Legalization of recreational use of marijuana by adults is on the horizon in New Jersey. At the same time, some healthcare experts are raising concerns that while the drug may have a positive impact on many patients who take it under medical supervision, there’s not enough solid science to show that its medicinal, economic or other benefits outweigh the public-health dangers involved with expanding access to the drug.
Doctors and other health professionals have flagged factors like the rise in marijuana exposure among children — which tripled in New Jersey from 2017 to 2018 when it came to reports involving edible forms of the drug — for a possible association with certain psychiatric conditions, and an increase in auto accidents in states that already have legalized cannabis consumption.
There is general agreement that the drug, especially certain of its components, can help with a number of conditions — reducing pain, nausea and anxiety, decreasing the frequency of seizures, and benefiting patients with multiple sclerosis.
‘So much uncertainty’
But critics said marijuana, which is roughly three times stronger than in the mid-1980s, has not undergone clinical trials designed to illuminate how these positives are worth the risks the drug presents. And some are urging policymakers to pump the breaks on programs that will result in greater use — like the legalization bill, which passed several legislative committees late last year and remains a priority for Gov. Phil Murphy — until more research is done.
“There is so much uncertainty around the science behind the politics” of marijuana legalization, said Dr. Diane Calello, executive and medical director of the New Jersey Poison Center, part of Rutgers New Jersey Medical School. “Everyone’s got an opinion based on the science that exists. But there’s a lot of wiggle room.”
State Department of Health Commissioner Dr. Shereef Elnahal has overseen a massive expansion of the state’s decade-old medical marijuana program, which now serves more than 39,000 residents. But he and other advocates of legalization generally agree more research is needed; that process has been hampered by federal restrictions on marijuana, which place it in the same category as heroin and cocaine, and the lack of funding for additional study.
But based on what is known, there is “ample evidence to demonstrate (marijuana’s) efficacy for so many conditions,” Elnahal said in an interview Thursday. He also noted that only about a third of all medical interventions are subjected to the most rigorous clinical testing designed to identify a full panel of risks.
New Jersey has approved a growing list of medical conditions that qualify a patient for participation in the medicinal cannabis program, including opioid use disorder, which was added as a qualifying condition Wednesday as part of a larger initiative to combat addiction. (Medicinal marijuana patients with substance use disorders would also need to participate in other proven therapies.)
“I operate on the strong belief that it is unjust to prevent access to patients who could benefit from this therapy,” added Elnahal, who engaged in a spirited debate over the merits of marijuana with Hackensack Meridian Health’s Dr. Roman Solhkhah, a psychiatrist who raised concerns about the approach during an NJ Spotlight roundtable on addiction last spring. “It all has to be taken into context within the big picture,” Elnahal said Thursday.
That big picture includes New Jersey’s opioid epidemic, which contributed to some 3,000 deaths last year — a 15 percent increase over 2017 — despite a decline in prescriptions and a growth in treatment programs. By expanding access to medical marijuana, the Murphy administration hopes to help some people avoid opioids entirely, and assist others as they try to get free of their addiction.
According to Elnahal, several respected studies have shown that opioid prescriptions and opioid-related deaths have declined in states that have robust medical marijuana programs. And the side-effects of marijuana are far less dangerous than those associated with heroin or prescription drugs, he said.
Others find fault with that argument, including Dr. Lewis Nelson, an emergency medicine professor at Rutgers New Jersey Medical School who oversees the emergency department at University Hospital in Newark. “We’re not in a place in the world where you can replace one drug with another; we’re in a place in the world where we’re going to add one drug to another,” he said recently.
‘Very weak’ scientific support
Nelson claims the science for medical marijuana programs in general is “very weak” and that the risk of harm is quite high. “It really comes down to a risk-benefit analysis,” he said, “and there’s no single answer for that.”
He and Calello also worry how the growth and popularity of medicinal marijuana programs could leave people with the impression that cannabis is essentially safe. They said this belief can become conflated with enthusiasm for legalization efforts — usually driven by social justice and economic factors — to give observers the sense that more pot will improve public health.
Instead, critics point to a well-regarded report from the National Institute of Drug Abuse, released in June, which acknowledged marijuana may provide therapeutic benefits, but noted that cannabis-related emergency room visits rose 21 percent nationwide between 2009 and 2011. The report also flagged concerns about the impact of cannabis consumption on children and pregnant women, respiratory damage, and a possible association with schizophrenia.
New Jersey has also seen an increase in emergency-related calls tied to marijuana, although the numbers remain very small. According to reports filed with NJPIES, 21 residents under age 20 reported exposure to marijuana edibles in 2018, up from six the previous year. When factoring in other forms of marijuana, the numbers rose to 45 reports for 2018, compared to 42 the year before. (Marijuana exposure is not something providers must report to regulators and the increase could reflect greater awareness, not just more exposure, according to the poison center.)
Most of these incidents are not serious, officials agreed, and they said no one is known to have died of a cannabis overdose. To underscore this fact, Elnahal said one ER doctor described how he addressed marijuana poisoning in most patients: a bottle of water, a dark room and a TV.
Concern about auto safety
Calello, on the other hand, sees reason for caution. “We’ve seen close calls, and at some point, we’re going to see a fatality,” she said. “And when you are dealing with young children, one (death) is too many.”
Another area of concern is auto safety; one of the few findings common among studies is that smoking pot can impact brain function, including concentration and coordination. Data from Colorado, which legalized the drug in 2014, showed that marijuana-related ER visits jumped 70 percent and fatal auto accidents involving a driver that tested positive for the drug increased 80 percent between 2013 and 2015.
Elnahal stressed that, if marijuana is legalized here, the state would have an important role to play in protecting public health, much as it does now with alcohol. This would include outreach and education over safe use, including communicating the dangers involved for children and pregnant women, input on labeling and packaging, and assistance for local law enforcement patrolling the roads.
These public health questions remain a concern to a number of behavioral health providers and medical associations, including the state chapter of the American Association of Pediatrics, which have testified against New Jersey’s legalization proposal. Law enforcement and business leaders are also struggling to figure out how greater access to the drug will impact the safety of communities and workplaces.
“Remember, the plural of anecdote is not data,” Nelson said, noting that legalization is like “jumping head first in this pool without knowing how deep it is.”