Medical cannabis in the United States
In the United States, the use of cannabis for medical purposes is legal in 38 states, four out of five permanently inhabited U.S. territories, and the District of Columbia, as of March 2023.[1] Ten other states have more restrictive laws limiting THC content, for the purpose of allowing access to products that are rich in cannabidiol (CBD), a non-psychoactive component of cannabis.[1] There is significant variation in medical cannabis laws from state to state, including how it is produced and distributed, how it can be consumed, and what medical conditions it can be used for.[2]
The first state to effectively legalize medical cannabis was California in 1996, when voters approved Proposition 215 by a 56–44 margin. Several states followed with successful ballot initiatives in 1998, and in 2000 Hawaii became the first to legalize through an act of state legislature.[3] By 2016, legalization of medical cannabis had spread to a majority of states.
At the federal level, cannabis remains a prohibited substance by way of the Controlled Substances Act (CSA) of 1970. Under the CSA, the Drug Enforcement Administration (DEA) classifies cannabis as a Schedule I drug, determined to have a high potential for abuse and no accepted medical use – thereby prohibiting its use for any purpose. The Justice Department has enforced this policy through various means, including criminal prosecutions, civil asset forfeiture, and paramilitary-style raids targeting medical cannabis providers, and various penalties threatened or initiated against other individuals involved in state-legal medical cannabis activities (doctors, landlords, state officials and employees).[4] In December 2014, however, the Rohrabacher–Farr amendment was signed into law, prohibiting the Justice Department from spending funds to interfere with the implementation of state medical cannabis laws.[5]
In October 2022, President Joe Biden announced that he would ask the Secretary of Health and Human Services and Attorney General to initiate a review as to how cannabis should be scheduled under federal law, adding that the Schedule I classification of cannabis "makes no sense".[6] In April 2024, following a review by the Food and Drug Administration (FDA) and recommendation from Health and Human Services to move cannabis to Schedule III, the Drug Enforcement Administration confirmed its intention to reclassify cannabis as a Schedule III drug.
Federal policy[edit]
Controlled Substances Act[edit]
On October 27, 1970, the Comprehensive Drug Abuse Prevention and Control Act was signed into law by President Richard Nixon. Title II of the act – the Controlled Substances Act – established a system under which all controlled substances are categorized, varying from Schedule I (the strictest classification) to Schedule V (the least strict). Cannabis was placed in the Schedule I category, assumed to have a high potential for abuse and no accepted medical use – thereby prohibiting its use for any purpose.[16] This placement was intended only as a temporary measure, however, pending the results of a commission formed under decree of the CSA to study the dangers of cannabis.[12] Formally known as the National Commission on Marihuana and Drug Abuse, the Shafer Commission – led by former Pennsylvania governor Raymond P. Shafer – submitted the first of its two final reports to the President and Congress in March 1972. Although the report did not address the subject of scheduling,[17] it found that the harms caused by cannabis were overstated, and recommended removal of criminal penalties for possession and distribution of small amounts of the drug.[18] Despite these findings, no action was subsequently taken to move cannabis into a less restrictive category,[19] and the Schedule I classification of cannabis remains in place, alongside other drugs such as heroin, LSD, MDMA, DMT, and peyote – none of which can be prescribed. Schedule II drugs – determined to have a high potential for abuse but also some accepted medical use (thus able to be prescribed) – include cocaine, PCP, methamphetamine, oxycodone, and fentanyl.[20][21]
Rescheduling efforts[edit]
Since enactment of the Controlled Substances Act, there have been a number of efforts seeking to place cannabis in a less restrictive category, but none have succeeded. The Drug Enforcement Administration is granted authority under the CSA to change the classification of any drug, based upon the recommendation of the Food and Drug Administration which evaluates all drugs for safety and efficacy.[22] A 2016 FDA review concluded that cannabis has "no currently accepted medical use in treatment in the United States", in response to a petition filed with the DEA in 2011 by the governors of Washington and Rhode Island.[23] Previous efforts to petition the DEA for rescheduling have also been unsuccessful, spanning the years 1972–1994, 1995–2001, and 2002–2013.[24][25] Congressional attempts to reschedule have failed as well, including a 1981 bill introduced by Representatives Stewart McKinney and Newt Gingrich that grew to 84 cosponsors but never received a floor vote.[26][27] However, President Joe Biden announced in October 2022 that he would ask the Secretary of Health and Human Services and Attorney General to initiate a review as to how cannabis should be scheduled under federal law, adding that the Schedule I classification of cannabis "makes no sense".[28][29] In August 2023, following a review by the Food and Drug Administration, the Department of Health and Human Services issued a recommendation to the DEA that cannabis be moved to Schedule III.[30] In April 2024, the DEA confirmed its intention to reclassify cannabis as a Schedule III drug, pending review by the Office of Management and Budget, a public comment period, and review by an administrative judge.[31]
The classification of cannabis as a Schedule I drug was first challenged by the National Organization for the Reform of Marijuana Laws (NORML) in a 1972 petition to the Bureau of Narcotics and Dangerous Drugs (which was merged with other agencies to form the DEA in 1973).[32] After a decade of legal battles in which the DEA refused to consider the petition,[25] public hearings were finally held on the matter beginning in 1986.[9] In September 1988, after two years of extensive public hearings, DEA Chief Administrative Law Judge Francis L. Young ruled in favor of moving cannabis to a Schedule II classification, finding that "Marijuana, in its natural form, is one of the safest therapeutically active substances known to man."[33][34] Young concluded: "The evidence in this record clearly shows that marijuana has been accepted as capable of relieving the distress of great numbers of very ill people, and doing so with safety under medical supervision. It would be unreasonable, arbitrary and capricious for DEA to continue to stand between those sufferers and the benefits of this substance in light of the evidence in this record."[16][35] As Young's ruling was only a non-binding recommendation, however, it was rejected by DEA Administrator John Lawn in December 1989.[36] In February 1994, a final ruling on the original 1972 petition was issued when a U.S. Court of Appeals upheld the decision to keep cannabis a Schedule I drug.[24]
Compassionate IND program[edit]
Despite an official policy denying the medical value of cannabis, the federal government began providing the drug to a limited number of patients through the Compassionate Investigational New Drug program in 1978. The program was created following a lawsuit filed by Robert Randall, a Washington, D.C. resident who was arrested for cultivating cannabis in 1975.[37] Citing the glaucoma that threatened to take his eyesight, Randall employed a medical necessity defense at trial to justify his use of cannabis.[37] The charges against Randall were dismissed, and as a result of an ensuing petition filed with the FDA, Randall became the first person to receive cannabis from the federal government in 1976.[37] After his supply was cut off in 1978, he filed a lawsuit to have it restored,[37] setting in motion the creation of the Compassionate Investigational New Drug program shortly thereafter.[38] The program allowed patients with serious medical conditions to receive a regular supply of cannabis from the federal government; however, only 13 ended up participating due to the complicated and drawn-out application process involved.[9]
The Compassionate IND program was closed to new patients in 1992, due to a flood of new applications from AIDS patients and concerns that the program undercut Bush administration efforts to discourage illegal drug use.[39] James O. Mason, the head of U.S. Public Health Service, explained that keeping the program in place created the perception that "this stuff can't be so bad", and noted that AIDS patients provided with cannabis would be more likely to engage in unsafe sex.[40] Twenty-eight applications that had recently been approved were rescinded, and only the 13 individuals who were already receiving cannabis were allowed to do so moving forward.[9] All but two of the patients have since died; the surviving two patients are the only persons who currently receive cannabis through the program.[41]
State policy[edit]
Early laws (late 1970s and early 80s)[edit]
Due to increasing public awareness of the medical benefits of cannabis, and in anticipation of forthcoming changes to federal policy, a number of states passed laws in the late 1970s and early 1980s addressing the medical use of cannabis.[13] New Mexico was the first to do so in 1978, and by the end of 1982 over thirty states had followed suit.[62] The majority of these laws sought to provide cannabis through federally-approved research programs administered by the states, using cannabis supplied by the National Institute on Drug Abuse. Only seven states ended up implementing the programs, however,[2] due to the large bureaucratic and regulatory obstacles imposed by the federal government.[9] Other states passed legislation allowing doctors to prescribe cannabis, or reclassifying cannabis in a state's internal drug scheduling system. These laws were largely ineffectual though, due to the continued prohibition of medical cannabis at the federal level.[2] A few states passed laws affirming the right of individuals to present a medical necessity defense at trial.[13] By the mid-80s, however, efforts to pass new medical cannabis laws had ground to a halt, and a number of existing laws were either repealed or allowed to expire.[13]
California (early and mid-1990s)[edit]
Medical cannabis advocates began to gain ground in the early 1990s with a series of legislative achievements in the state of California. Proposition P was approved by 79% of San Francisco voters in November 1991, calling on state lawmakers to pass legislation allowing the medical use of cannabis.[12] Additionally, the city board of supervisors passed a resolution in August 1992 urging the police commission and district attorney to "make lowest priority the arrest or prosecution of those involved in the possession or cultivation of [cannabis] for medicinal purposes" and to "allow a letter from a treating physician to be used as prima facia evidence that marijuana can alleviate the pain and suffering of that patient's medical condition".[63] The resolution enabled the open sale of cannabis to AIDS patients and others within the city, most notably through the San Francisco Cannabis Buyers Club which was operated by medical cannabis activist Dennis Peron (who spearheaded Proposition P and later the statewide Proposition 215).[64] Similar clubs appeared outside San Francisco in the ensuing years as other cities passed legislation to support the medical use of cannabis. The Wo/Men's Alliance for Medical Marijuana was founded in 1993 after 75% of Santa Cruz voters approved Measure A in November 1992.[65] And the Oakland Cannabis Buyers' Cooperative was founded in 1995 shortly before the city council passed multiple medical cannabis resolutions.[65]
Following the lead of San Francisco and other cities in California, state lawmakers passed Senate Joint Resolution 8 in 1993, a non-binding measure calling on the federal government to enact legislation allowing physicians to prescribe cannabis.[66] In 1994, Senate Bill 1364 was approved by state legislators, to reclassify cannabis as a Schedule II drug at the state level.[66] And Assembly Bill 1529 was approved in 1995, to create a medical necessity defense for patients using cannabis with a physician's recommendation, for treatment of AIDS, cancer, glaucoma, and multiple sclerosis.[66] Both SB 1364 and AB 1529 were vetoed by Governor Pete Wilson, however, paving the way for the passage of Proposition 215 in 1996.[66]
Modern laws (1996 to present)[edit]
Frustrated by vetoes of medical cannabis bills in successive years, medical cannabis advocates in California took the issue directly to the voters, collecting 775,000 signatures for qualification of a statewide ballot initiative in 1996.[67] Proposition 215 – the Compassionate Use Act of 1996 – was subsequently approved with 56% of the vote, legalizing the use, possession, and cultivation of cannabis by patients with a physician's recommendation, for treatment of cancer, anorexia, AIDS, chronic pain, spasticity, glaucoma, arthritis, migraine, or "any other illness for which marijuana provides relief".[68] The law also allowed patient caregivers to cultivate cannabis, and urged lawmakers to facilitate the "safe and affordable distribution of marijuana".[68]
Also in 1996, 65% of Arizona voters approved Proposition 200, a drug policy reform initiative containing a provision allowing physicians to prescribe cannabis.[69] The medical use provision was then essentially repealed by state legislators a few months later,[70] but the change was rejected by voters in a 1998 veto referendum.[71] Ultimately the medical use provision was ineffective, however, due to language that created significant conflict with federal law (use of the word "prescribe" instead of "recommend").[2]
In 1998, medical cannabis initiatives were voted on in the states of Washington, Oregon, Alaska, and Nevada – all of which passed.[16] Also, in Washington, D.C., Initiative 59 to legalize the medical use of cannabis passed with 69% of the vote,[72] but a series of amendments introduced by Rep. Bob Barr and approved by Congress prevented its implementation for over a decade.[73] The initial Barr amendment was enacted prior to the November 1998 election but after ballots had been printed, thereby allowing D.C. residents to vote on the initiative but preventing the results from being made public.[74] The amendment was challenged by the American Civil Liberties Union on grounds that it violated First Amendment rights, and in September 1999 U.S. District Judge Richard W. Roberts agreed, overturning the Barr amendment.[75] Rep. Barr then introduced a similar amendment which became law in November 1999, setting off a long legal battle[76] until finally in December 2009 the Barr amendment was removed from the annual D.C. appropriations bill, allowing the original 1998 ballot initiative to move forward.[73]
Following the approval of several ballot measures in 1998, Maine voters passed a medical cannabis initiative in 1999 that was expanded by both state legislature and another ballot initiative in subsequent years.[2] In 2000, medical cannabis initiatives were passed in the states of Colorado and Nevada, with Nevada's initiative passing for a second consecutive election as required to amend the state's constitution.[77] Also in 2000, Hawaii became the first state to legalize medical cannabis through an act of state legislature.[16]
Effects of legalizing medical cannabis[edit]
A 2016 study found significant drops in violent crime in states that have legalized medical cannabis.[200] A 2017 study similarly found that introduction of medical cannabis laws caused a reduction in violent crime in American states that border Mexico.[201]
A 2018 study found that legalizing medical cannabis in some states made residents of neighboring states increasingly tolerant toward cannabis regulation.[202]
A 2013 study found that medical cannabis legalization is associated with an 8-11% reduction in traffic fatalities.[203]
Several studies have found decreased rates of opioid use and abuse in states that have legalized medical cannabis.[204][205][206][207][208]
Several studies have found no increase in teen use in states that have legalized cannabis for medical purposes.[209][210][211][212][213][214][215] A 2018 meta-analysis in the journal Addiction similarly found no increase.[216]