increased appetite and consumption of food, lowered blood pressure, impairment of short-term and working memory [4] , psychomotor coordination, and concentration. Long-term effects are less clear [5] . In humans, relatively few adverse clinical health effects have been documented from chronic cannabis use.

Cannabis Edges India? Why?

Psychoactive drugs fall in the category of anti-depressants, hallucinogens and cannabis is one such drug that is a mix of all these properties making it most sought after. THC is typically considered the primary active component of the cannabis plant; various scientific studies have suggested that certain other cannabinoids like CBD may also play a significant role in its psychoactive effects. It’s been proved by medical studies that marijuana is one of the top-end substances which are being used as painkillers for arthritis and glaucoma as well as cancer and that the results produced by this plant are unquestionable. [6]

Medical Use

Cannabis used medically has several well-documented beneficial effects. Among these are: the reduction of nauseating sensation and vomiting in chemotherapy as well as stimulation of hunger and the same for AIDS patients, lowered intraocular eye pressure as well as to treat pain and muscle spasticity (shown to be effective for treating glaucoma), as well as the general anaesthetic effects (pain reliever). Most recent studies indicate that cannabis helps in de-stressing and acts as an anti-depressant.

People Jailed for Possession

After the enactment of the NDPS Act, it was a harsh blow on the population of India as a violation of the Act would lead to 15 years prison sentence. It was later on that the rules became a little more formidable where the sentence was decreased. Before this easement of the sentence, people had been getting picked off the streets and have been tossed into jail. By legalization, the burden of the police will also reduce and the number of people rotting in jail would also decrease to a large extent.

Ineffectiveness of Prohibition

The third major reason why marijuana should be legal is that prohibition does not help the country in any way. There is no sufficient evidence to state that prohibition decreases drug use, and there are several theories that suggest prohibition can actually increase drug use (i.e. the “forbidden fruit” effect, and easier accessibility for youth due to lack of regulation). One unintended effect of marijuana prohibition is that marijuana is very popular in the Indian setting. Why? Because it is available. You don’t have to be 21 to buy Marijuana – Marijuana dealers usually don’t care how old you are as long as you have the money. It is actually easier for many college kids to obtain marijuana than it is for them to obtain alcohol because alcohol is legal and therefore is regulated to keep it from within the reach of kids. If our goal is to reduce drug consumption, then our main aim should be to should focus on open and honest programs to educate youth, regulate and safeguard in such a way to keep kids away from drugs, and treatment programs for people with drug problems. But the current prohibition scheme does not allow for any such reasonable approaches to marijuana. We tried prohibition with alcohol, and that failed miserably. And we sure are trying the same procedure with marijuana and until we fail, which we are sure to do, we would have not realized our mistake.

Saving on Costs

It is quite impossible to ban something that grows naturally in our country. The hemp plant grows naturally in most of the high altitude regions of India and even though our government decides to ban the drug, people in the country will still be able to get their hands on the plant as it can be found anywhere and banning it is “BORDERLINE” stupidity. So the fact that our government tries very hard to keep this ban on Marijuana, they should realize that it is not getting them anywhere and hence if it was legalized then it could be used to the advantage of the government since we find it in abundance in our country. The resources that go into prohibiting the drug are being squandered and wasted as there are no measures that can be taken to ban or even enforce a ban on a plant that is unique to our country. If these resources were used elsewhere in terms of regulating Marijuana, our country will have the funds to deal with other widespread problems such as poverty and human trafficking.

Money Creation (Tax Revenue)

It is evident that legalizing marijuana through the process of regulation [7] , it would allow for legal distribution and taxation of cannabis in India. Marijuana legalization offers an important advantage over prohibition [8] which is that it allows for taxation on the legal distribution of marijuana. Without taxation [9] , the free market price of cannabis is estimated to be extremely low. Therefore, taxation could be implemented at extremely high rates, while maintaining the price of the drug at a rate competitive to other intoxicants, such as alcohol. Taxation [10] on legalized marijuana would both create government revenue as well as provide a less harmful and addictive substitute to tobacco and alcohol costly enforcement and incarceration expenses. It would create an economic boom in our country which would leave smiles on many, many farmers as well as growers whose livelihood is based on growing Marijuana especially in the Kullu Valley/Region of Himachal Pradesh.

In a country like India where their unity in diversity, the fact that many religions depend on marijuana to reach their god must also be considered in this argument. These “sadhus” or “godmen” who proclaim to get closer to god only by smoking marijuana are not going to stop smoking Marijuana just because it’s illegal. It does not really matter to them as long as they get their share for the day which indirectly puts the government in a bad light as it will be said that the government has not taken effective measures in actually prohibiting the drug they said was illegal to possess. Since our country has decided to ban such a drug, it is necessary that the legislation takes all aspects of the drug into notice as it plays a very important role in the realm of religion. If it is banned then no one, including the “sadhus”  should be allowed to use the drug for any sort of recreational use.

Counter Arguments Regarding Legalization of Marijuana in India

These were a few reasons that were given by the Parliament on why the recreational use of Marijuana is banned in the country. In the below arguments I have provided both sides of the argument. The counterarguments have been researched upon and written by me.

The Gateway to Drugs theory

This theory states that the use of less deleterious drugs may lead to a future risk of using more dangerous drugs. Cannabis, alcohol and tobacco are ascribed to this theory. Some scientific studies show that the consumption of cannabis can possibly predict a significantly higher risk for the subsequent use of “harder” illicit drugs, while other studies show that it cannot [11] . A 10 yearlong study conducted in Australia found that adults of 24 years used a drug called Amphetamines [12] which was preceded by the use of cannabis.

In 2006 a counter-study was conducted on rats, in Sweden, which examined the brains of the rats after dosing them with cannabis and found that the THC alters the opioid system that is the system associated with positive emotions, where it lessens the effect of the opiates on the rat’s brain and thus causing them to use more heroin. The rats were given THC at a very young age of 28 days, which is why it is impossible to extrapolate the results of this study to humans. Also, the previously cannabis-exposed adult rats, despite being desensitized to heroin, were no more likely to get addicted (as measured by the likelihood of self-administration) than the controls.

There are many more controversial approaches [13] to this theory making it the most criticized theory against the battle for legalization. Many medical studies have just been logical fallacies. A major one is the invalidity of the argument saying that there exists a causal relationship between the two variables – ‘using less harmful drugs to move on to harder drugs- ‘from a relationship which is strictly parallel’ [14] . Also if looked at logically, there are individuals who would yes to all if they were given a new drug to try for whatever the reasons may be and hence these mild drugs such as Marijuana could be seen as irrelevant in terms of being a ‘gateway drug [15] ’ except the fact that they are available at an earlier age than the harder drugs.

Effects on the Brain

A 35-year cohort study published August 2012 in Proceedings of the National Academy of Sciences and funded partly by NIDA and other NIH institutes reported an association between long-term cannabis use and neuropsychological decline [16] , even after controlling for education. It was found that the persistent use of marijuana before age 18 was associated with lasting harm to a person’s intelligence, attention and memory, and was suggestive of neurological harm from cannabis [17] .

However, individuals who started cannabis use after the age of 18 [18] did not show such decline. Results of the study [19] came into question when a new analysis, published January 2013 in Proceedings of the National Academy of Sciences, noted other differences among the study group including education, occupation and other socioeconomic factors that showed the same effect on IQ as cannabis use. Existing research suggests that the 2012 study was likely to be an overestimate and that the true effect could be zero. Three more research studies collaborate this finding [20] .

The Inefficiency Of The NDPS Act In The Prohibition Of Marijuana

While examining different angles identified with liquor, drugs and HIV, it is alluring that we additionally inspect no less than one of the enactments in point of interest relating to drugs. Subsequently in this unit let us inspect the Narcotic Drugs and Psychotropic Substance (NDPS) Act, 1985 [21] . The NDPS Act, as it is known prevalently, is intended to face an imperative social issue: drug trafficking. This is additionally one of the unique Acts that has preceded the courts often and has been having an extensive number of clashing judgments hence confounding the overall population. Preceding the NDPS Act, the statutory control over opiate drugs was practised in India through various Central and State Enactments. The Principal Central Act, 1930 was authorized quite a while back being of the first enactments regarding the prohibition of drugs in India. With the progression of time and the advancements in the field of illegal drug movement and substance misuse at the national and international level, numerous insufficiencies in the current laws have come into notice.

Sec. 2 [22] (iii) characterizes Cannabis as “cannabis (hemp)” as charas, that seems to be, the differentiated pitch, in whatever structure, whether rough or sanitized; from the cannabis plant furthermore incorporates concentrated planning and tar known as hashish oil or fluid hashish; ganja, that is, the blooming or fruiting highest points of the cannabis plant (barring the seeds and leaves when not joined by the tops), by whatever name they may be known or assigned; and any mixture, with or without any material, of any of the above types of cannabis or any beverage arranged subsequently [23] . The definition in this Act prohibits leaves and seeds when not joined by tops. Bhang is not secured by the Act however it incorporates charas. Bhang is an arrangement produced using cannabis leaves expended in parts of India on a few celebrations. As it is not produced using cannabis tar or from blooming tops, it is not secured under the NDPS Act, 1985. The creation and offer of Bhang are allowed by numerous State Governments.

Likewise sec. 8 [24] expresses that no individual can produce or grow the opium poppy or any cannabis plant with an exemption for medicinal or logical purposes in the way and to the degree given by the procurements of this Act. Therapeutic utilization and logical exploration of Marijuana is, hence, lawful in India according to this segment but recreational use is strictly unlawful. On the other hand, restorative utilization of cannabis has so far been to a great degree restricted and kept to as a substitutive solution, for example, homoeopathy and Ayurveda. State Governments have really not been authorizing the development of cannabis for strictly medical purposes. Recently, there has been developing worldwide enthusiasm among researchers in investigating conceivable restorative employments of cannabis. Development of cannabis won’t be allowed provided for its constrained demonstrated uses for restorative purposes.

Development should be allowed for exploration including trials of different mixtures of cannabis. Notwithstanding this inconsistency, the Central Government does not allow consent to utilize cannabis for modern and green purposes (exploratory examination). The Cannabis plant can be a wellspring of biomass and fibre for modern purposes. Cannabis seeds can be utilized to create cannabis seed oil – a high esteemed oil. A few nations permit the development of cannabis mixtures that have a low substance of tetrahydrocannabinol (THC), the dynamic fixing which has an inebriating impact. These mixed bags of cannabis are utilized to create filaments which are, thusly, utilized as a part of a generation of fabrics and for the creation of biomass.

Cannabis grown for any recreational purposes [25] (Cannabis Sativa) is an offence under the NDPS Act. Anybody developing cannabis for any reason other than for medicinal and experimental research is obligated under Section 20 which expresses that development or generation or offering or buying ganja will sum to five years of detainment with a fine reaching out to fifty thousand rupees, and for whatever other manifestations of cannabis other than ganja will prompt least ten years of detainment with a fine stretching out to one lakh rupees. Likewise, the court has the tact, in light of sensible legitimization, to force a fine surpassing two lakh rupees.

I submit that this Act irrationally groups ganja, charas in examination with bhang. How can it be that charas and ganja are illicit, yet bhang is devoured lawfully on an expansive scale? Isn’t this disparity going to befuddle the general population? The administration has neglected to draw a line between the booked medications and gentle intoxicants. On the off chance that at all a line is to be drawn then, either the whole classification of cannabis ought to be banned or no part of it ought to be disallowed as this is an outlandish and uncalled for order. In addition, the exemption to giving the restorative utilization of cannabis is a make-conviction procurement as it is just about difficult to look for consent for its logical and therapeutic utilization. The administration’s strict zero-tolerance approach has blinded it from recognizing the evidence and subsequently, this has made it lose its centre from successfully satisfying its obligation through the methodology of making statutes/rules in this Act.

The obstruction corrective procurements of the NDPS Act, 1985 and other administrative, managerial and preventive measures were discovered deficient to control the illegal travel activity in drugs. It was, accordingly, felt that a preventive confinement law ought to be instituted with a perspective to successfully immobilize individuals occupied with any sort of illegal activity of opiate drugs and psychotropic substances. To attain this destination, the President proclaimed the “Prevention of Illicit Traffic in Narcotic Drugs and Psychotropic Substances Ordinance [26] ” on the fourth of July, 1988. – focused on the UN Convention and SAARC Convention of 1988.

This Act enables the Central Government and the State Governments to make requests of detainment concerning any individual (counting a non-native) in the event that they are of the conclusion that it is important so to do with a perspective to keeping him from submitting illegal activity in opiate drugs and psychotropic substances. The outflow “illegal movement” had been characterized to incorporate the development of any coca plant or assembling any segment of coca plants, developing the opium poppy or any cannabis plant, or taking part in the creation, make, ownership, and so forth of opiate medications or psychotropic substance.

As I would see it in spite of the procurements that have been made by the legislature, unlawful trafficking of drugs still prevail. I concur that the stringent demeanour has helped control this uncontrolled procedure to a certain degree, however not a noteworthy degree. This is likely because of the hazy boundaries of the drugs in the aforementioned Act. By what means can the administration work effectively if the Act spreads clarity? It is high time that a legitimate line is drawn and the administration concentrates on fighting the perilous drugs and quits characterizing the mellow intoxicants in the same group.

Hence I submit that there is a chance for decriminalizing Marijuana in India due to the ineffectiveness of the Act in prohibiting it. In light of the above argument, it can be seen that the provisions regarding Marijuana prohibition in India do not cover all aspects of the subject matter hence the presence of loopholes tend to be present which give rise to unnecessary problems, in this case, illicit trafficking of drugs and other substances.

Is there a legal basis in banning marijuana in India or does the basis lie in non-legal cultural/moral norms?

A recent article in the “The Times of India” gave an excerpt on the history of the NDPS Act and marijuana legalisation. –

“For 25 years since 1961, India has withstood American pressure to keep marijuana legal [27] .”

“Since 1961, the US has been fighting for a worldwide law against all drugs, both hard and soft. Given that ganja, charas and bhang was a lifestyle in India, we restricted this extreme measure. However, by the early ’80s, the American culture was pondering over some drug issues and supposition had developed against the “overabundances” of the nonconformist era. In 1985, the Gandhi government feeling burdened under all that pressure went ahead and instituted a law called the Narcotic Drugs & Psychotropic Substances (NDPS) Act.” It was a poor law that clubbed cannabis, hashish and bhang with hard drugs like smack, heroin, cocaine and split, and banned all of them. The base discipline for infringement of the NDPS Act was 10 years of prison (it was understood to have been loose and the crackdown on weed has sort of lessened). What happened as an aftereffect of this law was that practically overnight the whole exchange moved from selling grass or charas to smack and much harder drugs.

And before anyone could figure what had happened we had a there was a drug problem in India. In urban areas like Delhi, case in point, production of smack developed. The addicts were generally destitute and came from lower backgrounds – the individuals who had prior smoked grass were currently “pursuing” smack. The misguided NDPS Act had really created a drug problem when there wasn’t even one in the first place.

The 1961 “single convention on narcotic drugs” was the first-ever universal arrangement to have clubbed cannabis (or marijuana) with hard drugs and forced a sweeping boycott on their generation and supply aside from therapeutic and exploration purposes. Amid the transactions for the UN settlement marked in New York, a gathering of cannabis and opium-producing nations, headed by India, restricted its bigotry to the sociocultural utilization of natural ‘medication’. They were however overpowered by the US and other western nations which upheld tight controls on the creation of natural crude material and on illegal trafficking [28] .

The sharp divergences between the councils headed by India and the US exuded from their differentiating household strategies, especially on cannabis. While the vast majority of the states in the US had banned all opiate medicates by the ’40s, India had a more business-like methodology since its pioneer days: its limitations were centred on harder substances like opium. The Indian hemp medication commission selected in 1893, a long way from thinking that it was addictive, hailed cannabis for the “gentle rapture” and “charming unwinding” brought about by it.

The predominant view on cannabis in the UN consultations prompting the 1961 arrangement couldn’t have been more diverse. Notwithstanding, in the bargains that emulated to work out an agreement, the last draft of the settlement characterized cannabis in such a way, to the point that it cleared out-degree for India to bear on, for example, with the custom of bhang being devoured on an extensive scale on Holi. The settlement illuminated that the cannabis illegal by it was just “the blossoming or fruiting highest points of the cannabis plant”, particularly “barring the seeds and leaves when not joined by the tops”.

In regard to the scale of customary utilization in India, the 1961 arrangement additionally provided for it a relief of 25 years to brace down on recreational medications determined from the tops. It was towards the end of this exclusion period that the Rajiv Gandhi government concocted a law in 1985 adjusting to the 1961 bargain: the Narcotic drugs and psychotropic substances Act (NDPS).

In like manner, NDPS duplicated the proviso given in the arrangement’s meaning of cannabis, whereby its leaves and seeds have been saved the disgrace of booty. In addition, NDPS pointed out that cannabis implied charas (the gum separated from the plant), ganja (the blooming or fruiting highest points of the plant) and any mixture or beverage readied from both of the two allowed manifestations of weed. Hence, NDPS permits individuals to smoke pot or beverage bhang so long as they can demonstrate that they had devoured just the leaves and seeds of the cannabis plant.

Then again, since cannabis develops wild the nation over as a strong weed, it is troublesome for the Narcotic Control Bureau, set up under NDPS, or the neighbourhood police to check individuals from assimilating the prohibited tops. The dubiousness of the procurement on pot is the closest India has possessed the capacity to come to recognize what Colorado and Washington are presently looking to accomplish through their choice: recreational utilization of the weed.

The bases of cannabis are profound and strongly spread all through antiquated India. From 2000-1400 BC to up until the 1980s’ Marijuana was lawfully sold [29] , even at typical shops, and utilized widely by individuals. However, there was a gigantic setback to the same with the requirement of the Narcotic Drugs and Psychotropic Substances Act, 1985 (NDPS Act 1985) which made Marijuana illicit in India. With the improvement of the NDPS Act, there was an increment in drug wars and planned unlawful acts.

Legitimization of cannabis will spare time and exertion used by our administration on a trivial medication, for example, weed, which could be adequately used towards more genuine and unsafe drugs, for example, heroin, and cocaine and so on. Studies do uncover that unlawful acts and wars happen generally because of forceful and rough streaks in people. With the assistance of Marijuana, they can be tranquil and stunned which will, thus, diminish the inclination to savagery. This comes as some assistance for the legislature in times of such roughness and interruptions in the country, (for example, terrorist acts, religious upheaval and so forth.). Additionally with the accessibility of milder medications, for example, cannabis, the inclination to enjoy more unsafe medications will definitely diminish. Financially talking likewise, the sanctioning pot will help as an additional wage for the recently authorized conveys and merchants. Likewise regulation over the deal can create gigantic duty incomes which can free obliged India from WHO and UN. I might want to infer that the time it now, time that India – considering the age-old custom of utilizing cannabis off-spring (bhang) for revering divine beings and goddesses furthermore for individual joy/recreational utilization ought to set an illustration, being the subcontinent, and authorize pot. Examines over the world demonstrate that direct utilization of cannabis is far less hurtful than tobacco or liquor, it bodes well for maintaining the boycott on its recreational utilization.

Obviously, the exorbitant utilization of marijuana can be unfavourable. However, that is additionally valid for liquor – banning which is seen, rightly, as unreasonable. On the off chance that tobacco and liquor are sold over the counter and the customers are anticipated to utilize as much as they want within it is a need, there is no motivation behind why the same approach can’t be received for Marijuana. Additionally, the profits of therapeutic Marijuana are generally recognized, which supports its qualifications as a mellow medication. Authorizing/Legalizing Marijuana [30] , brought together with an illuminated medical approach, will stop the spread of more hazardous intoxicants and lead towards a more modern and developed India.

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• Meier, Madeline H., Avshalom Caspi, Antony Ambler, HonaLee Harrington, Renate Houts, Richard S. E. Keefe, Kay McDonald, Aimee Ward, Richie Poulton, and Terrie E. Moffitt. “Persistent Cannabis Users Show Neuropsychological Decline from Childhood to Midlife.” Proceedings of the National Academy of Sciences 109, no. 40 (October 2, 2012): E2657–64. doi:10.1073/pnas.1206820109.
• Mitta, The author has posted comments on this articleManoj, TNN | Nov 10, 2012, and 06 41am Ist. “Recreational Use of Marijuana: Of Highs and Laws.” The Times of India . Accessed October 8, 2014. http://timesofindia.indiatimes.com/india/Recreational-use-of-marijuana-Of-highs-and-laws/articleshow/17165524.cms .
• N, The author has posted comments on this articleDurgesh, an Jha, TNN | Nov 10, 2012, and 06 38am Ist. “Hope for Dope: Alcoholics Face a Greater Risk than Marijuana Users, Doctors Insist.” The Times of India . Accessed October 8, 2014. http://timesofindia.indiatimes.com/india/Hope-for-dope-Alcoholics-face-a-greater-risk-than-marijuana-users-doctors-insist/articleshow/17165501.cms .
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• Rogeberg, Ole. “Correlations between Cannabis Use and IQ Change in the Dunedin Cohort Are Consistent with Confounding from Socioeconomic Status.” Proceedings of the National Academy of Sciences 110, no. 11 (March 12, 2013): 4251–54. doi:10.1073/pnas.1215678110.
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• Strat, Yann Le, and Bernard Le Foll. “Obesity and Cannabis Use: Results From 2 Representative National Surveys.” American Journal of Epidemiology , August 24, 2011, kwr200. doi:10.1093/aje/kwr200.
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• Varma, The author has posted comments on this articleSubodh, TNN | Nov 10, 2012, and 06 51am Ist. “Mankind and Grass Go Back 5,000 Years.” The Times of India . Accessed October 8, 2014. http://timesofindia.indiatimes.com/india/Mankind-and-grass-go-back-5000-years/articleshow/17165592.cms .
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[1] “Hemp (plant),” Encyclopedia Britannica , accessed October 4, 2014, http://www.britannica.com/EBchecked/topic/261088/hemp.

[2] “Oxford English Dictionary.” (Oxford University Press, 6 th edt.).

[3] United Nations Office on Drugs and Crime, “. Cannabis: Why We Should Care.,” (PDF, 2006).

[4] L. Iversen, “Long-Term Effects of Exposure to Cannabis”. Current Opinion in Pharmacology , 1st ed., vol. 5, 2005.

[5] Harold Kalant, “Adverse Effects of Cannabis on Health: An Update of the Literature since 1996,” Progress in Neuro-Psychopharmacology and Biological Psychiatry , Festschrift in Honour of Corneille Radouco-Thomas (1916-2003), 28, no. 5 (August 2004): 849–63, doi:10.1016/j.pnpbp.2004.05.027.

[6] Fusar-Poli P et al., “Distinct Effects of δ9-Tetrahydrocannabinol and Cannabidiol on Neural Activation during Emotional Processing,” Archives of General Psychiatry 66, no. 1 (January 1, 2009): 95–105, doi:10.1001/archgenpsychiatry.2008.519.

[7] “Legalizing Marijuana Would Generate Billions In Additional Tax Revenue Annually – Cannabis Politics and News,” GreenPassion – Dedicated to Medicinal Cannabis , accessed October 8, 2014, https://www.greenpassion.org/index.php/topic/34410-legalizing-marijuana-would-generate-billions-in-additional-tax-revenue-annually/.

[8] “Colorado Makes $3.5M in Pot Revenue in January,” accessed October 8, 2014, http://www.usatoday.com/story/news/nation-now/2014/03/10/marijuana-revenue-colorado-taxes/6261131/.

[9] “Legalizing Marijuana Can Reduce Crime, Increase Revenue for State,” Daily Sundial , accessed October 8, 2014, http://sundial.csun.edu/2009/11/legalizing-marijuana-can-reduce-crime-increase-revenue-for-state/.

[10] “These 5 Numbers Show Marijuana Legalization Is Going Well in Colorado | Just Say Now,” accessed October 8, 2014, http://justsaynow.firedoglake.com/2014/02/25/these-5-numbers-show-marijuana-legalization-is-going-well-in-colorado/.

[11] Anita Srikameswaran Pittsburgh Post-Gazette, “Researchers Say Smoking Pot Not Always Path to Hard Drugs Drug Use,” Pittsburgh Post-Gazette , accessed October 8, 2014, http://www.post-gazette.com/news/health/2006/12/05/Researchers-say-smoking-pot-not-always-path-to-hard-drugs-drug-use/stories/200612050152.

[12] “Amphetamine Abuse & Addiction Causes, Symptoms & Side Effects – Virginia – Mount Regis Rehab Center,” accessed October 8, 2014, http://www.mtregis.com/addiction/amphetamines/effects-signs-symptoms.

[13] Marc Kaufman, “Study Finds No Cancer-Marijuana Connection,” The Washington Post , May 26, 2006, sec. Health, http://www.washingtonpost.com/wp-dyn/content/article/2006/05/25/AR2006052501729.html.

[14] Craig Reinarman, Peter D. A. Cohen, and Hendrien L. Kaal, “The Limited Relevance of Drug Policy: Cannabis in Amsterdam and in San Francisco,” American Journal of Public Health 94, no. 5 (May 2004): 836–42.

[15] Post-Gazette, “Researchers Say Smoking Pot Not Always Path to Hard Drugs Drug Use.”

[16] Anahad O’Connor, “‘Moderate Marijuana Use Does Not Impair Lung Function, Study Finds’.,” November 1, 2012, NYTimes.com.

[17] Ole Rogeberg, “Correlations between Cannabis Use and IQ Change in the Dunedin Cohort Are Consistent with Confounding from Socioeconomic Status,” Proceedings of the National Academy of Sciences 110, no. 11 (March 12, 2013): 4251–54, doi:10.1073/pnas.1215678110.

[18] Madeline H. Meier et al., “Persistent Cannabis Users Show Neuropsychological Decline from Childhood to Midlife,” Proceedings of the National Academy of Sciences 109, no. 40 (October 2, 2012): E2657–64, doi:10.1073/pnas.1206820109.

[19] Iversen, “Long-Term Effects of Exposure to Cannabis”. Current Opinion in Pharmacology .

[20] Rogeberg, “Correlations between Cannabis Use and IQ Change in the Dunedin Cohort Are Consistent with Confounding from Socioeconomic Status.”

[21] The Narcotic Drugs and Psychotropic Substances Act, 1985 (Georg Thieme Verlag, n.d.).

[23] The author has posted comments on this articleDurgesh N et al., “Hope for Dope: Alcoholics Face a Greater Risk than Marijuana Users, Doctors Insist,” The Times of India , accessed October 8, 2014, http://timesofindia.indiatimes.com/india/Hope-for-dope-Alcoholics-face-a-greater-risk-than-marijuana-users-doctors-insist/articleshow/17165501.cms.

[24] The Narcotic Drugs and Psychotropic Substances Act, 1985 .

[25] “How Cannabis Was Criminalised,” Independent Drug Monitoring Unit , accessed September 30, 2014, http://www.idmu.co.uk/historical.htm.

[26] The Narcotic Drugs and Psychotropic Substances Act, 1985 .

[27] The author has posted comments on this articleManoj Mitta et al., “Recreational Use of Marijuana: Of Highs and Laws,” The Times of India , accessed October 8, 2014, http://timesofindia.indiatimes.com/india/Recreational-use-of-marijuana-Of-highs-and-laws/articleshow/17165524.cms.

[29] The author has posted comments on this articleSubodh Varma et al., “Mankind and Grass Go Back 5,000 Years,” The Times of India , accessed October 8, 2014, http://timesofindia.indiatimes.com/india/Mankind-and-grass-go-back-5000-years/articleshow/17165592.cms.

[30] “These 5 Numbers Show Marijuana Legalization Is Going Well in Colorado | Just Say Now”; Renee Jacques and Todd Van Luling, “This Is Why Marijuana Should Be Legal Everywhere,” Huffington Post , October 24, 2013, http://www.huffingtonpost.com/2013/10/24/marijuana-legalization_n_4151423.html; “Why Legalizing Weed Just Makes Sense – YouTube,” accessed October 4, 2014, https://www.youtube.com/watch?v=lvPbmKt-PRU.

Legalization of Marijuana in India: Pros, Cons and Other Alternatives

The history of cannabis in the indian context, pros of legalization.

• The consumers are forced by the statute to purchase products the from a local dealer or, more commonly, from black market. Users would be able to obtain the goods through legal channels.  
• Legalization would address the major issue of drug cartels and black-market sales while also making safer and higher-quality pharmaceuticals available to consumers.
• One of the most alluring and contentious aspects of legalizing marijuana is the tax money. On the plus side, tax revenue obtained from sales may be utilized to improve h research on infrastructure, education, and other important goals. As is well known, a significant amount of police resources as well as money are used to uphold the anti-marijuana regulations.  
• A large number of offenders under the NDPS act are those prosecuted for mere possession or consumption of marijuana. Legalization of marijuana would allow the state to direct the precious time of police and state fund towards prevention of crimes which are more dangerous and harm public at large.  
• The incidents of fight and violence between drug gangs and sometimes between the supplier and consumer is also an issue which can be resolved. The legalization would enable the suppliers to do the business in legitimate way and both the suppliers and the customers can take help of legal authorities in case of any dispute related to business or product quality. Thus, ensuring peace and tranquility in society and preventing such drug reacted violence.
• It is believed that for many people marijuana acts as a gateway drug. Who in some cases switch to other hard drugs like heroin, cocaine in layer stages of their life.  
• In India drunk driving leading to road accidents is already a major issue, which leads to grievous injuries and loss of life per year. It is asserted that further legalization of marijuana will add to the already existing problem. And would create more responsibility on the police and add burden on the government resource for safety and enforcement of the laws.  
• There have been several theories and claims made by the opponents of legalization starting from the danger it poses to the youth [3] especially vulnerable teenagers, secondhand smoking, road accidents, to long term brain damage and lung cancer.  
• Particularly if the assertions that it is more than cigarettes are true, especially if it is as addictive as other narcotic. These still need to be discovered through well-funded research. When considering marijuana-related laws, we tend to lean either toward legalization or prohibition. But there is also a middle ground. And perhaps it's a superior strategy for some justice introductions for specific social groups.

Alternatives to prohibition or legalization:

• Sin tax is a widely used concept [4]. Often applied on goods including cigarettes, alcohol, and fuel. As demand [5] is responsive to price. Such laws are designed to discourage the usage of particular products by increasing their tax obligations.  
• Educational campaigns: Programs that focus on harm reduction seek to reduce the negative effects of marijuana usage rather than just criminalizing or legalizing it. To assist users in making educated decisions and lowering risks associated with addiction, mental health, and social repercussions, these programs provide education, counseling, and support services. These can be effective only when it reaches the target group, and in an effective way. A community-based educational approach should be taken. Not a pedagogical or religious instructional training.  
• The supply chain of marijuana could be managed by the government, similar to how certain state and local authorities handle the distribution of alcohol. The underlying rationale is that by removing the profit motive, the government would be compelled to consider public health, safety concerns, and other potential issues in addition to financial incentives.
• Jenner, Matthew S. "International Drug Trafficking: A Global Problem with a Domestic Solution." Indiana Journal of Global Legal Studies, vol. 18, no. 2, pp. 901–27, 2011.
• Rao, S. V. Joga. "Drug Addiction: Penal Policy." Journal of the Indian Law Institute, vol. 34, no. 2, pp. 275–84, 1992.
• Thornton, Mark. "Prohibition versus Legalization: Do Economists Reach a Conclusion on Drug Policy?" The Independent Review, vol. 11, no. 3, pp. 417–33, 2007.
• Miron, Jeffrey A. "The Economics of Drug Prohibition and Drug Legalization." Social Research, vol. 68, no. 3, pp. 835–55, 2001.
• Nadelmann, Ethan A. "Thinking Seriously about Alternatives to Drug Prohibition." Daedalus, vol. 121, no. 3, pp. 85–132, 1992.

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Medicinal Cannabis: History, Pharmacology, And Implications for the Acute Care Setting

The authors review the historical use of medicinal cannabis and discuss the agent’s pharmacology and pharmacokinetics, select evidence on medicinal uses, and the implications of evolving regulations on the acute care hospital setting.

INTRODUCTION

Medicinal cannabis, or medicinal marijuana, is a therapy that has garnered much national attention in recent years. Controversies surrounding legal, ethical, and societal implications associated with use; safe administration, packaging, and dispensing; adverse health consequences and deaths attributed to marijuana intoxication; and therapeutic indications based on limited clinical data represent some of the complexities associated with this treatment. Marijuana is currently recognized by the U.S. Drug Enforcement Agency’s (DEA’s) Comprehensive Drug Abuse Prevention and Control Act (Controlled Substances Act) of 1970 as a Schedule I controlled substance, defined as having a high potential for abuse, no currently accepted medicinal use in treatment in the United States, and a lack of accepted safety data for use of the treatment under medical supervision. 1

Cannabis is the most commonly cultivated, trafficked, and abused illicit drug worldwide; according to the World Health Organization (WHO), marijuana consumption has an annual prevalence rate of approximately 147 million individuals or nearly 2.5% of the global population. 2 In 2014, approximately 22.2 million Americans 12 years of age or older reported current cannabis use, with 8.4% of this population reporting use within the previous month. 3 , 4 General cannabis use, both for recreational and medicinal purposes, has garnered increasing acceptance across the country as evidenced by legislative actions, ballot measures, and public opinion polls; an October 2016 Gallup poll on American’s views on legalizing cannabis indicated that 60% of the population surveyed believed the substance should be legalized. 5 Further, a recent Quinnipiac University poll concluded 54% of American voters surveyed would favor the legalization of cannabis without additional constraints, while 81% of respondents favored legalization of cannabis for medicinal purposes. 6 Limited data suggest that health care providers also may consider this therapy in certain circumstances. 7 – 9 In the United States, cannabis is approved for medicinal use in 28 states, the District of Columbia, Guam, and Puerto Rico as of January 2017. 10

The use and acceptance of medicinal cannabis continues to evolve, as shown by the growing number of states now permitting use for specific medical indications. The Food and Drug Administration (FDA) has considered how it might support the scientific rigor of medicinal cannabis claims, and the review of public data regarding safety and abuse potential is ongoing. 11 , 12 The purpose of this article is to review the historical significance of the use of medicinal cannabis and to discuss its pharmacology, pharmacokinetics, and select evidence on medicinal uses, as well as to describe the implications of evolving medicinal cannabis regulations and their effects on the acute care hospital setting.

HISTORICAL SIGNIFICANCE

Cannabis is a plant-based, or botanical, product with origins tracing back to the ancient world. Evidence suggesting its use more than 5,000 years ago in what is now Romania has been described extensively. 13 There is only one direct source of evidence (Δ 6 -tetrahydrocannabinol [Δ 6 -THC] in ashes) that cannabis was first used medicinally around 400 ad . 14 In the U.S., cannabis was widely utilized as a patent medicine during the 19th and early 20th centuries, described in the United States Pharmacopoeia for the first time in 1850. Federal restriction of cannabis use and cannabis sale first occurred in 1937 with the passage of the Marihuana Tax Act. 15 , 16 Subsequent to the act of 1937, cannabis was dropped from the United States Pharmacopoeia in 1942, with legal penalties for possession increasing in 1951 and 1956 with the enactment of the Boggs and Narcotic Control Acts, respectively, and prohibition under federal law occurring with the Controlled Substances Act of 1970. 1 , 17 , 18 Beyond criminalization, these legislative actions contributed to creating limitations on research by restricting procurement of cannabis for academic purposes.

In 1996, California became the first state to permit legal access to and use of botanical cannabis for medicinal purposes under physician supervision with the enactment of the Compassionate Use Act. As previously stated, as of January 1, 2017, 28 states as well as Washington, D.C., Guam, and Puerto Rico will have enacted legislation governing medicinal cannabis sale and distribution; 21 states and the District of Columbia will have decriminalized marijuana and eliminated prohibition for possession of small amounts, while eight states, including Alaska, California, Colorado, Maine, Massachusetts, Nevada, Oregon, and Washington, as well as the District of Columbia, will have legalized use of marijuana for adult recreation. 10 , 19

THE MEDICINAL CANNABIS DEBATE

As a Schedule I controlled substance with no accepted medicinal use, high abuse potential, concerns for dependence, and lack of accepted safety for use under medical supervision—along with a national stigma surrounding the potential harms and implication of cannabis use as a gateway drug to other substances—transitioning from a vilified substance to one with therapeutic merits has been controversial. The United States Pharmacopoeia and the FDA have considered the complexities of regulating this plant-based therapy, including the numerous compounds and complex interactions between substances in this product, and how it might fit into the current regulatory framework of drugs in United States. 11 , 12 , 17

The emergence of interest in botanical medicinal cannabis is thought by many to be a collateral effect of the opioid abuse epidemic; public perception surrounding the use of medicinal cannabis suggests that this plant-based therapy is viewed as not much different than a botanical drug product or supplement used for health or relief of symptoms if disease persists. Like some herbal preparations or supplements, however, medicinal cannabis may similarly pose health risks associated with its use, including psychoactive, intoxicating, and impairing effects, which have not been completely elucidated through clinical trials. Proponents argue that there is evidence to support botanical medicinal cannabis in the treatment of a variety of conditions, particularly when symptoms are refractory to other therapies; that beneficial cannabinoids exist, as evidenced by single-entity agents derived from cannabis containing the compounds THC and cannabidiol (CBD); that cannabis is relatively safe, with few deaths reported from use; that therapy is self-titratable by the patient; and that therapy is relatively inexpensive compared with pharmaceutical agents. 20 – 22 Opponents of medicinal cannabis use argue, in part, that well-designed randomized trials to confirm benefits and harms are lacking; that it has not been subject to the rigors of the FDA approval process; that standardization in potency or quantity of pharmacologically active constituents is absent; that adverse health effects relate not only to smoking cannabis but to unmasking mental health disorders, impairing coordination, and affecting judgment; that standardization does not exist for product packaging and controls to prevent inadvertent use by minors or pets; that there is a potential for dependence, addiction, and abuse; and that costs pose a potential burden. 23 – 25

Regardless of personal views and perceptions, to deny or disregard the implications of use of this substance on patient health and the infrastructure of the health care system is irresponsible; clinicians must be aware of these implications and informed about how this therapy may influence practice in a variety of health care settings, including acute care.

PHARMACOLOGY

Endocannabinoids (eCBs) and their receptors are found throughout the human body: nervous system, internal organs, connective tissues, glands, and immune cells. The eCB system has a homeostatic role, having been characterized as “eat, sleep, relax, forget, and protect.” 26 It is known that eCBs have a role in the pathology of many disorders while also serving a protective function in certain medical conditions. 27 It has been proposed that migraine, fibromyalgia, irritable bowel syndrome, and related conditions represent clinical eCB deficiency syndromes (CEDS). Deficiencies in eCB signaling could be also involved in the pathogenesis of depression. In human studies, eCB system deficiencies have been implicated in schizophrenia, multiple sclerosis (MS), Huntington’s disease, Parkinson’s disease, anorexia, chronic motion sickness, and failure to thrive in infants. 28

The eCB system represents a microcosm of psycho-neuroimmunology or “mind–body” medicine. The eCB system consists of receptors, endogenous ligands, and ligand metabolic enzymes. A variety of physiological processes occur when cannabinoid receptors are stimulated. Cannabinoid receptor type 1 (CB 1 ) is the most abundant G-protein–coupled receptor. It is expressed in the central nervous system, with particularly dense expression in (ranked in order): the substantia nigra, globus pallidus, hippocampus, cerebral cortex, putamen, caudate, cerebellum, and amygdala. CB 1 is also expressed in non-neuronal cells, such as adipocytes and hepatocytes, connective and musculoskeletal tissues, and the gonads. CB 2 is principally associated with cells governing immune function, although it may also be expressed in the central nervous system.

The most well-known eCB ligands are N-arachidonyl-ethanolamide (anandamide or AEA) and sn-2-arachidonoyl-glycerol (2-AG). AEA and 2-AG are released upon demand from cell membrane phospholipid precursors. This “classic” eCB system has expanded with the discovery of secondary receptors, ligands, and ligand metabolic enzymes. For example, AEA, 2-AG, N-arachidonoyl glycine (NAGly), and the phytocannabinoids Δ 9 -THC and CBD may also serve, to different extents, as ligands at GPR55, GPR18, GPR119, and several transient receptor potential ion channels (e.g., TRPV1, TRPV2, TRPA1, TRPM8) that have actions similar to capsaicin. 28 The effects of AEA and 2-AG can be enhanced by “entourage compounds” that inhibit their hydrolysis via substrate competition, and thereby prolong their action through synergy and augmentation. Entourage compounds include N-palmitylethanolamide (PEA), N-oleoylethanolamide (SEA), and cis-9-octadecenoamide (OEA or oleamide) and may represent a novel route for molecular regulation of endogenous cannabinoid activity. 29

Additional noncannabinoid targets are also linked to cannabis. G-protein–coupled receptors provide noncompetitive inhibition at mu and delta opioid receptors as well as norepinephrine, dopamine, and serotonin. Ligand-gated ion channels create allosteric antagonism at serotonin and nicotinic receptors, and enhance activation of glycine receptors. Inhibition of calcium, potassium, and sodium channels by noncompetitive antagonism occurs at nonspecific ion channels and activation of PPARα and PPARγ at the peroxisome proliferator-activated receptors is influenced by AEA. 30

THC is known to be the major psychoactive component of cannabis mediated by activation of the CB 1 receptors in the central nervous system; however, this very mechanism limits its use due to untoward adverse effects. It is now accepted that other phytocannabinoids with weak or no psychoactivity have promise as therapeutic agents in humans. The cannabinoid that has sparked the most interest as a nonpsychoactive component is CBD. 31 Unlike THC, CBD elicits its pharmacological effects without exerting any significant intrinsic activity on CB 1 and CB 2 receptors. Several activities give CBD a high potential for therapeutic use, including antiepileptic, anxiolytic, antipsychotic, anti-inflammatory, and neuroprotective effects. CBD in combination with THC has received regulatory approvals in several European countries and is under study in registered trials with the FDA. And, some states have passed legislation to allow for the use of majority CBD preparations of cannabis for certain pathological conditions, despite lack of standardization of CBD content and optimal route of administration for effect. 32 Specific applications of CBD have recently emerged in pain (chronic and neuropathic), diabetes, cancer, and neurodegenerative diseases, such as Huntington’s disease. Animal studies indicate that a high dose of CBD inhibits the effects of lower doses of THC. Moreover, clinical studies suggest that oral or oromucosal CBD may prolong and/or intensify the effects of THC. Finally, preliminary clinical trials suggest that high-dose oral CBD (150–600 mg per day) may exert a therapeutic effect for epilepsy, insomnia, and social anxiety disorder. Nonetheless, such doses of CBD have also been shown to cause sedation. 33

PHARMACOKINETICS AND ADMINISTRATION

The three most common methods of administration are inhalation via smoking, inhalation via vaporization, and ingestion of edible products. The method of administration can impact the onset, intensity, and duration of psychoactive effects; effects on organ systems; and the addictive potential and negative consequences associated with use. 34

Cannabinoid pharmacokinetic research has been challenging; low analyte concentrations, rapid and extensive metabolism, and physicochemical characteristics hinder the separation of compounds of interest from biological matrices and from each other. The net effect is lower drug recovery due to adsorption of compounds of interest to multiple surfaces. 35 The primary psychoactive constituent of marijuana—Δ 9 -THC—is rapidly transferred from lungs to blood during smoking. In a randomized controlled trial conducted by Huestis and colleagues, THC was detected in plasma immediately after the first inhalation of marijuana smoke, attesting to the efficient absorption of THC from the lungs. THC levels rose rapidly and peaked prior to the end of smoking. 36 Although smoking is the most common cannabis administration route, the use of vaporization is increasing rapidly. Vaporization provides effects similar to smoking while reducing exposure to the byproducts of combustion and possible carcinogens and decreasing adverse respiratory syndromes. THC is highly lipophilic, distributing rapidly to highly perfused tissues and later to fat. 37 A trial of 11 healthy subjects administered Δ 9 -THC intravenously, by smoking, and by mouth demonstrated that plasma profiles of THC after smoking and intravenous injection were similar, whereas plasma levels after oral doses were low and irregular, indicating slow and erratic absorption. The time courses of plasma concentrations and clinical “high” were of the same order for intravenous injection and smoking, with prompt onset and steady decline over a four-hour period. After oral THC, the onset of clinical effects was slower and lasted longer, but effects occurred at much lower plasma concentrations than they did after the other two methods of administration. 38

Cannabinoids are usually inhaled or taken orally; the rectal route, sublingual administration, transdermal delivery, eye drops, and aerosols have been used in only a few studies and are of little relevance in practice today. The pharmacokinetics of THC vary as a function of its route of administration. Inhalation of THC causes a maximum plasma concentration within minutes and psychotropic effects within seconds to a few minutes. These effects reach their maximum after 15 to 30 minutes and taper off within two to three hours. Following oral ingestion, psychotropic effects manifest within 30 to 90 minutes, reach their maximum effect after two to three hours, and last for about four to 12 hours, depending on the dose. 39

Within the shifting legal landscape of medical cannabis, different methods of cannabis administration have important public health implications. A survey using data from Qualtrics and Facebook showed that individuals in states with medical cannabis laws had a significantly higher likelihood of ever having used the substance with a history of vaporizing marijuana (odds ratio [OR], 2.04; 99% confidence interval [CI], 1.62–2.58) and a history of oral administration of edible marijuana (OR, 1.78; 99% CI, 1.39–2.26) than those in states without such laws. Longer duration of medical cannabis status and higher dispensary density were also significantly associated with use of vaporized and edible forms of marijuana. Medical cannabis laws are related to state-level patterns of utilization of alternative methods of cannabis administration. 34

DRUG INTERACTIONS

Metabolic and pharmacodynamic interactions may exist between medical cannabis and other pharmaceuticals. Quantification of the in vitro metabolism of exogenous cannabinoids, including THC, CBD, and cannabinol (CBN), indicates hepatic cytochrome 450 (CYP450) isoenzymes 2C9 and 3A4 play a significant role in the primary metabolism of THC and CBN, whereas 2C19 and 3A4 and may be responsible for metabolism of CBD. 40 Limited clinical trials quantifying the effect of the exogenous cannabinoids on the metabolism of other medications exist; however, drug interaction data may be gleaned from the prescribing information from cannabinoid-derived pharmaceutical products such as Sativex (GW Pharmaceuticals, United Kingdom) and dronabinol (Marinol, AbbVie [United States]). 41 , 42 Concomitant administration of ketoconazole with oromucosal cannabis extract containing THC and CBD resulted in an increase in the maximum serum concentration and area under the curve for both THC and CBD by 1.2-fold to 1.8-fold and twofold, respectively; coadministration of rifampin is associated with a reduction in THC and CBD levels. 40 , 41 In clinical trials, dronabinol use was not associated with clinically significant drug interactions, although additive pharmacodynamic effects are possible when it is coadministered with other agents having similar physiological effects (e.g., sedatives, alcohol, and antihistamines may increase sedation; tricyclic antidepressants, stimulants, and sympathomimetics may increase tachycardia). 41 Additionally, smoking cannabis may increase theophylline metabolism, as is also seen after smoking tobacco. 40 , 42

ADVERSE EFFECTS

Much of what is known about the adverse effects of medicinal cannabis comes from studies of recreational users of marijuana. 43 Short-term use of cannabis has led to impaired short-term memory; impaired motor coordination; altered judgment; and paranoia or psychosis at high doses. 44 Long-term or heavy use of cannabis, especially in individuals who begin using as adolescents, has lead to addiction; altered brain development; cognitive impairment; poor educational outcomes (e.g., dropping out of school); and diminished life satisfaction. 45 Long-term or heavy use of cannabis is also associated with chronic bronchitis and an increased risk of chronic psychosis-related health disorders, including schizophrenia and variants of depression, in persons with a predisposition to such disorders. 46 – 48 Vascular conditions, including myocardial infarction, stroke, and transient ischemic attack, have also been associated with cannabis use. 49 – 51 The use of cannabis for management of symptoms in neurodegenerative diseases, such as Parkinson’s, Alzheimer’s, and MS, has provided data related to impaired cognition in these individuals. 52 , 53

A systematic review of published trials on the use of medical cannabinoids over a 40-year period was conducted to quantify adverse effects of this therapy. 54 A total of 31 studies evaluating the use of medicinal cannabis, including 23 randomized controlled trials and eight observational studies, was included. In the randomized trials, the median duration of cannabinoid exposure was two weeks, with a range between eight hours and 12 months. Of patients assigned to active treatment in these trials, a total of 4,779 adverse effects were reported; 96.6% (4,615) of these were not deemed by authors to be serious. The most common serious adverse effects included relapsing MS (9.1%; 15 events), vomiting (9.8%; 16 events), and urinary tract infections (9.1%; 15 events). No significant differences in the rates of serious adverse events between individuals receiving medical cannabis and controls were identified (relative risk, 1.04; 95% CI, 0.78–1.39). The most commonly reported non-serious adverse event was dizziness, with an occurrence rate of 15.5% (714 events) among people exposed to cannabinoids. 54

Other negative adverse effects reported with acute cannabis use include hyperemesis syndrome, impaired coordination and performance, anxiety, suicidal ideations or tendencies, and psychotic symptoms, whereas chronic effects may include mood disturbances, exacerbation of psychotic disorders, cannabis use disorders, withdrawal syndrome, and neurocognitive impairments, as well as cardiovascular and respiratory conditions. 52 Long-term studies evaluating adverse effects of chronic medicinal cannabis use are needed to conclusively evaluate the risks when used for an extended period of time.

MEDICINAL USES

Cannabis and cannabinoid agents are widely used to alleviate symptoms or treat disease, but their efficacy for specific indications is not well established. For chronic pain, the analgesic effect remains unclear. A systematic review of randomized controlled trials was conducted examining cannabinoids in the treatment of chronic noncancer pain, including smoked cannabis, oromucosal extracts of cannabis-based medicine, nabilone, dronabinol, and a novel THC analogue. 55 Pain conditions included neuropathic pain, fibromyalgia, rheumatoid arthritis, and mixed chronic pain. Fifteen of the 18 included trials demonstrated a significant analgesic effect of cannabinoids compared with placebo. Cannabinoid use was generally well tolerated; adverse effects most commonly reported were mild to moderate in severity. Overall, evidence suggests that cannabinoids are safe and moderately effective in neuropathic pain with preliminary evidence of efficacy in fibromyalgia and rheumatoid arthritis. 55

While there is not enough evidence to suggest routine use of medicinal cannabis for alleviating chemotherapy-related nausea and vomiting by national or international cancer societies, therapeutic agents based on THC (e.g., dronabinol) have been approved for use as an antiemetic in the United States for a number of years. Only recently has the efficacy and safety of cannabis-based medicines in managing nausea and vomiting due to chemotherapy been evaluated. In a review of 23 randomized, controlled trials, patients who received cannabis-based products experienced less nausea and vomiting than subjects who received placebo. 56 The proportion of people experiencing nausea and vomiting who received cannabis-based products was similar to those receiving conventional antiemetics. Subjects using cannabis-based products experienced side effects such as “feeling high,” dizziness, sedation, and dysphoria and dropped out of the studies at a higher rate due to adverse effects compared with participants receiving either placebo or conventional antiemetics. In crossover trials in which patients received cannabis-based products and conventional antiemetics, patients preferred the cannabis-based medicines. Cannabis-based medications may be useful for treating chemotherapy-induced nausea and vomiting that responds poorly to conventional antiemetics. However, the trials produced low to moderate quality evidence and reflected chemotherapy agents and antiemetics that were available in the 1980s and 1990s.

With regard to the management of neurological disorders, including epilepsy and MS, a Cochrane review of four clinical trials that included 48 epileptic patients using CBD as an adjunct treatment to other antiepileptic medications concluded that there were no serious adverse effects associated with CBD use but that no reliable conclusions on the efficacy and safety of the therapy can be drawn from this limited evidence. 57 The American Academy of Neurology (AAN) has issued a Summary of Systematic Reviews for Clinicians that indicates oral cannabis extract is effective for reducing patient-reported spasticity scores and central pain or painful spasms when used for MS. 58 THC is probably effective for reducing patient-reported spasticity scores but is likely ineffective for reducing objective measures of spasticity at 15 weeks, the AAN found; there is limited evidence to support the use of cannabis extracts for treatment of Huntington’s disease, levodopa-induced dyskinesias in patients with Parkinson’s disease, or reducing tic severity in Tourette’s. 58

In older patients, medical cannabinoids have shown no efficacy on dyskinesia, breathlessness, and chemotherapy-induced nausea and vomiting. Some evidence has shown that THC might be useful in treatment of anorexia and behavioral symptoms in patients with dementia. The most common adverse events reported during cannabinoid treatment in older adults were sedation-like symptoms. 59

Despite limited clinical evidence, a number of medical conditions and associated symptoms have been approved by state legislatures as qualifying conditions for medicinal cannabis use. Table 1 contains a summary of medicinal cannabis indications by state, including select disease states and qualifying debilitating medical conditions or symptoms. 10 , 60 , 61 The most common conditions accepted by states that allow medicinal cannabis relate to relief of the symptoms of cancer, glaucoma, human immunodeficiency virus/acquired immunodeficiency syndrome, and MS. A total of 28 states, the District of Columbia, Guam, and Puerto Rico now allow comprehensive public medical marijuana and cannabis programs. 10 The National Conference of State Legislatures uses the following criteria to determine if a program is comprehensive:

Medicinal Cannabis Indications for Use by State 10 , 60 , 61

1 = State law additionally covers any condition where treatment with medical cannabis would be beneficial, according to the patient’s physician

2 = State law covers any severe condition refractory to other medical treatment

3 = Additional restrictions on the use for this indication exist in this state

4 = State law requires providers to certify the existence of a qualifying disease and symptom

HIV/AIDS = human immunodeficiency virus/acquired immunodeficiency syndrome

Table adapted with permission from the Marijuana Policy Project; 60 table is not all-encompassing and other medical conditions for use may exist. The reader should refer to individual state laws regarding medicinal cannabis for specific details of approved conditions for use. In addition, states may permit the addition of approved indications; list is subject to change.

• Protection from criminal penalties for using marijuana for a medical purpose;
• Access to marijuana through home cultivation, dispensaries, or some other system that is likely to be implemented;
• Allows a variety of strains, including more than those labeled as “low THC;” and
• Allows either smoking or vaporization of some kind of marijuana products, plant material, or extract.

Some of the most common policy questions regarding medical cannabis now include how to regulate its recommendation and indications for use; dispensing, including quality and standardization of cultivars or strains, labeling, packaging, and role of the pharmacist or health care professional in education or administration; and registration of approved patients and providers.

REGULATORY IMPLICATIONS OF MEDICINAL CANNABIS

The regulation of cannabis therapy is complex and unique; possession, cultivation, and distribution of this substance, regardless of purpose, remain illegal at the federal level, while states that permit medicinal cannabis use have established individual laws and restrictions on the sale of cannabis for medical purposes. In a 2013 U.S. Department of Justice memorandum to all U.S. attorneys, Deputy Attorney General James M. Cole noted that despite the enactment of state laws authorizing marijuana production and sale having a regulatory structure that is counter to the usual joint efforts of federal authorities working together with local jurisdictions, prosecution of individuals cultivating and distributing marijuana to seriously ill individuals for medicinal purpose has not been identified as a federal priority. 62

There are, however, other regulatory implications to consider based on the federal restriction of cannabis. Physicians cannot legally “prescribe” medicinal cannabis therapy, given its Schedule I classification, but rather in accordance with state laws may certify or recommend patients for treatment. Medical cannabis expenses are not reimbursable through government medical assistance programs or private health insurers. As previously described, the Schedule I listing of cannabis according to federal law and DEA regulations has led to difficulties in access for research purposes; nonpractitioner researchers can register with the DEA more easily to study substances in Schedules II–V compared with Schedule I substances. 63 Beyond issues related to procurement of the substance for research purposes, other limitations in cannabis research also exist. For example, the Center for Medicinal Cannabis Research at the University of California–San Diego had access to funding, marijuana at different THC levels, and approval for a number of clinical research trials, and yet failed to recruit an adequate number of patients to conduct five major trials, which were subsequently canceled. 64 Unforeseen factors, including the prohibition of driving during the clinical trials, deterred patients from trial enrollment. The limited availability of clinical research to support or refute therapeutic claims and indications for use of cannabis for medicinal purposes has frequently left both state legislative authorities and clinicians to rely on anecdotal evidence, which has not been subjected to the same rigors of peer review and scrutiny as well-conducted, randomized trials, to validate the safety and efficacy of medicinal cannabis therapy. Furthermore, although individual single-entity pharmaceutical medications, such as dronabinol, have been isolated, evaluated, and approved for use by the FDA, a plant cannot be patented and mass produced by a corporate entity. 65 Despite this limitation, some corporations, including GW Pharmaceuticals, are mass producing cannabis plants and extracting complex mixtures or single cannabinoids for clinical trials. 65 The complex pharmacology related to the numerous substances and interactions among chemicals in the cannabis plant coupled with environmental variables in cultivation further complicate regulation, standardization, purity, and potency as a botanical drug product.

RELEVANCE TO HOSPITAL PRACTITIONERS

Although the public has largely accepted medicinal cannabis therapy as having a benefit when used under a provider’s supervision, the implications of the use of this substance when patients transition into the acute care setting are additionally complex and multifaceted. The Schedule I designation of cannabis causes hospitals and other care settings that receive federal funding, either through Medicare reimbursement or other federal grants or programs, to pause to consider the potential for loss of these funds should the federal government intercede and take action if patients are permitted to use this therapy on campus. Similarly, licensed practitioners registered to certify patients for state medicinal cannabis programs may have comparable concerns regarding jeopardizing their federal DEA registrations and ability to prescribe other controlled substances as well as jeopardizing Medicare reimbursements. In 2009, U.S. Attorney General Eric Holder recommended that enforcement of federal marijuana laws not be a priority in states that have enacted medicinal cannabis programs and are enforcing the rules and regulations of such a program; despite this, concerns persist.

The argument for or against the use of medicinal cannabis in the acute care setting encompasses both legal and ethical considerations, with the argument against use perhaps seeming obvious on its surface. States adopting medical cannabis laws may advise patients to utilize the therapy only in their own residence and not to transport the substances unless absolutely necessary. 66 Further, many acute care institutions have policies prohibiting smoking on facility grounds, thus restricting the smoking of cannabis, regardless of purpose or indication. Of note, several Canadian hospitals, including Montreal’s Jewish General Hospital and Quebec’s Centre Hospitalier Universitaire de Sherbrooke, have permitted inpatient cannabis use via vaporization; the pharmacy departments of the respective institutions control and dispense cannabis much like opioids for pain. Canada has adopted national regulations to control and standardize dried cannabis for medical use. 67 , 68 There are complicated logistics for self-administration of medicinal cannabis by the patient or caregiver; in particular, many hospitals have policies on self-administration of medicines that permit patients to use their own medications only after identification and labeling by pharmacy personnel. The argument can be made that an herb- or plant-based entity cannot be identified by pharmacy personnel as is commonly done for traditional medicines, although medicinal cannabis dispensed through state programs must be labeled in accordance with state laws. Dispensing and storage concerns, including an evaluation of where and how this product should be stored (e.g., within the pharmacy department and treated as a controlled substance, by security personnel, or with the patient); who should administer it, and implications or violations of federal law by those administering treatment; what pharmaceutical preparations should be permitted (e.g., smoked, vaporized, edible); and how it should be charted in the medical record represent other logistical concerns. Inpatient use of medicinal cannabis also carries implications for nursing and medical staff members. The therapy cannot be prescribed, and states may require physicians authorizing patient use to be registered with local programs. In a transition into the acute care setting from the community setting, a different clinician who is not registered could be responsible for the patient’s care; that clinician would be restricted in ordering continuation of therapy.

Despite the complexities in the logistics of continuing medicinal cannabis in the acute care setting, proponents of palliative care and continuity of care argue that prohibiting medicinal cannabis use disrupts treatment of chronic and debilitating medical conditions. Patients have been denied this therapy during acute care hospitalizations for reasons stated above. 69 Permission to use medicinal cannabis in the acute care setting may be dependent on state legislation and restrictions imposed by such laws. Legislation in Minnesota, as one example, has been amended to permit hospitals as facilities that can dispense and control cannabis use; similar legislative actions protecting nurses from criminal, civil, or disciplinary action when administering medical cannabis to qualified patients have been enacted in Connecticut and Maine. 70 – 73 Proposed legislation to remove restrictions on the certification of patients to receive medicinal cannabis by doctors at the Department of Veterans Affairs was struck down in June; prohibitions continue on the use of this therapy even in facilities located in states permitting medicinal cannabis use. 74

Despite lingering controversy, use of botanical cannabis for medicinal purposes represents the revival of a plant with historical significance reemerging in present day health care. Legislation governing use of medicinal cannabis continues to evolve rapidly, necessitating that pharmacists and other clinicians keep abreast of new or changing state regulations and institutional implications. Ultimately, as the medicinal cannabis landscape continues to evolve, hospitals, acute care facilities, clinics, hospices, and long-term care centers need to consider the implications, address logistical concerns, and explore the feasibility of permitting patient access to this treatment. Whether national policy—particularly with a new presidential administration—will offer some clarity or further complicate regulation of this treatment remains to be seen.

Disclosures: The authors report no commercial or financial interests in regard to this article.