By Donald Lyman, MD
The federal government recently directed the U.S. Attorney General to re-evaluate cannabis, potentially reclassifying it from Schedule I to Schedule III. This shift would lower restrictions, making cannabis more accessible and easier to regulate medically, but it also raises complex public health issues and persistent misconceptions. California, a pioneer in cannabis reform, now faces questions on how to responsibly balance access, protect public health, and address lingering myths about marijuana’s risks — particularly among youth.
What does this mean for physicians? In the short term, the reclassification won’t bring immediate changes to medical practice. However, it does represent a shift in the broader landscape of substance use, one that will evolve as cannabis becomes even more accessible. As with alcohol, we may see new opportunities for regulation and control, impacting how physicians approach cannabis-related health concerns and patient education.
Physicians can legally provide expert medical advice about cannabis use, including discussing its potential effects, risks, and benefits with patients, as long as they don't prescribe it. Offering such advice is considered part of patient education and falls under protected medical guidance. This approach allows physicians to engage in informed discussions about cannabis while staying compliant with legal restrictions around prescribing a Schedule I substance (or Schedule III, if reclassified).
Federal Reclassification: Implications for California and Beyond
California challenged federal restrictions on cannabis with the passage of Proposition 215 in 1996, which legalized medical use. Proposition 64 in 2016 expanded this to include adult recreational use, inspiring similar laws in other states. The current push for Schedule III reclassification suggests that federal policy may be aligning with state-level reforms, moving away from the "War on Drugs" stance to a recognition of potential medical applications for cannabis.
However, the shift brings challenges that California’s cannabis market knows well:
- Black Market Competition: Despite legalization, California’s regulated market still competes heavily with unregulated sellers. National reclassification could open up interstate commerce, which could help regulated products gain a stronger foothold.
- Security and Banking Access: Reclassifying cannabis as a Schedule III substance could provide cannabis businesses with improved access to banking services, alleviating the reliance on cash-only transactions and enhancing operational safety. Under the current system, dispensaries often handle vast amounts of cash due to banking restrictions, creating substantial security risks. This setup necessitates the frequent use of armored vehicles and armed security to protect funds and staff, underscoring the urgency for safer, more streamlined financial operations in the industry.
- Product Evolution: As demand increasingly favors processed and labeled cannabis products, consumers will benefit from safer, quality-controlled options — a clear advantage over unregulated black-market goods. Dispensary customers can expect to see labels that assure product safety and consistency, a level of transparency that remains absent in the black market.
While indications point toward a possible reclassification to Schedule III, it’s not guaranteed – only removal from Schedule I is certain. Some groups, such as Physicians for Drug Policy Reform, are advocating for full descheduling, suggesting that oversight and regulation should lie beyond the FDA. If cannabis does move to Schedule III, it would restrict federal law enforcement’s ability to take action against it, further altering the landscape of cannabis regulation.
Persistent Myths About Cannabis and Youth Drug Use
Despite cannabis legalization and potential federal reclassification, misconceptions about marijuana and other substances endure, particularly among youth and parents. These myths impact prevention efforts and risk downplaying the drug’s potential harm. Here are some of the most common myths and the facts.
Myth #1
“They’re Too Young for Drug Talks.”
Many parents delay discussing drug and alcohol use with their children, thinking the conversation isn’t necessary until high school. Research shows that prevention is most effective when started in late elementary school, around ages 10 or 11, as 90% of people with substance addictions started using before age 18. The most significant influence on a teenager’s decision to use substances remains parental guidance.
Myth #2:
“Marijuana Isn’t Addictive.”
A prevalent belief among parents and teens is that marijuana isn’t addictive; however, about 1 in 6 people who start using marijuana as teens develop an addiction. The marijuana of today is far more potent than in past decades, with THC levels rising from 1-3% in the 1960s-70s to 14-35% today. High-potency concentrates like vape pens can reach nearly 100% THC, and newer variants like THCP are reportedly up to 30 times more potent than THC, raising addiction risks and adverse health effects.
Myth #3:
“It’s Just Teen Experimentation.”
Parents often view marijuana as a "rite of passage," but attitudes about marijuana use have shown an inverse relationship with actual usage rates over the years. More troubling, early marijuana use can predict other substance use disorders. Studies have shown that cannabis use during adolescence may indicate a higher likelihood of future opioid use and mental health challenges. Furthermore, some users develop a condition called Cannabinoid Hyperemesis Syndrome, which leads to severe nausea, vomiting, and weight loss.
Myth #4:
“Teens Don’t Have Easy Access.”
Many parents underestimate teens' access to drugs, believing it requires “connections.” However, students today can often find access through the internet or social media. A recent investigation revealed that one could locate a drug dealer in just two clicks, whereas it took five clicks to log out of the same social media account.
Sacramento has approved cannabis lounges and California has legalized Amsterdam-style cannabis cafés with food and beverages.
Cannabis Smoking Lounges and Secondhand Smoke: A Public Health Risk
With increased cannabis use comes a new public health challenge: secondhand smoke exposure. In California, the Sacramento City Council has approved a pilot program for cannabis smoking lounges that prompted debate over the potential risks. Currently, cannabis consumption is limited to private residences, thereby limiting public exposure to secondhand smoke. These lounges would allow public smoking, posing risks to workers, patrons, and bystanders. There are several concerns raised by smoking lounges and by the Amsterdam-style cannabis cafes, which will offer food, beverages and even live music, recently made legal in California through the signing of Assembly Bill 1775:
- Health Risks of Secondhand Smoke: Studies show that secondhand cannabis smoke contains harmful particulates such as ammonia, pesticides, and heavy metals. Negative pressure rooms can help limit smoke, but there is no air filtration system that fully removes these particulates, posing a danger to those nearby.
- Worker Safety: Employees working in cannabis lounges would face prolonged smoke exposure, risking respiratory issues and potential secondhand intoxication. Workers with existing health conditions are especially vulnerable, raising ethical concerns over safety and employer obligations.
- Customer Health: Patrons with asthma or other respiratory conditions may be discouraged from using the lounges or risk worsening their conditions if they do. This poses a dilemma, as some users prefer cannabis in non-combustible forms.
Lessons From California’s Cannabis Experiment
As California anticipates a new federal approach to cannabis regulation, lessons from the past decade will be valuable in shaping future policy. Key takeaways include:
- Robust Regulation Is Essential: Effective regulatory frameworks, such as quality controls and consistent labeling, help compete with black markets and assure public safety.
- Public Health Comes First: Despite legal acceptance, cannabis consumption spaces must be evaluated cautiously to avoid normalizing smoking in public venues and undermining decades of progress against tobacco and other smoking-related health risks.
- Ongoing Education on Myths and Risks: Persistent myths, particularly those affecting youth and their parents, need to be addressed proactively to prevent misinformation and promote safer, healthier choices.
Moving Forward
As the nation moves closer to federal reclassification, California’s experience underscores the importance of balancing access with public health protections. Establishing a cautious, informed approach that incorporates prevention, safety, and education is crucial to supporting both industry growth and community health in a new era for cannabis.
