By: Steven Teutsch, Yasmin Hurd, and Elizabeth Boyle

The landscape of cannabis legalization in the United States has been changing dramatically. Cannabis is now available throughout the United States, with policies that vary significantly in terms of public health protection. In most states, legalization occurred through ballot initiatives and public ad campaigns often financed by wealthy donors. Voters acknowledged cannabis’s widespread use, its large illegal market, the criminalization of seemingly minor infractions, and discrimination in enforcement. Today, changes in the classification of cannabis under the federal Controlled Substances Act are pending, as is a possible change in the definition of “hemp.” These sweeping changes are occurring when many of the health consequences of cannabinoids remain quite uncertain. And those changes are coupled with a disturbing legacy of discrimination during the “war on drugs,” with associated devastating consequences for individuals and communities of color in particular. The legalization of an increasingly powerful intoxicating drug has necessitated a greater fusion of public health and drug policy in the states.

In the face of this complexity, how, then, is one to assess the consequences of the changes in cannabis policy for public health and social equity? This was the charge to the Committee on the Public Health Consequences of Changes in the Cannabis Landscape. The 2017 report of the National Academies of Sciences, Engineering, and Medicine, The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research, focuses on the health effects and potential therapeutic benefits of cannabis, noting the paucity of high-quality studies on its health effects. Regrettably, little has changed in this regard since that report was published, and scant to no research exists on the explosion of new cannabis and cannabinoid products. The present report focuses on the public health consequences of cannabis policies that have not been examined by the National Academies.

States have received little federal guidance on how to proceed regarding the health impact of cannabis on the public and communities. Other than two memoranda deferring to states, the federal government has been noticeably missing from this dialogue. Yet cannabis can cause real harms, as multiple investigators, families, and various groups attested to our committee. The tools of public health—assessment, policy development, and assurance—can provide the critical health information decision-makers need to protect the public health and make amends for past cannabis-related inequities, but those tools are only slowly being applied.

With legalization by states now widespread, it is time to ask about its impact, especially given the large variation in state policies. These natural experiments provide a rich but very complex set of experiences for analysis, but these policies are all of relatively recent vintage. Consequently, available products, use patterns, and markets have not yet stabilized. Facing these challenges, the committee reviewed what is known about these policies, formulated recommendations where possible, and delineated a path forward. With a strong commitment to policy research and the application of traditional public health tools, we fully anticipate that better and more consistent policies will unfold.

This report would not have been possible without the deep expertise, wide range of perspectives, and strong commitment of all the committee members. Elizabeth Boyle, study director, and her National Academies colleagues, Khala Hurst-Beatty, Alexandra McKay, and Mia Saltrelli, labored long and hard to tie together all the disparate pieces of this report. We are deeply grateful to all of them. Lastly, we want to express our appreciation to our sponsors, the Centers for Disease Control and Prevention and the National Institutes of Health, without whose vision this study would not have been possible.

The National Academies Press 2024

By Felipe Botero Escobar

Cannabis is the most widely consumed illicit drug globally, with around 219 million users in 2021, according to the UNODC. It is also the illicit drug that is being legalized most rapidly for medicinal or recreational use. While Colombia has taken steps toward regulation, such as legalizing medicinal cannabis in 2015, the complete legalization of recreational cannabis is still under discussion.

This report draws on experiences from countries like Uruguay, Canada, and the United States, which have already implemented cannabis legalization, to explore the possible outcomes for Colombia. It concludes that while legalization could reduce the size of the illegal cannabis market, a grey market supplying both local and international demands is likely to persist.

A key focus is on how criminal control over cannabis production areas could hinder the transition of growers to a legal market. The report emphasizes the need for coordinated cannabis regulatory and security policies to protect small-scale and traditional growers and integrate them into the legal market. Furthermore, the potential for reduced violence is explored, though the report notes that this is unlikely to happen immediately. Criminal groups may resist the establishment of a legal market, leading to short-term increases in violence as they compete for control over remaining illicit markets.

Another significant finding is the potential transformation of Colombia’s criminal justice system. Legalization could free up resources, allowing law enforcement to prioritize more serious public safety issues and reducing low-level cannabis prosecutions and prison overcrowding.

This report offers crucial insights for policymakers, emphasizing that while cannabis legalization is not a cure-all for crime and violence in Colombia, it is a critical step toward more effective drug policy reform and organized crime reduction.

Geneva, SWIT: Global Initiative Against Transnational Organized Crime, 2024. 35p.

By Jakob Manthey, Jürgen Rehm,and Uwe Vertheina

With the enforcement of the Cannabis Act on 1 April 2024, Germany has adopted one of the most liberal legal approaches to cannabis on the continent. The German model prioritises a non-profit approach and precludes legal market mechanisms. We believe these are the main drivers for increasing cannabis use and related health problems, based on observations following cannabis legalisation in Canada and many states in the U.S. Although legalising cannabis possession and cultivation may not immediately eliminate the illegal market, it is expected to serve public health goals. Despite the overall positive evaluation of the Cannabis Act in Germany, there are three potential areas of concern: the potential for misuse of the medical system, the normalization of cannabis use, and the influence of the cannabis industry. The German model may herald the beginning of a new generation of European cannabis policies, but concerted efforts will be required to ensure that these policy reforms serve rather than undermine public health goals.

The LANCET Regional Health - Europe, Vol 42 July, 2024

By R. Santamarina  D. Caldicott , J. Fitzgerald , J.L. Schumann 

Background : Illicit drug use is overrepresented in music festival attendees compared with the general population. Drug use often involves a wide range of substances with the potential to cause drug toxicity. Law enforcement-centred strategies intended to deter drug use and supply at these mass gatherings have been implemented throughout Australia. However, many have been criticised for their lack of effectiveness, with evidence suggesting that they can inadvertently increase the risk of drug harm. Drug deaths are often multifactorial, providing added challenges in the development of prevention strategies. This study aimed to determine the frequency of deaths involving alcohol and other drugs at music festivals in Australia and to identify potential risk factors that may inform future harm reduction strategies.

Methods : A descriptive case series study was conducted using the National Coronial Information System (NCIS) to investigate drug-related deaths at music festivals throughout Australia between 1 July 2000 (Queensland from 1 January 2001) and 31 December 2019, using a list of keywords comprising music festival names and terms.

Results : There were 64 deaths, of which most involved males (73.4%) aged in their mid-20s (range 15-50 years). Drug toxicity was the most common primary cause of death (46.9%) followed by external injuries (37.5%). The drug most commonly detected or reported as being used was MDMA (65.6%), followed by alcohol (46.9%) and cannabis (17.2%), with most cases reporting the use of two or more drugs (including alcohol) and 36% reporting a history of drug misuse in the coroner's findings. Most deaths were unintentional, with less than a fifth of cases (17.2%) involving intentional self-harm. Clinical intervention was involved in 64.1% of cases and most festivals occurred in inner city locations (59.4%).

Conclusions : The findings suggest that drug-related deaths at music festivals in Australia typically involve young people using multiple illicit substances in combination with alcohol. Most are unintentional and could potentially be prevented through the implementation of a range of harm reduction strategies, including mobile medical care, drug checking services, and increased consumer education and awareness.

International Journal of Drug Policy Volume 123, January 2024, 104274

By Anine Kriegler

Cannabis legalization has the potential to weaken organized crime, but it can just as easily strengthen it unless a balance is found between restriction and liberalization, coordinated across both the supply and demand sides of the market. South Africa’s current cannabis policy lacks coherence, with reforms driven more by legal challenges than by strategic policymaking, posing challenges in effectively countering organized crime.

This paper summarizes the history and status of cannabis decriminalization in South Africa and draws on a review of literature to identify a key set of variables that determine the impact of legalization on organized crime: the type and degree of restrictiveness of the new regulations; various cultural, socio-economic, and political factors; features of the criminal justice system; and the structure and nature of criminal organization in the illegal cannabis market.

Reflections are provided on what these suggest about the likely impact of South African cannabis legalization on organized crime, and potential lessons and recommendations are proposed for effective policy reform in South Africa, as well as guidance for similar decision-making in other contexts.

Effective reform requires integrating marginalized communities and black-market participants into the legal market, along with considerations for managing legal supply, strategic enforcement against criminal gangs, and public health education to ensure a comprehensive approach to reducing organized crime. A phased implementation of regulatory frameworks, ongoing monitoring, and investment in data collection are essential to assess and optimize the impact of legalization on organized crime. Geneva: SWIT: Global Initiative Against Transnational Organized Crime , 2024. 29p.

By Pascal Tanguay

Elections in 2023 have brought a new government to power, headed by Prime Minister Srettha Thavisin, who declared in late September that his government intends to achieve in the next six months a partial reversal of the reforms, recriminalizing recreational use and leaving the medical market as the sole legal arena.

Through a methodical data collection process involving key informant interviews and literature reviews, this report sheds light on the substantial impacts of such policy changes, especially on the illicit markets and organized crime networks. Informed by these insights, the GI-TOC has formulated preliminary policy recommendations to secure a resilient Thai cannabis market that is as balanced as it is sustainable.

Geneva, SWIT: The Global Initiative Against Transnational Organized Crime (GI-TOC),  2024. 34p.

By The International Drug Policy Consortium (IDPC)

In September 2023, the UN High Commissioner for Human Rights released a landmark report on human rights in drug policy. Prepared at the request of the Human Rights Council as a contribution to the mid-term review of the 2019 Ministerial Declaration on drugs, this report constitutes the most ambitious and comprehensive UN document to date on the alignment of drug policies with human rights. The report consolidates existing human rights standards, develops new recommendations, and proposes a blueprint for transformative change, from a global punitive paradigm to drug policies based on health and human rights.

This IDPC advocacy note focuses on three key issues. First, the new standards and recommendations developed in the OHCHR report, which update our understanding of the human rights dimension of drug policies. Secondly, the consolidation of prior human rights standards developed by other UN bodies. Lastly, we lay down our recommendations for an effective implementation of the vision proposed by the report.

London: IDPC, 2023. 7p.

By UK Parliament, House of Commons, Home Affairs Committee

Drugs can have a significant and negative impact on people who use drugs, their loved ones and society. Trends in drugs may vary over time but this consequence is constant. Concerningly, drug misuse deaths across the UK continue to increase with opiates playing a significant role in this, and ‘street’ benzodiazepines and polydrug use also playing an increasing role. There were 250 drug misuse deaths per million population in Scotland in 2022—significantly higher than in England, Wales and Northern Ireland. In her Independent Review of Drugs, Professor Dame Carol Black estimated the total cost of drugs to society to be more than £19 billion per year—more than twice the value of the illicit drugs market (an estimated £9.4 billion).

In recent years, the response by the international community and devolved nations to drugs has increasingly focused on responding to drugs through a public health lens. UK policy should ensure that an approach originally and primarily based on criminal justice principles continues to adapt to achieve a proper balance of public health interventions that may reduce illicit drug use in the longer term rather than aiming simply to disrupt demand. We believe that this approach would be best supported by making drug policy the joint responsibility of the Home Office and the Department of Health and Social Care, with a minister sitting across both departments.

The main piece of legislation controlling drugs in the UK—the Misuse of Drugs Act 1971—is more than 50 years old. It is in need of review. Further, a full review by the Advisory Council is required on whether the most commonly controlled drugs in the UK are correctly classified and scheduled (under the Misuse of Drugs Regulations 2001), based on the evidence of their harms.

The Government’s latest drugs strategy, ‘From Harm to Hope: A 10-Year drugs plan to cut crime and save lives’ (the 10-Year Drugs Strategy) signals a shift towards recognising the need for a holistic response to drugs that not only aims to tackle the illicit drug market but also supports people who use drugs, their loved ones and society. However, the Government’s response could go further by adopting a broader range of public health-based harm reduction methods in tandem with its support of law enforcement efforts to tackle the illicit drugs market.

We support the use of diamorphine assisted treatment supported by psychosocial support as a second-line treatment for people with a chronic heroin dependency. We visited a centre in Middlesbrough and saw the dramatic and positive effect this treatment had on the lives of a small group of people who had used drugs and, albeit on a small scale, to local crime reduction. Disappointingly, such treatment programmes are few and controversial, and the Middlesbrough programme lost its funding. The Government should provide centralised funding for such programmes.

Safe consumption facilities, where people who use drugs may do so in safe, secure surroundings, may also reduce harm and deaths, but the status of such facilities is uncertain because of the restrictive regime in place under the 1971 Act. We recommend that the Government support a pilot facility in Glasgow and create a legislative pathway to enable more.

A national drug checking service in England could enable people to anonymously test samples of drugs, again preventing harm and potentially death. We recommend the Government establish a drug checking service, taking into account the experience of Wales. We also recommend the expansion of on-site drug checking services at temporary events such as music festivals and in the night-time economy through the creation of a dedicated licensing scheme. The power to issue such licences could include the devolution of power to grant licences to local authorities.

These public health and harm reduction interventions must be balanced with the role of police in applying the law. The police can also have a role in aiding prevention of drug use and treatment of harms. Scotland’s pioneering programme of having all police officers carry naloxone (a nasal spray or injection that can be administered immediately to reverse the effects of an opioid overdose) should be rolled out elsewhere in the UK as a straightforward means of saving lives. The police can also play an important role in diverting young people who have committed low-level drug-related offences away from the criminal justice system. We support greater standardisation of police-led diversion across England and Wales, to avoid a ‘postcode lottery’ in the treatment of such offenders.

London: House of Commons, 2023. 98p.

By Amanda Doggett, ; Kyla Belisario,; André J. McDonald,; et al

Importance A key concern about recreational cannabis legalization is increases in use and adverse consequences, particularly among young adults (aged 18-29 years) who have the highest prevalence of cannabis use, and especially in higher-risk, more vulnerable young adults. However, few longitudinal studies have examined patterns of cannabis consumption in high-risk young adults over the course of legalization.

Objective To examine changes in cannabis use frequency and cannabis-related consequences over recreational cannabis legalization in Canada in a longitudinal sample of high-risk young adults.

Design, Setting, and Participants Longitudinal observational cohort study following young adults in Ontario, Canada, aged 19.5 to 23.0 years who reported regular heavy episodic drinking (65% past-month cannabis use) at enrollment. Participants were surveyed every 4 months for 3 years between February 2017 and February 2020 (3 prelegalization waves, 4 postlegalization waves). Data were analyzed from March to May 2023.

Exposures Recreational cannabis legalization in Canada and 4 potential moderators of change: sex, income, education, and prelegalization cannabis use frequency.

Main Outcomes and Measures Cannabis use frequency and cannabis-related adverse consequences.

Results In a cohort of 619 high-risk young adults (baseline mean [SD] age, 21.0 [1.2] years; 346 female participants [55.9%]), omnibus model testing revealed significant overall decreases in both cannabis use frequency (F = 2.276, 3000.96; P = .03) and cannabis-related consequences (F = 10.436, 3002.21; P < .001) over time, but these changes were substantially moderated by prelegalization frequency (frequency: F = 7.5224, 3021.88; P < .001; consequences: F = 7.2424, 2986.98; P < .001). Follow-up tests showed individuals who used cannabis more frequently prelegalization significantly decreased their use and cannabis-related consequences postlegalization. In contrast, individuals who did not use cannabis prelegalization exhibited a small magnitude increase in frequency over time but nonsignificant changes in cannabis-related consequences. Sex, income, and education did not moderate changes over time.

Conclusions and Relevance In this cohort study of high-risk young adults, individuals using cannabis frequently prelegalization showed significant reductions in use and consequences over time, reflecting an aging out pattern. Small increases in use among participants with no prelegalization use were observed over time, but without parallel changes in cannabis-related consequences. The results did not reveal substantive adverse near-term outcomes across the legalization period, although a within-participants design cannot rule out the possibility of alternative trajectories in the absence of legalization.

JAMA Netw 5 September 2023Open; 6(9); 2023

By Izedomi Ayeni

Purpose: The purpose of this phenomenological qualitative study was to discover the attitudes and perceptions of police officers on the legalization of recreational cannabis and crime.

Methodology: This qualitative, phenomenological methodology employed the use of semi-structured interview questions consisting of open-ended questions to understand the lived experiences of Colorado Police and Sheriff Officers and their perspectives on the experiences with the legalization of cannabis and crime. The sample size of 16 officers was selected from the sampling frame, which included Denver Police officers and Larimer County Sheriff officers.

Findings: Analysis of the data from interviews resulted in the identification of 14 major findings; 1) Officers oppose legalization; 2) Officers have an unfavorable opinion regarding legalization because they feel it can lead to increased access/use of illicit drugs; 3) Officers feel that the only reason the state legalized cannabis is for the tax revenue it generates for the state; 4) Officers’ viewpoint is that legalization has led to more violent crimes; 5) Officers perceive that Amendment 64 was designed to change perceptions about legal recreational marijuana; 6) Officers feel that legalization has led to an increase in burglary; 7) Officers are cognizant of the possibility of an increase in organized crime activities; 8) Officers expressed displeasure with the decriminalization of non-medical use, possession, and purchase of narcotics; 9) Officers express how an increase in crime has negatively impacted policing efforts; 10) Officers attribute an increase in homelessness and transient population as a symptom of the legalization of recreational cannabis; 11) Officers express frustration with lack of effective regulation; 12) Officers expressed that legalization has had no effect on timely responses to crime; 13) Officers expressed that the biggest challenge faced is maneuvering the demands of state versus federal law; 14) Officers express frustration in navigating the legal requirements relating to legal search and seizure.

Conclusions: As more states are considering legalizing cannabis for recreational use, these findings present significant suggestions for the state legislature and the members of the law enforcement community in those states.

Recommendations: Additional research should be conducted in other states to expand on the perceptions of the law enforcement community pre-and post-legalization of recreational cannabis and the impact it has on crime.

Irvine, CA: Brandman University, 2020. 217p.

By European Monitoring Centre on Drugs and Drug Addiction (EMCDDA)

Our overall assessment is that drug availability and use remain at high levels across the European Union, although considerable differences exist between countries. Approximately 83.4 million or 29 % of adults (aged 15–64) in the European Union are estimated to have ever used an illicit drug, with more males (50.5 million) than females (33.0 million) reporting use. Cannabis remains the most widely consumed substance, with over 22 million European adults reporting its use in the last year. Stimulants are the second most commonly reported category. It is estimated that in the last year 3.5 million adults consumed cocaine, 2.6 million MDMA and 2 million amphetamines.

Lisbon: EMCDDA: 2022. 60p.