Abstract

Recreational cannabis is currently legal in nineteen states and the District of Columbia. The history of each states pathway for passing laws codifying fully legal status varies greatly across the United States. A study was conducted with the aim of identifying factors that significantly impact a states fully legal status on cannabis employing a logistic regression design. Independent factors analyzed included the marijuana possession arrest rate (MPAR), new cancer cases, and opioid overdose rate. All data were from 2010 to assess if these factors impacted passage of laws approving recreational cannabis, as all such laws were passed after 2010. The dependent variable was dichotomous toward fully legal status or not fully legal status in states. Results showed statistically significance with the MPAR variable (P<.05). The opioid over dose rate and cancer cases did not yield statistically significant results. Consistent with the federalist system, select state legislatures have made the decision to pass laws regarding recreational cannabis propelled by public support when cannabis is still illegal under federal law. This paper delineates both recreational cannabis and medical cannabis laws, and provides salient discussion on variables analyzed and ideas for future policy studies.

1. Introduction

Cannabis is a dioecious plant in the family Cannabaceae that is one of the most commonly used substances today and has penetrated cultures across the globe for centuries. It has been used for medicinal purposes reportedly since 4000 BC, as documented in the pen-ts’ao, an ancient pharmacopoeia that originated in China. The Chinese used Cannabis to ameliorate rheumatic pain, intestinal constipation, disorders of the female reproductive system, and malaria. In India, as early as 1000 BC cannabis was used as an analgesic, hypnotic, anesthetic, anti-inflammatory, antibiotic, antiparasitic, diuretic, and expectorant. People of India also described cannabis as a source of happiness, donator of joy, and bringer of freedom reflective of the recreational aspect of cannabis. It was listed in Avicenna’s the Canon of Medicine as a diuretic, digestive, and anti-flatulent. In Africa, it aided in cases of snake bites, childbirth, malaria, fever, blood poisoning, and dysentery. ¹ Current evidence-based practice on the medicinal uses of cannabis include multiple sclerosis (MS), chronic pain, fibromyalgia, epilepsy, insomnia, and lessening of tremors in Parkinson’s disease ². The pharmacology of Cannabis is predicated on substances called cannabinoids. The most psychoactive cannabinoid is delta-9-tetrahydrocannabinol (THC); the next most active compound is cannabidiol (CBD). The plant Cannabis sativa contains higher amounts of THC, and Cannabis indica contains higher amounts of CBD. THC is considered the active ingredient eliciting psychoactive effects associated with the euphoric high people experience after using marijuana. Cannabis can be smoked or ingested in the form of edibles. The latter may include candies, gummies, brownies, or tinctures. The psychoactive effect is procured through cannabinoid receptors located throughout the body [brain, liver, thyroid, bones, and peripheral nervous system]. Many states have codified laws on the legalization of cannabis based upon medicinal benefits and public approval despite its classification as a Schedule I controlled substance at the federal level under the Controlled Substances Act of 1971 ³. Legalization of cannabis in select states has propagated enumerable businesses to market CBD products such as oils and lotions with sales reaching 5.3 billion in 2021 ⁴. Laws can be delineated in a trifecta of fully legal, medicinal only, or prohibited. States that are classified as fully legal (Table 1, Figure 1) allowing use of cannabis for medicinal and recreational purposes are Alaska, Arizona, California, Colorado, Connecticut, Illinois, Maine, Massachusetts, Michigan, Montana, Nevada, New Jersey, New Mexico, New York, Oregon, Rhode Island, Virginia, Vermont, and Washington. States characterized as not fully legal, restricting CBD use for medicinal purposes only, or prohibiting CBD use for any purpose are Alabama, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Minnesota, Mississippi, Missouri, New Hampshire, Nebraska, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, West Virginia, Wisconsin, and Wyoming (Table 2). This study serves to identify factors that have a significant effect on cannabis policies across the United States as well as delineate similarities and differences among state policies.

2. Methods

Logistic regression was performed using SPSS (v28); P value <.05 is considered statistically significant. The unit of analysis was state where Forty-eight states were included in the study. Florida and North Dakota were excluded from the analysis because data was not available for all independent variables. States were coded as 1 if their policy is classified as fully legal, and 0 for states with a policy that was not fully legal. Fully legal is defined as policies that allow cannabis use for medicinal and recreation; not fully legal is defined as policies that prohibit the use of cannabis for any reason, or restricted cannabis to medicinal purposes. Independent variables are the opioid overdose rate, marijuana possession arrest rate (MPAR), and cancer rate. The cancer rate data was accessed from the American Cancer Society representing new cases of cancer in 2010. The MPAR was accessed from ACLU report ⁶⁵ examining race disparities in marijuana arrests in 2018 and 2010. The report noted the percent change between 2018 and 2010; having the arrest rate from 2018 and percent change from 2010, the MPAR for 2010 could be derived. Data from the state of Florida was not included in the ACLU report. The 2010 opioid overdose rate was accessed from Centers for Disease Control and Prevention; data for North Dakota was not available. The rationale for choosing 2010 for all independent variables was to capture a timepoint that may have precipitated laws to be passed respective of fully legal status as no state passed a law allowing recreational cannabis before 2010.

3. Results

The marijuana possession arrest rate was statistically significant and had an inverse effect given the negative beta coefficient (Table 3). This can be interpreted as the odds of a state having a fully legal policy on cannabis decreases by a factor of .989 with a one unit increase in the marijuana possession arrest rate. The variables opioid overdose rate and new cancer cases were not statistically significant.

4. Discussion

This study explored the impact of the MPAR, opioid deaths, and new cancer cases from 2010 on cannabis policies in forty-eight states. Employing logistic regression stratified by states that are fully legal or not fully legal revealed only the MPAR was statistically significant. The range for the 2010 MPAR was 16 to 849, with Massachusetts having lowest rate and South Dakota with the highest rate. Massachusetts has fully legal status while South Dakota limits use of cannabis for medicinal purposes. Other states on the lower end of MPAR with full legal status are Alaska (97), California (121), Connecticut (113), Colorado (204), Illinois (129), Maine (133), Michigan (157), Montana (206), Nevada (202), New Mexico (147), Oregon (209), Rhode Island (127), and Washington (90). States on the higher end of the MPAR and classified as not fully legal are South Carolina (745), Wyoming (685), West Virginia (407), North Dakota (407), Georgia (467), and Nebraska (594). These findings comport with the statistical significance finding for the MPAR variable, that is, a salient association between the MPAR and fully legal status; lower MPAR’s found more frequently in the fully legal status cohort.

In the absence of similar regression studies linking the MPAR to fully legal status cannabis laws the concept of decriminalization has tacit relevance. Decriminalization can be described as a state reducing the penalty for possessing small amounts of cannabis from a criminal offense to a civil offense ⁶⁶. In 2008 voters in Massachusetts convincingly approved [65 to 35 percent] a ballot initiative to decriminalize possession of small amounts of marijuana where a fine of $100 would be incurred if a person is caught with less than an ounce of marijuana. Opponents of the initiative posited that passage of the initiative would promote drug use ⁶⁷. Grucza et al conducted a study employing state Youth Risk Behavior Surveys from 2007 to 2015 to ascertain if there was an association between changes in state policies toward decriminalization of cannabis and increased arrests. The states studied included Massachusetts, Connecticut, Rhode Island, Vermont, and Maryland. Investigators found a 75 percent reduction in the rate of drug-related arrests for both youth and adults ⁶⁶. In 2019, Plunk et al studied 38 states inclusive of fully legal states, in part, and states that had enacted decriminalization policies from 2000 to 2016 with the aim determining increases or decreases in the arrest rates for cannabis possession. They found a decrease in the adult arrest rate by 131.28 per 100,000 population post decriminalization policies, and a decrease of 168.50 per 100,000 population post fully legal status ⁶⁸. In 2011, voters in Connecticut were in support of decriminalization by a two to one margin [65 to 32 percent] with every demographic lending support ⁶⁹. Alaska decriminalized cannabis in 1975 ⁷⁰, nearly forty years before recreational cannabis was legal. Decriminalization of cannabis may have served as a salient forerunner to select states decision to legalize cannabis, and may be a factor in the future for states that are not fully legal in turning the tide toward legalization.

The opioid overdose rate ranged from 2.8 in Louisiana to 25.6 in West Virginia. New cases of cancer in 2010 ranged from 2540 in Wyoming to 157,320 in California. These variables did not yield statistical significance. It has been reported that cancer patients have great difficulty acquiring a medical marijuana card in states with a medical marijuana program. State law requires physician approval before patients can be registered in medical marijuana programs. In 2018, just 1 percent of Massachusetts 25,000 physicians are registered with the state to prescribe cannabis ⁷¹. Moreover, hospitals with a federal research grant risk losing funding or paying steep penalties if clinicians give patients cannabis because marijuana is still considered an illegal drug in the eyes of the federal government. In 2017, Valencia et al ⁷² outlined challenges patients face in obtaining medical marijuana cards. Persons who are employed, have health insurance, and large incomes tend to participate more in a medical marijuana program than persons with less means. States may charge a standard fee for the required registration, such as Arizona, which charges a fee of $150; these fees are not covered by health insurance plans. Satterlund et al ⁷³ asserts there is a stigma associated with medical cannabis use. Social labels such as “junkie” may dissuade patients from engaging in a discussion of cannabis use with their physician, and physician’s themselves may be ambivalent about giving their recommendation on cannabis use for their patients. In 2014, Michalec et al ⁷⁴ found that 39 percent of specialists and 34 percent of primary care physicians in Delaware reported being very unlikely to authorize eligible patients for medical marijuana. These findings suggest that patients and their caregivers may have an easier path to procuring cannabis in fully legal states, even given the limited amount persons can possess or grow under the auspices of respective state laws.

The majority of states with fully legal status permit persons ≥21 years of age to possess up to 1 ounce of marijuana. States that allow more than 1 ounce include Connecticut, Maine, Michigan, New Mexico, New York, and Oregon. Fines across the fifty states vary considerably for possession of cannabis as outlined in Table 1 and Table 2. Decriminalization laws have been passed in Alaska, California, Colorado, Connecticut, Delaware, Hawaii, Illinois, Maine, Massachusetts, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Hampshire, New Mexico, New York, North Carolina, North Dakota, Ohio, Oregon, Rhode Island, Vermont, Virginia, and Maryland. Maryland’s decriminalization law was passed in 2014 rendering possession of less than 10 g of marijuana a civil offense punishable by a fine of up to $100 for a first offense, $250 for a second offense, and $500 for a third offense; there is no prison time. Supporters of the law echo that the law reallocates time of law enforcement officials allowing them to focus on more nefarious crimes ⁷⁵. Driving under the influence of cannabis (DUI-C) is prohibited in all states regardless of fully legal status or adoption of medical marijuana programs. For example, in California, a first DUI-C offense can result in up to 6 months of prison and up to $1000 fine ⁷⁶. Regarding home cultivation of cannabis in fully legal states, most states allow a defined number of plants with the caveat that the plants must be out of public view. New Jersey prohibits home cultivation of cannabis plants, and only persons with a medical marijuana card may cultivate cannabis in the state of Washington.

Medical marijuana programs vary with regard to patient eligibility such as qualifying diseases, reciprocity, cannabis supply maximum, registration fees, home cultivation, approved dispensaries, and physician registration. Conservative states like Alabama, Arkansas, Oklahoma, Iowa, West Virginia, Utah, and North Dakota prohibit home cultivation of cannabis, or limit access to cannabis through state approved dispensaries such as Louisiana and Mississippi. Reciprocity refers to patients having access to medical marijuana while visiting other states. States that allow reciprocity include Georgia, Hawaii, Iowa, Mississippi, New Hampshire, Oklahoma, and South Dakota; West Virginia only permits reciprocity for terminally ill cancer patients. States that have not adopted a medical marijuana program but allow FDA-approved drugs [containing low concentrations of THC] for patients with seizure disorders include Idaho, Indiana, Kansas, Kentucky, Nebraska, North Carolina, South Carolina, Tennessee, Texas, and Wisconsin. The state of Wyoming does not allow cannabis use for any medical disorder.

The limitation of this study is the exclusion of two states from the logistic regression analysis because of data not being available. These states were Florida and North Dakota.

5. Conclusion

This study analyzed data from 2010 reflective of cancer cases, opioid deaths, and MPAR and found that the MPAR was statistically significant in the logistic regression model. Decriminalization laws and medical marijuana laws have preceded passage of recreational cannabis laws in select states, and this trend may continue culminating in more states becoming fully legal. Cannabis classification of a Schedule I drug at the federal level will not likely change in the foreseeable future leaving states to chart their own course on cannabis legalization. Future studies should focus on cannabis taxation, continued monitoring of marijuana arrests among youth and adults, and standardization of CBD product content. Insight into how sales tax on cannabis products was formulated and revenue allocation would be informative. Tracking marijuana possession and trafficking arrests across demographics in fully legal states and states that are not fully legal would provide prospective clarity on whether recreational cannabis translates to increased or decreased arrests compared to states that prohibit recreational cannabis. Regulating CBD product content may accelerate approval of research studies that aim to elucidate physiological mechanisms toward treatment of disease and standardization of care. The path toward legalization of cannabis for nineteen states is not predicated on a solitary factor; public opinion, ideology, arrest statistics, health benefits may collectively play a role and serve as a blueprint for future legalization legislation.

References