drug legalization research paper

• Research article
• Open access
• Published: 04 February 2020

Marijuana legalization and historical trends in marijuana use among US residents aged 12–25: results from the 1979–2016 National Survey on drug use and health

• Xinguang Chen 1 ,
• Xiangfan Chen 2 &
• Hong Yan 2  

BMC Public Health volume  20 , Article number:  156 ( 2020 ) Cite this article

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Marijuana is the most commonly used illicit drug in the United States. More and more states legalized medical and recreational marijuana use. Adolescents and emerging adults are at high risk for marijuana use. This ecological study aims to examine historical trends in marijuana use among youth along with marijuana legalization.

Data ( n  = 749,152) were from the 31-wave National Survey on Drug Use and Health (NSDUH), 1979–2016. Current marijuana use, if use marijuana in the past 30 days, was used as outcome variable. Age was measured as the chronological age self-reported by the participants, period was the year when the survey was conducted, and cohort was estimated as period subtracted age. Rate of current marijuana use was decomposed into independent age, period and cohort effects using the hierarchical age-period-cohort (HAPC) model.

After controlling for age, cohort and other covariates, the estimated period effect indicated declines in marijuana use in 1979–1992 and 2001–2006, and increases in 1992–2001 and 2006–2016. The period effect was positively and significantly associated with the proportion of people covered by Medical Marijuana Laws (MML) (correlation coefficients: 0.89 for total sample, 0.81 for males and 0.93 for females, all three p values < 0.01), but was not significantly associated with the Recreational Marijuana Laws (RML). The estimated cohort effect showed a historical decline in marijuana use in those who were born in 1954–1972, a sudden increase in 1972–1984, followed by a decline in 1984–2003.

The model derived trends in marijuana use were coincident with the laws and regulations on marijuana and other drugs in the United States since the 1950s. With more states legalizing marijuana use in the United States, emphasizing responsible use would be essential to protect youth from using marijuana.

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Introduction

Marijuana use and laws in the united states.

Marijuana is one of the most commonly used drugs in the United States (US) [ 1 ]. In 2015, 8.3% of the US population aged 12 years and older used marijuana in the past month; 16.4% of adolescents aged 12–17 years used in lifetime and 7.0% used in the past month [ 2 ]. The effects of marijuana on a person’s health are mixed. Despite potential benefits (e.g., relieve pain) [ 3 ], using marijuana is associated with a number of adverse effects, particularly among adolescents. Typical adverse effects include impaired short-term memory, cognitive impairment, diminished life satisfaction, and increased risk of using other substances [ 4 ].

Since 1937 when the Marijuana Tax Act was issued, a series of federal laws have been subsequently enacted to regulate marijuana use, including the Boggs Act (1952), Narcotics Control Act (1956), Controlled Substance Act (1970), and Anti-Drug Abuse Act (1986) [ 5 , 6 ]. These laws regulated the sale, possession, use, and cultivation of marijuana [ 6 ]. For example, the Boggs Act increased the punishment of marijuana possession, and the Controlled Substance Act categorized the marijuana into the Schedule I Drugs which have a high potential for abuse, no medical use, and not safe to use without medical supervision [ 5 , 6 ]. These federal laws may have contributed to changes in the historical trend of marijuana use among youth.

Movements to decriminalize and legalize marijuana use

Starting in the late 1960s, marijuana decriminalization became a movement, advocating reformation of federal laws regulating marijuana [ 7 ]. As a result, 11 US states had taken measures to decriminalize marijuana use by reducing the penalty of possession of small amount of marijuana [ 7 ].

The legalization of marijuana started in 1993 when Surgeon General Elder proposed to study marijuana legalization [ 8 ]. California was the first state that passed Medical Marijuana Laws (MML) in 1996 [ 9 ]. After California, more and more states established laws permitting marijuana use for medical and/or recreational purposes. To date, 33 states and the District of Columbia have established MML, including 11 states with recreational marijuana laws (RML) [ 9 ]. Compared with the legalization of marijuana use in the European countries which were more divided that many of them have medical marijuana registered as a treatment option with few having legalized recreational use [ 10 , 11 , 12 , 13 ], the legalization of marijuana in the US were more mixed with 11 states legalized medical and recreational use consecutively, such as California, Nevada, Washington, etc. These state laws may alter people’s attitudes and behaviors, finally may lead to the increased risk of marijuana use, particularly among young people [ 13 ]. Reported studies indicate that state marijuana laws were associated with increases in acceptance of and accessibility to marijuana, declines in perceived harm, and formation of new norms supporting marijuana use [ 14 ].

Marijuana harm to adolescents and young adults

Adolescents and young adults constitute a large proportion of the US population. Data from the US Census Bureau indicate that approximately 60 million of the US population are in the 12–25 years age range [ 15 ]. These people are vulnerable to drugs, including marijuana [ 16 ]. Marijuana is more prevalent among people in this age range than in other ages [ 17 ]. One well-known factor for explaining the marijuana use among people in this age range is the theory of imbalanced cognitive and physical development [ 4 ]. The delayed brain development of youth reduces their capability to cognitively process social, emotional and incentive events against risk behaviors, such as marijuana use [ 18 ]. Understanding the impact of marijuana laws on marijuana use among this population with a historical perspective is of great legal, social and public health significance.

Inconsistent results regarding the impact of marijuana laws on marijuana use

A number of studies have examined the impact of marijuana laws on marijuana use across the world, but reported inconsistent results [ 13 ]. Some studies reported no association between marijuana laws and marijuana use [ 14 , 19 , 20 , 21 , 22 , 23 , 24 , 25 ], some reported a protective effect of the laws against marijuana use [ 24 , 26 ], some reported mixed effects [ 27 , 28 ], while some others reported a risk effect that marijuana laws increased marijuana use [ 29 , 30 ]. Despite much information, our review of these reported studies revealed several limitations. First of all, these studies often targeted a short time span, ignoring the long period trend before marijuana legalization. Despite the fact that marijuana laws enact in a specific year, the process of legalization often lasts for several years. Individuals may have already changed their attitudes and behaviors before the year when the law is enacted. Therefore, it may not be valid when comparing marijuana use before and after the year at a single time point when the law is enacted and ignoring the secular historical trend [ 19 , 30 , 31 ]. Second, many studies adapted the difference-in-difference analytical approach designated for analyzing randomized controlled trials. No US state is randomized to legalize the marijuana laws, and no state can be established as controls. Thus, the impact of laws cannot be efficiently detected using this approach. Third, since marijuana legalization is a public process, and the information of marijuana legalization in one state can be easily spread to states without the marijuana laws. The information diffusion cannot be ruled out, reducing the validity of the non-marijuana law states as the controls to compare the between-state differences [ 31 ].

Alternatively, evidence derived based on a historical perspective may provide new information regarding the impact of laws and regulations on marijuana use, including state marijuana laws in the past two decades. Marijuana users may stop using to comply with the laws/regulations, while non-marijuana users may start to use if marijuana is legal. Data from several studies with national data since 1996 demonstrate that attitudes, beliefs, perceptions, and use of marijuana among people in the US were associated with state marijuana laws [ 29 , 32 ].

Age-period-cohort modeling: looking into the past with recent data

To investigate historical trends over a long period, including the time period with no data, we can use the classic age-period-cohort modeling (APC) approach. The APC model can successfully discompose the rate or prevalence of marijuana use into independent age, period and cohort effects [ 33 , 34 ]. Age effect refers to the risk associated with the aging process, including the biological and social accumulation process. Period effect is risk associated with the external environmental events in specific years that exert effect on all age groups, representing the unbiased historical trend of marijuana use which controlling for the influences from age and birth cohort. Cohort effect refers to the risk associated with the specific year of birth. A typical example is that people born in 2011 in Fukushima, Japan may have greater risk of cancer due to the nuclear disaster [ 35 ], so a person aged 80 in 2091 contains the information of cancer risk in 2011 when he/she was born. Similarly, a participant aged 25 in 1979 contains information on the risk of marijuana use 25 years ago in 1954 when that person was born. With this method, we can describe historical trends of marijuana use using information stored by participants in older ages [ 33 ]. The estimated period and cohort effects can be used to present the unbiased historical trend of specific topics, including marijuana use [ 34 , 36 , 37 , 38 ]. Furthermore, the newly established hierarchical APC (HAPC) modeling is capable of analyzing individual-level data to provide more precise measures of historical trends [ 33 ]. The HAPC model has been used in various fields, including social and behavioral science, and public health [ 39 , 40 ].

Several studies have investigated marijuana use with APC modeling method [ 17 , 41 , 42 ]. However, these studies covered only a small portion of the decades with state marijuana legalization [ 17 , 42 ]. For example, the study conducted by Miech and colleagues only covered periods from 1985 to 2009 [ 17 ]. Among these studies, one focused on a longer state marijuana legalization period, but did not provide detailed information regarding the impact of marijuana laws because the survey was every 5 years and researchers used a large 5-year age group which leads to a wide 10-year birth cohort. The averaging of the cohort effects in 10 years could reduce the capability of detecting sensitive changes of marijuana use corresponding to the historical events [ 41 ].

Purpose of the study

In this study, we examined the historical trends in marijuana use among youth using HAPC modeling to obtain the period and cohort effects. These two effects provide unbiased and independent information to characterize historical trends in marijuana use after controlling for age and other covariates. We conceptually linked the model-derived time trends to both federal and state laws/regulations regarding marijuana and other drug use in 1954–2016. The ultimate goal is to provide evidence informing federal and state legislation and public health decision-making to promote responsible marijuana use and to protect young people from marijuana use-related adverse consequences.

Materials and methods

Data sources and study population.

Data were derived from 31 waves of National Survey on Drug Use and Health (NSDUH), 1979–2016. NSDUH is a multi-year cross-sectional survey program sponsored by the Substance Abuse and Mental Health Services Administration. The survey was conducted every 3 years before 1990, and annually thereafter. The aim is to provide data on the use of tobacco, alcohol, illicit drug and mental health among the US population.

Survey participants were noninstitutionalized US civilians 12 years of age and older. Participants were recruited by NSDUH using a multi-stage clustered random sampling method. Several changes were made to the NSDUH after its establishment [ 43 ]. First, the name of the survey was changed from the National Household Survey on Drug Abuse (NHSDA) to NSDUH in 2002. Second, starting in 2002, adolescent participants receive $30 as incentives to improve the response rate. Third, survey mode was changed from personal interviews with self-enumerated answer sheets (before 1999) to the computer-assisted person interviews (CAPI) and audio computer-assisted self-interviews (ACASI) (since 1999). These changes may confound the historical trends [ 43 ], thus we used two dummy variables as covariates, one for the survey mode change in 1999 and another for the survey method change in 2002 to control for potential confounding effect.

Data acquisition

Data were downloaded from the designated website ( https://nsduhweb.rti.org/respweb/homepage.cfm ). A database was used to store and merge the data by year for analysis. Among all participants, data for those aged 12–25 years ( n  = 749,152) were included. We excluded participants aged 26 and older because the public data did not provide information on single or two-year age that was needed for HAPC modeling (details see statistical analysis section). We obtained approval from the Institutional Review Board at the University of Florida to conduct this study.

Variables and measurements

Current marijuana use: the dependent variable. Participants were defined as current marijuana users if they reported marijuana use within the past 30 days. We used the variable harmonization method to create a comparable measure across 31-wave NSDUH data [ 44 ]. Slightly different questions were used in NSDUH. In 1979–1993, participants were asked: “When was the most recent time that you used marijuana or hash?” Starting in 1994, the question was changed to “How long has it been since you last used marijuana or hashish?” To harmonize the marijuana use variable, participants were coded as current marijuana users if their response to the question indicated the last time to use marijuana was within past 30 days.

Chronological age, time period and birth cohort were the predictors. (1) Chronological age in years was measured with participants’ age at the survey. APC modeling requires the same age measure for all participants [ 33 ]. Since no data by single-year age were available for participants older than 21, we grouped all participants into two-year age groups. A total of 7 age groups, 12–13, ..., 24–25 were used. (2) Time period was measured with the year when the survey was conducted, including 1979, 1982, 1985, 1988, 1990, 1991... 2016. (3). Birth cohort was the year of birth, and it was measured by subtracting age from the survey year.

The proportion of people covered by MML: This variable was created by dividing the population in all states with MML over the total US population. The proportion was computed by year from 1996 when California first passed the MML to 2016 when a total of 29 states legalized medical marijuana use. The estimated proportion ranged from 12% in 1996 to 61% in 2016. The proportion of people covered by RML: This variable was derived by dividing the population in all states with RML with the total US population. The estimated proportion ranged from 4% in 2012 to 21% in 2016. These two variables were used to quantitatively assess the relationships between marijuana laws and changes in the risk of marijuana use.

Covariates: Demographic variables gender (male/female) and race/ethnicity (White, Black, Hispanic and others) were used to describe the study sample.

Statistical analysis

We estimated the prevalence of current marijuana use by year using the survey estimation method, considering the complex multi-stage cluster random sampling design and unequal probability. A prevalence rate is not a simple indicator, but consisting of the impact of chronological age, time period and birth cohort, named as age, period and cohort effects, respectively. Thus, it is biased if a prevalence rate is directly used to depict the historical trend. HAPC modeling is an epidemiological method capable of decomposing prevalence rate into mutually independent age, period and cohort effects with individual-level data, while the estimated period and cohort effects provide an unbiased measure of historical trend controlling for the effects of age and other covariates. In this study, we analyzed the data using the two-level HAPC cross-classified random-effects model (CCREM) [ 36 ]:

Where M ijk represents the rate of marijuana use for participants in age group i (12–13, 14,15...), period j (1979, 1982,...) and birth cohort k (1954–55, 1956–57...); parameter α i (age effect) was modeled as the fixed effect; and parameters β j (period effect) and γ k (cohort effect) were modeled as random effects; and β m was used to control m covariates, including the two dummy variables assessing changes made to the NSDUH in 1999 and 2002, respectively.

The HAPC modeling analysis was executed using the PROC GLIMMIX. Sample weights were included to obtain results representing the total US population aged 12–25. A ridge-stabilized Newton-Raphson algorithm was used for parameter estimation. Modeling analysis was conducted for the overall sample, stratified by gender. The estimated age effect α i , period β j and cohort γ k (i.e., the log-linear regression coefficients) were directly plotted to visualize the pattern of change.

To gain insight into the relationship between legal events and regulations at the national level, we listed these events/regulations along with the estimated time trends in the risk of marijuana from HAPC modeling. To provide a quantitative measure, we associated the estimated period effect with the proportions of US population living with MML and RML using Pearson correlation. All statistical analyses for this study were conducted using the software SAS, version 9.4 (SAS Institute Inc., Cary, NC).

Sample characteristics

Data for a total of 749,152 participants (12–25 years old) from all 31-wave NSDUH covering a 38-year period were analyzed. Among the total sample (Table  1 ), 48.96% were male and 58.78% were White, 14.84% Black, and 18.40% Hispanic.

Prevalence rate of current marijuana use

As shown in Fig.  1 , the estimated prevalence rates of current marijuana use from 1979 to 2016 show a “V” shaped pattern. The rate was 27.57% in 1979, it declined to 8.02% in 1992, followed by a gradual increase to 14.70% by 2016. The pattern was the same for both male and female with males more likely to use than females during the whole period.

Prevalence rate (%) of current marijuana use among US residents 12 to 25 years of age during 1979–2016, overall and stratified by gender. Derived from data from the 1979–2016 National Survey on Drug Use and Health (NSDUH)

HAPC modeling and results

Estimated age effects α i from the CCREM [ 1 ] for current marijuana use are presented in Fig.  2 . The risk by age shows a 2-phase pattern –a rapid increase phase from ages 12 to 19, followed by a gradually declining phase. The pattern was persistent for the overall sample and for both male and female subsamples.

Age effect for the risk of current marijuana use, overall and stratified by male and female, estimated with hierarchical age-period-cohort modeling method with 31 waves of NSDUH data during 1979–2016. Age effect α i were log-linear regression coefficients estimated using CCREM (1), see text for more details

The estimated period effects β j from the CCREM [ 1 ] are presented in Fig.  3 . The period effect reflects the risk of current marijuana use due to significant events occurring over the period, particularly federal and state laws and regulations. After controlling for the impacts of age, cohort and other covariates, the estimated period effect indicates that the risk of current marijuana use had two declining trends (1979–1992 and 2001–2006), and two increasing trends (1992–2001 and 2006–2016). Epidemiologically, the time trends characterized by the estimated period effects in Fig. 3 are more valid than the prevalence rates presented in Fig. 1 because the former was adjusted for confounders while the later was not.

Period effect for the risk of marijuana use for US adolescents and young adults, overall and by male/female estimated with hierarchical age-period-cohort modeling method and its correlation with the proportion of US population covered by Medical Marijuana Laws and Recreational Marijuana Laws. Period effect β j were log-linear regression coefficients estimated using CCREM (1), see text for more details

Correlation of the period effect with proportions of the population covered by marijuana laws: The Pearson correlation coefficient of the period effect with the proportions of US population covered by MML during 1996–2016 was 0.89 for the total sample, 0.81 for male and 0.93 for female, respectively ( p  < 0.01 for all). The correlation between period effect and proportion of US population covered by RML was 0.64 for the total sample, 0.59 for male and 0.49 for female ( p  > 0.05 for all).

Likewise, the estimated cohort effects γ k from the CCREM [ 1 ] are presented in Fig.  4 . The cohort effect reflects changes in the risk of current marijuana use over the period indicated by the year of birth of the survey participants after the impacts of age, period and other covariates are adjusted. Results in the figure show three distinctive cohorts with different risk patterns of current marijuana use during 1954–2003: (1) the Historical Declining Cohort (HDC): those born in 1954–1972, and characterized by a gradual and linear declining trend with some fluctuations; (2) the Sudden Increase Cohort (SIC): those born from 1972 to 1984, characterized with a rapid almost linear increasing trend; and (3) the Contemporary Declining Cohort (CDC): those born during 1984 and 2003, and characterized with a progressive declining over time. The detailed results of HAPC modeling analysis were also shown in Additional file 1 : Table S1.

Cohort effect for the risk of marijuana use among US adolescents and young adults born during 1954–2003, overall and by male/female, estimated with hierarchical age-period-cohort modeling method. Cohort effect γ k were log-linear regression coefficients estimated using CCREM (1), see text for more details

This study provides new data regarding the risk of marijuana use in youth in the US during 1954–2016. This is a period in the US history with substantial increases and declines in drug use, including marijuana; accompanied with many ups and downs in legal actions against drug use since the 1970s and progressive marijuana legalization at the state level from the later 1990s till today (see Additional file 1 : Table S2). Findings of the study indicate four-phase period effect and three-phase cohort effect, corresponding to various historical events of marijuana laws, regulations and social movements.

Coincident relationship between the period effect and legal drug control

The period effect derived from the HAPC model provides a net effect of the impact of time on marijuana use after the impact of age and birth cohort were adjusted. Findings in this study indicate that there was a progressive decline in the period effect during 1979 and 1992. This trend was corresponding to a period with the strongest legal actions at the national level, the War on Drugs by President Nixon (1969–1974) President Reagan (1981–1989) [ 45 ], and President Bush (1989) [ 45 ],and the Anti-Drug Abuse Act (1986) [ 5 ].

The estimated period effect shows an increasing trend in 1992–2001. During this period, President Clinton advocated for the use of treatment to replace incarceration (1992) [ 45 ], Surgeon General Elders proposed to study marijuana legalization (1993–1994) [ 8 ], President Clinton’s position of the need to re-examine the entire policy against people who use drugs, and decriminalization of marijuana (2000) [ 45 ] and the passage of MML in eight US states.

The estimated period effect shows a declining trend in 2001–2006. Important laws/regulations include the Student Drug Testing Program promoted by President Bush, and the broadened the public schools’ authority to test illegal drugs among students given by the US Supreme Court (2002) [ 46 ].

The estimated period effect increases in 2006–2016. This is the period when the proportion of the population covered by MML progressively increased. This relation was further proved by a positive correlation between the estimated period effect and the proportion of the population covered by MML. In addition, several other events occurred. For example, over 500 economists wrote an open letter to President Bush, Congress and Governors of the US and called for marijuana legalization (2005) [ 47 ], and President Obama ended the federal interference with the state MML, treated marijuana as public health issues, and avoided using the term of “War on Drugs” [ 45 ]. The study also indicates that the proportion of population covered by RML was positively associated with the period effect although not significant which may be due to the limited number of data points of RML. Future studies may follow up to investigate the relationship between RML and rate of marijuana use.

Coincident relationship between the cohort effect and legal drug control

Cohort effect is the risk of marijuana use associated with the specific year of birth. People born in different years are exposed to different laws, regulations in the past, therefore, the risk of marijuana use for people may differ when they enter adolescence and adulthood. Findings in this study indicate three distinctive cohorts: HDC (1954–1972), SIC (1972–1984) and CDC (1984–2003). During HDC, the overall level of marijuana use was declining. Various laws/regulations of drug use in general and marijuana in particular may explain the declining trend. First, multiple laws passed to regulate the marijuana and other substance use before and during this period remained in effect, for example, the Marijuana Tax Act (1937), the Boggs Act (1952), the Narcotics Control Act (1956) and the Controlled Substance Act (1970). Secondly, the formation of government departments focusing on drug use prevention and control may contribute to the cohort effect, such as the Bureau of Narcotics and Dangerous Drugs (1968) [ 48 ]. People born during this period may be exposed to the macro environment with laws and regulations against marijuana, thus, they may be less likely to use marijuana.

Compared to people born before 1972, the cohort effect for participants born during 1972 and 1984 was in coincidence with the increased risk of using marijuana shown as SIC. This trend was accompanied by the state and federal movements for marijuana use, which may alter the social environment and public attitudes and beliefs from prohibitive to acceptive. For example, seven states passed laws to decriminalize the marijuana use and reduced the penalty for personal possession of small amount of marijuana in 1976 [ 7 ]. Four more states joined the movement in two subsequent years [ 7 ]. People born during this period may have experienced tolerated environment of marijuana, and they may become more acceptable of marijuana use, increasing their likelihood of using marijuana.

A declining cohort CDC appeared immediately after 1984 and extended to 2003. This declining cohort effect was corresponding to a number of laws, regulations and movements prohibiting drug use. Typical examples included the War on Drugs initiated by President Nixon (1980s), the expansion of the drug war by President Reagan (1980s), the highly-publicized anti-drug campaign “Just Say No” by First Lady Nancy Reagan (early 1980s) [ 45 ], and the Zero Tolerance Policies in mid-to-late 1980s [ 45 ], the Anti-Drug Abuse Act (1986) [ 5 ], the nationally televised speech of War on Drugs declared by President Bush in 1989 and the escalated War on Drugs by President Clinton (1993–2001) [ 45 ]. Meanwhile many activities of the federal government and social groups may also influence the social environment of using marijuana. For example, the Federal government opposed to legalize the cultivation of industrial hemp, and Federal agents shut down marijuana sales club in San Francisco in 1998 [ 48 ]. Individuals born in these years grew up in an environment against marijuana use which may decrease their likelihood of using marijuana when they enter adolescence and young adulthood.

This study applied the age-period-cohort model to investigate the independent age, period and cohort effects, and indicated that the model derived trends in marijuana use among adolescents and young adults were coincident with the laws and regulations on marijuana use in the United States since the 1950s. With more states legalizing marijuana use in the United States, emphasizing responsible use would be essential to protect youth from using marijuana.

Limitations

This study has limitations. First, study data were collected through a household survey, which is subject to underreporting. Second, no causal relationship can be warranted using cross-sectional data, and further studies are needed to verify the association between the specific laws/regulation and the risk of marijuana use. Third, data were available to measure single-year age up to age 21 and two-year age group up to 25, preventing researchers from examining the risk of marijuana use for participants in other ages. Lastly, data derived from NSDUH were nation-wide, and future studies are needed to analyze state-level data and investigate the between-state differences. Although a systematic review of all laws and regulations related to marijuana and other drugs is beyond the scope of this study, findings from our study provide new data from a historical perspective much needed for the current trend in marijuana legalization across the nation to get the benefit from marijuana while to protect vulnerable children and youth in the US. It provides an opportunity for stack-holders to make public decisions by reviewing the findings of this analysis together with the laws and regulations at the federal and state levels over a long period since the 1950s.

Availability of data and materials

The data of the study are available from the designated repository ( https://nsduhweb.rti.org/respweb/homepage.cfm ).

Abbreviations

Audio computer-assisted self-interviews

Age-period-cohort modeling

Computer-assisted person interviews

Cross-classified random-effects model

Contemporary Declining Cohort

Hierarchical age-period-cohort

Historical Declining Cohort

Medical Marijuana Laws

National Household Survey on Drug Abuse

National Survey on Drug Use and Health

Recreational Marijuana Laws

Sudden Increase Cohort

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Additional file 1: table s1..

Estimated Age, Period, Cohort Effects for the Trend of Marijuana Use in Past Month among Adolescents and Emerging Adults Aged 12 to 25 Years, NSDUH, 1979-2016. Table S2. Laws at the federal and state levels related to marijuana use.

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Yu, B., Chen, X., Chen, X. et al. Marijuana legalization and historical trends in marijuana use among US residents aged 12–25: results from the 1979–2016 National Survey on drug use and health. BMC Public Health 20 , 156 (2020). https://doi.org/10.1186/s12889-020-8253-4

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Americans overwhelmingly say marijuana should be legal for medical or recreational use

With a growing number of states authorizing the use of marijuana, the public continues to broadly favor legalization of the drug for medical and recreational purposes. 

An overwhelming share of U.S. adults (88%) say either that marijuana should be legal for medical and recreational use by adults (59%) or that it should be legal for medical use only (30%). Just one-in-ten (10%) say marijuana use should not be legal, according to a Pew Research Center survey conducted Oct. 10-16, 2022. These views are virtually unchanged since April 2021.

The new survey follows President Joe Biden’s decision to pardon people convicted of marijuana possession at the federal level and direct his administration to review how marijuana is classified under federal law. It was fielded before the Nov. 8 midterm elections, when two states legalized the use of marijuana for recreational purposes – joining 19 states and the District of Columbia , which had already done so.

Pew Research Center asked this question to track public views about the legal status of marijuana. For this analysis, we surveyed 5,098 adults from Oct. 10-16, 2022. Everyone who took part in this survey is a member of the Center’s American Trends Panel (ATP), an online survey panel that is recruited through national, random sampling of residential addresses. This way nearly all U.S. adults have a chance of selection. The survey is weighted to be representative of the U.S. adult population by gender, race, ethnicity, partisan affiliation, education and other categories. Read more about the ATP’s methodology .

Here are the questions used for this report, along with responses, and its methodology .

Over the long term, there has been a steep rise in public support for marijuana legalization, as measured by a separate Gallup survey question that asks whether the use of marijuana should be made legal – without specifying whether it would be legalized for recreational or medical use. This year, 68% of adults say marijuana should be legal , matching the record-high support for legalization Gallup found in 2021.

There continue to be sizable age and partisan differences in Americans’ views about marijuana. While very small shares of adults of any age are completely opposed to the legalization of the drug, older adults are far less likely than younger ones to favor legalizing it for recreational purposes.

This is particularly the case among those ages 75 and older, just three-in-ten of whom say marijuana should be legal for both medical and recreational use. Larger shares in every other age group – including 53% of those ages 65 to 74 – say the drug should be legal for both medical and recreational use.

Republicans are more wary than Democrats about legalizing marijuana for recreational use: 45% of Republicans and Republican-leaning independents favor legalizing marijuana for both medical and recreational use, while an additional 39% say it should only be legal for medical use. By comparison, 73% of Democrats and Democratic leaners say marijuana should be legal for both medical and recreational use; an additional 21% say it should be legal for medical use only.

Ideological differences are evident within each party. About four-in-ten conservative Republicans (37%) say marijuana should be legal for medical and recreational use, compared with a 60% majority of moderate and liberal Republicans.

Nearly two-thirds of conservative and moderate Democrats (63%) say marijuana should be legal for medical and recreational use. An overwhelming majority of liberal Democrats (84%) say the same.

There also are racial and ethnic differences in views of legalizing marijuana. Roughly two-thirds of Black adults (68%) and six-in-ten White adults say marijuana should be legal for medical and recreational use, compared with smaller shares of Hispanic (49%) and Asian adults (48%).

Related: Clear majorities of Black Americans favor marijuana legalization, easing of criminal penalties

In both parties, views of marijuana legalization vary by age

While Republicans and Democrats differ greatly on whether marijuana should be legal for medial and recreational use, there are also age divides within each party.

A 62% majority of Republicans ages 18 to 29 favor making marijuana legal for medical and recreational use, compared with 52% of those ages 30 to 49. Roughly four-in-ten Republicans ages 50 to 64 (41%) and 65 to 74 (38%) say marijuana should be legal for both purposes, as do 18% of those 75 and older.

Still, wide majorities of Republicans in all age groups favor legalizing marijuana for medical use. Even among Republicans 65 and older, just 17% say marijuana use should not be legal even for medical purposes.

While majorities of Democrats across all age groups support legalizing marijuana for medical and recreational use, older Democrats are less likely to say this. About half of Democrats ages 75 and older (51%) say marijuana should be legal for medical or recreational purposes; larger shares of younger Democrats say the same. Still, only 8% of Democrats 75 and older think marijuana should not be legalized even for medical use – similar to the share of all other Democrats who say this.

Note: Here are the questions used for this report, along with responses, and its methodology .

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Ted Van Green is a research analyst focusing on U.S. politics and policy at Pew Research Center .

9 facts about Americans and marijuana

Most americans favor legalizing marijuana for medical, recreational use, most americans now live in a legal marijuana state – and most have at least one dispensary in their county, clear majorities of black americans favor marijuana legalization, easing of criminal penalties, concern about drug addiction has declined in u.s., even in areas where fatal overdoses have risen the most, most popular.

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Drug Legalization?: Time for a real debate

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March 1, 1996

• 11 min read

Whether Bill Clinton “inhaled” when trying marijuana as a college student was about the closest the last presidential campaign came to addressing the drug issue. The present one, however, could be very different. For the fourth straight year, a federally supported nationwide survey of American secondary school students by the University of Michigan has indicated increased drug use. After a decade or more in which drug use had been falling, the Republicans will assuredly blame the bad news on President Clinton and assail him for failing to carry on the Bush and Reagan administrations’ high-profile stand against drugs. How big this issue becomes is less certain, but if the worrisome trend in drug use among teens continues, public debate about how best to respond to the drug problem will clearly not end with the election. Indeed, concern is already mounting that the large wave of teenagers—the group most at risk of taking drugs—that will crest around the turn of the century will be accompanied by a new surge in drug use.

As in the past, some observers will doubtless see the solution in much tougher penalties to deter both suppliers and consumers of illicit psychoactive substances. Others will argue that the answer lies not in more law enforcement and stiffer sanctions, but in less. Specifically, they will maintain that the edifice of domestic laws and international conventions that collectively prohibit the production, sale, and consumption of a large array of drugs for anything other than medical or scientific purposes has proven physically harmful, socially divisive, prohibitively expensive, and ultimately counterproductive in generating the very incentives that perpetuate a violent black market for illicit drugs. They will conclude, moreover, that the only logical step for the United States to take is to “legalize” drugs—in essence repeal and disband the current drug laws and enforcement mechanisms in much the same way America abandoned its brief experiment with alcohol prohibition in the 1920s.

Although the legalization alternative typically surfaces when the public’s anxiety about drugs and despair over existing policies are at their highest, it never seems to slip off the media radar screen for long. Periodic incidents—such as the heroin-induced death of a young, affluent New York City couple in 1995 or the 1993 remark by then Surgeon General Jocelyn Elders that legalization might be beneficial and should be studied—ensure this. The prominence of many of those who have at various times made the case for legalization—such as William F. Buckley, Jr., Milton Friedman, and George Shultz—also helps. But each time the issue of legalization arises, the same arguments for and against are dusted off and trotted out, leaving us with no clearer understanding of what it might entail and what the effect might be.

As will become clear, drug legalization is not a public policy option that lends itself to simplistic or superficial debate. It requires dissection and scrutiny of an order that has been remarkably absent despite the attention it perennially receives. Beyond discussion of some very generally defined proposals, there has been no detailed assessment of the operational meaning of legalization. There is not even a commonly accepted lexicon of terms to allow an intellectually rigorous exchange to take place. Legalization, as a consequence, has come to mean different things to different people. Some, for example, use legalization interchangeably with “decriminalization,” which usually refers to removing criminal sanctions for possessing small quantities of drugs for personal use. Others equate legalization, at least implicitly, with complete deregulation, failing in the process to acknowledge the extent to which currently legally available drugs are subject to stringent controls.

Unfortunately, the U.S. government—including the Clinton administration—has done little to improve the debate. Although it has consistently rejected any retreat from prohibition, its stance has evidently not been based on in- depth investigation of the potential costs and benefits. The belief that legalization would lead to an instant and dramatic increase in drug use is considered to be so self-evident as to warrant no further study. But if this is indeed the likely conclusion of any study, what is there to fear aside from criticism that relatively small amounts of taxpayer money had been wasted in demonstrating what everyone had believed at the outset? Wouldn’t such an outcome in any case help justify the continuation of existing policies and convincingly silence those—admittedly never more than a small minority—calling for legalization?

A real debate that acknowledges the unavoidable complexities and uncertainties surrounding the notion of drug legalization is long overdue. Not only would it dissuade people from making the kinds of casual if not flippant assertions—both for and against—that have permeated previous debates about legalization, but it could also stimulate a larger and equally critical assessment of current U.S. drug control programs and priorities.

First Ask the Right Questions

Many arguments appear to make legalization a compelling alternative to today’s prohibitionist policies. Besides undermining the black-market incentives to produce and sell drugs, legalization could remove or at least significantly reduce the very problems that cause the greatest public concern: the crime, corruption, and violence that attend the operation of illicit drug markets. It would presumably also diminish the damage caused by the absence of quality controls on illicit drugs and slow the spread of infectious diseases due to needle sharing and other unhygienic practices. Furthermore, governments could abandon the costly and largely futile effort to suppress the supply of illicit drugs and jail drug offenders, spending the money thus saved to educate people not to take drugs and treat those who become addicted.

However, what is typically portrayed as a fairly straightforward process of lifting prohibitionist controls to reap these putative benefits would in reality entail addressing an extremely complex set of regulatory issues. As with most if not all privately and publicly provided goods, the key regulatory questions concern the nature of the legally available drugs, the terms of their supply, and the terms of their consumption (see page 21).

What becomes immediately apparent from even a casual review of these questions—and the list presented here is by no means exhaustive—is that there is an enormous range of regulatory permutations for each drug. Until all the principal alternatives are clearly laid out in reasonable detail, however, the potential costs and benefits of each cannot begin to be responsibly assessed. This fundamental point can be illustrated with respect to the two central questions most likely to sway public opinion. What would happen to drug consumption under more permissive regulatory regimes? And what would happen to crime?

Relaxing the availability of psychoactive substances not already commercially available, opponents typically argue, would lead to an immediate and substantial rise in consumption. To support their claim, they point to the prevalence of opium, heroin, and cocaine addiction in various countries before international controls took effect, the rise in alcohol consumption after the Volstead Act was repealed in the United States, and studies showing higher rates of abuse among medical professionals with greater access to prescription drugs. Without explaining the basis of their calculations, some have predicted dramatic increases in the number of people taking drugs and becoming addicted. These increases would translate into considerable direct and indirect costs to society, including higher public health spending as a result of drug overdoses, fetal deformities, and other drug-related misadventures such as auto accidents; loss of productivity due to worker absenteeism and on-the-job accidents; and more drug-induced violence, child abuse, and other crimes, to say nothing about educational impairment.

Advocates of legalization concede that consumption would probably rise, but counter that it is not axiomatic that the increase would be very large or last very long, especially if legalization were paired with appropriate public education programs. They too cite historical evidence to bolster their claims, noting that consumption of opium, heroin, and cocaine had already begun falling before prohibition took effect, that alcohol consumption did not rise suddenly after prohibition was lifted, and that decriminalization of cannabis use in 11 U.S. states in the 1970s did not precipitate a dramatic rise in its consumption. Some also point to the legal sale of cannabis products through regulated outlets in the Netherlands, which also does not seem to have significantly boosted use by Dutch nationals. Public opinion polls showing that most Americans would not rush off to try hitherto forbidden drugs that suddenly became available are likewise used to buttress the pro-legalization case.

Neither side’s arguments are particularly reassuring. The historical evidence is ambiguous at best, even assuming that the experience of one era is relevant to another. Extrapolating the results of policy steps in one country to another with different sociocultural values runs into the same problem. Similarly, within the United States the effect of decriminalization at the state level must be viewed within the general context of continued federal prohibition. And opinion polls are known to be unreliable.

More to the point, until the nature of the putative regulatory regime is specified, such discussions are futile. It would be surprising, for example, if consumption of the legalized drugs did not increase if they were to become commercially available the way that alcohol and tobacco products are today, complete with sophisticated packaging, marketing, and advertising. But more restrictive regimes might see quite different outcomes. In any case, the risk of higher drug consumption might be acceptable if legalization could reduce dramatically if not remove entirely the crime associated with the black market for illicit drugs while also making some forms of drug use safer. Here again, there are disputed claims.

Opponents of more permissive regimes doubt that black market activity and its associated problems would disappear or even fall very much. But, as before, addressing this question requires knowing the specifics of the regulatory regime, especially the terms of supply. If drugs are sold openly on a commercial basis and prices are close to production and distribution costs, opportunities for illicit undercutting would appear to be rather small. Under a more restrictive regime, such as government-controlled outlets or medical prescription schemes, illicit sources of supply would be more likely to remain or evolve to satisfy the legally unfulfilled demand. In short, the desire to control access to stem consumption has to be balanced against the black market opportunities that would arise. Schemes that risk a continuing black market require more questions—about the new black markets operation over time, whether it is likely to be more benign than existing ones, and more broadly whether the trade-off with other benefits still makes the effort worthwhile.

The most obvious case is regulating access to drugs by adolescents and young adults. Under any regime, it is hard to imagine that drugs that are now prohibited would become more readily available than alcohol and tobacco are today. Would a black market in drugs for teenagers emerge, or would the regulatory regime be as leaky as the present one for alcohol and tobacco? A “yes” answer to either question would lessen the attractiveness of legalization.

What about the International Repercussions?

Not surprisingly, the wider international ramifications of drug legalization have also gone largely unremarked. Here too a long set of questions remains to be addressed. Given the longstanding U.S. role as the principal sponsor of international drug control measures, how would a decision to move toward legalizing drugs affect other countries? What would become of the extensive regime of multilateral conventions and bilateral agreements? Would every nation have to conform to a new set of rules? If not, what would happen? Would more permissive countries be suddenly swamped by drugs and drug consumers, or would traffickers focus on the countries where tighter restrictions kept profits higher? This is not an abstract question. The Netherlands’ liberal drug policy has attracted an influx of “drug tourists” from neighboring countries, as did the city of Zurich’s following the now abandoned experiment allowing an open drug market to operate in what became known as “Needle Park.” And while it is conceivable that affluent countries could soften the worst consequences of drug legalization through extensive public prevention and drug treatment programs, what about poorer countries?

Finally, what would happen to the principal suppliers of illicit drugs if restrictions on the commercial sale of these drugs were lifted in some or all of the main markets? Would the trafficking organizations adapt and become legal businesses or turn to other illicit enterprises? What would happen to the source countries? Would they benefit or would new producers and manufacturers suddenly spring up elsewhere? Such questions have not even been posed in a systematic way, let alone seriously studied.

Irreducible Uncertainties

Although greater precision in defining more permissive regulatory regimes is critical to evaluating their potential costs and benefits, it will not resolve the uncertainties that exist. Only implementation will do that. Because small-scale experimentation (assuming a particular locality’s consent to be a guinea pig) would inevitably invite complaints that the results were biased or inconclusive, implementation would presumably have to be widespread, even global, in nature.

Yet jettisoning nearly a century of prohibition when the putative benefits remain so uncertain and the potential costs are so high would require a herculean leap of faith. Only an extremely severe and widespread deterioration of the current drug situation, nationally and internationally—is likely to produce the consensus—again, nationally and internationally that could impel such a leap. Even then the legislative challenge would be stupendous. The debate over how to set the conditions for controlling access to each of a dozen popular drugs could consume the legislatures of the major industrial countries for years.

None of this should deter further analysis of drug legalization. In particular, a rigorous assessment of a range of hypothetical regulatory regimes according to a common set of variables would clarify their potential costs, benefits, and trade- offs. Besides instilling much-needed rigor into any further discussion of the legalization alternative, such analysis could encourage the same level of scrutiny of current drug control programs and policies. With the situation apparently deteriorating in the United States as well as abroad, there is no better time for a fundamental reassessment of whether our existing responses to this problem are sufficient to meet the likely challenges ahead.

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• Volume 10, Issue 9
• Impact evaluations of drug decriminalisation and legal regulation on drug use, health and social harms: a systematic review
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• http://orcid.org/0000-0001-8498-9829 Ayden I Scheim 1 , 2 ,
• Nazlee Maghsoudi 2 , 3 ,
• Zack Marshall 4 ,
• Siobhan Churchill 5 ,
• Carolyn Ziegler 6 ,
• Dan Werb 2 , 7
• 1 Epidemiology and Biostatistics , Dornsife School of Public Health, Drexel University , Philadelphia , Pennsylvania , USA
• 2 Centre on Drug Policy Evaluation , St Michael's Hospital , Toronto , Ontario , Canada
• 3 Institute of Health Policy, Management and Evaluation , University of Toronto , Toronto , Ontario , Canada
• 4 Social Work , McGill University , Montreal , Quebec , Canada
• 5 Epidemiology and Biostatistics , Western University , London , Ontario , Canada
• 6 Library Services , Unity Health Toronto , Toronto , Ontario , Canada
• 7 Medicine , University of California San Diego , La Jolla , California , USA
• Correspondence to Dr Dan Werb; dwerb{at}ucsd.edu

Objectives To review the metrics and findings of studies evaluating effects of drug decriminalisation or legal regulation on drug availability, use or related health and social harms globally.

Design Systematic review with narrative synthesis.

Data sources We searched MEDLINE, Embase, PsycINFO, Web of Science and six additional databases for publications from 1 January 1970 through 4 October 2018.

Inclusion criteria Peer-reviewed articles or published abstracts in any language with quantitative data on drug availability, use or related health and social harms collected before and after implementation of de jure drug decriminalisation or legal regulation.

Data extraction and synthesis Two independent reviewers screened titles, abstracts and articles for inclusion. Extraction and quality appraisal (modified Downs and Black checklist) were performed by one reviewer and checked by a second, with discrepancies resolved by a third. We coded study-level outcome measures into metric groupings and categorised the estimated direction of association between the legal change and outcomes of interest.

Results We screened 4860 titles and 221 full-texts and included 114 articles. Most (n=104, 91.2%) were from the USA, evaluated cannabis reform (n=109, 95.6%) and focussed on legal regulation (n=96, 84.2%). 224 study outcome measures were categorised into 32 metrics, most commonly prevalence (39.5% of studies), frequency (14.0%) or perceived harmfulness (10.5%) of use of the decriminalised or regulated drug; or use of tobacco, alcohol or other drugs (12.3%). Across all substance use metrics, legal reform was most often not associated with changes in use.

Conclusions Studies evaluating drug decriminalisation and legal regulation are concentrated in the USA and on cannabis legalisation. Despite the range of outcomes potentially impacted by drug law reform, extant research is narrowly focussed, with a particular emphasis on the prevalence of use. Metrics in drug law reform evaluations require improved alignment with relevant health and social outcomes.

• substance misuse
• public health
• law (see medical law)

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjopen-2019-035148

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Strengths and limitations of this study

This is the first study to review all literature on the health and social impacts of decriminalisation or legal regulation of drugs.

We systematically searched 10 databases over a 38-year period, without language restrictions.

The review was limited to study designs appropriate for evaluating interventions, nevertheless, most included studies used relatively weak evaluation designs.

Included outcomes were heterogeneous and not quantitatively synthesised.

Heterogeneity in the details and implementation of decriminalisation or legal regulation policies was not considered in this review.

Introduction

An estimated 271 million people used an internationally scheduled (‘illicit’) drug in 2017, corresponding to 5.5% of the global population aged 15 to 64. 1 Despite decades of investment, policies aimed at reducing supply and demand have demonstrated limited effectiveness. 2 3 Moreover, prohibitive and punitive drug policies have had counterproductive effects by contributing to HIV and hepatitis C transmission, 4 5 fatal overdose, 6 mass incarceration and other human rights violations 7 8 and drug market violence. 9 As a result, there have been growing calls for drug law reform 10–12 and in 2019, the United Nations Chief Executives Board endorsed decriminalisation of drug use and possession. 13 Against this backdrop, as of 2017 approximately 23 countries had implemented de jure decriminalisation or legal regulation of one or more previously illegal drugs. 14–16

A wide range of health and social outcomes are affected by psychoactive drug production, sales and use, and thus are potentially impacted by drug law reform. Nutt and colleagues have categorised these as physical harms (eg, drug-related morbidity and mortality to users, injury to non-users), psychological harms (eg, dependence) and social harms (eg, loss of tangibles, environmental damage). 17 18 Concomitantly, a diverse and sometimes competing set of goals motivate drug policy development, including ameliorating the poor health and social marginalisation experienced by people who use drugs problematically, shifting patterns of use to less harmful products or modes of administration, curtailing illegal markets and drug-related crime and reducing the economic burden of drug-related harms. 19

Given ongoing interest by states in drug law reform, as well as the recent position statement by the United Nations Chief Executives Board endorsing drug decriminalisation, 13 a comprehensive understanding of their impacts to date is required. However, the scientific literature has not been well-characterised, and thus the state of the evidence related to these heterogeneous policy targets remains largely unclear. Systematic reviews, including two meta-analyses, are narrowly focussed on adolescent cannabis use. Dirisu et al found no conclusive evidence that cannabis legalisation for medical or recreational purposes increases cannabis use by young people. 20 In the two meta-analyses, Sarvet et al found that the implementation of medical cannabis policies in the USA did not lead to increases in the prevalence of past-month cannabis use among adolescents 21 and Melchior et al found a small increase in use following recreational legalisation that was reported only among lower-quality studies. 22

Given increasing interest in quantifying the impact of drug law reform, as well as a lack of systematic assessment of outcomes beyond adolescent cannabis use to date, we conducted a systematic review of original peer-reviewed research evaluating the impacts of (a) legal regulation and (b) drug decriminalisation on drug availability, use or related health and social harms. Our primary aim is to characterise studies with respect to metrics and indicators used. The secondary aim is to summarise the findings and methodological quality of studies to date.

Consistent with our aim of synthesising evidence on the impacts of decriminalisation and legal regulation across the spectrum of potential health and social effects, we conducted a systematic review using narrative synthesis 23 without meta-analysis. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed in preparing this manuscript. 24 The review protocol was registered in PROSPERO (CRD42017079681) and can be found online at https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=79681 .

Search strategy and selection criteria

The review team developed, piloted and refined the search strategy in consultation with a research librarian and content experts. We searched MEDLINE, Embase, PsycINFO, Web of Science, Criminal Justice Abstracts, Applied Social Sciences Index & Abstracts, International Bibliography of the Social Sciences, PAIS Index, Policy File Index and Sociological Abstracts for publications from 1 January 1970 through 4 October 2018. We used MeSH (Medical Subject Headings) terms and keywords related to (a) scheduled psychoactive drugs, (b) legal regulation or decriminalisation policies and (c) quantitative study designs. Search terms specific to health and social outcomes were not employed so that the search would capture the broad range of outcomes of interest. See online supplemental appendix A for the final MEDLINE search strategy. For conference abstracts, we contacted authors for additional information on study methods and to identify subsequent relevant publications.

Supplemental material

We included peer-reviewed journal articles or conference abstracts reporting on original quantitative studies that collected data both before and after the implementation of drug decriminalisation or legal regulation. We did not consider as original research studies that reproduced secondary data without conducting original statistical analyses of the data. We defined decriminalisation as the removal of criminal penalties for drug use and/or possession (allowing for civil or administrative sanctions) and legal regulation as the development of a legal regulatory framework for the use, production and sale of formerly illegal psychoactive drugs. Studies were excluded if they evaluated de facto (eg, changes in enforcement practices) rather than de jure decriminalisation or legal regulation (changes to the law). This exclusion applied to studies analysing changes in outcomes following the US Justice Department 2009 memo deprioritising prosecution of cannabis-related offences legal under state medical cannabis laws. Eligible studies included outcome measures pertaining to drug availability, use or related health and social harms. We used the schema developed by Nutt and colleagues to conceptualise health and social harms, including those to users (physical, psychological and social) and to others (injury or social harm). 18

Both observational studies and randomised controlled trials were eligible in principle, but no trials were identified. There were no geographical or language restrictions; titles, abstracts and full-texts were translated on an as-needed basis for screening and data extraction. We excluded cross-sectional studies (unless they were repeated) and studies lacking pre-implementation and post-implementation data collection because such designs are inappropriate for evaluating intervention effects.

Data analysis

Screening and data extraction were conducted in DistillerSR (Evidence Partners, Ottawa, Ontario). We began with title-only screening to identify potentially relevant titles. Two reviewers screened each title. Unless both reviewers independently decided a title should be excluded, it was advanced to the next stage. Next, two reviewers independently screened each potentially eligible abstract. Inter-rater reliability was good (weighted Kappa at the question level=0.75). At this stage, we retrieved full-text copies of all remaining references, which were screened independently by two reviewers. Disagreements on inclusion were resolved through discussion with the first author. Finally, one reviewer extracted data from each included publication using a standardised, pre-piloted form and performed quality appraisal. A second reviewer double-checked data extraction and quality appraisal for every publication, and the first author resolved any discrepancies.

The data extraction form included information on study characteristics (author, title, year, geographical location), type of legal change studied and drug(s) impacted, details and timing of the legal change (eg, medical vs recreational cannabis regulation), study design, sampling approach, sample characteristics (size, age range, proportion female) and quantitative estimates of association. We coded each study-level outcome measure into one metric grouping, using 24 pre-specified categories and a free-text field (see figure 1 for full list). Examples of metrics include: prevalence of use of the decriminalised or regulated drug, overdose or poisoning and non-drug crime.

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Metrics examined by included studies. excl., excluding.

We also categorised the estimated direction of association of the legal change on outcome measure(s) of interest (beneficial, harmful, mixed or null). These associations were coded at the outcome (not study) level and classified as beneficial if a statistically significant increase in a positive outcome (eg, educational attainment) or decrease in a negative outcome (eg, substance use disorder) was attributed to implementation of decriminalisation or legal regulation, and vice versa for harmful associations. The association was categorised as mixed if associations were both harmful and beneficial across participant subgroups, exposure definitions (eg, loosely vs tightly regulated medical cannabis access) or timeframes. Although any use of cannabis and other psychoactive drugs need not be problematic at the individual level, we categorised drug use as a negative outcome given that population-level increases in use may correspond to increases in negative consequences; we thought that this cautious approach to categorisation was appropriate given that such increases are generally conceptualised as negative within the scientific literature. For outcomes that are not unambiguously negative or positive, the coding approach was predetermined taking a societal perspective. For example, increased healthcare utilisation (eg, hospital visits due to cannabis use) was coded as negative because of the increased burden placed on healthcare systems. The association was categorised as null if no statistically significant changes following implementation of drug decriminalisation or legal regulation were detected. We set statistical significance at a= 0.05, including in cases where authors used more liberal criteria.

Quality assessment at the study level was conducted for each full-length article using a modified version of the Downs and Black checklist 25 for observational studies ( online supplemental appendix B ), which assesses internal validity (bias), external validity and reporting. Each study could receive up to 18 points, with higher scores indicating more methodologically rigorous studies. Conference abstracts were not subjected to quality assessment due to limited methodological details.

Patient and public involvement

This systematic review of existing studies did not include patient or public involvement.

Study characteristics

As shown in the PRISMA flow diagram ( figure 2 ), we screened 4860 titles and abstracts and 213 full-texts, with 114 articles meeting inclusion criteria ( online supplemental appendix C ). Key reasons for exclusion at the full-text screening stage were that the article did not report on original quantitative research (n=59) or did not evaluate decriminalisation or legal regulation as defined herein (n=23). Details of each included study are presented in online supplemental table 1 . Included studies had final publication dates from 1976 to 2019; 44.7% (n=51) were first published in 2017 to 2018, 43.9% (n=50) were published in 2014 to 2016 and 11.4% (n=13) were published before 2014.

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram.

Characteristics of included studies are described in table 1 , both overall and stratified by whether they evaluated decriminalisation (n=19) or legalisation (n=96) policies (one study evaluated both policies). Most studies (n=104, 91.2%) were from the USA and examined impacts of liberalising cannabis laws (n=109, 95.6%). Countries represented in non-US studies included Australia, Belgium, China, Czech Republic, Mexico and Portugal. The most common study designs were repeated cross-sectional (n=74, 64.9%) or controlled before-and-after (n=26, 22.8%) studies and the majority of studies (n=87, 76.3%) used population-based sampling methods. Figure 3 illustrates the geographical distribution of studies among countries where national or subnational governments had decriminalised or legally regulated one or more drugs by 2017.

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Characteristics of studies evaluating drug decriminalisation or legal regulation, 1970 to 2018

Number of included studies from countries that implemented decriminalisation or legal regulation by 2017. Note: Policy changes were classified, following the review inclusion criteria, based on the implementation of a change to national or subnational law to decriminalise drug use and/or possession or to legalise at least one class of drugs. We did not evaluate the extent to which legal changes were reflected in policing and criminal justice practice. Implementation of cannabis legalisation for medical purposes only is not reflected in this map.

Study quality

Quality assessment was performed for the 93 full-length articles included in the review, excluding 21 conference abstracts ( online supplemental table 1 ). Scores ranged from 7 to 18 of 18 possible points, with a mean of 14.4 (SD=2.56). Quality scores were similar comparing US to non-US-based studies ( X =14.4 and 13.7, respectively, p=0.386) but higher for studies evaluating legal regulation ( X =14.8) versus decriminalisation ( X =12.8) (p=0.003). Study quality differed significantly (p<0.001) by the direction of the association with the outcome of interest, with higher quality scores among studies estimating mixed ( X =15.4) or beneficial ( X =15.2) versus null ( X =14.2) or harmful ( X =13.1) effects of legal change on the outcome of interest. Study quality did not appear to increase over time (eg, X =14.0 in 2014 and 14.4 in 2018).

Study outcome measures and metrics

Across 114 studies we extracted 224 outcome measures, which were coded into 32 metrics ( figure 1 ). The most common metric employed by studies was the prevalence of use of the decriminalised or legally regulated drug, which was examined in 39.5% of studies (n=45) and represented 22.3% of outcome measures (n=50). Of these studies, 13 (28.9%; 8 full-length articles and 5 abstracts) did not report any other metric 26–38 and an additional 6 studies (13.3%) reported on the prevalence of use in addition to a single drug-related perception metric (either harmfulness or availability). 39–44 The second most common metric was the frequency of use of the decriminalised or legally regulated drug (14.0% of studies, n=16) and the third was the prevalence or frequency of use of tobacco, alcohol or drugs that remained illegal (12.3% of studies, n=14). The fourth most commonly employed metric was any change in the perceived health harmfulness of using the decriminalised or regulated drug (10.5% of studies, n=12), which was assessed among adolescents or young adults in all studies except for one that assessed this metric among parents. 45

All other metrics were assessed in <10% of included studies. Health service utilisation was evaluated in 7.9% of studies (n=9) using 12 outcome measures, primarily related to emergency department visits and/or hospitalisations. Prescribed (primarily opioid) drug use and perceived availability of the decriminalised or legally regulated drug were reported in 7.0% of studies each (n=8). Overdose or poisoning by the decriminalised or regulated drug, and by other drugs (predominantly opioids), were examined in 5.3% (n=6) and 6.1% of studies (n=7), respectively. Driving while under the influence or with detectable concentrations of the decriminalised or regulated drug (cannabis) was examined in seven studies (6.1%) inclusive of eight outcome measures. Notably, one study assessed self-reported impaired driving, 46 while others assessed the proportion of fatally injured drivers screening cannabis-positive or the overall prevalence of driving with detectable tetrahydrocannabinol (THC) concentrations in blood. Remaining metrics were measured in less than 5% of studies ( figure 1 ). Some pre-specified metrics were not represented in any of the articles, including infectious disease incidence (eg, HIV, hepatitis C), environmental impacts (eg, drug production waste, discarded needles) and labour market participation.

Studies outside the US

Of the 10 studies conducted outside the USA, 6 focussed on cannabis decriminalisation. All three studies from Australia examined the prevalence of cannabis use post-decriminalisation, 31 34 47 while one also measured perceived cannabis availability. 47 Following cannabis decriminalisation, one European multi-country study including Belgium and Portugal examined the prevalence of cannabis use and uptake of cannabis-related addictions treatment 48 and one Czech study considered the age of first cannabis use. 49 An international study using United Nations Office on Drugs and Crime data from 102 countries compared availability, as reflected by cannabis seizures and plant eradication, in countries that had decriminalised cannabis versus those that had not. 50 Three non-US studies evaluated decriminalisation of all psychoactive drugs. Two studies from Portugal examined healthcare and non-healthcare costs and psychoactive drug prices, respectively. 51 52 One study from Mexico examined drug-related criminal justice involvement (arrests) and (violent) crimes. 53 Finally, a study of historic opium legalisation in China (1801 to 1902) measured the price and availability (quantity of exports) of opium before and after legalisation. 54

Impacts of decriminalisation and legal regulation

Results of individual studies are provided in online supplemental table 1 . Online supplemental table 2 tallies findings and average quality scores for each of the metrics; here we summarise findings for metrics examined in more than 5% of studies, in descending order based on the number of datapoints. Across all three substance use metrics (prevalence of use, frequency of use and use of other alcohol or drugs), drug law reform was most often not associated with use (with null findings for 48.0% to 52.4% of outcome measures falling under these metrics). With respect to change in perceived harmfulness of the decriminalised or regulated drug, mixed results were found in half of cases, with heterogeneity detected on the basis of age, gender and state. 39 43 55–57 For example, legal regulation of cannabis for medical use was associated with greater perceived harmfulness of cannabis among eighth graders but not older students in an analysis of US Monitoring the Future data 39 while a study employing US National Survey on Drug Use and Health data found greater perceived harmfulness of cannabis among young adults aged 18 to 25 but not adolescents aged 12 to 17. 57

Among nine studies that employed health service utilisation metrics, harmful effects were reported for 6 of 12 outcome measures, with increases in emergency department visits and/or hospitalisations attributed to decriminalisation or legal regulation. 58–63 However, all but one of those studies 58 assessed change over time in one jurisdiction, without a control group. Further, two studies that also examined changes in acute care use for non-cannabis drugs found reductions in those visits or admissions following cannabis decriminalisation or legal regulation. 60 64 In contrast, six of nine prescription drug use associations were beneficial, with reductions observed in rates of opioid 65–69 and other drug prescribing 70 71 attributed to legal regulation of cannabis for medical use; outcomes in this category came from studies of higher average quality ( X =16.3). Perceived availability of the decriminalised or regulated drug appeared largely unaffected by decriminalisation (null associations for five of nine outcome measures) but two studies indicated increased perceived availability of cannabis among Colorado, US, adolescents following legal regulation for adult use 72 and among adults in US states with legal regulation for medical use. 44 Across the subset of seven outcome measures for overdose or poisoning by the decriminalised or regulated drug (cannabis), in all cases an increase in calls to poison control centres or unintentional paediatric exposures was reported. 59 73–77 However, studies assessing the impacts of cannabis regulation on overdose or poisoning by drugs other than cannabis concluded that the effects were either beneficial (four outcome measures 64 76 78 79 ) or mixed/null (three outcome measures 80–82 ). Driving with detectable concentrations of THC was most often found to increase following decriminalisation or legal regulation (five of eight outcome measures; 83–87 ), but these studies were of lower average quality ( X =12.0).

Impacts of decriminalisation

Of the 19 studies evaluating impacts of decriminalisation, six measured the prevalence of use of the decriminalised drug with eight unique outcome measures. No association was detected for all but three outcomes; following cannabis decriminalisation lifetime use increased among adults in South Australia, 31 while past-month use increased among 12 th graders but not younger students in California, 56 relative to the rest of the country in both cases. After peyote use for ceremonial purposes was decriminalised in the USA in 1994, self-reported use increased among American Indians. 88 Three studies evaluated relationships between decriminalisation and drug-related criminal justice involvement in Mexico and the USA. One high-quality study found that decriminalisation positively influenced criminal justice involvement: in five US states, arrests for cannabis possession decreased among youth and adults. 89 When possession of small amounts of cannabis was decriminalised in the 1970s in Nebraska, however, the mean monthly number of arrests did not change, while cannabis-related prosecutions increased among youth. 90 In Tijuana, Mexico, decriminalisation of all drugs had no apparent impact on the number of drug possession arrests. 53 Two historical and one recent study measured healthcare utilisation. US states that decriminalised cannabis in the 1970s saw greater emergency department visits related to cannabis, but decreased visits related to other drugs. 60 In Colorado, US, decriminalisation was associated with increased emergency department visits for cyclic vomiting. 62 Addiction treatment utilisation, healthcare and non-healthcare costs, driving after use, price of drugs, availability of drugs, frequency of use, attitudes towards use and perceived harmfulness were each evaluated in only one or two studies of decriminalisation.

This systematic review identified 114 peer-reviewed publications and conference abstracts evaluating the impacts of drug decriminalisation or legal regulation from 1970 to 2018. Within this search period, 88.6% were published in 2014 or later. This rapid growth in scholarship was driven by the implementation and subsequent evaluation of cannabis legalisation in a number of US states beginning in 2012, and knowledge production will surely continue to accelerate as longer-term data become available and as other jurisdictions (eg, Canada and Uruguay) analyse the effects of recently implemented cannabis legalisation. Indeed, a first study on the impacts of cannabis legalisation on adolescent use in Uruguay was published in May 2020 (finding no impact on risk of use 91 ). The present study provides an overview of the emerging literature based on our systematic review and suggests three key patterns.

First, peer-reviewed longitudinal evaluations of drug decriminalisation and legal regulation are overwhelmingly geographically concentrated in the US and focussed on cannabis legalisation. Importantly, the lack of non-US studies evaluating legal regulation of cannabis for medical use may reflect the more tightly controlled nature of medical cannabis regulation in other countries, and thus the more limited potential for population-level effects. It is notable that decriminalisation in the absence of legal regulation was evaluated in only 18 studies (15.8%), despite being far more common globally than legal regulation. These gaps may hamper evidence-based drug law reform in countries that are less well-developed, that play a substantial role in drug production and transit or that have different baseline levels of substance (mis)use as compared with the US.

Second, prevalence of use was the predominant metric used to assess the impact of drug law reform, despite its limited clinical significance (eg, much cannabis use is non-problematic) and limited responsiveness to drug policy. This is because ecological analyses have indicated little relationship between drug policies and prevalence of use, 52 as have studies assessing within-state change in use related to legal regulation. 21 These findings are supported by the preponderance of evidence synthesised in this review, although some variation is evident in relation to the specific provisions of legal reforms (eg, liberal vs tightly regulated medical markets 92 ). Impacts of legal cannabis regulation on prevalence and frequency of use continue to be evaluated, with recent data suggesting small increases among adults, but not youth. 93 Drug policies may be more able to influence the types of drugs that people use, drug-related risk behaviours and modes of drug consumption. 94 Metrics to assess these outcomes, however, were lacking in the reviewed literature. For example, only one study (0.8%) investigated whether legal regulation of cannabis was associated with changes in the mode of cannabis consumption. 72 Although the prevalence of use was often measured alongside more clinically or socially significant metrics (eg, prevalence of substance use disorders, educational outcomes among young adults), 42.2% of studies assessing substance use prevalence included that metric alone or in combination with a single drug-related attitude metric.

Third, there was a lack of alignment between the stated policy objectives of drug law reform and the metrics used to assess its impact in the scientific literature. For instance, removal of criminal sanctions to prevent their negative sequelae is a key rationale for decriminalisation and legal regulation, 12 13 95 but only four studies (3.5%) evaluated changes in drug-related criminal justice involvement following drug law reform. Similarly. improving the physical and mental health of people who (already) use drugs is a motivation for drug policy reform but no included studies examined mental or physical health outcomes (aside from substance use disorders) in this population. As a result, there is a risk that decisions on drug policy may be informed by inappropriate metrics. Promisingly, in recent months, additional studies assessing legal regulation that employ a range of criminal justice metrics have been published. 96–98 Finally, despite ample evidence of the impact of criminalisation on infectious disease transmission and acquisition risks, 5 we found no studies evaluating the impact of decriminalisation on these outcomes.

Both the included studies and our systematic review have important strengths and limitations. To our knowledge, we conducted the first review of all global literature on decriminalisation and legal regulation and applied no language restrictions. All eligible articles identified were published in English; this may reflect a paucity of evaluation research published in other languages and/or limitations of our search strategy (eg, some non-English journals may not be indexed in the 10 databases searched). In addition, we excluded grey literature, non-original research and study designs that are not suited to evaluating policy effects (eg, cross-sectional studies), but these restrictions narrowed the geographical scope of included studies. For example, two articles on Portugal were excluded as non-original research, but nevertheless provide important insight on impacts of decriminalisation. 99 100 Despite restricting eligibility to more rigorous study designs, most included studies used relatively weaker eligible designs that are known to be vulnerable to pre-existing trends and confounding; only 22.8% and 5.3%, respectively, used controlled before-and-after or interrupted time series designs to address these threats to validity. The use of these study designs may be related to limited resources for prospective drug policy evaluations, with many studies relying on publicly available, routinely collected data. That the US is unique in the extent to which data on drug use and related harms are routinely collected helps to explain its over-representation in our review. Scoping reviews inclusive of grey literature and cross-sectional designs would be valuable for describing the full range of evaluations that have been conducted globally.

While beyond the scope of our high-level synthesis, the implementation and specific provisions of drug policies vary widely. Decriminalisation policies vary in their definitions of quantities for personal use, application of administrative penalties and the extent to which the law ‘on the books’ is reflected in policing and criminal justice practice. Indeed, in some jurisdictions with nominal decriminalisation, arrests for possession of small quantities of the decriminalised drugs remain routine. 53 Legal regulation models for cannabis are also heterogeneous. For example, policies legally regulating cannabis for medical use may or may not allow for legal dispensaries, and this provision has been shown to substantially modify the impact of legal regulation on cannabis use. 101 To the extent that individual studies employed crude exposure measures (eg, presence vs absence of a law), they may have obscured context-dependent effects of drug law liberalisation. Further, the impact of drug laws on drug use and related outcomes may be limited by a lack of public awareness of the details of local laws. 102

Our use of vote-counting in this synthesis (ie, categorising individual outcome measures as indicating beneficial, harmful, mixed/subgroup-specific or no statistically significant associations) is subject to the same limitation. Vote-counting should also be interpreted with caution in light of the heterogeneity of outcome definitions, the inherent arbitrariness of statistical significance thresholds and the key distinction between statistical and clinical significance. In addition, many included studies are evaluating the same policies (eg, cannabis legalisation in western US states), sometimes using overlapping data but drawing different conclusions based on analytical choices and timeframes. The existence of multiple datapoints for a particular outcome does not imply that the outcome has been well-studied across diverse contexts such that scientific consensus on its effects has been reached. Moreover, as illustrated by a recently published extension of the included article by Bachhuber et al , 79 multiple high-quality studies may generate results that are later revealed to be spurious as additional follow-up data become availability. Specifically, Shover et al demonstrated that the positive association reported between medical cannabis legalisation and opioid overdose mortality in 1999 to 2010 reversed direction in later years, suggesting that earlier findings of a protective effect should not be given causal interpretations. 103 This was foreshadowed in the included article by Powell et al , which found that the purportedly positive effect of medical cannabis legalisation was attenuated in 2010 to 2013. 82 This scientific back-and-forth can be expected given that most included articles are evaluating legal changes introduced rather recently, and thus are examining early impacts with limited years of follow-up. Longer-term impacts of non-medical cannabis legalisation, and how they might be influenced by increased commercialisation, are yet to be seen. 104

Conclusions

The findings of this review indicate a need for a broadening of the metrics used to assess the impacts of drug decriminalisation and legal regulation. Given the growing number of jurisdictions considering decriminalisation or legal regulation of psychoactive drugs, 14–16 the disproportionate emphasis on metrics assessing drug use prevalence, as well as the limited geo-cultural diversity in evaluations, are concerning. Experts have called for a more fulsome approach to evaluating drug policies in line with public health and the United Nations Sustainable Development Goals, with attention to the full breath of health and social domains potentially impacted, including human rights and social inclusion (eg, stigma), peace and security (eg, drug market violence), development (eg, labour market participation), drug market regulation (eg, safety of the drug supply) and clinically-significant health metrics (eg, drug-related morbidity). 105 Drawing on methods such as multi-criterion decision analysis, 19 the engagement of both scientists and policymakers in priority-setting may help to produce evidence that provides a more comprehensive understanding of the breadth of impacts that should be anticipated with drug law reform efforts. Funding will also be required to support rigorous prospective evaluations of legal reforms.

Acknowledgments

The authors would like to thank Gelareh Ghaderi for assistance with screening and data extraction.

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Twitter @aydenisaac

Presented at Presented at the International Society for the Study of Drug Policy (May 22, 2019) and the International Harm Reduction Conference (April 29, 2019).

Contributors DW and AIS conceptualised and supervised the review. CZ designed and conducted the literature searches. AIS drafted the manuscript. SC, ZM and AIS conducted screening and data extraction. NM contributed to drafting the manuscript and developing figures. All authors contributed to interpretation of findings and revising the manuscript for important intellectual content.

Funding This review was supported by the Canadian Institutes of Health Research (CIHR) via the Canadian Research Initiative on Substance Misuse (SMN-139150), the MAC AIDS Foundation, and the Open Society Foundations. Ayden Scheim was supported by a Canadian Institutes of Health Research Postdoctoral Fellowship. Nazlee Maghsoudi is supported by a CIHR Vanier Canada Graduate Scholarship. Dan Werb is supported by a US National Institute on Drug Abuse Avenir Award (DP2- DA040256), a CIHR New Investigator Award, an Early Researcher Award from the Ontario Ministry of Research, Innovation and Science and the St Michael’s Hospital Foundation.

Map disclaimer The depiction of boundaries on the map(s) in this article does not imply the expression of any opinion whatsoever on the part of BMJ (or any member of its group) concerning the legal status of any country, territory, jurisdiction or area or of its authorities. The map(s) are provided without any warranty of any kind, either express or implied.

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Patient consent for publication Not required.

Provenance and peer review Not commissioned; externally peer reviewed.

Data availability statement All relevant data are contained within the article and supplementary materials.

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The Wider Impact of Drug Legalization on the Criminal Justice System

by aseneviratne | Mar 16, 2021 | All , Criminal Justice Reform , Public Health

This paper will discuss the effect of legalizing possession of all drugs on the criminal justice system. This paper will begin with a brief history of the modern War on Drugs to establish why drug possession should not be a criminal matter. Discussion of the impact of legalization will primarily focus on reduction in caseload and the resulting benefits.

The modern War on Drugs began during the Nixon presidency with the passage of the Controlled Substances Act of 1970 (“CSA”), which established federal regulatory power over the manufacture, importation, possession, use, and distribution of certain substances. [1] The CSA was ostensibly a public health response to the growing heroin epidemic in the mid-1960s. [2] In 1973, Nixon created the Drug Enforcement Agency (“DEA”) to carry out enforcement of the CSA. [3]

The War on Drugs expanded into a system of mass incarceration under the Comprehensive Crime Control Act of 1984, which increased criminal penalties associated with cannabis possession and established mandatory minimum sentences. [4] From 1980 to 1997, “the number of [individuals incarcerated] for nonviolent drug law offenses [jumped] from 50,000 . . . to over 400,000.” [5] “By 1991, the United States had surpassed the former Soviet Union and South Africa as having the largest prison population in the world.” [6] The racial impact from the ‘Tough on Crime’ approach reared its ugly head as “the sentences of black inmates were 41% longer than that of whites.” [7]

Most critically, the War on Drugs has been ineffective in deterring drug use. [8] In 2000, law enforcement seized over 4.4 million tablets of ecstasy, an increase from 350,000 tablets just two years prior. [9] From 2010 to 2015, the lifetime prevalence of 8th graders who have used illicit drugs consistently hovered around 20%. [10] Over that same period, the number of drug-induced deaths increased from 40,393 to 55,403. [11]

In light of the racial bias stemming from the War on Drugs as well as its failure to achieve its supposed intended purpose, drug possession is a worthy candidate for exploration into forms of treatment outside of the criminal realm. [12]

Legalization v. Decriminalization

For the purposes of this paper, assume that legalization means that the possession, sale, and manufacturing of all drugs would be regulated similarly to alcohol or cigarettes. At the outset, it is important to note why legalization is preferable to decriminalization. Decriminalization of drug possession simply means that possession is not a criminal offense. [13] In 2001, Portugal decriminalized all drugs, and the public health benefits have been palpable. [14] Under a system of decriminalization, however, the manufacturing and sale of drugs is still criminal. [15] As a result, the drug market is still propped up and supplied by drug cartels, just as it is in a system of prohibition. [16] Legalization goes further than decriminalization by legalizing drug production. [17] Allowing companies to manufacture drugs removes the viability of the black market drug trade, such as in Mexico where one cartel alone “had annual earnings calculated to be as high as $3 billion.” [18] In 2018, the DEA spent over $445 million on international enforcement to decrease the impact of these cartels in the United States. [19] Legalization treats the cause of the disease, and the consequent reduction in symptoms would decrease the need for these yearly international enforcement expenditures.

Court Decluttering

In 2017, there were 1,632,921 drug related violations in the U.S., of which 85.4% were for possession; an average of 3,820 possession arrests per day. [20] Under a system of legalization, American courts would no longer be inundated with this entire class of offense. The benefits of legalization on the courts are multifaceted: for the drug possessor, who is no longer a victim of the fruitless War on Drugs; for the judge, who enjoys greater flexibility with a decluttered docket; and most importantly, for the public defender, who can take advantage of the much-needed decrease in workload to provide better counsel to clients. [21]

In 2016, Louisiana had an estimated annual workload of 147,220 total cases to be divided among its 363 public defenders. [22] This meant that “the Louisiana public defense system [could only] handle 21 percent of [its] workload in compliance with [state] guidelines.” [23]

“Unsurprisingly, excessive workloads diminish the quality of legal representation.” [24] With such an enormous caseload, public defenders do not have the time available to conduct basic defense tasks necessary for a trial, creating an incentive for guilty pleas. [25] Guilty pleas based on time constraint rather than merit render “an ethical and constitutional plea bargain . . . impossible.” [26]

Given the sheer number of drug arrests, legalization would likely drastically reduce the public defense system’s case load. [27] With this caseload reduction, public defenders would be able to work towards closing the gap between the actual and necessary amount of time devoted to each client. [28] With more time to evaluate each case, public defenders can more effectively assess the appropriateness of a plea deal on the merits, rather than time constraints. [29] The increased legitimacy and efficiency of the public defense system resulting from legalization will likely lead to broader indirect benefits for all public defense clients, no matter what crime they are accused of. [30 ]

An argument against legalization posits that these reductions in public defense caseload would be offset by an increase in crime, such as petty crime and driving under the influence, due to legalization. [31] This line of reasoning rests on the assumption that if there are no criminal penalties for drug possession or use, then the number of drug users will increase. [32] With more people using drugs, more people will become addicts, who are more prone to committing crimes. [33]

The assumption that the absence of criminal sanctions entails more people using drugs is unsound, as under Portugal’s system of decriminalization, “in almost every category of drug, and for drug usage overall, the lifetime prevalence rates . . . were higher” prior to decriminalization. [34] Cocaine usage in Portugal was significantly lower than usage in the United States, which was head and shoulders above the rest of the world. [35] The heroin usage rate in Portugal from 1999 to 2005 actually decreased from 2.5% to 1.8% among those in the 16-18 age group. [36] Decreased drug use does not necessarily follow from from punitive state response, just as increased drug use does not necessarily follow from rehabilitative state response. [37] If the pool of drug users remains consistent after legalization, then pool of criminal drug users would likely remain consistent as well.

Still, even assuming that the number of drug addicts would increase post-legalization, leading to an increase in the number of petty crime and driving under the influence (“DUI”) cases, these cases differ quantitatively and qualitatively from possession and crimes currently associated with the black market for drugs.

Quantitatively, the increased caseload for petty crime and driving under the influence would still be significantly less the number of possession charges the system currently deals with. [38] Further, under the current system of prohibition, courts and society at large must deal with violent crimes associated with the black market for narcotics: in 2016, 11.2% of all federal prisoners held in state correctional facilities were incarcerated for drug trafficking and drug offenses other than possession. [39] Under a system of legalization, the profitability of the black market is greatly reduced, which would likely result in these arguably more serious crimes becoming less prevalent and further decreasing the caseload related to drugs despite a potential increase in petty crime and driving under the influence cases. [40]

Qualitatively, DUIs directly present significant and real risks of harm to other members of society in a way that drug possession does not. “In 2016, 10,497 people died in alcohol-impaired driving crashes, accounting for 28% of all traffic-related deaths in the United States.” [41] Given the increased culpability and blameworthiness of these crimes, it is not a waste of the public defense system resources to criminalize DUI and bear the associated costs of doing so; rather, these are precisely the crimes which fall under the purview of the criminal justice system. [42]

In conclusion, the War on Drugs has disproportionately impacted minorities [43] and has not effectively reduced drug consumption and usage. [44] In light of this, the United States should take steps to legalize drug possession and emulate the success of other nations who have treated drug use as public health matter, instead a criminal one. [45] Further, the benefits of legalization extend beyond drug users. [46] Globally, legalization helps to curtail the influence of cartels. [47] Domestically, legalization frees up the criminal justice system, permitting more efficient and legitimate legal representation for all individuals. [48]

[1] See Controlled Substances Act of 1970, 21 U.S.C. § 811.

[2] See Pub. Broadcasting Serv., Interview Dr. Robert DuPont , FRONTLINE: DRUG WARS, https://www.pbs.org/wgbh/pages/frontline/shows/drugs/interviews/dupont.html (last visited Mar. 20, 2020).

[3] See History , DRUG ENF’T AGENCY, dea.gov/history (last visited Jun. 29, 2020).

[4] See Comprehensive Crime Control Act of 1984, Pub. L. No. 98-473, 98 Stat. 1976.

[5] A Brief History of the Drug War , DRUG POL’Y ALL., https://www.drugpolicy.org/issues/brief-history-drug-war, (last visited Mar. 23, 2020).

[6] Charles Ogletree, Getting Tough on Crime: Does It Work? 38 Boston B. J. 9, 27 (1994).

[8] See Ross C. Anderson, We Are All Casualties of Friendly Fire in the War on Drugs , 13 Utah B.J. 10, 11 (2000).

[9] Id. at 11.

[10] See OFFICE OF NAT’L DRUG CONTROL POL’Y, NATIONAL DRUG CONTROL STRATEGY: PERFORMANCE REPORTING SYSTEM REPORT 27 (2016); What is Prevalence? NAT’L INST. MENTAL HEALTH (Nov. 2017), https://www.nimh.nih.gov/health/statistics/what-is-prevalence.shtml (explaining that “[l]ifetime prevalence is the proportion of a population who, at some point in life has ever had the characteristic.”).

[11] Id. at 12.

[12] See Anderson, supra note 8, at 11.

[13] See GLENN GREENWALD, DRUG DECRIMINALIZATION IN PORTUGAL: LESSONS FOR CREATING FAIR AND SUCCESSFUL DRUG POLICIES 2 (2009), https://www.cato.org/publications/white-paper/drug-decriminalization-portugal-lessons-creating-fair-successful-drug-policies.

[14] See id. at 14-15 (explaining that since decriminalization, Portugal has experienced a slight decline in drug use, a significant decline in drug related pathologies such as HIV, and a substantial increase in use of treatment programs).

[15] See i d. at 2.

[16] See German Lopez, What People Get Wrong About Prohibition , VOX (Oct. 19, 2015), https://www.vox.com/2015/10/19/9566935/prohibition-myths-misconceptions-facts.

[17] See GREENWALD, supra note 13, at 2.

[18] JUNE S. BEITTEL, CONG. RSCH. SERV., R41576, MEXICO: ORGANIZED CRIME AND DRUG TRAFFICKING ORGANIZATIONS 19 (2019).

[19] DRUG ENF’T ADMIN., FY 2019 BUDGET REQUEST, 4 (2018).

[20] See 2017 Crime in the United States: Persons Arrested , FED. BUREAU INVESTIGATION: UNIFORM CRIME REPORTING, https://ucr.fbi.gov/crime-in-the-u.s/2017/crime-in-the-u.s.-2017/topic-pages/persons-arrested (last visited Aug. 15, 2020).

[21] See Lisa C. Wood et al., Meet-and-Plead: The Inevitable Consequence of Crushing Defender Workloads , 42 LITIG. 20, 23 (2016).

[22] See A.B.A. & POSTLETHWAITE & NETTERVILLE, THE LOUISIANA PROJECT: A STUDY OF THE LOUISIANA DEFENDER SYSTEM AND ATTORNEY WORKLOAD STANDARDS 2 (2017).

[24] Wood et al., supra note 21, at 23.

[25] See id.

[27] See id. at 26.

[28] See id .

[29] See id .

[30] See id.

[31] See Paul Stares, Drug Legalization?: Time for a Real Debate , BROOKINGS INST. (Mar. 1, 1996), https://www.brookings.edu/articles/drug-legalization-time-for-a-real-debate/.

[32] See id.

[33] See id.

[34] GREENWALD, supra note 13, at 14-15 (emphasis added).

[35] See id. at 22-24.

[36] Id. at 14.

[37] See Stares, supra note 31 .

[38] See 2016 Crime in the United States: Table 18 , FED. BUREAU INVESTIGATION: UNIFORM CRIME REPORTING, https://ucr.fbi.gov/crime-in-the-u.s/2016/crime-in-the-u.s.-2016/topic-pages/tables/table-18 (last visited Aug. 15 2020) (illustrating that arrests for drug abuse violations are nearly eight times as high as arrests for burglary – a petty crime that is often related to drugs).

[39 ] JENNIFER BRONSON & E. ANN CARSON, BUREAU OF JUSTICE STATISTICS, NCJ 252156 , PRISONERS IN 2017 21 (2019).

[40] See Lopez, supra note 16 .

[41] Impaired Driving: Get the Facts, CENTERS FOR DISEASE CONTROL AND PREVENTION ( Aug. 24, 2020, 12:00 AM), https://www.cdc.gov/motorvehiclesafety/impaired_driving/impaired-drv_factsheet.html.

[42] See Janine Geske, Achieving the Goals of Criminal Justice: A Role for Restorative Justice , 30 Quinnipiac L. Rev. 527, 530-31 (2012).

[43] See Anderson, supra note 8, at 11 .

[44] See id.

[45] See GREENWALD, supra note 13, at 14-15.

[46] See Stares, supra note 31.

[47] See i d.

[48] See Wood et al., supra note 21, at 23, 26; s ee also Lopez, supra note 16.

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• The Legalization of Drugs: For & Against

The Legalization of Drugs: For & Against

Douglas Husak and Peter de Marneffe, The Legalization of Drugs: For & Against , Cambridge University Press, 2005, 204pp., $18.99 (pbk), ISBN 0521546869.

Reviewed by William Hawk, James Madison University

In the United States the production, distribution and use of marijuana, heroin, and cocaine are crimes subjecting the offender to imprisonment. The Legalization of Drugs , appearing in the series "For and Against" edited by R. G. Frey for Cambridge University Press, raises the seldom-asked philosophical question of the justification, if any, of imprisoning persons for drug offenses.

Douglas Husak questions the justification for punishing persons who use drugs such as marijuana, heroin, and cocaine. He develops a convincing argument that imprisonment is never morally justified for drug use. Put simply, incarceration is such a harsh penalty that drug use, generally harmless to others and less harmful to the user than commonly supposed, fails to justify it. Any legal scheme that punishes drug users to achieve another worthy goal, such as creating a disincentive to future drug users, violates principles of justice.

Peter de Marneffe contends that under some circumstances society is morally justified in punishing persons who produce and distribute heroin. He argues a theoretical point that anticipated rises in drug abuse and consequent effects on young people may justify keeping heroin production and distribution illegal. According to de Marneffe's analysis, however, harsh prison penalties currently imposed on drug offenders are unjustified.

The points of discord between Husak's and de Marneffe's positions are serious but not as telling as is their implicit agreement. Current legal practices and policies which lead to lengthy incarceration of those who produce, distribute and use drugs such as marijuana, heroin, and cocaine are not, and cannot be, morally justified. Both arguments, against imprisoning drug users and for keeping heroin production illegal, merit a broad and careful reading.

The United States has erected an enormous legal structure involving prosecution and incarceration designed to prohibit a highly pleasurable, sometimes medically indicated and personally satisfying activity, namely using marijuana, heroin, and cocaine. At the same time, other pleasure-producing drugs, such as tobacco, alcohol, and caffeine, though legally regulated for the purposes of consumer safety and under-age consumption, can be purchased over the counter. As a result, while the health and safety risks of cigarettes may be greater than those proven to accompany marijuana, one can buy cigarettes from a vending machine and but go to prison for smoking marijuana. A rational legal system, according to Husak, demands a convincing, but as yet not forthcoming, explanation of why one pleasurable drug subjects users to the risk of imprisonment while the other is accommodated in restaurants.

Drug prohibitionists must face the problem that any "health risk" argument used to distinguish illicit drugs and subject offenders to prison sentences runs up against the known, yet tolerated, health risks of tobacco, as well as the additional health risks associated with incarceration. "Social costs" arguments targeting heroin or cocaine runs up against the known, yet tolerated, social costs of alcohol, as well as the additional social costs of incarceration. Even if one were to accept that illicit drugs were more harmful or exacted greater social costs than tobacco and alcohol (and the empirical studies referred to in the text do not generally support this thesis), that difference proves insufficient to justify imprisoning producers, distributors or especially users of illicit drugs.

Decriminalizing Drug Use. Douglas Husak presents a very carefully argued case for decriminalizing drug use. He begins his philosophical argument by clarifying the concepts and issues involved. To advocate the legalization of drugs calls for a legal system in which the production and sale of drugs are not criminal offenses. (p. 3) Criminalization of drugs makes the use of certain drugs a criminal offense, i.e. one deserving punishment. To argue for drug decriminalization, as Husak does, is not necessarily to argue for legalization of drugs . Husak entertains, but cautiously rejects the notion of a system where production and sale of drugs is illegal while use is not a crime. De Marneffe advocates such a system.

Punishing persons by incarceration demands justification. Since the state's use of punishment is a severe tool and incarceration is by its nature "degrading, demoralizing and dangerous" (p. 29) we must be able to provide "a compelling reason … to justify the infliction of punishment… ." (p. 34) Husak finds no compelling reason for imprisoning drug users. After considering four standard justifications for punishing drug users Husak concludes that "the arguments for criminalization are not sufficiently persuasive to justify the infliction of punishment."

Reasons to Criminalize Drug Use . 1) Drug users, it is claimed, should be punished in order to protect the health and well being of citizens . No doubt states are justified in protecting the health and well being of citizens. But does putting drug users in prison contribute to this worthy goal? Certainly not for those imprisoned. For those who might be deterred from using drugs the question is whether the drugs from which they are deterred by the threat of imprisonment actually pose a health risk. For one, Husak quotes research showing that currently illicit drugs do not obviously pose a greater health threat than alcohol or tobacco. For another, he quotes a statistic showing that approximately four times as many persons die annually from using prescribed medicines than die from using illegal drugs. In addition, one-fourth of all pack-a-day smokers lose ten to fifteen years of their lives but no one would entertain the idea of incarcerating smokers to further their health interests or in order to prevent non-smokers from beginning. In sum, Husak accepts that drug use poses health risks but contends that the risks are not greater than others that are socially accepted. Even if they were greater, imprisonment does not reduce, but compounds the health risks for prisoners.

2) Punishing drug users protects children . Husak here responds to de Marneffe's essay which focuses on potential drug abuse and promotes the welfare of children as a justification for keeping drug production and sale illegal. Husak finds punishing adolescent users a peculiar way to protect them. To punish one drug-using adolescent in order to prevent a non-using adolescent from using drugs is ineffective and also violates justice. Punishing adult users so that youth do not begin using drugs and do not suffer from neglect -- which is de Marneffe's position -- is not likely to prevent adolescents from becoming drug users, and even if it did, one would have to show that the harm prevented to the youth justifies imprisoning adults. Husak contends that punishing adults or youth, far from protecting youth, puts them at greater risk.

3) Some, e.g. former New York City mayor Guiliani, argue that punishing drug use prevents crime . Husak, conceding a connection between drug use and crime, turns the argument upside-down, showing how punishment increases rather than decreases crime. For one, criminalization of drugs forces the drug industry to settle disputes extra-legally. Secondly, drug decriminalization would likely lower drug costs thereby reducing economic crimes. Thirdly, to those who contend that illicit drugs may increase violence and aggression Husak responds that: a) empirical evidence does not support marijuana or heroin as causes of violence and b) empirical evidence does support alcohol, which is decriminalized, as leading to violence. Husak concludes "if we propose to ban those drugs that are implicated in criminal behavior, no drug would be a better candidate for criminalization than alcohol." (p. 70) Finally, punishing drug users likely increases crime rates since those imprisoned for drug use are released with greater tendencies and skills for future criminal activity.

4) Drug use ought to be punished because using drugs is immoral . In addition to standard philosophical objections to legal moralism, Husak contends that there is no good reason to think that recreational drug use is immoral. Drug use violates no rights. Other recreationally used drugs such as alcohol, tobacco or caffeine are not immoral. The only accounts according to which drug use is immoral are religiously based and generally not shared in the citizenry. Husak argues that legal moralism fails, and with it the attempts to justify imprisoning drug users because of health and well-being, protecting children, or reducing crime. Husak concludes, "If I am correct, prohibitionists are more clearly guilty of immorality than their opponents. The wrongfulness of recreational drug use, if it exists at all, pales against the immorality of punishing drug users." (p. 82)

Reasons to Decriminalize Drug Use. Husak's positive case for decriminalizing drug use begins with acknowledgement that drug use is or may be highly pleasurable. In addition, some drugs aid relaxation, others increase energy and some promote spiritual enlightenment or literary and artistic creativity. The simple fun and euphoria attendant to drug use should count for permitting it.

The fact that criminalization of drug use proves to be counter-productive provides Husak a set of final substantial reasons for decriminalizing use. Criminalizing drugs proves counter-productive along several different lines: 1) criminalization is aimed and selectively enforced against minorities, 2) public health risks increase because drugs are dealt on the street, 3) foreign policy is negatively affected by corrupt governments being supported solely because they support anti-drug policies, 4) a frank and open discussion about drug policy is impossible in the United States, 5) civil liberties are eroded by drug enforcement, 6) some government corruption stems from drug payoffs and 7) criminalization costs tens of billions of dollars per year.

Douglas Husak provides the conceptual clarity needed to work one's way through the various debates surrounding drug use and the law. He establishes a high threshold that must be met in order to justify the state's incarcerating someone. Having laid this groundwork Husak demonstrates that purported justifications for drug criminalization fail and that good reasons for decriminalizing drug use prevail. For persons who worry about what drug decriminalization means for children, Husak counsels that there is more to fear from prosecution and conviction of youth for using drugs than there is to fear from the drugs themselves.

Against Legalizing Drug Production and Distribution. Peter de Marneffe offers an argument against drug legalization . The argument itself is simple. If drugs are legalized, there will be more drug abuse. If there is more drug abuse that is bad. Drug abuse is sufficiently bad to justify making drug production and distribution illegal. Therefore, drugs should not be legalized. The weight of this argument is carried by the claim that the badness of drug abuse is sufficient to justify making drug production and sale illegal.

De Marneffe centers his argument on heroin. Heroin, he contends, is highly pleasurable but sharply depresses motivation to achieve worthwhile goals and meet responsibilities. Accordingly, children in an environment where heroin is legal will be subjected to neglect by heroin using parents and, if they themselves use heroin, they will be harmed by diminished motivation for achievement for the remainder of their lives. It is this later harm to the ambition and motivation of young people that, according to de Marneffe, justifies criminalizing heroin production and sale. As he puts it:

… the risk of lost opportunities that some individuals would bear as the result of heroin legalization justifies the risks of criminal liability and other burdens that heroin prohibition imposes on other individuals. The legalization of heroin would create a social environment -- call it the legalization environment -- in which some children would be at a substantially higher risk of irresponsible heroin abuse by their parents and in which some adolescents would be at a substantially higher risk of self-destructive heroin abuse. (p. 124)

Are the liberties of individual adult drug producers, distributors and users sacrificed? Yes, but this may be justified by de Marneffe's "burdens principle." According to the burdens principle, "the government violates a person's moral rights in adopting a policy that limits her liberty if and only if in adopting this policy the government imposes a burden on her that is substantially worse than the worst burden anyone would bear in the absence of this policy." (p. 159) According to this, de Marneffe claims that burdens on drug vendors or users may be justified by the prevention of harms to a particular individual or individuals. As he puts it:

What I claim in favor of heroin prohibition is that the reasons of at least one person to prefer her situation in a prohibition environment outweigh everyone else's reasons to prefer his or her situation in a legalization environment, assuming that the penalties are gradual and proportionate and other relevant conditions are met. (p. 161)

According to this view, the objective interest of a single adolescent in not losing ambition, motivation and drive justifies the imposition of burdens on other youth and adults who would prefer using drugs. Although Johnny might choose heroin use, his objective interest is for future motivation and ambition that is not harmed by heroin use.

De Marneffe's "burdens principle" seems to hold the whole society hostage to the objective liberty interests of one individual. Were this principle applied to drug producers or distributors who faced imprisonment it seems that imprisonment could not be justified. I suspect a concern for consistency here gives de Marneffe reason to make drug production and distribution illegal but without attaching harsh prison sentences for offenders. He advocates an environment where drugs are not legal, in order to protect youth against both abuse and their own choices that may cause them to become unmotivated, but recognizes that prison sentences are unjustified as a way to support such a system.

In The Legalization of Drugs the reader gets two interesting arguments. Douglas Husak makes a compelling case against punishing drug users. His position amounts to drug decriminalization with skepticism toward making drug production and sale illegal. On the other side, Peter de Marneffe justifies making drug production and sale illegal based upon the diminishment of future interests of young people. De Marneffe introduces a "burdens principle" which is likely much too strong a commitment to individual interests than could ever be realized in a civil society. In both instances, the reader is treated to arguments that effectively undermine current drug policy. The book provides philosophical argumentation that should stimulate a societal conversation about the justifiability of current drug laws.

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Expert Commentary

Marijuana legalization: Research review on crime and impaired driving

Crime and drunk driving tend to fall after marijuana legalization, according to a 2016 research review.

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This work is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License .

by David Trilling, The Journalist's Resource September 23, 2016

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In November 2016, voters in nine states decided whether to legalize marijuana for medical or recreational use, according to a running tally by The Cannabist , a project of The Denver Post . Recreational use of the drug is already permitted in a handful of states, and can be prescribed by doctors in over half, though it remains banned under federal law.

Reports on the issue suggest voters were concerned: does marijuana use affect crime rates? A growing body of research addresses the question, tackling arguments used often by opponents and advocates of marijuana liberalization.

Opponents often claim that people who use marijuana are more likely to move on to harder drugs — the “gateway drug” theory — and that users of hard drugs engage in predatory crimes to feed their habits. Critics of legalization also argue that increasing accessibility means more youth   will smoke or eat weed, that marijuana shops and growers are attractive targets for criminals, that marijuana use encourages alcohol abuse, and that stoned drivers are a public menace.

On the flip side, advocates for legalization argue it will undercut the black market, which is associated with criminals and violent elements. Crime may fall as police resources are reallocated to other pressing issues, they argue. Researchers have found, moreover, that some people substitute marijuana for alcohol, which means they drink less. And legalization of marijuana may reduce racial disparity in drug arrests. Black men, according to federal data collated by the  American Civil Liberties Union  and widely cited by scholars, are almost four times more likely to be arrested for marijuana possession than whites, even though both groups use the drug at roughly the same rate.

Most research on the link between marijuana and crime finds that medical marijuana laws (often abbreviated as MML) cause a general uptick in the use and availability of marijuana — beyond the patients who are prescribed the drug. “The legalization of marijuana for medicinal purposes approaches de facto legalization of marijuana for recreational purposes,” write D. Mark Anderson of Montana State University and Daniel I. Rees of the University of Colorado Denver in the Journal of Policy Analysis and Management . By examining pre- and post-legalization in these MML states, they can “make predictions about what will happen in” states that legalize marijuana for recreational use.  

Impact on crime

Several studies have found reductions in crime after marijuana is legalized for medical use, demonstrating a relationship, but not necessarily causation.

Showing a “clear connection between medicinal use and reductions in non-drug crime,” Arthur Huber III, Rebecca Newman and Daniel LaFave of Colby College link medical marijuana to a 4 percent to 12 percent reduction in property crimes  such as theft and burglaries. Crime has fallen across the United States in recent years, but in states with MML it has fallen approximately 5 percent more. Contrariwise, Huber and his colleagues find that depenalization — lowering penalties and, thus, the risk of possession — is linked to an increase in such crimes by 6 percent to 11 percent. That effect is similar to the amount crime would rise during an uptick in unemployment of 2 percent to 3 percent.

In widely cited research , Robert G. Morris of the University of Texas and colleagues see crime fall in every state that has introduced MML. Using FBI data on seven types of crime across states with and without MML, they dismiss concerns about rising crime.

“MML is not predictive of higher crime rates and may be related to reductions in rates of homicide and assault,” Morris and colleagues write in the study, published in  PLoS One  in 2014. That may be because people seem to use alcohol less when they have access to pot: “Given the relationship between alcohol and violent crime, it may turn out that substituting marijuana for alcohol leads to minor reductions in violent crimes.”

Moreover, contrary to concerns that marijuana dispensaries become magnets for crime, the shops may diminish crime in their immediate vicinity because of their heightened security, cameras and lights.

Economists Edward M. Shepard and Paul R. Blackley of Le Moyne College find  that medical marijuana is associated with significant drops in violent crime. Looking at crime data from 11 states in the west, seven of which had medical marijuana laws before 2009, they see “no evidence of significant, negative spillover effects from MMLs on crime.” Instead, they suspect a fall in the involvement of criminal organizations after marijuana is legalized for medical use and conclude, “MMLs likely produce net benefits for society.”

Looking at crime data before and after the depenalization of marijuana in the United Kingdom in 2004, Nils Braakmann and Simon Jones of Newcastle University suggest most types of crime, risky behavior and violence fall. But they observe a 5 percent to 7 percent increase in property crimes among 15- to 17-year-olds.

More/less alcohol consumption

Katarina Guttmannova of the University of Washington and colleagues examined 15 studies on the relationship between alcohol and marijuana use. Their analysis indicates mixed results , suggesting both substitution — when marijuana is more readily available, people use it and drink less — and complementation — people drink more when they use marijuana.

Substitution would have positive public health implications, assuming, as some researchers do , that alcohol is a more destructive drug with higher costs for society.

Driving under the influence 

Alcohol accounts for over 30 percent of motor-vehicle fatalities in the U.S. each year — almost 10,000 deaths — according to the U.S. Centers for Disease Control and Prevention .

In the first year after a medical marijuana law comes into effect, traffic fatalities decrease between 8 percent and 11 percent, according to research published in 2013 in  The Journal of Law & Economics : “The impact of legalization on traffic fatalities involving alcohol is larger and estimated with more precision than its impact on traffic fatalities that do not involve alcohol. Legalization is also associated with sharp decreases in the price of marijuana and alcohol consumption, which suggests that marijuana and alcohol are substitutes.”

In their Journal of Policy Analysis and Management paper, Anderson and Rees describe the relative dangers of driving while intoxicated or stoned: “While driving under the influence of marijuana is associated with a twofold increase in the risk of being involved in a collision, driving with a blood alcohol concentration (BAC) of 0.08 or greater is associated with a 4- to 27-fold increase in this same risk.” The active ingredient in marijuana, tetrahydrocannabinol (THC), impairs driving ability, but users tend to overcompensate and drive slower, whereas alcohol consumers tend to drive faster and take more risks, they write.

Huber and his colleagues at Colby College also chart a fall in DUIs in states with MML laws.

A team of researchers at Stanford University is developing a “potalyzer” to detect THC molecules in drivers’ saliva. The portable test could produce results in three minutes, they reported in Analytical Chemistry in July 2016.

More people will use weed

There is growing evidence that as marijuana is legalized, more people use it. Legal medical marijuana increases both the supply of the drug as well as demand.

Braakmann and Jones see a 4.6 percent increase in cannabis consumption among 15- to 17-year-olds after depenalization, which they suspect may be partially an increase in the number of first-time users. They do not see an increase among older groups.

Relatedly, a 2014 paper   in the American Journal of Public Health finds a negative relationship between marijuana and suicide. In states with MML, legalization is associated with a 10.8 percent reduction in the suicide rate of men between ages 20 and 39 — another indication of increased usage, and possibly of decreased alcohol consumption.

Gateway drug

Are teenagers who use pot more likely to begin using harder drugs like cocaine and heroin? Research is largely inconclusive and the issue is addressed in many of the studies listed above.

A related question is how MML affect the use and abuse of opioids for pain. Writing in JAMA Internal Medicine , Marcus Bachhuber of the Philadelphia Veterans Affairs Medical Center and colleagues find “medical cannabis laws are associated with significantly lower state-level opioid overdose mortality rates.” Patients seem to be using these as substitutes, and marijuana is far less addictive and dangerous than drugs derived from the opium poppy. A 2016 study by Columbia University researchers confirmed those findings and observed that states with MML had fewer opioid-related car accidents.

Racial justice

Significant research has shown that young black men are arrested at a much higher rate than white men for the same marijuana-related crimes.

Economists Wesley Austin of the University of Louisiana and Rand W. Ressler of Georgia Southern University explore the relationship between marijuana crimes and arrest in a 2016 paper for Applied Economics Letters . They find arrest much more likely if the offender is poor and black, compared with perpetrators who are either poor or black or poor and a member of another race.

Racial profiling is the topic of a 2016 paper by Frank R. Baumgartner of the University of North Carolina at Chapel Hill and colleagues. They discover black men far more likely than white men to be searched during traffic stops, yet less likely to be found with contraband. “This discrepancy points strongly toward racial bias in the policing of [North Carolina] motorways,” where police use their discretion to decide of a search is warranted. “Blacks in North Carolina appear to have good reasons to be mistrustful of the police, and that these trends appear to be growing over time.”

Related research:

A 2016 paper profiled by Journalist’s Resource finds the U.S. could reap up to $12 billion in new tax revenues by regulating recreational marijuana. It also finds that access to marijuana is associated with greater usage.

The number of American cannabis users is rising. According to an August 2016 Gallup Poll , 13 percent of Americans say they use the drug, up from 7 percent in 2007. Slightly older data from the U.S. Department of Health and Human Services shows that over 22 million Americans aged 12 or older have used marijuana in the past month. That is 8.4 percent of the population.

Bloomberg Businessweek estimates that edible weed may have made up half the $5.4 billion in legal marijuana sales in the U.S. in 2015.

The National Institutes of Health (NIH) publishes research on the health impact of cannabis consumption.

According to the Marijuana Policy Project , an advocacy group, there are over 2 million marijuana patients in the U.S.

CannabisWire.com and High Times magazine are among the news outlets that cover the growing legal marijuana business.

“Cannabis Control and Crime: Medicinal Use, Depenalization and the War on Drugs” Huber III, Arthur; Newman, Rebecca; LaFave, Daniel. The B.E. Journal of Economic Analysis & Policy, 2016 . doi: 10.1515/bejeap-2015-0167.

Abstract: “To date, 27 states and the District of Columbia have passed laws easing marijuana control. This paper examines the relationship between the legalization of medical marijuana, depenalization of possession, and the incidence of non-drug crime. Using state panel data from 1970 to 2012, results show evidence of 4-12 percent reductions in robberies, larcenies, and burglaries due to the legalization of medical marijuana, but that depenalization has little effect and may instead increase crime rates. These effects are supported by null results for crimes unrelated to the cannabis market and are consistent with the supply-side effects of medicinal use that are absent from depenalization laws as well as existing evidence on the substitution between marijuana and alcohol. The findings contribute new evidence to the complex debate surrounding marijuana policy and the war on drugs.”

“Cannabis Depenalisation, Drug Consumption and Crime – Evidence from the 2004 Cannabis Declassification in the UK” Braakmann, Nils; Jones, Simon. Social Science & Medicine , 2014. doi: 10.1016/j.socscimed.2014.06.003.

Abstract: “This paper investigates the link between cannabis depenalization and crime using individual-level panel data for England and Wales from 2003 to 2006. We exploit the declassification of cannabis in the UK in 2004 as a natural experiment. Specifically, we use the fact that the declassification changed expected punishments differently in various age groups due to thresholds in British criminal law and employ a difference-in-differences type design using data from the longitudinal version of the Offending, Crime and Justice Survey. Our findings suggest essentially no increases in either cannabis consumption, consumption of other drugs, crime and other forms of risky behavior.”

“The Effect of Medical Marijuana Laws on Crime: Evidence from State Panel Data, 1990-2006” Morris, Robert G.; et al. PLoS ONE , 2014. doi: 10.1371/journal.pone.0092816.

Abstract: “Background: Debate has surrounded the legalization of marijuana for medical purposes for decades. Some have argued medical marijuana legalization (MML) poses a threat to public health and safety, perhaps also affecting crime rates. In recent years, some U.S. states have legalized marijuana for medical purposes, reigniting political and public interest in the impact of marijuana legalization on a range of outcomes. Methods: Relying on U.S. state panel data, we analyzed the association between state MML and state crime rates for all Part I offenses collected by the FBI. Findings: Results did not indicate a crime exacerbating effect of MML on any of the Part I offenses. Alternatively, state MML may be correlated with a reduction in homicide and assault rates, net of other covariates. Conclusions: These findings run counter to arguments suggesting the legalization of marijuana for medical purposes poses a danger to public health in terms of exposure to violent crime and property crimes.”

“The Legalization of Recreational Marijuana: How Likely Is the Worst-Case Scenario?” Anderson, D. Mark; Rees, Daniel I . Journal of Policy Analysis and Management , 2013. doi: 10.1002/pam.21727.

Summary: This literature review looks at the concerns of those opposing legalization. It concludes that legal recreational marijuana is a net benefit for society because it is associated with a reduction in alcohol-related traffic deaths and alcohol use more generally, and thus also a reduction in crime. The usage of marijuana will increase, though, the authors expect.

“Medical Marijuana and Crime: Further Evidence From the Western States” Shepard, Edward M.; Blackley, Paul R. Journal of Drug Issues , 2016. doi: 10.1177/0022042615623983 .

Abstract: “State medical marijuana programs have proliferated in the United States in recent years. Marijuana sales are now estimated in the billions of dollars per year with over two million patients, yet it remains unlawful under federal law, and there is limited and conflicting evidence about potential effects on society. We present new evidence about potential effects on crime by estimating an economic crime model following the general approach developed by Becker. Data from 11 states in the western United States are used to estimate the model and test hypotheses about potential effects on rates of violent and property crime. Fixed effects methods are applied to control for state-specific factors, with adjustments for first-order autocorrelation and cross-section heteroskedasticity. There is no evidence of negative spillover effects from medical marijuana laws (MMLs) on violent or property crime. Instead, we find significant drops in rates of violent crime associated with state MMLs.”

“Impacts of Changing Marijuana Policies on Alcohol Use in the United States” Katarina Guttmannova; et al. Alcoholism: Clinical and Experimental Research , 2015. doi: 10.1111/acer.12942.

Abstract: “Results: The extant literature provides some evidence for both substitution (i.e., more liberal marijuana policies related to less alcohol use as marijuana becomes a substitute) and complementary (i.e., more liberal marijuana policies related to increases in both marijuana and alcohol use) relationships in the context of liberalization of marijuana policies in the United States. Conclusions: Impact of more liberal marijuana policies on alcohol use is complex, and likely depends on specific aspects of policy implementation, including how long the policy has been in place. Furthermore, evaluation of marijuana policy effects on alcohol use may be sensitive to the age group studied and the margin of alcohol use examined. Design of policy evaluation research requires careful consideration of these issues.”

“A Micro-Temporal Geospatial Analysis of Medical Marijuana Dispensaries and Crime in Long Beach, California” Freisthler, Bridget; et al. Addiction , 2016. doi: 10.1111/add.13301.

Abstract: “Aims: To determine whether the density of marijuana dispensaries in California, USA, in 2012-13 was related to violent and property crimes, both locally and in adjacent areas, during a time in which local law enforcement conducted operations to reduce the number of storefront medical marijuana dispensaries. Design: Data on locations of crimes and medical marijuana dispensaries as well as other covariates were collected for a sample of 333 Census block groups. […] Findings: After adjustment for covariates, density of medical marijuana dispensaries was unrelated to property and violent crimes in local areas but related positively to crime in spatially adjacent areas [incident rate ratio (IRR) = 1.0248, CI (1.0097, 1.0402) for violent crime, IRR = 1.0169, CI (1.0071, 1.0268) for property crime. Conclusions: Using law enforcement to reduce medical marijuana dispensaries in California appears to have reduced crime in residential areas near to, but not in, these locations.”

“Medical Cannabis Laws and Opioid Analgesic Overdose Mortality in the United States, 1999-2010” Bachhuber, Marcus A.; et al. JAMA Internal Medicine,  2014. doi: 10.1001/jamainternmed.2014.4005.

Conclusions and Relevance: “Medical cannabis laws are associated with significantly lower state-level opioid overdose mortality rates. Further investigation is required to determine how medical cannabis laws may interact with policies aimed at preventing opioid analgesic overdose.”

“Medical Marijuana Laws, Traffic Fatalities, and Alcohol Consumption” Anderson, D. Mark; Hansen, Benjamin; Rees, Daniel I. The Journal of Law & Economics , 2013. doi: 10.1086/668812.

Abstract: “To date, 19 states have passed medical marijuana laws, yet very little is known about their effects. The current study examines the relationship between the legalization of medical marijuana and traffic fatalities, the leading cause of death among Americans ages 5-34. The first full year after coming into effect, legalization is associated with an 8-11 percent decrease in traffic fatalities. The impact of legalization on traffic fatalities involving alcohol is larger and estimated with more precision than its impact on traffic fatalities that do not involve alcohol. Legalization is also associated with sharp decreases in the price of marijuana and alcohol consumption, which suggests that marijuana and alcohol are substitutes. Because alternative mechanisms cannot be ruled out, the negative relationship between legalization and alcohol-related traffic fatalities does not necessarily imply that driving under the influence of marijuana is safer than driving under the influence of alcohol.”

“Medical Marijuana Laws and Suicides by Gender and Age” Anderson, D. Mark; Rees, Daniel I.; Sabia, Joseph J. American Journal of Public Health , 2014. doi: 10.2105/AJPH.2013.301612.

Conclusions: “Suicides among men aged 20 through 39 years fell after medical marijuana legalization compared with those in states that did not legalize. The negative relationship between legalization and suicides among young men is consistent with the hypothesis that marijuana can be used to cope with stressful life events. However, this relationship may be explained by alcohol consumption. The mechanism through which legalizing medical marijuana reduces suicides among young men remains a topic for future study.”

“Who Gets Arrested for Marijuana Use? The Perils of Being Poor and Black” Austin, Wesley; Ressler, Rand W. Applied Economics Letters , 2016. doi: 10.1080/13504851.2016.1178838.

Abstract: “We explore the relationship between income, race and the probability of being arrested. Our data set is comprised of individuals who have all violated federal marijuana laws, some of whom have been arrested. We reason that the cost of arresting a poor individual with diminished social status is lower. Our empiricism reveals that the probability of arrest is higher when the law breaker is poor and African American.”

“Targeting Young Men of Color for Search and Arrest During Traffic Stops: Evidence from North Carolina, 2002–2013” Baumgartner, Frank R.; et al. Politics, Groups, and Identities , 2016. doi: 10.1080/21565503.2016.1160413.

Abstract: “North Carolina mandated the first collection of demographic data on all traffic stops during a surge of attention to the phenomenon of ‘driving while black’ in the late 1990s. Based on analysis of over 18 million traffic stops, we show dramatic disparities in the rates at which black drivers, particularly young males, are searched and arrested as compared to similarly situated whites, women, or older drivers. Further, the degree of racial disparity is growing over time. Finally, the rate at which searches lead to the discovery of contraband is consistently lower for blacks than for whites, providing strong evidence that the empirical disparities we uncover are in fact evidence of racial bias. The findings are robust to a variety of statistical specifications and consistent with findings in other jurisdictions.”

Keywords: Cannabis, medical marijuana laws, recreational marijuana, crime, anti-social behavior, gateway theory, risk-taking, legalization, weed, pot, dope, edibles

About The Author

David Trilling

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Medical Marijuana and Marijuana Legalization

Rosalie liccardo pacula.

1 RAND Corporation, Santa Monica, California 90407; gro.dnar@alucap , gro.dnar@tramsr

2 National Bureau of Economic Research, Cambridge, Massachusetts 02138

Rosanna Smart

State-level marijuana liberalization policies have been evolving for the past five decades, and yet the overall scientific evidence of the impact of these policies is widely believed to be inconclusive. In this review we summarize some of the key limitations of the studies evaluating the effects of decriminalization and medical marijuana laws on marijuana use, highlighting their inconsistencies in terms of the heterogeneity of policies, the timing of the evaluations, and the measures of use being considered. We suggest that the heterogeneity in the responsiveness of different populations to particular laws is important for interpreting the mixed findings from the literature, and we highlight the limitations of the existing literature in providing clear insights into the probable effects of marijuana legalization.

INTRODUCTION

Although the federal law has prohibited the use and distribution of marijuana in the United States since 1937, for the past five decades states have been experimenting with marijuana liberalization polices. State decriminalization policies were first passed in the 1970s, patient medical access laws began to get adopted in the 1990s, and more recently states have been experimenting with legalization of recreational markets. This has resulted in a spectrum of marijuana liberalization policies across the United States that is often not fully recognized or considered when conducting evaluations of recent policy changes. Consider for example the state of marijuana policies in the United States at a single point of time. As shown in Figure 1 , as of January 1, 2016, 21 states 1 have decriminalized certain marijuana possession offenses ( NCSL 2016a ), 26 states have legalized medical marijuana use, and another 16 states have adopted cannabidiol (CBD)-only laws ( NCSL 2016b ) that protect only certain strains of marijuana to be used for medicinal purposes. However, there is tremendous overlap because some states have implemented combinations of each of these policies, as shown by the fact that the five states currently legalizing recreational marijuana use (Alaska, Colorado, Oregon, Washington, and the District of Columbia) all initially decriminalized marijuana and then passed medical marijuana allowances before passing their legalization policies. Thus, the vast majority of US states have moved away from a strict prohibition position toward marijuana well before they started considering outright legalization.

State marijuana policies as of January 1, 2016. Data from the RAND Marijuana Policy Database ( Pacula et al. 2015 ) and NCSL (2016a , b) with permission. Abbreviation: CBD, cannabidiol.

A number of factors have driven the policy changes observed over the past several decades, including rising state budgetary costs associated with arresting and incarcerating nonviolent drug offenders ( Raphael & Stoll 2013 , Reuter et al. 2001 ), growing scientific evidence of the therapeutic benefits of cannabinoids found in the marijuana plant ( Hill 2015 , Koppel et al. 2014 ), and strained state budgets that have caused legislatures to look for new sources of tax revenue ( Caulkins et al. 2015 , Kilmer et al. 2010 ).

The tremendous policy variation over time and across states would appear to give researchers ample opportunities to quantitatively assess the effect of marijuana liberalization policies on a variety of health and social outcomes. However, the scientific literature has been slow to develop, and what exists in the literature offers generally mixed and largely insignificant findings. This has led many to conclude that the previous liberalization policies must be harmless and that ongoing legalization would similarly generate very little harm to society. Indeed, recent surveys of people’s attitudes about marijuana show a clear shift in favor of legalization ( Caulkins et al. 2015 ).

As we will argue throughout this article, however, at least three reasons suggest that we use caution in drawing conclusions from the mixed empirical evidence or, more importantly, in assuming that a change to legally protected commercial markets would result in outcomes similar to those of the previous experiments. First, the literature has largely treated both decriminalization and medical marijuana policies as if they were simple dichotomous choices, implemented similarly across states. Such a treatment ignores the significant heterogeneity in these policies that can differentially influence harms and benefits and also contributes to what appear to be mixed results from evaluations. Second, the vast majority of policy evaluations conducted thus far examine the effect of the policy in terms of changes in prevalence rates in the general population, which assumes that the proportion of casual and heavy users, who are pooled together in these simple prevalence rates, remains stable even as the policy changes. Finally, research has been slow to consider the extent to which these changes in policies influence the method by which the typical user consumes marijuana. The potential acute harm associated with smoking a joint is different from that associated with consuming an edible or dabbing wax, particularly given that the average potency of the product typically differs and the body’s rate of absorption of THC varies by method ( Huestis 2007 ).

In this article, we review the existing literature on the effects of decriminalization and medical marijuana laws on marijuana use and marijuana use disorders in light of these limitations. Unlike other reviews, our goal is not to summarize all the existing literature on the effects of decriminalization and medicalization. Rather, the purpose of this review is to provide a better understanding of what can be gleaned from the literature when more consideration is given to the complexities of these policies, the populations examined, and the measures of use considered. Doing so allows us to convey the need for more research, in terms of measurement and analysis, before we can truly understand the impacts of marijuana liberalization policies.

WHAT IS MEANT BY HETEROGENEOUS MARIJUANA POLICIES

Defining the policies.

It is important for any discussion of the literature to begin by defining the policies being considered. For the purposes of this review, we define four specific marijuana policies (prohibition, decriminalization, medical marijuana, and legalization) in terms of their legal definitions rather than their implementation in local communities, as the latter is often a function of the level of enforcement, which is difficult to measure in a systematic and analytic way. Prohibition, therefore, can be defined as a law that maintains the criminal status of any action related to marijuana possession, use, cultivation, sale, or distribution. The level of crime may be statutorily defined as either a misdemeanor (incurring relatively lower criminal penalties that may or may not include jail time) or a felony (entailing much more serious charges, tougher sanctions, and certain prison time), and the charge may be a function of the amount of marijuana involved or simply of the nature of the activity (e.g., sale to minors). Regardless, the emphasis is on the criminal status of the related offenses, not the degree to which local law enforcement chooses to enforce it. The US federal government, for example, retains its prohibition on all marijuana activities (possession, use, cultivation, distribution, processing, and sale) as do cities like San Francisco, although San Francisco has adopted a policy of low-priority enforcement ( Ross & Walker 2017 ).

Decriminalization is a policy that was first defined by the 1972 Shaffer Commission (also known as the National Commission on Marihuana and Drug Abuse), and it describes policies that do not define possession for personal use or casual (nonmonetary) distribution as a criminal offense. The Shaffer Commission clearly stated that policies that simply lowered the penalties without removing the criminal status of the offense were not technically decriminalized, because they maintained the substantial social harm of the associated criminal convictions ( Natl. Comm. Marihuana Drug Abus. 1972 ). This distinction between policies that simply lower penalties and those that actually change the legal status of the offense is important, and yet it is not widely understood by many researchers evaluating even the early policies. At least 2 of the 11 widely recognized decriminalized states from the 1970s and 1980s, California and North Carolina, did not remove the criminal status of the offense ( Pacula et al. 2003 , Reuter & MacCoun 1995 ). Instead, these states merely reduced the penalties associated with possession and/or use of marijuana, a policy generally known as depenalization ( MacCoun & Reuter 2001 , Pacula et al. 2005 ). Yet, individuals in depenalization jurisdictions can still face significant barriers to access work, student loans, and public assistance if caught in possession of marijuana, even if they are only charged with a small fine, because they can still get a criminal charge on their record.

Medical marijuana laws (MMLs) remove state penalties for the use of marijuana for medicinal purposes under specified conditions. Although the federal government continues to retain the 1970 classification of marijuana as a Schedule I substance with high potential for abuse and no accepted medical value (Title II of the Comprehensive Drug Abuse Prevention and Control Act of 1970, P.L. 91–513, October 27, 1970, 84 Stat. 1242, 21 U.S.C. 801, et seq.), states have employed a number of regulatory approaches aimed at increasing access to marijuana for medicinal purposes since the 1970s. Early initiatives through the 1980s aimed to encourage study of the therapeutic value of marijuana, but they had little practical significance due to their heavy reliance on federal cooperation and the failure to establish a legitimate supply channel for patients ( Pacula et al. 2002 ). Initiatives passed since the 1990s have been far more comprehensive, establishing allowances for the use, possession, and supply of high (>3%) Δ 9 -tetrahydrocannabinol (THC) products for qualifying patients and their caregivers or providers. These modern MMLs have become the most commonly evaluated policies in comparative alcohol and drugs policy analysis ( Ritter et al. 2016 ), but incomplete consideration of widespread variation in how these laws have been designed and implemented has resulted in inconclusive and often contradictory findings ( Hunt & Miles 2015 ; Pacula et al. 2014a , 2015 ).

Legalization removes criminal and monetary penalties for the possession, use, and supply of marijuana for recreational purposes. Whereas decriminalized countries such as the Netherlands have histories of de facto legalization, and medical marijuana programs are often regarded as thinly veiled recreational legalization ( Fischer et al. 2015 , Haney & Evins 2016 ), de jure legalization is a relatively new phenomenon. The November 2012 ballot initiatives passed by voters in Colorado and Washington marked the first time that any jurisdiction worldwide has legally regulated marijuana. Much attention has been given to the recently created retail markets for legal marijuana in these two states, but the commercial model is but one regulatory option for legal production, and a number of alternative strategies are available ( Caulkins et al. 2015 ). Research has not yet assessed the consequences of legalization, but the effects on the prevalence of marijuana use and use disorders will depend largely on the specific state-level regulations adopted as well as the response of the federal government.

Establishing clear definitions for decriminalized, medicalized, and legalized states is not merely a semantic exercise; rather, it highlights the different mechanisms through which policies may influence use, including changes in perceptions of risk or social disapproval, changes in product availability and variety, and changes in production methods or costs that reduce prices. Although it is tempting to use evaluations of decriminalization and medical marijuana policies to shed light on the likely consequences of legalization, the experiences of these states may not fully reflect the changes in price, potency, and product variety that will likely result from increased commercialization and promotion under legalization ( Caulkins et al. 2012 ). Additionally, prior research on decriminalization and MMLs has suffered from serious limitations due to an overreliance on crude indicators that do not account for the complex and varied ways in which states have designed and implemented their policies ( Pacula & Sevigny 2014a , b ; Pacula et al. 2005 ). Although the existing literature may be limited in answering how legalization will affect marijuana use and associated outcomes, it offers significant insights into how we should evaluate the effects of marijuana policy changes in a rapidly evolving and multilayered policy environment.

Decriminalization and Definitional Problems

As stated previously, much of the scientific research evaluating the impacts of decriminalization in the United States has ignored the legal definition provided by the Shaffer Commission. In an examination of the original 11 statutes passed shortly after the Shaffer Commission, Pacula and colleagues (2003) discovered that 2 of the 11 widely recognized decriminalized states (California and North Carolina) retained the criminal status of marijuana possession offenses. Moreover, the reduced penalties in 4 of the original 11 states (Minnesota, Mississippi, Nebraska, and North Carolina) only applied to first-time offenders, a distinction not consistent with the spirit of the Shaffer Commission definition. A comparison of state statutory penalties in so-called nondecriminalized states and in decriminalized states reveals that it is not possible to uniquely distinguish the two groups ( Pacula et al. 2003 , 2005 ). As early as 2001, there were 7 so-called nondecriminalized states that had removed the criminal status of all marijuana possession offenses and another 13 states that allowed for the reduced penalties and expungement of the criminal offense for first-time offenders ( Pacula et al. 2005 ). Yet, research continued to use the decriminalization variable to identify differences in state marijuana policies that were not truly based on the criminal status or level of penalties.

Given that most US studies have made use of a single dichotomous measure that cannot uniquely differentiate states with lower penalties and reduced criminal status, it is not surprising that they had mixed results. Even early studies examining immediate changes in laws using data from the 1970s and 1980s did not generate consistent findings. Although several studies making use of population survey data found no statistically significant impact of decriminalization on general prevalence rates of marijuana use ( Johnston et al. 1981 , Maloff 1981 , Single 1989 ), one study looking at emergency room episodes found that cities in states that had decriminalized had higher marijuana-involved episodes than cities in nondecriminalized states ( Model 1993 ). More recent studies that analytically relied on cross-sectional variation in decriminalization status in the late 1980s and 1990s also produced mixed findings. For example, studies examining self-reported use among youth and young adults that only included the single dichotomous measure for marijuana decriminalization found no statistical association with measures of past-year or past-month use ( DiNardo & Lemieux 2001 , Pacula 1998 , Thies & Register 1993 ). Yet analyses of the adult household population ( Saffer & Chaloupka 1999 ) and studies examining youth but incorporating other measures of legal risk ( DeSimone & Farrelly 2003 , Pacula et al. 2003 ) did find evidence of a positive association between decriminalization status and prevalence of use. MacCoun et al. (2009) note that the fact that the state decriminalization indicator remains positive and significant in analyses that also include additional controls for the statutory penalties for these offenses suggests that this measure is picking up something other than a signal related to a reduction in the legal risk. Hypotheses offered include a proxy of broader social acceptance of marijuana use and an advertising effect of the reduced policies.

Even beyond the problem of policy measurement, results from US studies evaluating the impact of marijuana decriminalization need to be interpreted with caution for several reasons. First, in many studies, marijuana possession penalties do not vary substantially over time, which analytically confounds the effects of unobserved state characteristics (e.g., tough-on-crime lawmakers) with differences observed in the level of penalties. Second, because there is no comprehensive data source reporting the actual penalties incurred by offenders, these studies have all relied on proxies, such as maximum or median fines as indicated by statutory laws. These statutory penalties may or may not accurately reflect the true severity of the penalties imposed in a jurisdiction. Last, evidence has shown that citizens have relatively limited knowledge as to the statutory penalties and policies for marijuana possession in their states ( MacCoun et al. 2009 ), which makes it difficult to interpret evidence showing that removal of such penalties has a significant causal effect on marijuana consumption.

Medical Marijuana Laws in a Complex and Dynamic Policy Environment

In 1996, California became the first state to pass what is now commonly recognized as an MML. As of January 2016, 25 additional states have passed similar legislation. Empirical evidence consistently shows a strong correlation between MMLs and the prevalence of marijuana use and marijuana use disorders ( Cerdá et al. 2012 , Wall et al. 2011 ), but studies have not consistently supported a causal interpretation ( Anderson et al. 2015 , Hasin et al. 2015b , Lynne-Landsman et al. 2013 , Wen et al. 2015 ).

One explanation for the inconsistent findings from causal studies is that the specific provisions of state MMLs have varied widely both among states and within any given state over time ( Pacula et al. 2014a , b ). The use of a single dichotomous indicator for the initial passage of an MML in policy evaluation obscures both types of variation. Because the effects of any policy will depend on the specific statutory provisions and their implementation, studies examining outcome data covering different time frames are in fact evaluating the effects of very different policies. Further confounding comparison of prior estimates is the fact that the federal enforcement position has changed over time, and state MML provisions have adapted alongside changes in the federal stance.

When one takes a historical look at how MMLs have evolved since the passage of California’s law in 1996, it becomes easy to understand how a single dichotomous measure falls short of describing these policies within a state and across states over time. We broadly categorize state policies into three waves, each initiated by an important political change: the ballot era (1996–2000), the early legislative era (2000–2009), and the late legislative era (2009–present).

The ballot era states are the first seven states that enacted policies through ballot initiatives (whether subsequently contested by state courts or not). These early laws aimed to protect the rights of patients who used medical marijuana and their caregivers who assisted in that use. Federal opposition to these policies was explicit, and one month after Proposition 215 passed in California, then-drug czar Barry McCaffrey threatened to arrest any physician who recommended cannabis to a patient ( Pertwee 2014 ). The threat of federal enforcement created an important barrier to establishing clearly defined legal access to medical marijuana. Early MMLs during the ballot era were often vague, defining medical use broadly to include consumption, home cultivation, production, transportation, and acquisition. Most of the laws were ambiguous as to the legality of group growing or storefront dispensaries, resulting in confusion among law enforcement, patients, and caregivers as to what constituted legal participation in the medical marijuana market. Furthermore, the uncertainty of the federal response to these state experiments meant that ballot era policies rarely mandated patients to register with a state authority, making it even more difficult for law enforcement to differentiate legitimate medical users from recreational users. It is thus unsurprising that research examining the effects of the early state ballot laws on marijuana use has found insignificant effects ( Gorman & Huber 2007 , Khatapoush & Hallfors 2004 ).

With the passage of S.B. 862 in 2000, Hawaii became the first state to pass an MML through the state legislature rather than by ballot initiative. Learning from the frustrating experiences of patients and law enforcement under the earlier state policies, states that passed laws during this early legislative era (2000–2009) made more explicit allowances regarding the supply chain. Most laws passed during this period included patient registry provisions, allowances for home cultivation, and limits on the amount of marijuana that patients or caregivers could possess and grow. In addition, many states that had initially passed laws through ballot initiatives (e.g., California and Oregon) made further policy changes through their state legislatures during this period in an attempt to clarify issues and address tensions that had emerged.

Although MMLs during this early legislative era established clearer definitions of what constituted legal supply, uncertainty about the federal response to these policies inhibited a formal state regulation of producers. For instance, Colorado’s 2001 law did not explicitly sanction cooperative growing, but the ambiguity of the law allowed for its de facto operation. Through S.B. 420, California amended its initial MML to explicitly allow for cooperative cultivation, but regulatory discretion was left to local governments. New Mexico was the only state in the early legislative era to establish legal provisions for state-licensed dispensaries in its initial legislation in July 2007, but threats of federal prosecution led to indefinite delays in licensing ( Baker 2007 ).

Protracted legal disputes about the legitimacy of retail outlets under state law combined with tremendous uncertainty about the federal response led to the slow development of medical marijuana markets throughout many states during the early legislative era, which helps explain why many studies evaluating MMLs from this period find insignificant effects on prevalence of marijuana use ( Anderson et al. 2012 , 2015 ; Harper et al. 2012 ; Lynne-Landsman et al. 2013 ; Pacula et al. 2015 ). Whereas norms may have been changing in response to these laws, direct access through markets was not necessarily increasing ( Smart 2016 ). Yet, two studies making use of data from only this time period find a significant positive effect of MML enactment on use among specific high-risk populations ( Chu 2014 , Pacula et al. 2010 ). Making use of quarterly data from the 2000–2003 Arrestee Drug Abuse Monitoring (ADAM), Pacula et al. (2010) find a positive association between MML and self-reported marijuana use (confirmed through urine samples) among adult male arrestees. Chu (2014) similarly found significant positive effects of MML policies on marijuana possession arrests and marijuana-related treatment admissions, though the results are sensitive to model specification. These studies may indicate that increased medical marijuana supply in an uncertain policy environment primarily affected marijuana consumption among an at-risk population of heavy users. However, the results are also consistent with endogenous responses by police enforcement or treatment facilities and may not reflect actual changes in use.

In 2009, the uncertainty about the federal government’s response was seemingly resolved. Shortly following the inauguration of President Barack Obama, Attorney General Eric Holder issued a statement that federal authorities would cease interfering with medical marijuana dispensaries operating in compliance with state law ( Johnston & Lewis 2009 ). On October 19, 2009, Deputy Attorney General David Ogden formalized this policy of federal nonenforcement with a memorandum stating that federal prosecutors “should not focus federal resources … on individuals who are in clear and unambiguous compliance with existing state laws providing for the medical use of marijuana” ( Ogden 2009 , pp. 1–2).

The clarification of the federal position dramatically changed the regulatory structure of state medical marijuana supply channels. State MMLs passed during the late legislative era (2009–present) established far more comprehensive and explicit regulations regarding medical marijuana distribution, often requiring elaborate systems that would take years to fully implement. Several early-enacting states (e.g., Oregon and Maine) amended their laws to formally allow and regulate state-licensed dispensaries. State regulatory authorities became more prominently involved in the production and distribution of marijuana by overseeing the dispensing, manufacturing, and labeling of cannabis-derived products.

Following the Ogden Memo, requirements for the registration of patients and caregivers became far more standard in state policies, and the participation of both increased dramatically in state medical marijuana programs ( Fairman 2015 , Sevigny 2014 ). States that had delayed the implementation of formal supply channels (e.g., New Mexico) moved quickly to license dispensaries, and other states began to resolve legislative disputes about what constituted legally protected sources of supply. Alongside this expansion of medical marijuana markets during this period, media attention toward the issue of legal marijuana also increased markedly ( Schuermeyer et al. 2014 , Stringer & Maggard 2016 ).

Compared to earlier time periods, in the late legislative era marijuana use might respond more significantly to changes in policy as the availability and potency of the drug evolved with the changing structure and size of medical marijuana markets ( Sevigny et al. 2014 ). Indeed, the one study to evaluate the effects of MML passage using only policies enacted in the early and late legislative eras ( Wen et al. 2015 ) found a significant positive effect of MML enactment on the probability of recent marijuana use (14%), daily marijuana use (15%), and marijuana use disorders (10%). More studies focused on these later laws are needed to assess if these findings are robust.

Perhaps because of the federal permission for states to regulate medical marijuana more directly, medical marijuana policies adopted by states for the first time during this postlegislative era (e.g., by New York, Massachusetts, Illinois) contain a variety of features that differ considerably from those of the laws of early adopting states. For example, all MMLs passed after 2009 have established a state-licensed dispensary system and do not allow personal cultivation by patients or their caregivers, except under narrowly defined circumstances. Moreover, since 2010, states have adopted medical marijuana policies that are more consistent with traditional medical care and pharmaceutical regulation ( Williams et al. 2016 ). For example, all require testing and labeling of marijuana cannabinoid profiles in addition to a bona-fide clinical doctor-patient relationship requiring the ongoing management of the condition.

Evidence that MML statutes are continuing to move in a more medicalized direction is evident by the growing number of high CBD-only laws since 2014. CBD is a naturally occurring nonpsychoactive compound in cannabis that has been demonstrated in a variety of clinical studies not only to have therapeutic effects but also to counter the intoxicating effects of THC ( Koppel et al. 2014 , Russo et al. 2007 , Whiting et al. 2015 ). These new laws allow qualifying patients to use CBD extract, mostly in oil form, with minimal THC content, and its use is generally only allowed for a narrow range of medical conditions. Sixteen states have passed CBD laws since 2014, but these policies have been largely ignored by advocacy groups, and no research is studying their impacts ( NCSL 2016b ). With some exceptions, there is still limited regulation on potency (THC concentration) and other cannabinoids, medical product testing, and methods of consumption.

Considering Heterogeneous Implementation of Legalization

As of July 2016, five states have policies legalizing the possession of specified quantities of marijuana by adults aged 21 and older for recreational purposes. 2 Voters in Colorado and Washington approved legalization initiatives in November 2012, and additional policies were passed in Alaska, Oregon, and the District of Columbia in November 2014. The current regulatory environment is complex and dynamic, as state and local governments are continually adapting legislation to evolve along with the industry ( Subritzky et al. 2016 ). The effects of these policies on marijuana use and use disorders will be determined by how the design and implementation of the legal regulatory framework influence market structure, price and availability, and perceptions of risk and social approval. As research moves forward in evaluating the effects of recreational legalization, consideration needs to be given to differences and similarities in the regulatory frameworks established by each state.

The District of Columbia is the only legalized jurisdiction in the United States that does not allow the sale of marijuana for recreational use. Under DC’s law, adults can legally grow up to six plants (of which no more than three can be mature) in their primary residence and transfer up to 1 ounce of marijuana to another adult aged 21 and older if there is no remuneration. Sale of any amount of marijuana remains a criminal offense, punishable by up to six months in jail and a fine of $1,000 ( Marijuana Work. Group 2016 ). In contrast, policies in Colorado, Washington, Oregon, and Alaska establish commercialized models of marijuana regulation. Retail sales in Colorado and Washington began respectively in January and July 2014, and Oregon began allowing sales for recreational use from medical marijuana dispensaries in October 2015. Alaska began licensing retail and product manufacturers in September 2016 ( Hall & Lynskey 2016 ). Relative to the home cultivation model of the District of Columbia, commercialization is expected to substantially reduce production costs and generate incentives for legal suppliers to promote heavy consumption ( Caulkins & Kilmer 2016 ).

However, the commercial model of legalization also offers increased scope for regulation, and each state has crafted its own collection of regulatory guidelines and legal provisions that could have important implications for the markets that develop within them. For example, whereas all states require separate licenses for cultivators, manufacturers or processors, and retailers, as well as licensing or certification for testing facilities, Washington alone has adopted regulations restricting the number of licenses a single firm can own. Moreover, Washington prohibits license holders from being involved in both production and retail, in an effort to forbid vertical integration and the efficiencies in production and distribution that can come with it. Washington has further limited the number of retail store licenses available to avoid issues related to overproduction; the other states have not. However, all states except Alaska restrict the size of cultivation facilities, and Washington has an additional cap on total statewide production. In addition to this policy heterogeneity at the state level, local municipalities have some discretion in determining the number of establishments permitted, the strictness of zoning requirements, and the time and manner in which businesses are allowed to operate. These differences in the structure of the market should theoretically influence the availability and cost of marijuana in each state, for reasons described in greater detail below.

Other important legal differences exist across states in terms of the allowance for a nonretail market. Washington is the only state that requires all marijuana for recreational use to be purchased through state-licensed retailers; no home cultivation is allowed. The other three states permit home cultivation by adults subject to specified plant limits (as in the District of Columbia). There are also different approaches to taxation. Currently, the three states with operating retail markets (Colorado, Washington, and Oregon) have instituted ad valorem taxes specific to marijuana, ranging from 17% in Oregon to 37% in Washington. In contrast, Alaska’s policy establishes a tax on cultivation, imposing a $50 per ounce tax on marijuana bud (i.e., flowers) and a $15 per ounce tax on other parts of the plant (stems and leaves).

Differences in how state and local governments regulate the commercial market will generate heterogeneous effects on the retail price of marijuana, which will have important consequences for both the extensive and intensive margins of use and abuse ( Pacula & Lundberg 2014 , Pacula et al. 2014b ). Moreover, because marijuana is involved in a variety of forms and potencies, choices about the tax level, base, and point of collection can also influence the products and potencies available to consumers and the prices they face ( Caulkins et al. 2015 ). Currently, retail stores are allowed to offer marijuana flowers, concentrates, and infused products in solid and liquid form. The original legalization measures in Colorado and Washington did not explicitly distinguish between product types when establishing consumer purchase limits. As marijuana concentrates and infused products have captured an increasing share of legal retail sales, regulations have had to expand. Effective October 2016, adult residents in Colorado are limited to purchasing 1 ounce of marijuana flower, 8 g of concentrates, or 80 10-mg servings of THC in infused product form. In Washington and Alaska, consumers can purchase 1 ounce of marijuana flower, 7 g of marijuana concentrates, 16 ounces of infused product in solid form, or 72 ounces in beverage form. Oregon’s regulations are similar, except for a stricter limit of 5 g for marijuana concentrates. Alaska’s rules also limit buyers to 5,600 mg of THC in a single purchase.

Due to concerns regarding accidental ingestion of edibles by children, states have further regulated marijuana-infused products by implementing stricter packaging and labeling requirements and designating potency limits for individual serving sizes. Washington and Colorado designate individual serving sizes of 10 mg of THC and 100 mg total for an individually wrapped package. In Colorado, products that cannot be stamped, such as drinks or granola, must contain no more than a designated individual serving, effectively banning many of the high-potency marijuana-infused beverages currently sold. Oregon and Alaska have more conservative requirements, designating individual serving sizes of 5 mg of THC and 50 mg total for an individually wrapped package. Still, no state has capped the potency of marijuana products. A measure to limit the THC content of all marijuana products sold at retail stores in Colorado to 16% (Initiative 139) was withdrawn by the Healthy Colorado Coalition in 2016 due to the emergence of a well-funded opposition campaign ( Armbrister 2016 ). In Alaska, a proposal to cap marijuana product potency at 76% THC was also voted down. The lack of restrictions on potency enables the marketing of products with very high (and often uncertain) levels of THC.

Increased marketing has been an important concern under the commercial model, because advertising can be used to promote harmful use and has been shown to influence adolescent marijuana use and intention to use ( D’Amico et al. 2015 ). Colorado’s regulations prohibit Internet pop-up advertisements and advertisements that target children. Washington allows retailers to have only two signs (not to exceed 1,600 square inches) at their place of business, but the signs cannot contain marijuana-themed imagery nor can marijuana-related imagery be featured in window displays. Alaska and Oregon continue to revise rules for marijuana marketing. The strictness of state regulations for advertising and the way they are enforced can partly mediate the extent to which legalization influences perceptions and consumption behaviors among legal consumers as well as adolescents. However, these potential benefits of advertising restrictions must be balanced against potential efficiency costs resulting from information asymmetries between suppliers and consumers.

As was the case with decriminalization and MMLs, legalization is not a binary policy variable. The home cultivation model of the District of Columbia will have very different implications for supply than the commercialized models of Colorado, Washington, Oregon, and Alaska. Within commercialized states, heterogeneity in how production and price are regulated will lead to different consequences for consumption by legal adult users and spillovers to adolescent markets. Restrictions placed on advertising could limit youth exposure to messaging that could encourage experimentation, but only if the regulations are enforced. The way in which product availability and potency are regulated will have important effects on the total quantity of marijuana consumed by users and their level of intoxication, which will in turn influence the prevalence of marijuana use disorders. Legalized states have chosen different ways of regulating, and this policy heterogeneity will need to be considered in future work when assessing the effects of legalization on use.

WHAT IS MEANT BY HETEROGENEOUS POPULATIONS

The previous section focused on the heterogeneity of the policies being implemented. However, the effects of these diverse policies may well vary depending on the population group studied. Heterogeneous effects across population subgroups may be driven by differences in budget constraints ( Markowitz & Taurus 2009 ), price elasticities ( Pacula & Lundberg 2014 ), preferences for risk ( Fox & Tannenbaum 2011 ), or search costs ( Galenianos et al. 2012 , Pacula et al. 2010 ), to name a few. Mixed findings in the current literature with respect to the impact of prior liberalization policies may thus reflect legitimate differences in the populations being studied.

Past research has generally attempted to accommodate this potential heterogeneity by stratifying analyses by age (e.g., adolescents, young adults, older adults) and, to a lesser extent, frequency of use (number of times used in the past month/year or near-daily use). The potential effects on youth consumption have been of particular concern in the literature, because evidence suggests that use of marijuana during early adolescence predicts increased risk of dependence, lower educational attainment, and cognitive impairment ( Hall 2009 , 2015 ). Limiting the analysis to adolescents, research shows that MML enactment has largely insignificant or even negative effects on youth marijuana use measures ( Anderson et al. 2015 , Choo et al. 2014 , Gorman & Huber 2007 , Harper et al. 2012 , Hasin et al. 2015b , Lynne-Landsman et al. 2013 ), with only Wen et al. (2015) finding a significant increase in the probability of past-year initiation among youths aged 12–20. The results of the few studies that have focused on changes in marijuana consumption among adults have been more mixed, with some showing no effect of MML passage on measures of use ( Gorman & Huber 2007 , Harper et al. 2012 ) and others finding significant positive effects ( Chu 2014 , Wen et al. 2015 ).

Yet, as noted above, the use of a dichotomous MML variable misses important variations in the specific implementation of supply channels, which may be particularly important in determining the extent to which medical marijuana is diverted to adolescent markets ( Boyd et al. 2015 , Nussbaum et al. 2015 , Salomonsen-Sautel et al. 2012 ). When studies focus on the effects of dispensary legalization, there is some evidence of a significant increase in youth consumption ( Pacula et al. 2015 , Wen et al. 2015 ), though other studies find no effect ( Hasin et al. 2015b ). Even within the same study, estimated effects switch sign depending on whether consumption is measured by past-month use, frequency of use, or dependence ( Pacula et al. 2015 , Wen et al. 2015 ). Similar inconsistencies exist in studies of the effects of specific dimensions of MML policy on measures of marijuana use in the general population ( Anderson & Rees 2014 , Choi 2014 , Pacula et al. 2015 ). Thus, age alone is clearly not an adequate way of capturing population heterogeneity.

Perhaps a more relevant dimension of population heterogeneity pertains to differentiating casual or light users from high-risk consumers, often identified in this literature as arrestees ( Chu 2014 , Pacula et al. 2010 ), polysubstance users ( Wen et al. 2015 , Williams & Mahmoudi 2004 ), or those admitted to treatment ( Pacula et al. 2015 ). Only a few studies have focused on high-risk users, but those that have tend to find more consistent evidence that marijuana liberalization significantly increases use ( Chu 2014 ; Model 1993 ; Pacula et al. 2010 , 2015 ; Wen et al. 2015 ). The response of high-risk users to marijuana policy changes will likely differ from that of casual users or nonusers due to differences in price sensitivity ( Pacula & Lundberg 2014 , Sumnall et al. 2004 ), knowledge of the policy environment ( MacCoun et al. 2009 ), engagement with drug markets ( Pacula et al. 2010 ), and perceived social or physical harms from use ( Haardörfer et al. 2016 , Kilmer et al. 2007 ). By examining how marijuana liberalization policy affects the prevalence of marijuana use, many past evaluations have conflated changes in the consumption of casual users with changes in the consumption of regular or heavy users. Because casual users represent a larger proportion of the total number of users, such analyses will discount the behaviors of heavy users, who account for a larger proportion of the total quantity of marijuana consumed ( Burns et al. 2013 , Davenport & Caulkins 2016 ).

The overreliance on using prevalence measures as the outcome of interest in past work is largely a consequence of limited data availability, but as legal markets for marijuana develop, there is an urgent need to assess the alternative measures of use that are more relevant for understanding potential harms. Nationally representative data show that the number of daily or near-daily (DND) users has increased approximately sevenfold since 1992 ( Burns et al. 2013 ), and the prevalence of marijuana use disorders has almost doubled since 2001 ( Hasin et al. 2015a ). Simultaneous use of marijuana with other substances (e.g., tobacco and alcohol) is common and has been shown to be associated with increased risk of adverse consequences ( Subbaraman & Kerr 2015 , Terry-McElrath et al. 2014 ). Currently, we have little evidence to indicate how marijuana liberalization policies will affect these outcomes ( Wen et al. 2015 ). Moving forward, it will be important to develop more comprehensive data collection and sampling designs to assess how marijuana liberalization policies affect populations at risk for problematic use as well as the use of particularly dangerous products or methods of consumption.

WHAT IS MEANT BY HETEROGENEOUS PRODUCTS

Past research has generally focused on how liberalization affects the prevalence of marijuana use and has paid less attention to how liberalization affects the type of marijuana used or the way in which it is consumed. But marijuana is not a uniform product. The cannabis plant itself can develop in a number of different ways, depending on the genetic variety, temperature, culture condition, and lighting it receives. The potency of the consumable product, typically measured by concentration or level of THC, will vary by strain, cultivation technique, and method of processing. There are also a variety of ways to consume marijuana, with the most common methods including smoking, vaporization, and ingestion of edible products ( Schauer et al. 2016 ).

Both potency and methods of consumption have evolved over time. Decriminalization occurred during a time when marijuana was largely smoked, which facilitated comparisons of marijuana use rates between decriminalized and nondecriminalized states. Medical marijuana brought with it new products (e.g., oils and edibles), new methods for consuming it (e.g., dabbing, vaping), and new techniques for controlling potency ( Pacula et al. 2016 , Rendon 2013 ). Legalization only extends these new products to even more users. It is difficult to predict the extent to which legalization will increase product innovation, as growth in the industry will promote the development of new methods for extracting and synthesizing the hundreds of chemicals in the cannabis plant, of which relatively little is known ( Caulkins et al. 2015 ).

Systematic data collection on methods of use and potency is limited, but available evidence indicates that marijuana users in states with medical or recreational legalization consume a different product mix than users in other states. Individuals living in MML states, particularly in states with greater access to dispensaries, have significantly higher likelihood of vaporizing or ingesting marijuana products compared to individuals in states without MMLs ( Borodovsky et al. 2016 ). Evidence also suggests that states that legally permit medical marijuana dispensaries experience significant increases in average marijuana potency ( Sevigny et al. 2014 ). Within states with legalized dispensaries, adults who use marijuana for medicinal purposes are significantly more likely to vaporize it or consume edibles than individuals who use it for recreational purposes ( Pacula et al. 2016 ).

It is complicated to assess the impact of policy on use if the product being consumed or the method of consumption changes in line with the policy. Outcomes such as level of intoxication or dependency may well vary according to the type and method of marijuana consumption, and simply comparing use in legalized states to use in nonlegalized states will not reflect these differences. Changes in product variety will not threaten the identification of changes on the extensive margin of use (meaning any use or prevalence), because existing survey measures can provide information on the number of people who transition from nonusers to users and those who continue using rather than quitting. However, most of the adverse physical and behavioral consequences associated with marijuana use come from heavy users ( Gordon et al. 2013 , Hall 2015 , Volkow et al. 2014 ). Proper evaluation of the public health consequences of legalization relies on the ability of research to estimate the effects of marijuana policy changes on the intensive margin of use.

Data on quantity of marijuana used are surprisingly limited, and researchers have yet to construct a standardized measure for the unit of marijuana consumption (as exists with alcohol). Prior research has examined changes on the intensive margin through self-reported data on frequency of use, measured by days of use in the past month or past year. The implicit assumption has been that more days of use accurately proxies for higher intensity of use ( Temple et al. 2011 ). Yet, marijuana consumption among DND users can vary from smoking a single low-THC joint each day to using high-THC products multiple times per day via multiple delivery methods ( Hughes et al. 2014 , Zeisser et al. 2012 ). Given the variety of delivery devices, strains, and cannabinoid concentrations that become available as the legal industry expands, measuring changes in days of use will fail to capture a number of individuals who transition from occasional to heavy users.

Heterogeneity of marijuana products presents further problems for understanding how medical and recreational legalization affect marijuana use disorders. Previous research examining patterns of use and the development of dependence may not generalize to a legal environment in which there is greater social acceptance, fewer perceived risks and harms, and a wider variety of product types and potencies ( Asbridge et al. 2014 ). Although the definition of marijuana use disorder is evolving ( Compton & Baler 2016 , Hasin et al. 2013 ), there has been little clinical assessment of whether the use of different marijuana products carries different risks of dependence or harms. Some evidence suggests that vaporizing hash oil or dabbing is more positively associated with tolerance and withdrawal among adults compared to smoking marijuana ( Loflin & Earleywine 2014 ), but there may be differential effects for adolescents. As marijuana product diversity expands, there is a need for a more comprehensive understanding and analysis of consumption to accurately evaluate changes in use prevalence, intensity of use, and risk for marijuana use disorder.

AN ALTERNATIVE PERSPECTIVE FOR EVALUATING THE EFFECTS OF MEDICAL MARIJUANA LAWS AND LEGALIZATION

In light of the substantial variation underlying the policies being evaluated, the populations considered, and the products consumed, it is not surprising that the scientific literature evaluating the impact of these policies is inconclusive. The decisions made by researchers to focus on specific time periods, states, populations, and/or outcome measures have often been driven by what data were available and not by a careful consideration of the mechanisms by which these policies are expected to influence marijuana use or use disorders among various populations. As this article has established, these decisions can influence the likelihood of finding—or not finding—specific effects because of the heterogeneity of these policies and of the markets that are emerging in light of them.

The program evaluation literature has widely recognized the time it takes between the passing of new policies and their full implementation as a problematic issue ( Hunt & Miles 2015 , King & Behrman 2009 ). A common empirical strategy for accommodating delays in implementation is the inclusion of lagged policy variables, and this approach has been explored in a few articles from the medical marijuana literature ( Anderson et al. 2013 , Bachhuber et al. 2014 , Chu 2014 ). However, assuming a constant allowance for lagged effects obscures the fact that these delays are not random but are correlated with the specific provisions established by state law, the broader federal policy environment, and the setting in which the policy change occurs.

The relationship between state policy heterogeneity and variation in how long it takes for markets to emerge is something that is just beginning to receive the attention it deserves in the literature ( Collett et al. 2013 , Smart 2016 ). As explained by Smart (2016) , patient registration rates do a better job than simple dichotomous policy variables at capturing the extent to which medical marijuana markets are operating throughout a state. Smart notes that despite the adoption of early policies by many states, the relative size of the associated markets, as measured by registered patients, remained small in most states until federal enforcement policy was clarified in 2009, at which time markets in all states grew substantially faster. In an analysis that explicitly accounts for changes in the size of medical marijuana markets, Smart (2016) finds statistically more robust and consistent evidence of the impacts of these markets on various measures of consumption across users from all age groups.

The consideration of the relative size of these markets across states highlights the necessity to consider the issue of dynamics. Whereas some aspects of medical marijuana and legalization policies can have immediate impacts (e.g., on the criminalization of marijuana use or the ability to grow it at home), other effects of these policies take time to occur or disseminate. In the case of markets, for example, it takes time for regulations to develop regarding how many businesses are allowed, who is allowed to operate a business, and where those businesses are allowed to operate. It takes even longer once those rules are passed for businesses to obtain permits and begin distribution. Thus, it should not be surprising that after the passing of marijuana legalization measures in Colorado and Washington in November 2012, it took at least 18–20 months for retail stores to open. Data on the consequences of the opening of these stores beyond sales and tax revenues are just beginning to become available, which is why rigorous scientific evaluations of the impact of these policies have been slow to develop.

What that means is that researchers working in this space need to pay far greater attention to the specific mechanisms that different types of policies are likely to influence and to consider them within the proper timeframe when assessing impacts on specific populations. We show in Figure 2 some of the primary mechanisms discussed in the literature through which these changes in policies might impact use (i.e., perceived harm, disapproval of regular use, legal risk of use, ease of access and price) as well as the hypothesized effects of various types of policies on each. For simplicity, we consider each mechanism separately, though it is important to note that these are likely not independently determined (e.g., changes in legal risk may influence perceived harms, or changes in ease of access may influence disapproval). A small, medium, or large arrow (pointing up or down) in each cell indicates the relative magnitude and direction of the hypothesized effect. Shading represents the availability of empirical evidence to support the theoretical prediction, with white indicating an absence of existing studies and darker shades representing greater and more consistent support for the hypothesized effect. We provide three simplified versions of a medical marijuana policy and a legal recreational market to illustrate a wider range of policies that would to varying degrees influence the general size of the associated markets (in terms of both users and sellers).

Mechanisms through which marijuana policies might affect marijuana use and use disorders. This simple illustration shows that even within a single policy area (e.g., medical marijuana), the different variations of the policy can differentially influence each of the mechanisms related to use. For example, we hypothesize that medical marijuana policies will ceteris paribus have a larger impact on people’s perceptions about the drug (perceived harm and disapproval of regular use) than they will have on the legal risk and ease of access to marijuana regardless of policy, assuming that only medical users are provided access and legal protections. Relatedly, because these markets serve a relatively smaller group of users, the overall impacts on price are presumed to be small, although they might increase with the third type of MML, which could allow for competitive forces among suppliers to start influencing price ( Anderson et al. 2013 , Humphreys 2016 , Pacula et al. 2010 ) and potency ( Sevigny et al. 2014 ) in these markets. The existing evidence generally suggests that the passage of any type of MML significantly lowers perceived harms among adults ( Choi 2014 , Khatapoush & Hallfors 2004 ) but not among adolescents ( Choi 2014 , Keyes et al. 2016 ). However, the expansion of commercial medical marijuana markets and increased exposure to medical marijuana after 2009 have been associated with significant reductions in adolescent perceptions of harm or disapproval associated with marijuana use ( Miech et al. 2015 , Schuermeyer et al. 2014 , Sobesky & Gorgens 2016 , Thurstone et al. 2011 ).

Of course, under a policy of legalization, the hypothesized effects on some of the mechanisms (perceptions and legal risk) are larger and more immediate. Preliminary evidence from Colorado and Washington shows that commercial legalization has significantly reduced perceived harms and disapproval of marijuana use ( Kosterman et al. 2016 , Sobesky & Gorgens 2016 ), and marijuana-related arrests have plummeted ( Gettman 2015a , b ). Access and prices, however, will likely still be differentially influenced by the regulations that shape the market structure and the level of competition in the market ( Caulkins et al. 2015 , Smart 2016 ). The overall impact on consumption, then, would depend on ( a ) the relative importance of perceptions and legal risk vis-à-vis access and price for the specific population being evaluated, and ( b ) whether one is evaluating an immediate (short-run) response to the policy or a long-run effect that is inclusive of market mechanisms.

Another important consideration for interpreting findings when evaluating legalization effects is the baseline policy in place prior to legalization. Because most careful evaluations are done based on marginal changes over time, the baseline policy in the states that subsequently legalize will determine the extent to which a particular mechanism is impacted by the change in formal policy. States like Washington and Colorado, for example, which moved to legalization from a medical marijuana policy that already provided broad access and loose regulation of dispensaries, will likely experience far less of an impact on perceptions and access than states starting from a more restrictive medical marijuana policy or no law at all. Generalization of findings from these two state experiences, therefore, would not necessarily apply to states that may be considering a move to legalization without first allowing medical marijuana markets.

Thus far we have discussed heterogeneous policies, populations, and products as limitations that complicate the evaluation of how marijuana liberalization policies affect marijuana use and marijuana use disorders. However, Figure 2 suggests that this rich variation also offers unique opportunities for future research. By carefully considering the specific aspects of legalization statutes in the context of existing state policies, researchers have increased the scope for determining the mechanisms that are most important for influencing marijuana use among different populations. As more comprehensive data on marijuana prices and products become available, future work can examine not only whether liberalization affects marijuana use, but also whether it affects who uses marijuana, what products are used, and how these products are consumed. The literature has shown that not all marijuana liberalization policies are created equal, but by exploiting this variation we will be able to better evaluate which policy designs will maximize the potential benefits of legalization while minimizing potential harms.

The variety of marijuana liberalization policies across the US states is often ignored or inadequately considered when assessing the impacts of further policy reform. Despite the widespread state experimentation with alternative marijuana policies since the 1970s, our knowledge of the impact of these liberalization policies on the consumption of marijuana, and its benefits and harms, is far less developed than one would expect. There are a number of reasons for this, including, particularly, lack of attention to the heterogeneity of existing policies, the specificity of the populations examined, and modes of consumption.

Although findings tend to be mixed when we look at the literature as a whole, some consistent themes seem to emerge when we consider the literature with an eye toward differences between policies and populations. For example, studies that are attentive to the development of medical marijuana markets (e.g., through measures of the presence of active dispensaries or the size of the market) seem to consistently show a positive correlation of liberalization policies with use among high-risk users (arrestees, people in need of treatment, and polysubstance users). Similarly, many studies have shown a positive association with adult use of marijuana, whereas most have found no association with youth prevalence or frequency of use in general school populations. The extent to which these findings can be drawn on to make inferences about the potential impact of legalization on these same populations is not clear. Just as it took time for researchers to pay more careful attention to the differential effects of policy elements over time ( Hasin et al. 2015b , Pacula et al. 2015 , Smart 2016 , Wen et al. 2015 ), as well as possible heterogeneous responses by different types of users ( Pacula et al. 2015 , Wen et al. 2015 ), it will take time for research to emerge that fully reconsiders these associations in light of the full policy dynamics (i.e., changes in a policy within a single state over time and duration of exposure of a population to a given policy type). As more studies account for and consider these heterogeneous effects and dynamics, we may get better clarity regarding the margins on which particular types of policies do or do not influence behavior, and for whom.

Because legal markets will continue to evolve before these questions are fully answered, the real work that lies ahead relies on obtaining more accurate information on the amount and type of products that various people are consuming. Imagine trying to communicate to the public health field the health benefits or harms of alcohol consumption without being able to indicate specific levels or amounts that translate into impairment in well-understood dose-response relationships. Or imagine trying to assess the harmful effects of smoking without being able to differentiate an experimental or occasional smoker from someone who smokes a pack a day. Yet, that is exactly where the science is today in terms of our measurement of marijuana consumption. Precise data on things such as a standardized dose, regular versus experimental use, heavy use, episodic impairment, or even simultaneous use of marijuana and alcohol are not yet captured in most of the data tracking systems used to evaluate the impact of these policies, and they are desperately needed. If marijuana is anything like alcohol, little harm will come from casual, occasional use by mature adults, and indeed such use might generate considerable benefits. Moreover, it is also possible that marijuana, like alcohol, generates positive benefits for one population (mature adults) while also causing negative harms for another population (youth and young adults). Scientific research needs to be mindful of this heterogeneity.

SUMMARY POINTS

• State policies legalizing marijuana are part of the evolution of state liberalization policies that has taken place since the 1970s.
• Existing studies evaluating the impacts of prior state experimentation have generated inconclusive findings, and only recently has research attempted to understand the reasons for these mixed results.
• One should be cautious when interpreting the evidence from all studies pooled together, because studies are not equivalent in their attention to policy heterogeneity, policy dynamics, and population heterogeneity.
• The literature has largely treated both decriminalization and medical marijuana policies as if they were simple dichotomous choices, when in fact there can be substantial variation in the implementation of these policies that influences how adults or youth respond.
• Relatively few studies evaluating the impact of MMLs give adequate consideration to the fact that some aspects of liberalizations policies are realized immediately (e.g., ability to grow one’s own), whereas other aspects may take time to evolve (e.g., opening of a market) or change in response to future state and federal policies.
• Studies that focus on how marijuana liberalization policies influence past-month or past-year prevalence conflate changes in consumption among light and casual users with changes in consumption among regular and heavy users.
• Although relatively few in number, studies that focus on high-risk users (arrestees, poly-substance users, heavy users) tend to find more consistent evidence that medical marijuana policies increase use, suggesting that this segment of the population is particularly sensitive to policy changes.

FUTURE ISSUES

• As legal markets for marijuana develop, there is an urgent need to assess the consequences of liberalization on alternative measures of use that are relevant for understanding potential harms; this requires developing better measures of standardized dose, heavy use, episodic impairment, and simultaneous use.
• Research needs to pay more attention to the influence of these policies on the types of products consumed, the amount of THC being consumed in different products, and product development.
• Future work also needs to give stronger consideration of the baseline from which new state policies are being evaluated. For example, legalization is likely to generate smaller population changes in medical marijuana states that already have active dispensaries than in states with no prior medical marijuana stores.
• Researchers need to pay far greater attention to the specific mechanisms different types of policies are likely to influence and to consider them within the proper timeframe when assessing impacts on specific populations because not all users will respond in the same ways.

ACKNOWLEDGMENTS

This article was supported by a grant from the National Institute on Drug Abuse to the RAND Corporation (R01DA032693). The article benefited from research assistance provided by Anne Boustead, Ervant Maksabedian, and Gabriel Weinberger. We should also give credit to several of our DPRC colleagues whom we have been fortunate enough to conduct research with and who have influenced our thinking on this literature, including Jonathan Caulkins, Beau Kilmer, Mark Kleiman, Mireille Jacobson, Priscillia Hunt, David Powell, Paul Heaton, Eric Sevigny, Peter Reuter, and Rob MacCoun. All errors in the article are our own.

DISCLOSURE STATEMENT

The authors are not aware of any affiliations, memberships, funding, or financial holdings that might be perceived as affecting the objectivity of this review.

1 For simplicity, this article refers to the District of Columbia (DC) as a state.

2 Uruguay also legalized recreational marijuana in 2013, and Canada’s prime minister is working on a formal proposal expected to be delivered to the Canadian Parliament in April 2017. We are focusing on the US experience here because no formal stores are open in either Uruguay or Canada at this time.

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MDMA therapy could be legal by summer. Why are so many advocates sounding the alarm?

Last summer, thousands of tie-dyed Burners and Patagonia-clad tech founders converged on the MAPS Psychedelic Science conference in Denver. Vendors offered complementary sound baths, Harvard-educated scientists showed off new research, and Jaden Smith spoke about emotionally connecting with a bee while tripping. The New York Jets quarterback Aaron Rodgers was there too, gushing about how psychedelic drugs "unlocked a whole new world" for him as an athlete. "Ayahuasca, 48 touchdowns, five interceptions, MVP," he said. "What are you going to say?"

But to some 12,000 attendees who paid up to $1,800 a ticket to attend the industry's biggest conference, the main draw wasn't the "wellness bro" self-help guru Andrew Huberman or any of the other A-list podcasters and C-list celebrities who peppered the lineup. It was a 69-year-old activist named Rick Doblin, who almost four decades ago decided to change the way America thought about drugs. Doblin kicked off the event in a white suit, looking like a cross between a televangelist and an aging rockstar. "Welcome to the psychedelic '20s!" he announced, before breaking into an impassioned speech about his plan to get to "net-zero trauma" by 2070 and about how MDMA could be used to create peace between Israelis and Palestinians.

Perhaps more than any other single person in the past half-century, Doblin, now 70, is responsible for mainstreaming psychedelics and other once maligned psychoactive substances. He's a big part of why your grandma is asking you about magic mushrooms and TikTok influencers are trying to sell you ketamine therapy in between dance challenges and makeup tutorials. When the government named MDMA a Schedule 1 substance — a category reserved for drugs like heroin with high abuse potential and no accepted medical use — Doblin sprung into action, founding a nonprofit called the Multidisciplinary Association for Psychedelic Studies in 1986.

MDMA, also known as molly or ecstasy, is a stimulant with hallucinogenic properties that works partly by flooding the brain with serotonin. The effect is an increase in empathy and a reduction in feelings of sadness and anxiety. This is thought to make it especially helpful for people with post-traumatic stress disorder — which is why one of MAPS's core goals is to get MDMA legalized as a prescription drug. In 2014, MAPS launched a public benefit corporation to focus on legalization, and this February, that entity, recently renamed Lykos Therapeutics, announced that the Food and Drug Administration had accepted its application to use MDMA to treat PTSD and granted it an expedited review. The agency is expected to announce its ruling as soon as August.

If the FDA rules in its favor, Lykos "could become a multibillion-dollar company," one investor said. Its funders have reason to be excited: Johnson & Johnson, whose esketamine nasal spray for depression was one of the few new treatments for mental illness approved in recent years, had global sales of almost $500 million in the first nine months of 2023.

The conference in Colorado felt like a victory lap. Against all odds, Doblin and MAPS seemed poised to turn MDMA from a derided club drug into a pharmaceutical blockbuster. "Their work is setting the precedent," Elizabeth Nielson, a MAPS researcher who cofounded her own psychedelic-therapy education startup, said. "There's a lot riding on it."

But what might not have been apparent to the attendees decked out in "Legalize Rick Doblin" merch was that Doblin's role in the movement was increasingly under siege. At the beginning of 2023, Doblin was replaced as MAPS's executive director. And a few months after Psychedelic Science, MAPS announced it was giving up sole control of Lykos to a group of outside investors led by the firm Helena — something that had long been anathema to its idealistic founder.

Conversations with more than 50 former and current MAPS employees, investors, and industry peers over the past few months suggested an organization that, having almost won its battle for mainstream respectability, is increasingly at war with itself. Depending on whom you ask, Doblin is either a pathbreaking hero whose dream was hijacked at the eleventh hour or a liability whose ouster may not have happened soon enough. While most of the former employees say they still believe in MDMA's therapeutic potential, some have begun voicing concerns about possible ethical lapses in the way Lykos conducted its clinical trials and questioning whether MAPS and the pharmaceutical company it birthed are the right stewards to bring it into the future.

"MAPS is at an inflection point," a former employee said, adding that the organization could either bring in a new "psychedelic renaissance" or "become Timothy Leary," referring to the drug crusader some blame for getting psychedelic research all but shut down in the 1960s. Like many of the former employees Business Insider spoke with, he had a simple, urgent plea: "I just don't want them to fuck it up."

As a young Jewish boy in Skokie, Illinois, in the 1950s and 1960s, Rick Doblin grew up hungry for the sort of spiritual awakening he wasn't getting in his middle-class suburb. When he arrived as a freshman at Florida's New College in 1971, he, like so many restless college students throughout history, discovered drugs. "When I first started taking LSD, I was like, this is what my bar mitzvah should have done," Doblin said in an interview with the Jewish Telegraphic Agency .  Doblin became convinced that his life's purpose was to become a psychedelic therapist. Timing-wise, it was a bit like deciding you wanted to be a potato farmer in mid-19th-century Ireland; the war on drugs was in full swing, and research into psychedelics' mental-health benefits had been shut down. But Doblin's goal was no less than preventing another Holocaust — he told the Sarasota Herald-Tribune in 2008 that "the antidote to Hitler is the study of the deep psyche."

After dropping out after one semester, Doblin became a disciple of Stanislav Grof, the pioneering Czech psychiatrist famous for his research on LSD. He spent the next decade experimenting with mind-altering substances while running a construction company in Sarasota and raising a pet wolf named Phaedrus. By the time he reenrolled at New College to finish his bachelor's in psychology, he had figured out which substance he'd use to save the world: not LSD, like his predecessors, or psilocybin and peyote, like the Indigenous practitioners they co-opted, but a legal drug called MDMA, which was becoming popular with both clubgoers and a small number of therapists using it to treat trauma.

In 1984, Doblin gave an ad hoc MDMA-and-LSD therapy session to a friend of a friend. She had become suicidal after confronting buried trauma from her past. (Ironically, Doblin had sold her the MDMA that caused these suppressed memories to surface in the first place.) The experience "broke the spell of this trauma, and she was able to rebuild her life," Doblin told The Guardian . But by 1985, with ecstasy spiking in popularity as a club drug, the specter of zombified ravers having their brains turned to goo had launched a moral panic. That year, the Drug Enforcement Administration criminalized MDMA. 

MAPS would become sort of a "Trojan horse" for the psychedelics industry, said Brad Burge, a former MAPS communications director. Doblin, who went on to get his doctorate in public policy at Harvard's Kennedy School of Government, believed that if MAPS could educate the world about the safety and efficacy of MDMA and get it through the FDA's front door, mainstream acceptance and increased access to other psychedelics would follow.

MAPS spent its first two-plus decades as a scrappy grassroots organization. From the beginning, Doblin declared that MAPS would be for the people, by the people: The nonprofit wouldn't seek patents, and its research would be funded primarily by philanthropy. Staffers lived together in Arcturus, a wood-and-stained-glass house Doblin built in the forests of southern Florida, raising money selling books and psychedelic art on eBay.

But even in 2000, by which point MAPS had teamed up with the scientists Dr. Michael Mithoefer and Annie Mithoefer to tackle the FDA's three-phase clinical-trial process, Doblin still had a ways to go in convincing the average American. Oprah was airing images of scans that appeared to show MDMA users with Swiss-cheese holes in their brains, and then-Sen. Joe Biden was pushing the RAVE Act, which stood for Reducing Americans' Vulnerability to Ecstasy and proposed arresting rave promoters for drug use at their events. But society slowly became more receptive to Doblin's pitch. The images Oprah had aired were eventually debunked, and the authors of a prominent study about MDMA's neurotoxicity retracted their work when they realized they'd actually given monkeys meth instead of MDMA. Now MAPS just needed money — and auctioning off items like a guitar signed by members of The Cure wasn't going to cut it much longer.

To take MAPS to the next level, Doblin needed to find rich people sympathetic to the cause. So he headed to Burning Man.

By 2005, MAPS had its own theme camp at the Nevada megafestival, with a huge parachute-covered dome featuring a metal sculpture of the LSD inventor Albert Hofmann riding a bicycle. That year, in between fire spinners and breathwork sessions, Doblin hit it off with a guy named David Bronner, and he spent that evening helping Bronner's friend through a difficult shroom trip. In addition to being the president of Dr. Bronner's Magic Soaps, whose screed-covered bottles line the shelves at Trader Joe's, Bronner was a fellow psychonaut and a passionate marijuana-industry activist. Over time he became one of MAPS's most significant donors, contributing about $7.5 million through Dr. Bronner's and eventually joining MAPS's board of directors.

More doors opened for Doblin. He developed a close relationship with Richard Rockefeller, the grandson of the financier John D. Rockefeller Jr. Despite dodging the Vietnam draft, Doblin had long wanted MAPS to make inroads with the military. In 2014, almost a decade after announcing that MAPS would be including people with war-related PTSD in its US studies, Doblin and Rockefeller, who had a cousin in the Senate, visited the Pentagon and convinced the Department of Veterans Affairs and the Department of Defense to move "from resistance to collaboration," as Doblin put it. Around this time, MAPS also began sending veterans to Washington, DC to lobby on behalf of its research.

Doblin knew how to get people to give him what he wanted. Neşe Devenot, a psychedelic researcher and Johns Hopkins lecturer who's now a vocal MAPS critic, used to volunteer for the group. In 2011, she was invited to a staff retreat held on a pot farm. There they participated in a workshop that taught them how to use neuro-linguistic programming, including mirroring prospective donors' body language to break past their defenses and encourage them to give to MAPS. The group felt "a little bit dangerous," Devenot said, describing MAPS's fundraising tactic as "harvesting the resources of vulnerable people." The staffers' mission was so important, she said, that "it doesn't matter the way they get there."

One insider said MAPS had always had a "strategy to fundraise around the drug experience," including inviting prospective donors to drug-fueled parties. Doblin would come to meetings and tell stories about courting donors by giving their family members MDMA therapy, another former staffer recalled, adding, "I guess seeing is believing with some of these substances." Providing donors with drugs was "not common," Doblin told BI over the phone in March. But, he said, "everyone deserves healing." (MAPS's director of communications, Betty Aldworth, told BI that drug-fueled parties did not "represent MAPS's fundraising strategy.")

In 2012, MAPS launched the Zendo Project, whose job was to go to festivals and care for people having difficult trips. Two of MAPS's multimillionaire supporters, the podcaster Tim Ferriss and the UPS heir T. Cody Swift, served as volunteers. A former staffer said Doblin "would bring people into the Zendo and do therapy with them there, like: Hey, let us give you the experience." Staff members said that for years they expressed worries that Zendo didn't have its own liability insurance, given how risky its work was. (Aldworth said it was "notoriously difficult to attain liability insurance" for direct-service harm-reduction programs like Zendo.) "I don't actually think he cared whether we were doing good work," Erica Siegal, a former MAPS researcher and Zendo contractor, said of Doblin. She said she felt like having a MAPS presence at Burning Man through Zendo was an "excuse" for Doblin to "take potential donors for 'transformational experiences'" in the desert.

Doblin never thought MAPS could make any real money from selling MDMA, given that it was synthesized in 1912 and has long been off-patent. Then he learned about an FDA policy that gives the company that brings a drug to market a period where nobody else can use its data to push a competing product. "That changed everything for me," Doblin told BI.

With that, MAPS Public Benefit Corporation was born. Public benefit corporations are for-profit entities that still prioritize social objectives. The plan was for the corporation to act as the pharmaceutical company that would conduct the research needed for the FDA application. Initially, MAPS PBC, which was founded in 2014, would be funded by donations raised by the MAPS nonprofit. Then, once MDMA became legal, the corporation would be able to sustain itself financially through sales of the drug and could funnel money back into the MAPS nonprofit to support other projects. While other pharmaceutical companies were accused of jacking up the prices of prescription drugs (like a new ALS drug that arrived in 2022 with an annual price tag of more than $150,000), MAPS promised to prioritize "human wellness over profit," a company newsletter said.

It was "my dream for the whole time to try to have nonprofit ownership," Doblin said. "I wanted the returns to go back to the nonprofit."

But the creation of MAPS PBC was an uneasy fit with MAPS's original mission. "You're on the one hand saying let's decriminalize this," which means "anybody can use it in an unsupervised fashion," said Seth Whitelaw, a former MAPS PBC compliance officer, while on the other side "the for-profit entity is saying that MDMA should only be used with trained therapists."

"I wanted the returns to go back to the nonprofit." Rick Doblin

By 2015, MAPS's 20 or so employees, including the staff of the PBC, were working out of a converted three-bedroom house on Mission Street in Santa Cruz. The vibe was less pharma company, more commune, and Doblin encouraged staffers to see themselves as a family. Wandering around the office in his usual attire of rumpled Hawaiian shirts, he exuded the laid-back energy of the neighborhood stoner dad who would roll you spliffs and pick you and your friends up from parties when you got too drunk.

Personal boundaries were pretty much nonexistent. A former employee described "power in the organization" as about how close you were to Doblin and how dedicated you were: "Are you a real tripper? Have you really destroyed your ego?" Another former employee said that "people would come to me and tell me all these things that were going on" that were an "HR nightmare." "Like, what do you mean you're in the hot tub naked with your direct manager?" they said (MAPS wouldn't get its own HR department until 2020). It was all par for the course for Doblin, who regularly encouraged people struggling with their mental health to visit practitioners who would provide psychedelic therapy on the down-low. At a conference, Doblin once compared this therapeutic community to the "Underground Railroad in slavery times" in how it was "helping people get free from emotional slavery."

Over the next few years, young, idealistic people flocked to Santa Cruz to join the crusade. To lead the PBC, Doblin tapped Amy Emerson, a pharmaceutical-industry alum with blue-streaked hair who'd joined MAPS's research team in 2003 after hearing Doblin speak at Burning Man.

Ifetayo Harvey started working as Doblin's executive assistant in 2015. She was MAPS's only Black staff member. When she was little, her father went to prison for selling drugs, and she became an activist speaking out about how parental incarceration and other aspects of the war on drugs affected children. She credited experiences with psilocybin, or magic mushrooms, with helping her find a way through a suicidal episode, and she wanted other people to experience the same life-changing benefits.

Initially, Harvey enjoyed the laid-back work environment. She first did LSD when Doblin offered it to her on a MAPS work trip to Chicago, during which some staffers slept in Doblin's parents' yard and handed out MAPS flyers at a Grateful Dead concert.

But some former MAPS staffers said Doblin's laissez-faire approach to management was ill suited for more difficult situations. When Harvey moved to Santa Cruz, Doblin found her a room in the home of a MAPS donor named Lauren Unger. A few weeks into living together, Unger told Harvey that her boyfriend, Casey Hardison, was planning to move in with them. Harvey didn't want to live with Hardison, who had just gotten out of prison for manufacturing LSD and 2C-B. But Hardison was a friend of Doblin's, and Doblin was excited about using his story to raise awareness about incarceration and decriminalization. Harvey thought that when she told Doblin about her discomfort, her boss would have her back; instead, he shrugged her off. Doblin was "very flippant," she recalled, adding, "I felt really unsupported by him." Her mental health began to suffer, and she quit the company shortly after.

Doblin's "kumbaya style" of management — "like, 'Oh, can't we all just get along?'" — isn't helpful "when you're dealing with conflict and some people have power," Harvey said.

Doblin was committed to preserving the peace — unless MAPS's image was at stake. In 2017, a 20-year-old woman named Baylee Ybarra Gatlin died in a hospital after spending time in the Zendo tent at the Lightning in a Bottle music festival in California. A wrongful-death lawsuit filed against MAPS said that though Gatlin, who had taken LSD, was convulsing and foaming at the mouth, she spent six hours with "negligently supervised" Zendo staffers before an ambulance was finally called. The cause of death was multi-organ failure due to hyperthermia.

The case dragged on through five years of messy litigation. Doblin was adamant about not settling the case or admitting wrongdoing. Someone who worked with Zendo said he and MAPS leadership "were more focused on principle than on taking care of the people involved." (A former longtime MAPS staffer said the reason Doblin fought the suit so hard was to protect the future of harm-reduction services.)

Ultimately, MAPS was found 25% liable in 2022 and was made to pay $1 million in damages. Doblin said that he didn't think "justice was served" and that MAPS should have appealed. "There's not one single piece of paper that has ever demonstrated that MAPS accepted or had any medical responsibility," he said.

Shortly after, MAPS cut Zendo loose from the organization.

A few years after MAPS PBC launched, the rest of the world was finally catching up to Doblin. "How to Change Your Mind," Michael Pollan's 2018 book, became an international bestseller, introducing groundbreaking research on psychedelics to the New Yorker tote-bag crowd.

MAPS concluded its phase-two trials in 2017 with remarkable results. More than half of the 72 participants who received MDMA no longer met diagnostic criteria for PTSD after treatment. By then MAPS was building up an impressive network of donors, largely in the tech world, which would come to include Space X's Steve Jurvetson — an old friend of Elon Musk's who's said to have used MDMA and LSD with the Tesla founder — and his wife, Genevieve. There was also the New York Mets owner Steve Cohen and his wife, Alexandra; Mark Zuckerberg's Facebook cofounder Dustin Moskovitz and his wife Cari Tuna; and Gwyneth Paltrow, who hosted Doblin on an episode of Goop's podcast. ("I'm really looking forward to it being legal because I want to try this out!" Paltrow said.) A few years ago, Doblin let two Bloomberg reporters follow him at Burning Man as he zoomed about in cargo shorts and green eyeshadow trying to find Sergey Brin to get him to donate.

Doblin became close with an entrepreneur and investor named Joe Green, whom he met at Summit at Sea, a debaucherous four-day business networking event on a cruise ship. Green had been Zuckerberg's college roommate, famously leaving billions on the table when he refused to drop out of school to develop Facebook with Zuckerberg. Bloomberg said Green began serving as "a sort of consigliere to Doblin," introducing him to other rich tech people at Burning Man and elsewhere. In 2017, Green launched an elite group of donors called the Psychedelic Science Funders Collaborative, which included Genevieve Jurvetson and David Bronner. Two years later, the group donated more than $4 million to MAPS, and it later led other donors in a $30 million fundraising challenge.

MAPS also started targeting deep-pocketed conservatives. In 2018, Doblin hired Jonathan Lubecky, an Iraq War veteran who said he had his PTSD cured in a MAPS trial, to be MAPS's "conservative whisperer," as Lubecky put it. Around that time, Doblin announced he'd taken $1 million from the prominent Republican donors Rebekah and Robert Mercer in a grant to research PTSD in military veterans. And in 2019, Elizabeth Koch, the daughter of the right-wing billionaire Charles Koch, pledged $2.7 million to MAPS. In her book "I Feel Love" about the history of MDMA, Rachel Nuwer wrote that before donating, Koch had found "someone off the grid" to give her MDMA therapy and it helped her let go of the "intense self-hatred" she'd felt since childhood. 

MAPS's ties to the military had always been controversial among its left-leaning members, but having Lubecky promote MAPS's work on Breitbart radio and partnering with the Mercers caused a whole new level of existential crisis. A few members of the clinical team collaborated on a parody MAPS board game with the prompt "Get $1 million from right-wing climate-change denier."

Doblin claimed that while there was some consternation at the time, most staffers came around. "Sometimes it takes people a while to see the wisdom of my approach," he said with a chuckle. "If you quote that, say I'm just joking."

Despite all the money and new hires, MAPS hadn't let go of its new-age-y spiritual culture. Elizabeth Crystal, a former researcher, said she was alarmed when PBC leaders made all staffers attend a talk about the Enneagram, a pseudoscientific personality test, after which everyone in the company was encouraged to open up about their core wound and post their Enneagram type in their Zoom name. Likewise, when Doblin spoke at a conference about giving MDMA to his dogs or joked with Joe Rogan about wearing a diaper at Burning Man so he wouldn't have to leave a cuddle puddle ("This woman turned to me and said, 'I don't understand'" how you haven't gotten up, Doblin recalled. "I said, 'I've been peeing the entire time!'") some of the new hires didn't think it was charming or funny. It seemed like he was jeopardizing everything they'd worked for. "Half the company was like, 'Oh, this is so inspiring,' and the other half is like, 'Jesus Christ, is this a cult?'" one ex-PBC staffer said.

Crystal said there was a feeling at MAPS that staffers "should sacrifice everything for the mission." But some were growing concerned with what they saw as a culture that brushed ethical issues under the rug.

The company's video department was a particular source of concern, multiple former employees said. The video team's job was to store recordings of every MDMA therapy session performed in the clinical trials. The multihour sessions often featured participants crying, screaming, and shaking as they relived the worst moments of their lives: sexual assaults, wars, the deaths of loved ones. But two former staffers with direct knowledge of the situation said that these videos were not stored securely and that the system for cataloging and reviewing them was a mess. A former employee said Doblin also had access to participant videos and had a habit of sending them to people outside the organization to show off MAPS's treatment. "People's most intimate traumas were made into tiny pieces of content" to advertise MAPS's product, the person said. "Video was flying out of the organization every which way." 

Half the company was like, 'Oh, this is so inspiring,' and the other half is like, 'Jesus Christ, is this a cult?' An ex-MAPS employee

Two former employees said that they raised these issues to Amy Emerson but that the problems persisted. During one training session for therapists, MAPS PBC instructors accidentally played a video of one of the therapists present receiving treatment. "That has got to be the most unprofessional thing I've ever seen," a therapist who witnessed the mishap said.

In 2018, a phase-two trial participant named Meaghan Buisson filed a civil lawsuit in British Columbia against two married MAPS therapists, Richard Yensen and Donna Dryer, who treated Buisson beginning in 2015. She said that Yensen sexually assaulted her, and she jointly accused the pair of negligence and breach of standard of care. A few years later, New York magazine's "Cover Story" podcast released a video showing the therapists pinning down and physically restraining a visibly distraught Buisson during a trial session. They were also seen cuddling and spooning her. A MAPS spokesperson told CBC News that the videos of Buisson's therapy weren't reviewed until years after they were filmed.

The lawsuit said that after the clinical trial ended, Buisson moved to live near Dryer and Yensen on a remote island in British Columbia for a year and a half. During that time, the complaint said, Yensen continued to provide her treatment while repeatedly sexually violating her. The complaint said that because of Dryer's and Yensen's actions, her "psychological condition deteriorated significantly and severely." (In his response, Yensen said that he and Buisson were engaged in a consensual relationship and that they were not doctor and patient at the time.) The case was settled out of court.

Buisson's allegations represented the worst-case scenario for the researchers who had been working on the trials. They believed what they were doing was going to help people with PTSD, not traumatize them further. "It destroyed me," said Crystal, the former researcher. "I had nightmares for a couple months." MAPS released a statement saying that it took the situation very seriously and that it was cutting ties with Yensen and Dryer and enforcing a new code of ethics. "One of these kinds of situations is one too many," Doblin told BI.

But in company meetings, Doblin continued to suggest MAPS had nothing to apologize for, some former staffers said. One former staffer recalled Doblin accusing Buisson of being "ungrateful" for everything the company had done for her. 

When asked about the situation, Doblin told BI that MAPS had provided Buisson with $15,000 to cover her therapy costs and "had gone above and beyond what was required of us," adding, "Whether she's grateful or not is up to her."

The Buisson suit also prompted broader criticisms of MAPS's psychedelic-therapy model. Doblin's approach to therapy was heavily informed by his idol Stanislav Grof. Grof believes in something called an "inner healing intelligence," an innate capacity for self-healing that psychedelic therapy helps unleash. (He also believed LSD could help treat homosexuality, which he described as a perversion.) Grof encouraged therapists to touch and physically restrain patients when needed during therapy, as well as to engage in forms of "psychodrama" like replaying traumatic situations. Both inner healing intelligence and touch remain part of MAPS PBC's — now Lykos' — psychedelic-therapy education.

In recent years, several critics have argued that MDMA, because of the nature of its effects, could heighten patients' susceptibility to coercive or exploitative dynamics. They've also maintained that the Yensen and Dryer case wasn't isolated but part of something more systemic. MAPS is "not filtering those kinds of people out," Kayla Greenstien, a psychedelic researcher, said, adding that it "fully embraces these unboundaried relationships because the movement is more about a spiritual practice than anything."

In Greenstien's view, it's not a couple of bad apples but the "core people in this movement" who have demonstrated that they "don't have basic abilities to engage ethically with people."

Two years ago, STAT News published an article about a wealthy Holocaust survivor in his 80s named George Sarlo who'd given more than $1 million to MAPS. In a mediation brief provided to BI, Sarlo's conservator and his two daughters claimed that Vicky Dulai, a MAPS-affiliated therapist and board member who served as his healthcare custodian, had engaged in elder abuse. They accused Dulai of encouraging Sarlo to use psychedelic drugs in order to increase his "dependence and affection for her" and of using her position to "funnel millions" in cash and gifts, including a Porsche and a private-jet trip to Hawaii, to herself and family members. In a separate filing, Dulai, along with other caregivers and friends (including Doblin), submitted a claim alleging elder abuse by Sarlo's daughters and ex-wife.

The case against Dulai was settled in 2022. She agreed to return some money and the Porsche, and the protective-services complaint was not pursued. MAPS told BI that it found nothing improper about Dulai's involvement with Sarlo's donations. After the allegations came out, Doblin appointed Dulai chair of MAPS's board. She was the opening speaker at last summer's conference.

MAPS closed its Santa Cruz office in 2020. There was a cleansing ceremony during which people wept and sang songs. "We have now evolved from a tribe into a corporation — actually, a small number of corporations," Doblin wrote in a MAPS newsletter, adding that the task at hand was for the organization to keep its soul throughout this transition. He was happy to report that in a "small example of retaining the soul of MAPS," its new employee manual featured a section called "smokable tasks," referring to workplace tasks best performed while stoned. "For me, smokable tasks primarily include strategizing, protocol design, and editing of regulatory submissions," he added.

By now the PBC was growing faster than MAPS, and it was increasingly trying to pull away from its parent company and be taken seriously in the pharma world. It helped that its research was continuing to exceed expectations. A phase-three study published in Nature in 2021 said 67% of participants who were given MDMA therapy no longer qualified for a PTSD diagnosis two months after treatment. "This is about as excited as I can get about a clinical trial," Gul Dolen, a Johns Hopkins neuroscientist, told The New York Times. The next year, the PBC hired Michael Mullette, a longtime pharma exec who'd come from Moderna, to be its chief operating officer.

Part of the PBC's hiring push involved adding experts in new regulatory, safety, and compliance departments that were necessary to meet FDA specifications. Four of these recruits told BI they were shocked by the company's lack of professionalism, including in things like using staff meetings to plan Burning Man sleeping arrangements. It was "completely disorganized," a former employee said. "The left hand doesn't know what the right hand is doing."

Several people told BI that around this time, PBC leaders tried to cut Doblin out of day-to-day operations, fearing he was a liability. Longtime employees were irate about morphing into the so-called Mullette Corporation and begged Doblin to intervene. Things got so messy that the company's lawyer told one since-departed PBC employee to inform Mullette if Doblin tried to meddle.

"I wouldn't say that I was pushed out," Doblin told BI. "I think it was bringing in more people with more pharma experience who would sometimes make different decisions than I would make."

Everyone at the PBC was fixated on getting FDA approval, so much so that some employees felt it was cutting corners to speed things up. In the New York magazine podcast, the hosts Lily Kay Ross and David Nickles raised several ethical questions about MAPS's data gathering, specifically around an idea called clinical equipoise , the notion that researchers should be neutral and unbiased about whether a treatment will work. The hosts argued that MAPS PBC was so invested in proving MDMA's benefits that it may have skewed the data. The podcast spoke with three women who'd participated in the trial and described major adverse effects, including suicidality, that weren't ultimately reflected in the published results. In March 2022, Ross filed a complaint with Health Canada that prompted a review of all the country's ongoing MDMA trials. (While MAPS was asked to make some improvements, its Canadian trial was found compliant and ultimately allowed to continue.)

Four former employees said they had concerns about MAPS PBC omitting adverse events from the data. "If you get hit by a meteor during a clinical trial, we report it," a pharma veteran who recently worked at the company said. But she said she repeatedly saw the PBC's leadership do "mental gymnastics" to explain why various issues weren't drug related. One research employee recounted a meeting where Amy Emerson said, "The FDA is only going to know what we provide them with." ("I don't feel that's true at all," Doblin said of allegations that MAPS PBC underreported adverse events.)

This April, a group of researchers including Devenot and Greenstien formally submitted a petition calling for the FDA to schedule an advisory meeting on Lykos' application because of concerns that the company had "normalized violations" of industry safety regulations. The petition included an account from an anonymous former MAPS PBC employee about an incident where a participant made "a serious suicide attempt during a dosing session" that was not reported. Two former MAPS employees who spoke with BI said they had heard about a participant attempting to run out into traffic during a session. They both confirmed this incident was not reported.

Another time, a patient who had come to an MDMA therapy session later acknowledged they had been under the influence of LSD during treatment. Three former employees said that when the site investigator found out about it, he called Doblin instead of reporting it through official channels, in violation of safety-reporting protocol.

An official report was eventually filed, these employees said. But "the fact that the first thing that the investigator did was call Rick is a perfect example of how biased these investigators are," one said.

("The public record will reflect both Rick's and MAPS' longstanding commitment to complete and accurate reporting in psychedelic-assisted therapy trials," Aldworth told BI.)

The pharma veteran also became increasingly concerned that the trials could be creating drug-seeking behavior in participants. She decided to hold a meeting with biostatisticians at the PBC. She discovered that about 32 people who'd never used MDMA before the trials said they were seeking or wanting to seek out more MDMA after their sessions were completed. When the pharma veteran suggested this should be reported, the response she got from senior employees, she said, was: "We are OK with that. We don't think that seeking out MDMA is a bad thing."

One employee who worked at MAPS for seven years said the organization promoted ideological conformity. "The longer I was there," she said, "the more it was like, you need to agree with this, or you're out."

A therapist involved with the trials told BI that she thought she was hired partly because she was "a little groupie" for MAPS. She said she felt like leaders thought of her as "one of us" — it was as if they were saying, "We know that you want psychedelics to advance."

When the new compliance and safety experts the PBC had hired started to raise issues, they felt they were sidelined. "I really think they thought the rules didn't apply to them," the pharma veteran said of the PBC's leaders. One compliance officer lasted just three months. "I was like, I need to get out of here if I want to keep my license," another seasoned industry hire said.

A representative for Lykos did not comment on specific allegations but told BI that "Lykos is confident its design and execution of a clinical development program" for MDMA "addresses the scientific and regulatory requirements to support a marketing application."

The longer I was there, the more it was like, you need to agree with this, or you're out. An ex-MAPS employee

Meanwhile, money was pouring into the psychedelics world . Psychedelic biotech firms backed by big names were starting to go public. Two Peter Thiel-backed companies, Compass Pathways and Atai Life Sciences, raised $147 million and $225 million in their initial public offerings.

People didn't want to donate anymore; they wanted a piece for themselves. And it was getting harder and harder for MAPS to convince supporters to give away money on which they'd never see a return.  

Though Doblin was still in charge of the MAPS nonprofit, he was beginning to find himself cut out of decision-making there as well. Joe Green from the Psychedelic Science Funders Collaborative joined the MAPS board in 2020. The MAPS insider said Green didn't think MAPS would be able to make enough money solely through donations and pushed the organization to move away from philanthropy. "Like it or not, we live in a capitalist system," he told Kara Swisher on her podcast this year. "Most stuff gets done by for-profit companies. And so let's try to set up this ecosystem where it's actually investable."

MAPS began hiring a bunch of leaders from the private sector and the consulting industry who butted heads with the old guard. This included Kris Lotlikar, who had started a renewable-energy firm that contracted for Whole Foods; Federico Menapace, a McKinsey alum who'd worked with Green at the PSFC; and Mo Septimus, another finance-industry veteran.

While Doblin had his flaws, without him steering the ship, some employees said, MAPS was losing its integrity. Over the next few years, as more big-name consultants and investors joined the board, there were layoffs and high employee turnover. Projects that had been integral to MAPS's social-justice mission began to fall by the wayside. By 2023, the company had halted plans for most of its expanded-access sites, where people with serious mental illnesses could get MDMA therapy without enrolling in a clinical trial. Monnica T. Williams, a clinical psychologist who was brought on to help increase diversity among trial participants and work on this initiative, said it went from being a group of people doing something they believed in to "more Big Pharma business as usual," adding, "It was a long line of broken promises."

To some in the company, it seemed clear that Doblin was in denial about MAPS's future. In 2021, MAPS partnered with a venture-capital fund called Vine Ventures to raise $70 million. It employed an unusual funding structure that allowed MAPS to stay the sole owner of MAPS PBC; Doblin declared that it would sell equity only as a "last resort." But things weren't looking good. The following year, MAPS developed a plan to take on loans that would eventually be converted to equity if the company couldn't repay them, Doblin told Lucid News. And in June 2023, The Wall Street Journal reported that MAPS had been forced to stop clinical trials in Europe and had only enough money for two more months of operations.

One investor said it increasingly became clear that Doblin "was not speaking for the company." In January 2023, Lotlikar quietly replaced Doblin as MAPS's executive director — so quietly that it took months for industry news sites to report the changeover.

As Doblin was lining up for selfies with fans at the Psychedelic Science conference and partying to The Flaming Lips, PBC leaders were setting up meetings with top VCs to figure out who else would get to join the private-equity firm Helena Special Investments in its Series A round.

Helena, which was leading the financing, was founded in 2015 by Henry Elkus, a Yale dropout, as a collective of global influencers. (At the time it inspired a Gawker post titled "I Have No Idea What This Startup Does and Nobody Will Tell Me.") It now bills itself as a global problem-solving organization with investments in AI, COVID-19 response, and green energy.

Doblin told BI that as late as December 2023 he was still fighting to keep the PBC under MAPS's control. But it was no longer his show. That year, the corporation decided to halt its training program for therapists, one of the things Doblin cares about most, because it was worried it could be construed by the FDA as preapproval drug marketing. In January, MAPS PBC formally announced it had changed its name to Lykos (which means "wolf" in Greek, an allusion to Doblin's old pet, Phaedrus) and raised more than $100 million in a private stock sale to a group of "mission-aligned" investors led by Helena. As part of the sale, MAPS announced that it would relinquish day-to-day control of the PBC, and though it would remain the single largest shareholder, it would no longer be its sole owner. 

Publicly, Lykos and MAPS are saying that taking on outside investment won't compromise their long-held vision. Elkus told BI that Helena and the MAPS PBC leaders had the same goal: "to get this treatment out to as many people as possible that need it."

However, many MAPS and PBC alums who spoke with BI expressed immense grief about MDMA therapy being subsumed into a traditional pharma model. MAPS staffers didn't "bust their ass" for decades so "the head of Lykos could get paid a million dollars a year," a former MAPS employee said. "Nobody was like, yeah, let's legalize MDMA" and be done with it. "Everybody was like, let's change the way the fucking mental-health industry works." 

There are legitimate reasons to be concerned. In Australia, where medical MDMA was legalized last year, treatments are expected to cost almost $20,000 for a single course. Emerson has acknowledged that patenting, which Doblin has long opposed, "is definitely on the table."

A former MAPS researcher in the clinical department said they worried about a "gold rush" of "inadequately trained providers" trying to capitalize on desperate patients hoping for a "magic bullet." Doblin said Lykos had agreed not to interfere with any drug-policy-reform efforts, but others are wary of how the pharma company might respond if there were a push to decriminalize MDMA more widely. "If another model of access comes to fruition during these years," would Lykos "be proactively trying to boycott it?" the person wondered. "That would be the dividing line between this model of healing for all and healing for our pockets." 

Meanwhile, Doblin has doubled down on his passion projects. MAPS has partnered with Numinus , with the hope of allowing future psychedelic therapists to fly to Canada to try MDMA during training. Recently, Doblin has been fundraising in support of an affiliate called MAPS Israel, which announced it would offer MDMA group therapy to 400 survivors of the October 7 attacks. He also helped fund shipments of the psychedelic drug ibogaine to Ukraine (something Aldworth described as "a personal project" undertaken independently of MAPS) and floated the idea that new US Army recruits be dosed with MDMA to make them "less reactive" soldiers. 

But Doblin's biggest passion project still has some hurdles to overcome. At the end of March, ICER, an independent nonprofit that evaluates medical research, published a draft review of the MAPS trials in which it expressed "substantial concerns about the validity of the results," saying poor experimental design choices and misconduct could have biased the results. (More than 70 Lykos therapists and people who worked on the trials hit back with a letter accusing ICER of misrepresenting its research.) And in April, researchers submitted the petition asking the FDA to convene an advisory committee meeting that would allow outside feedback on Lykos' application. The FDA recently announced it would schedule a meeting, featuring a public hearing, for June 4.

Some former MAPS acolytes said that at this point they don't really care what happens with Lykos and medicalization. In their view, Doblin has largely achieved his lifelong goal of changing the narrative around psychedelics. Upper East Side moms are taking mushroom edibles at private-school benefits, and tech bros are microdosing ketamine before investor meetings. Psychedelics are no longer something to be afraid of. Convincing the FDA would just be the cherry on top. 

"One of my favorite quotes is that there's many a slip 'twixt cup and the lip," Doblin said, meaning it's still possible for things to go wrong at the last moment. Whatever happens this summer, Doblin isn't giving up — even if the reality looks very different from the utopia he set out to create. "The reason that I could work for 38 years and not get burnt out," he added, is "that I didn't get ahead of myself."

Reporting for this story was supported by a Ferriss-UC Berkeley Psychedelic Journalism Fellowship.

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