The Misclassification of Medical Marijuana
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REGULAR ARTICLE The Misclassification of Medical Marijuana Hannah Krystal, BA Marijuana has a complicated legal, social, and economic history in the United States, as well as an uncertain future. Marijuana has been consistently tied to racial minority groups since its arrival in the United States in the 1900s, and former Attorney General Jeff Sessions further propagated that notion. AG Sessions even recently wrote a memo that directly contradicted Obama-era policy, demonstrating that the current legal status of marijuana in both state and federal government is currently up for debate. While several states have legalized marijuana for medical or even recreational purposes, federal law still categorizes cannabis as a drug with no currently accepted medical use and a high potential for abuse. The comparison between marijuana, opioids, and ketamine in this article demonstrates that marijuana has been unnecessarily withheld and stigmatized by the federal government. Also reviewed is the impact of stringent marijuana- based legal policies upon the racial makeup of prison populations. The implications of current policy upon potential and future research are also discussed, with the determination that current policy has stymied research and prevented a more accurate determination of the risks and benefits of medical marijuana. J Am Acad Psychiatry Law 46:472–79, 2018. DOI:10.29158/JAAPL.003790-18 Marijuana has a complicated legal, social, and eco- ijuana on the basis of its unknown risks and lack of nomic history in the United States, and the issue of proven benefits despite the fact that synthetic canna- legalization has not yet been resolved. This article binoids have been demonstrated to elicit FDA- will comment upon the legal status of only medical approved benefits. marijuana, but it will discuss the potential risks of both medical and recreational marijuana to allay the Marijuana in the United States of fear that the legalization of medical marijuana poses a America: 1900–2018 significant threat to public health. While several states have legalized marijuana for medical or even Cannabis was initially marked as Schedule I for recreational purposes, federal law still categorizes reasons related to race and class. Other drugs were marijuana as a drug with no currently accepted med- associated with other racial minorities, such as the ical use and a high potential for abuse.1 While the mythical linkage between Chinese men, opium, and the seduction of white women that eventually led to legalization of medical marijuana in several states 3,4 prompted the federal government to reevaluate the the 1909 Opium Exclusion Act. Marijuana has status of marijuana, the U.S. Drug Enforcement Ad- been typically associated with negative racial stereo- types about both African Americans and Mexicans, ministration (DEA) reaffirmed the status of mari- 4 juana as a Schedule I drug in 2016, citing lack of as well as other Latin-American immigrants. The evidence of efficacy.2 This decision demonstrated, wave of anti-marijuana legislation that led to the cat- however, not a realistic evaluation of the risks and egorization of cannabis as a Schedule I drug dates benefits of marijuana, but a demonstration of the back to the early 1900s, when one member of the current catch-22 within American legal policy re- Texas Senate stated on the floor, “All Mexicans are garding marijuana: namely, that few risks have been crazy, and this [marijuana] is what makes them crazy.”5 California was the first state to prohibit mar- demonstrated and few benefits have been studied. 2 The federal government has restricted access to mar- ijuana in 1913, with Texas following suit in 1914. The federal government soon caught the anti-drug Ms. Krystal is a first-year medical student at the Icahn School of bug, and in 1915 the U.S. Secretary of Agriculture Medicine of Mount Sinai and is pursuing a Masters in Clinical used the 1906 Pure Food and Drug Act to declare Ethics from a joint program with Clarkson University. Address marijuana importation illegal based on the threat it correspondence to: Hannah Krystal, Icahn School of Medicine at 4,5 Mount Sinai, 2A-3 Aron Hall, 50 E. 98th St., New York, NY 10029. posed to health. A famous 1927 New York Times E-mail: [email protected] article entitled “Mexican Family Go Insane,” pro- Disclosures of financial or other potential conflicts of interest: None. posed that “a widow and her four children have been 472 The Journal of the American Academy of Psychiatry and the Law Krystal driven insane by eating the marihuana plant, accord- A Brief Discussion of the Schedule System 5 ing to doctors.” The period of 1933–1937, notably The federal government classifies drugs into sev- marked by the production of the infamous anti- eral different categories, known as Schedules I–V. cannabis film Reefer Madness in 1936, thus saw al- This article will largely focus on Schedules I–III. most every state enforce the Uniform Narcotic Drug Schedule I drugs are currently defined, as described Act, thereby increasing the strength of policing for above, as having no currently accepted medical use marijuana and other drugs.3,5 In 1937, Congress cre- and a high potential for abuse.1 Along with mari- ated the federal Marihuana Tax Act, which forbade 3 juana, heroin, lysergic acid diethylamide (LSD), 3,4- recreational and unlicensed use of cannabis. Later methylenedioxymethamphetamine (ecstasy), and laws established in 1951 and 1956 increased federal 1 control on marijuana and foreshadowed the estab- peyote have been classified as Schedule I. Cannabis lishment of the Comprehensive Drug Abuse and Pre- is not the only drug on this list to have potential vention and Control Act of 1970, better known as medical use; LSD, for example, has recently been considered for use as an antidepressant or the Controlled Substances Act, by the Nixon Admin- 12 istration.6 A former Nixon aide tied the Controlled anxiolytic. Substances Act directly to the politics of race, stating, Schedule II drugs, on the other hand, have at least “the Nixon White House . had two enemies: the one already proven, efficacious medical use, with “a antiwar left and African American people.... By high potential for abuse, with use potentially leading getting the public to associate the hippies with mar- to severe psychological or physical dependence. 1 ijuana and African Americans with heroin, and then These drugs are also considered dangerous.” Sched- criminalizing both heavily, we could disrupt those ule II includes some unexpected drugs, such as co- communities.”7 Since the 1970s, the scheduling of caine and crystal methamphetamine, as well as most drugs into different risk-based categories has pre- opioids, amphetamine/dextroamphetine salts (Ad- sented various ethics, legal, and medical issues. While derall™), and methylphenidate (Ritalin™).1 Co- the Controlled Substances Act has worked to fight caine is a Schedule II drug because of its approved drug abuse and addiction, marijuana does not pres- medical use as a local anesthetic, despite its lengthy ent the high risk level of a Schedule I drug and should history of abuse;6 methamphetamines can suppress not be classified as such. appetite in obese patients and are legally prescribed Attorney General Sessions started to reverse to stabilize severe attention-deficit hyperactivity dis- Obama-era policies that allowed for the state-by- order (ADHD) symptoms in children over the age of state legalization of medical marijuana. In 2013, six.13 AdderallTM can be prescribed to children ages then-Deputy Attorney General James Cole issued a three or above.14 Nabilone (Cesamet™), a synthetic memo limiting prosecution to “the most significant oral cannabinoid derived from marijuana, has also threats in the most effective, consistent, and rational been classified as Schedule II due to its use as an 8 way.” Essentially, Deputy AG Cole encouraged the antiemetic.15 federal government to leave the regulation of medical Finally, Schedule III drugs maintain “a moder- and recreational marijuana to the states that imple- ate to low potential for physical and psychological mented policies of legalization.8 Following this shift dependence. Schedule III drugs abuse [sic] poten- in federal policy, a bipartisan bill was proposed by tial is less than Schedule I and Schedule II drugs Florida senators Matt Gaetz (Republican) and Dar- 1 ren Soto (Democrat) in April 2017 to recategorize but more than Schedule IV.” Schedule III drugs 9 include ketamine, testosterone, and anabolic ste- marijuana as a Schedule III drug. A January 4, 2018, 1 memo written by AG Sessions, however, essentially roids. A second synthetic cannabinoid and reneged on the Obama-era policy.10 This new memo marijuana derivative, dronabinol (Marinol™), re- directly contradicted the Deputy AG Cole’s memo, sides on the list of Schedule III drugs for its use as 16 although it did not contradict a later memo from an appetite stimulant and antiemetic. The fed- 2014 discouraging the prosecution of money made erally defined schedules have been enumerated from the sale of legal marijuana.10,11 Because of AG here to provide a context for the comparison Sessions’ stance on cannabis, the future of medical among the schedules of marijuana, opioids, and marijuana in the United States is currently uncertain. ketamine. Volume 46, Number 4, 2018 473 The Misclassification of Medical Marijuana Marijuana, Opioids, and Ketamine: Side ijuana presents less potential for abuse than ketamine Effects and less risk of addiction