Pot Commercialization Has Increased Hospitalizations

A new seven-year study[i] looks at the monthly rate of cannabis-induced hospitalizations in the four largest Canadian provinces, containing 86 percent of Canada's population, over three distinct time periods: pre-legalization of cannabis (January 2015 to September 2018), legalization with restrictions (October 2018 to February 2020), and commercialization (March 2020 to March 2021).

The period of legalization with restrictions is unique, a time when all provinces offered limited access to nonmedical legal cannabis. During this time, illegal dispensaries were closing while converting to legal retail sites. Legal cannabis was often in short supply in some provinces and restricted to dried cannabis flower (marijuana).

With full commercialization, higher-potency marijuana, and cannabis products such as vape pens, edibles, and concentrates became available, although the rate of availability for these new products varied among provinces. The advent of the COVID-19 pandemic at the onset of commercialization complicates data interpretation, but several factors help disambiguate the influences of commercialization from those of the pandemic.

During the seven-year study, 105,203 hospitalizations due to cannabis occurred above age 14, one-third of which involved those aged 15 to 24 years. The pre-legalization period was characterized by a gradually increasing rate of cannabis hospitalizations. The period of legalization with restrictions was then marked by a modest decrease in the monthly rate of hospitalizations. Commercialization was associated with an immediate increase in cannabis-related hospitalizations. The largest relative increase in hospitalizations was for cannabis-induced psychosis. Studies show that 47 percent of individuals who first present with cannabis-induced psychosis eventually are diagnosed with either schizophrenia or bipolar disorder, with those of younger ages more likely to develop schizophrenia[ii].

The authors of the cross-sectional study came to the simple conclusion that “legalization with restrictions was not associated with an increase in hospitalizations due to cannabis. but commercialization was.”

One of the primary rationales for regulating the cannabis industry is that no one expects free-enterprise marketers to voluntarily restrict the products entrepreneurs can legally sell solely to protect the public’s health. The free-enterprise capitalistic system has no inherent structural limitation on the products it offers other than the public’s unwillingness to purchase them.

Currently, the public underestimates the potential harms of cannabis. This is especially true among customers who prefer high potency THC predicts. The cannabis industry naturally produces more of what the public is eager to buy. If high-THC products are legal, failure to offer them for sale would place retailers at a disadvantage relative to retailers willing to offer such products.

While I served on California’s Cannabis Advisory Committee, I often heard the sales of high-potency cannabis products defended based on severely ill patients requiring larger than normal recreational doses of THC. While this may be true in limited cases, the argument was indirectly used to permit the sale of the products for nonmedical use as well. The only entity capable of restricting the sale of more harmful high-THC cannabis products is us, through our governmental agencies.

There will always be a dynamic tension between free enterprise and government regulation. Regulation is justified only when a substantial body of independent scientific research points toward likely harmful outcomes and/or epidemiologic data provides a convincing evidence base. Such a base exists and is demonstrated by this recent Canadian study.

Research by Di Forti has shown a four-fold increase in schizophrenia-like psychosis in regular users of high-potency marijuana (skunk)[iii]. She also demonstrated that European cities with high-potency marijuana generally available have higher emergency hospital visits for psychotic reactions than cities with lower THC marijuana available[iv]. These studies and many others provide the scientific basis pointing toward increased risk of psychosis with increasing THC concentration (see The Complex Link Between Cannabis Use and Psychosis).

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This unique epidemiologic data from Canada documents that legalization restricted to lower-potency THC (though still potent enough to get quite high) presents little or no increased public health consequences, while lull commercialization contributes to increased cannabis-induced psychotic reactions leading to hospitalization.

Once again, an inadequately regulated industry is making money while exporting the expense of mitigating the harmful consequences of its products onto the healthcare system. I continue to believe that the transition from cannabis criminalization to legalization should require commercialization to start low and go slow. Such a cautious approach would allow the legal sale of cannabis while following closely what levels of potency carry acceptable public health risks. The answer to this delicate question will never be provided by the cannabis industry, nor should we expect it to be. That would be naïve.

While the shift from cannabis criminalization to legalization is to some degree a civil rights and liberties issue, the shift to unfettered commercialization is less a civil rights than a public health issue.