Position Statements | Center on Addiction

Positioning statements

Position Statements

This collection of statements provides you with our stance on pressing addiction issues.

Position statements Accordion

In order to reduce crime and save taxpayer dollars, the U.S. justice system must address addiction and substance abuse as health problems and provide effective intervention and treatment. While individuals who commit crimes as a result of their substance use must be held accountable, incarceration alone cannot prevent or treat a disease.

As of 2005, 1.5 million (66%) of the 2.3 million inmates incarcerated in the U.S. met the clinical criteria for addiction or substance abuse in the year prior to their arrest. An additional 458,000 inmates had histories of illicit drug use or treatment for alcohol problems; were under the influence of alcohol or other drugs at the time of their crime; committed their offense to get money to buy drugs; were incarcerated for an alcohol or other drug law violation; or shared a combination of these characteristics. In total, 85% of America’s prison and jail inmates are substance-involved.

Crime related to addiction and substance use is not limited to adults in the justice system. 78% of 10- to 17-year olds in the juvenile justice system are substance-involved. Among juvenile offenders, 44% meet clinical criteria for a drug or alcohol problem, as do more than half of juvenile offenders incarcerated in state prisons and local jails.

Despite these high rates of addiction among both adult and juvenile offenders, few receive treatment. Center on Addiction found that less than 4% of juvenile offenders and only 11% of all prison and jail inmates who met clinical criteria for a substance problem receive any treatment. Most of those who do receive treatment do not receive evidence-based care.

Center on Addiction has documented the profound link between substance use and crime in 3 national research studies of America’s justice system: Behind Bars; Behind Bars II: Substance Abuse and America’s Prison Population; and Criminal Neglect: Substance Abuse, Juvenile Justice and the Children Left Behind, and has documented the enormous return on investment possible from providing addiction treatment. If all inmates who needed treatment and after care received such services and a mere 10% remained substance free, crime free and employed, our nation would reap an economic benefit of more than $90,000 per year for each of these inmates.

To reduce the number of substance-involved offenders, the justice systems must employ trained health care professionals to screen and treat offenders using evidence-based medications/therapies and provide care for co-occurring health (including mental health) conditions. Addiction treatment for inmates must be medically managed, and corrections-based treatment programs and providers should be required to be accredited. We must also expand the use of treatment-based alternatives to incarceration and assure that individuals with addiction facing release and re-entry receive appropriate post-release treatment, disease management and support services.

In order to effectively address our nation’s addiction crisis, addiction must be fully integrated within the mainstream health care system. To achieve this, all health professionals must be trained in the basics of addiction. Center on Addiction supports efforts to increase addiction education among health care professionals, including mandated provider training.

For over 100 years, the medical community has been effectively removed from addiction treatment. The separation of addiction care from mainstream medicine is evident in the minimal education and training that health care providers receive in relation to addiction. Medical schools and other health professional training programs barely address addiction.[1] As a result, many health care providers do not feel confident in their abilities to treat a patient with substance use disorder (SUD)[2] and tend to share many of the same stereotypes and misconceptions about such individuals as those held by the general public.[3] These biases significantly affect the type and quality of care that a patient with addiction receives.[4] The lack of medical professionals trained in addiction treatment makes it exceedingly difficult for patients and their families to find quality, effective, lifesaving care.

To ensure that people with addiction receive the treatment they need, health care professionals must be trained to treat SUD as they do any other complex disease and should no longer be allowed to dismiss addiction care as being outside of their profession’s purview. This change will not happen overnight. Many seasoned medical professionals who have not been involved in addiction treatment will likely have entrenched views about addiction and their responsibility to treat it. The greatest shift in care will most likely occur once emerging and future health professionals receive the proper education and training to address addiction as the treatable disease that it is. As the opioid epidemic has worsened in recent years, professional health care education and training programs have begun to incorporate some addiction training into their curricula.[5] Yet, such changes have not been widely adopted, signaling the need for mandated training requirements.

To truly transform how addiction is addressed in the United States, professional health care training programs must provide comprehensive and ongoing training about addiction prevention and treatment, just as they train health professionals to prevent and treat other complex chronic diseases that affect a significant proportion of the patient population. All medical and other health professional training programs, including residency training programs, that train providers to prescribe medication, should educate and train providers on the core competencies for identifying, treating and managing substance use and addiction. Such core competencies should also be required components of health processional licensing exams, board certification exams and continuing education requirements, including maintenance of certification programs.[6] Policy makers should provide additional resources and incentives to increase training. Where necessary, policy makers may also consider mandating training.

Given addiction’s prevalence, training requirements should apply to all health care professionals, but especially for those who prescribe controlled substances with potential for addiction. Under current law, training requirements are only imposed on health care providers who wish to prescribe buprenorphine, a medication used to treat opioid addiction. This requirement has not advanced the goal of increasing provider training, but rather created a barrier to providing addiction treatment (see position statement on Buprenorphine Prescribing Waiver).

Addiction is a disease but, as a country, we still have a long way to go to treat it as one. We cannot effectively end our nation’s addiction crisis without equipping our health care system to prevent, identify, treat and manage addiction like diabetes, heart disease, or any other chronic condition. While provider training, alone, will not achieve full integration of addiction treatment with the mainstream health care system, it is essential and will save lives.

[1] CASAColumbia. Addiction medicine: closing the gap between science and practice. New York: Author; 2012.

[2] Miller NS, Sheppard LM, Colenda CC, Magen J. Why physicians are unprepared to treat patients who have alcohol- and drug-related disorders. Acad Med. 2001;76(5):410–8.

[3] Lloyd C. The stigmatization of problem drug users: a narrative literature review. Drugs: Educ Prev Policy. 2013;20(2):85–95.

[4] McLellan AT, Lewis DC, O’Brien CP, Kleber HD. Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. J Am Med Assoc. 2000;284(13):1689–95.

Pauly BB, McCall J, Browne AJ, Parker J, Mollison A. Toward cultural safety: nurse and patient perceptions of illicit substance use in a hospitalized setting. Adv Nurs Sci. 2015;38(2):121–35.

[5] Commonwealth of Massachusetts. 2015. Baker-Polito administration announces groundbreaking medical school program to curb opioid crisis. Available at: https://core.ac.uk/download/pdf/146529648.pdf.

Commonwealth of Massachusetts. 2016. Baker-Polito administration, advanced practice nurses, physician assistants and community health centers expand on core competencies to combat opioid epidemic. Available at: https://www.mass.gov/news/baker-polito-administration-advanced-practice-....

McCance-Katz EF, George P, Scott NA, Dollase R, Tunkel AR, McDonald J. Access to treatment for opioid use disorders: medical student preparation. Am J Addict. 2017;26(4):316–8.

[6] CASAColumbia. Addiction medicine: closing the gap between science and practice. New York: Author; 2012.

Research documented in Center on Addiction's two recent reports, Adolescent Substance Use: America’s #1 Public Health Problem (2011) and Addiction Medicine: Closing the Gap between Science and Practice (2012), affirms that addiction is a brain disease that typically originates with substance use in adolescence.

In the U.S., 9 out of 10 people who meet clinical criteria for a substance use problem started smoking, drinking or using other drugs before age 18. The earlier substance use begins, the greater the likelihood of developing a substance problem. Individuals who first use any addictive substance before age 15 are 6 1/2 times as likely to develop a substance problem as those who delay first use until age 21 or older; yet the average age that high school students report starting to use an addictive substance is between 13 and 14 years.

Given that three-fourths (76%) of all high school students report having used an addictive substance in their lifetime and almost half (46%) have done so in the past month, it is critical to understand the link between adolescent substance use and addiction and address it accordingly. 1 in 8 high school students meets clinical criteria for a substance problem and, among those who have used an addictive substance in the past month, 1 in 3 already has a disorder.

The combination of several factors makes adolescence the critical period of vulnerability for beginning to use addictive substances and for developing the disease of addiction:

  1. Because the parts of the brain responsible for judgment, decision-making, emotion and impulse control are not fully developed until early adulthood, adolescents are more likely than adults to take risks, including experimenting with addictive substances
  2. Because these regions of the brain are still developing, they appear to be more vulnerable to the negative impact of addictive substances, further interfering with brain development and increasing the risk of addiction
  3. Compounding these biological vulnerabilities is the fact that adolescents are exposed to a constant stream of messages from friends, family, advertising and the entertainment media promoting and glamorizing substance use at a time of peak susceptibility to social influences. Some teens may also have genetic or biological conditions or personal experiences such as abuse or other trauma that when combined with these factors further increase their risk of addiction and substance use

Adolescent substance use not only increases the risk of addiction, it also has profound social and financial costs. It is directly linked to the three leading causes of death among adolescents—accidents, homicides and suicides—and is implicated in poor academic performance, cognitive impairment and school dropout; unprotected sex and unintended pregnancies; mental health problems; violence and criminal involvement; and numerous potentially fatal medical conditions.

Adolescent substance use is our country’s largest preventable and ultimately most costly health problem. To address it, the public, health professionals and policymakers must recognize it as a health problem rather than a normal rite of passage, help young people delay substance use for as long as possible, be vigilant for signs of risk and intervene appropriately as we do for any other health condition.

Center on Addiction supports reducing barriers to effective substance use disorder treatment, including eliminating the DATA 2000 waiver required to prescribe buprenorphine. Nonetheless, we stress that other policy changes are needed to ensure more people receive effective care. The buprenorphine requirement should be eliminated because (1) it has failed to meet its ostensible purpose, which is to prevent unscrupulous prescribing and diversion and (2) it has limited access to an effective opioid addiction medication during an unprecedented opioid epidemic. With 128 people dying every day from an opioid overdose, access to effective treatment is more critical now than ever before. The current waiver requirement is completely incompatible with the goal to increase access to evidence-based treatment for opioid use disorder (OUD).

Instead of reducing diversion, the waiver requirement has contributed to diversion of buprenorphine for self-treatment because treatment is unavailable.[1] It is also notable that the DEA has not used waiver requirements to reduce diversion of any other medication, including prescription opioids where diversion of such medications has resulted in unquestionable societal risk and harm. The differential treatment of buprenorphine versus other narcotic pain relievers is driven by stigma rather than science and results in discrimination against patients with OUD.  There is no clinical justification for imposing a patient limit, training and administrative requirements associated with prescribing buprenorphine. In fact, providers who prescribe oxycodone, a DEA Schedule II drug, or who prescribe methadone or buprenorphine for pain are not subject to these same restrictions. The only difference is that the patients to whom buprenorphine is prescribed are undergoing treatment for addiction. Given the effectiveness of buprenorphine in treating OUD, a life-threatening disorder, and the limited access to care, we find it unconscionable that the government would single out this treatment with patient limitations.

Efforts to reduce unscrupulous prescribing have, in fact, reduced overall prescribing of buprenorphine. A very small number of providers have obtained the waiver and fewer actually prescribe buprenorphine.[2] The waiver requirement has created the perception among providers that it is difficult or challenging to treat SUD, perpetuating stigma and discouraging providers from engaging in the practice. Increasing access to evidence-based SUD treatment is essential to address our nation’s addiction crisis and it is evident that the buprenorphine waiver requirement obstructs this goal.

While we support eliminating the requirement, we understand that, alone, it is insufficient to increase access to buprenorphine and other effective SUD care. Eliminating the waiver requirement must be accompanied by efforts to increase SUD training for health care providers and provide adequate reimbursement.

Despite the prevalence of the disease, health care providers receive very little training in SUD and this has left the health care system woefully unprepared to deal with addiction. To rectify this and increase the number of providers offering evidence-based care such as buprenorphine, addiction training must be incorporated into medical school curricula. Congress authorized a grant program for medical schools and teaching hospitals to establish curricula for prescribing medications for addiction treatment in the SUPPORT Act. This program should be fully funded to encourage and support medical schools to provide SUD training and better equip future generations of health care providers to treat addiction like any other disease.

In addition to medical school training, ongoing training should be required for health care providers through continuing medical education and licensing requirements. Providers also need support and guidance from more experienced providers to consult on complex cases as well as support staff, such as nurses, social workers, and peers to meet patients’ needs adequately.[3]  

Under the current waiver requirement, prescribers are required to have capacity to refer patients to counseling and other ancillary services. This requirement assumes that these services are accessible; yet, there are severe shortages of behavioral health services across the country. A requirement to refer to services that do not exist may reduce prescribing. Providers often cite lack of availability of behavioral health services as a barrier to prescribing buprenorphine.[4] Policy changes other than a referral requirement are needed to ensure patients have access to behavioral counseling and other ancillary services.

To ensure prescribers can hire appropriate support staff and to increase availability of ancillary services, the reimbursement rate must be increased. One possible reason for the shortage of quality behavioral health services is low insurance participation and reimbursement. Lack of insurance coverage is also cited as a barrier to prescribing buprenorphine.[5] A number of states have increased access to and quality of buprenorphine treatment by changing reimbursement policies in Medicaid.[6] These strategies should be replicated on the national level and applied in other insurance products, to ensure adequate access to effective addiction treatment. In addition, the SUPPORT Act requires the development of recommendations for improving coverage and payment for SUD medications in Medicare. Establishing an adequate Medicare reimbursement rate for SUD treatment is an important way to influence other payers to revise their rates.

In summary, removing the buprenorphine wavier requirement is an important policy change but it must be accompanied by other innovative policies to significantly increase access to effective OUD treatment. Center on Addiction supports eliminating the DATA 2000 waiver requirement, together with funding and requirements for provider training and increased reimbursement rates for SUD treatment, to increase access to life-saving care.  

[1] Schuman-Olivier, Z., Albanese, M., Nelson, S.E., Roland, L., Puopolo, F., Klinker, L., & Shaffer, H.J. (2010). Self-treatment: illicit buprenorphine use by opioid-dependent treatment seekers. Journal of Substance Abuse Treatment, 39(1), 41–50.
Carroll, J.J., Rich, J.D., & Greene, T.C. (2018). The More Things Change: Buprenorphine/naloxone Diversion Continues While Treatment Remains Inaccessible. Journal of Addiction Medicine, 12(6), 459–465. 
[2] Kissin, W., McLeod, C., Sonnefeld, J., & Stanton, A. (2006). Experiences of a National Sample of Qualified Addiction Specialists Who Have and Have Not Prescribed Buprenorphine for Opioid Dependence. Journal of Addictive Diseases, 25(4), 91-103.
[3] Walley, A.Y., Alperen, J.K., Cheng, D.M., Botticelli, M., Castro-Dolan, C., Samet, J.H., & Alford, D.P. (2008). Office-Based Management of Opioid Dependence with Buprenorphine: Clinical Practices and Barriers. Journal of General Internal Medicine, 23(9), 1393–1398.
Huhn, A.S., & Dunn, K.E. (2017). Why Aren’t Physicians Prescribing More Buprenorphine? Journal of Substance Abuse Treatment, 78, 1–7.
[4] Kissin, W., McLeod, C., Sonnefeld, J., & Stanton, A. (2006). Experiences of a National Sample of Qualified Addiction Specialists Who Have and Have Not Prescribed Buprenorphine for Opioid Dependence. Journal of Addictive Diseases, 25(4), 91-103.
[5] Kissin, W., McLeod, C., Sonnefeld, J., & Stanton, A. (2006). Experiences of a National Sample of Qualified Addiction Specialists Who Have and Have Not Prescribed Buprenorphine for Opioid Dependence. Journal of Addictive Diseases, 25(4), 91-103.
Walley, A.Y., Alperen, J.K., Cheng, D.M., Botticelli, M., Castro-Dolan, C., Samet, J.H., & Alford, D.P. (2008). Office-Based Management of Opioid Dependence with Buprenorphine: Clinical Practices and Barriers. Journal of General Internal Medicine, 23(9), 1393–1398.
Huhn, A.S., & Dunn, K.E. (2017). Why Aren’t Physicians Prescribing More Buprenorphine? Journal of Substance Abuse Treatment, 78, 1–7.
[6] O’Brien, J., Sadwith, T., Croze, C., & Parker, S. (2019). Review of State Strategies to Expand Medication Assisted Treatment: A Report to the Laura and John Arnold Foundation. Technical Assistance Collaborative. Retrieved from http://www.tacinc.org/media/90793/arnold-foundation-brief-expanding-mat_may-2019v02.pdf.

There has been a significant and alarming increase in the use of e-cigarettes (commonly referred to as vaping products) among youth. According to the U.S. Centers for Disease Control and Prevention (CDC), 27.5% of high school students (4.1 million) and 10.5% of middle school students (1.2 million) reported using e-cigarettes (vaping) in the past 30 days in 2019.[1] This represents a 114% increase among middle school students and a 32% increase among high school students since last year, despite growing public awareness about the dangers of vaping and increasing efforts to prevent vaping among youth.

As is the case with conventional cigarettes, e-cigarettes deliver high doses of nicotine, a highly addictive drug. A growing body of evidence suggests that early use of nicotine increases the risk of addiction involving not only nicotine but also alcohol and other drugs. In fact, 95% of cases of nicotine addiction originate with substance use before age 21. Nicotine and the other chemicals in e-cigarettes, many of which are toxic, also have been linked to numerous negative health effects, including cardiovascular and respiratory disease, cancer, and mental health and cognitive problems.

Due to the emergence of e-cigarettes and their strong appeal to youth, a generation that was on the cusp of being the first to broadly reject cigarette smoking and become tobacco free, instead has become hooked on nicotine due to a decade of lax oversight of e-cigarette products.

Center on Addiction recommends that the federal government adopt a number of policy changes to address the youth vaping epidemic.

First, the U.S. Food and Drug Administration (FDA) should take immediate action to assert the regulatory authority granted in the 2009 Tobacco Control Act and expanded in the 2016 deeming rule to regulate e-cigarettes as tobacco products.

Second, the federal government should ban all flavored vaping products, including mint and menthol, to address the significant increases in vaping among youth. Nearly all e-cigarettes are flavored in ways that appeal directly to children and adolescents – including candy, fruit, and mint – and use of flavored products has been shown to increase the likelihood that youth will use other addictive substances, including conventional cigarettes. The vast majority of youth who use e-cigarettes started with flavored products. A ban on flavored products is necessary to stop manufacturers from marketing products that appeal to youth and to delay the initiation of addictive substance use.

Third, the legal age of sale of all tobacco products, including e-cigarettes, should be raised to 21 years to delay initiation of use. Abundant research shows that use of any addictive substances prior to age 21 significantly increases the risk of addiction.

Fourth, manufacturers should be prohibited from marketing and advertising e-cigarettes to youth or in ways that might appeal to youth, including through social media channels. As the tobacco industry knows only too well, the best way to get lifetime customers is to start them early. This explains current e-cigarette marketing tactics that revive the glamorous promotional cues that for decades have attracted young people to the deadly habit of cigarette smoking.

Fifth, the government should impose a limit on nicotine content on e-cigarettes and other tobacco products. Currently, the amount of nicotine a vaping product can contain is unregulated, leading companies to use high nicotine levels to get customers addicted to their products and create long-term loyal customers. The high dose of nicotine in most vaping products makes it very difficult for people to quit, especially using current nicotine replacement therapies, which contain comparatively low doses of nicotine aimed at controlling cravings. It is within the FDA’s authority to limit how much nicotine a tobacco product can contain, and it should exercise that authority by setting low limits to reduce nicotine addiction – from either cigarettes, vaping, or other tobacco products – among youth and adults in the United States.

Finally, we recommend implementation of a model similar to that required for the sale of pseudoephedrine products, which are available only behind the counter in pharmacies, to allow for the sale of e-cigarette products to adults who wish to use them.[2] These products should not be sold in convenience stores, gas stations, or other venues that make them easily accessible to youth. In addition, e-cigarettes should not be sold online where youth can easily bypass age restriction requirements.

E-cigarette manufacturers have made a number of specious claims about their products’ safety and effectiveness as a smoking cessation tool. While they might be less toxic than conventional cigarettes, there is no evidence to assure their safety, and a growing body of evidence demonstrating their negative health effects. If e-cigarettes were used only as complete replacement products for smokers who have been unable to quit smoking using medically approved cessation tools, they could possibly serve a harm reduction role. However, research shows that the majority of those who use them to quit smoking end up becoming dual users, such that e-cigarettes supplement rather than replace other tobacco use. Companies interested in marketing e-cigarettes as smoking cessation tools should be required to use the established FDA process for bringing drugs to market while assuring their safety and efficacy.

The lack of regulations and oversight of e-cigarettes since their emergence on the market over a decade ago has caused an astonishingly high number of middle and high school students and young adults, many of whom otherwise would not have been susceptible to nicotine use, to use a highly addictive product. The federal government must take urgent action to adopt these changes and address this public health crisis.

[1] Cullen, K.A., Gentzke, A.S., Sawdey, M.D., Chang, A.T., Anic, G.M., Wang, T.W.,…King, B.A. (2019). E-Cigarette Use Among Youth in the United States, 2019. JAMA. Retrieved from https://jamanetwork.com/journals/jama/fullarticle/2755265.

[2] Nocera, J. (2019, November 6). The Sudafed Solution to the Vaping Problem. Bloomberg. Retrieved from https://www.bloomberg.com/opinion/articles/2019-11-06/the-sudafed-solution-to-america-s-vaping-problem.

Decriminalization is a public health-based approach that imposes penalties designed to discourage marijuana use and encourage treatment when necessary. Under decriminalization, marijuana remains an illegal drug but people who are caught possessing small amounts of marijuana (typically 1 ounce or less) for personal consumption are fined rather than arrested. Marijuana trafficking, distribution, and sale remain subject to serious criminal penalties, as does driving while intoxicated by marijuana.

Center on Addiction supports the decriminalization of marijuana because it more appropriately addresses marijuana use as a public health problem, rather than a crime. Incarcerating people for using marijuana serves neither the individual’s nor the public’s interest. Having a criminal record for marijuana use is damaging to individuals’ livelihoods and life opportunities, particularly for youth. The Center recommends that possession of marijuana for personal use not result in:

  • a criminal arrest, record, or incarceration, 
  • penalties that affect housing, child custody, education or employment opportunities, or
  • enhanced sentencing for other crimes (including probationers and parolees).

Center on Addiction also recognizes that the enforcement of marijuana laws has disproportionately impacted racial minorities. Racial bias is a serious problem that occurs in the enforcement of many laws, indicating that the solution requires more systemic changes. Although decriminalization alone will not eliminate racial bias in law enforcement, it would reduce racial disparities in arrest rates and incarceration for marijuana possession.

Marijuana laws should aim to deter marijuana use and facilitate treatment when needed. There is not yet sufficient evidence to suggest which consequences or penalties are most effective at deterring use and facilitating treatment. In designing and evaluating the effectiveness of a system of penalties for marijuana possession, states should consider the following recommendations:

  • Penalties for marijuana possession should discourage marijuana use and encourage treatment when necessary, for example, a fine with graduated consequences for repeat violations that could be mitigated by entering treatment.
  • Multiple violations for marijuana possession or public intoxication may indicate that the individual has a marijuana use disorder and should trigger a health-based intervention (e.g., evaluation by an addiction treatment professional, mandatory treatment), and possibly enhanced penalties (e.g., electronic monitoring, random drug testing, modified house arrest or brief lock-up) that are effective at motivating people to complete treatment.  For adolescents in particular, connection to treatment is important, as addressing substance problems early through treatment prevents further use and adverse consequences. 
  • Public use of marijuana should be strongly deterred with penalties, but should also be decriminalized.

For individuals charged with more serious marijuana crimes (e.g., distribution), courts should explore the use of alternative sentencing programs such as drug courts and evaluate their effectiveness in reducing substance use, recidivism, and costs. 

Center on Addiction opposes the legalization of marijuana for recreational use because it will increase access to and use of the drug among adolescents. Marijuana is an addictive drug that can interfere with brain development and exacerbate mental health conditions. The risks of marijuana use have been demonstrated through clinical and epidemiological research and the concerns about these health risks and the adverse consequences of legalization have been consistently voiced by national medical societies (e.g., American Medical Association, American Society of Addiction Medicine, American Psychiatric Association and the American Academy of Pediatrics).

Because legalizing marijuana is expected to increase the number of people who use the drug, it is also likely to increase the number of people who develop a marijuana use disorder. The addiction treatment system does not have the resources to treat everyone who currently needs care and is not prepared to handle an increase in patient demand.  

Instead of legalization, Center on Addiction supports keeping marijuana illegal but decriminalizing personal use (see our accompanying position statement). Decriminalization is a public health approach that prioritizes treatment over incarceration and eliminates commercial incentives to promote marijuana use. 

Marijuana use poses significant health risks to adolescents.

When used regularly during adolescence and early adulthood, a period of active brain development, marijuana can alter the structure and function of the brain, impairing learning and memory, and increasing the risk of addiction and psychosis. Although there is conflicting research and direct causation remains unclear, the bulk of evidence suggests that teens who use marijuana are at risk for cognitive impairment. Early and regular use during adolescence is associated with lower IQ later in adulthood and with decreased activity and/or connectivity in the areas of the brain related to executive function, learning and memory. Whether cognitive deficits are reversible is not completely clear. Early initiation and regular use are also associated with greater likelihood of developing a marijuana use disorder, which occurs in roughly one in six adolescent users – a rate that is nearly double that found among adult-onset users. Early initiation and regular use of marijuana also confers a higher risk for psychosis, especially among those predisposed to mental health problems. In addition to the health risks, adolescent marijuana use is associated with reduced educational attainment and increased likelihood of dropping out of high school.   

Unfortunately, regular or heavy use is the norm among young marijuana users, a pattern unlikely to be improved by legalization. National survey data suggest that on average, high school students who currently use marijuana use it 2 or 3 days per week.  

Marijuana use poses significant health risks to adults.

Approximately 9% of adults who use marijuana become addicted to it; this number may rise as levels of THC in marijuana increase. Regular marijuana use poses additional health risks, including cognitive and respiratory problems. Marijuana use can also exacerbate pre-existing mental health and medical problems and other substance use disorders.  

Marijuana use also poses a risk to drivers and others on the road. Marijuana is the illicit drug most frequently reported in connection with impaired driving and motor vehicle accidents, including fatal accidents. Following alcohol, cannabis is the second most commonly detected substance in drivers who were fatally injured in car crashes. There is evidence that the cumulative effects of marijuana and alcohol when used together cause greater impairment to driving than either substance alone.

Legalization is likely to increase marijuana use.

The very act of legalizing marijuana sends a message that the drug is safe and acceptable to use.  This shift in cultural norms puts adolescents, in particular, at risk. Legalizing marijuana for adult recreational use is expected to decrease teens’ perception of the harms of marijuana. Data from three decades of survey research indicate that decreased perceptions of harm are strongly associated with increased rates of adolescent use.

Legalization will inevitably lead to the growth of a commercial marijuana industry whose business model will be to promote marijuana use. The tobacco and alcohol industries provide an illustrative example of how businesses that profit from addictive substances put the public’s health at risk. Through innovations in product development, marketing and lobbying, the tobacco industry made its product more addictive and dramatically increased its consumer base in a relatively short period of time. The nascent marijuana industry has already begun implementing tobacco’s successful strategies. The alcohol industry garners roughly half of its profits from under age and excessive drinking, both of which are injurious to public health. The growing marijuana industry will similarly be incentivized to promote underage and heavy use. In Colorado, where recreational marijuana use is legal, 87% of the profits come from people who use the drug five to seven days per week. People who begin using marijuana as teens are much more likely to become the heavy users who drive profits, so a marijuana industry would need to market to teens in order to generate the greatest profits.

States that legalize marijuana will likely adopt minimum age laws as a way to deter teen use; however, such laws are not very effective at keeping substances out of the hands of teens.  Because teens’ primary sources of marijuana are their friends and family, if it is legal for adults, teens will have greater access to it, and greater access is associated with greater use. Alcohol is by far the most commonly used substance among teens, despite minimum legal drinking age restrictions.

Public health measures can help to reduce teen substance use. For example, there is reason to believe that the same strategies that have reduced smoking would also reduce marijuana use: strongly enforcing minimum purchase age laws; setting very high sales and excise taxes; imposing environmental use bans; prohibiting advertising, marketing and placement in entertainment media; and implementing sustained public awareness campaigns. All of these policies working together can have a positive impact on public health. 

However, discussions about legalizing marijuana fail to take into account the substantial investment needed to adequately regulate the drug and prevent adolescent use. States that have legalized marijuana use to date are imposing only modest taxes (relative to cigarette taxes), which are insufficient to keep prices high enough to deter adolescent use, and so far are failing to make adequate investments in other public health efforts.  

Legalizing marijuana will increase the number of people suffering from untreated addiction. 

Currently, only one in 10 people with alcohol or drug addiction receive treatment. In states where marijuana is legalized, we can expect more people to use the drug and consequently develop a marijuana use disorder. The problem is especially concerning for adolescents; marijuana is the primary drug used by most teens admitted to addiction treatment programs. Increasing the number of people with marijuana problems will place additional demands on a treatment system that is already severely under-resourced; as a result, a greater percentage of people who need treatment will not receive it. It is incumbent on states that are considering legalizing marijuana to commit resources to offer effective prevention and treatment services for those who are at risk of or develop a marijuana use disorder.

Center on Addiction encourages research on the medicinal value of marijuana and the use of any U.S. Food and Drug Administration (FDA)-approved medications derived from marijuana or containing cannabinoids. However, the Center opposes state “medical marijuana” laws because they bypass the FDA review process. 

The FDA’s process for approving new drugs is the current standard for verifying that a medication is safe and effective for a particular indication.  The FDA evaluates data on the safety, efficacy, dosage and side effects of new medicines and oversees the manufacturing process to ensure quality control and proper labeling. Without FDA review, there is no centralized evaluation of the evidence to determine whether a drug works to treat a specific condition and what dose is safe and effective.

State “medical marijuana” laws by-pass FDA review and allow patients to use marijuana if they have specific medical conditions approved by the state. Some states currently list medical conditions (e.g., some psychiatric and neurological disorders) based primarily on anecdotal reports, expert opinions and non-randomized studies. There is not sufficient high-quality evidence from randomized, controlled clinical trials to determine whether marijuana is actually safe and effective for treating most of these conditions. State medical marijuana laws also create a distribution channel that lacks sufficient oversight of standardization and purity of each “dose.” Furthermore, state marijuana laws approve smoked marijuana as medicine.  Smoking is not a medically-accepted route of administration for any medication because smoking can damage the lungs and results in second hand exposure.    

High-quality research has found that individual components of marijuana, known as cannabinoids, have therapeutic value for select health conditions, including chemotherapy-induced nausea and unwanted weight loss from AIDS. The two cannabinoids that are most studied for their therapeutic value are delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD). THC is responsible for the intoxicating ("high") effects of marijuana; CBD does not cause intoxication.     

The FDA has approved two THC-based drugs, Cesamet (which contains a compound similar to THC) and Marinol (which contain THC).  The FDA is currently reviewing clinical trials of drugs that contain CBD only and drugs with a combination of CBD and THC. More research is needed to develop better medications. Cesamet and Marinol are not ideal and may offer inadequate treatment because of their poor time of onset, duration of action, and time of offset.  Some have suggested that cannabinoids are less effective when isolated and that whole-plant based drugs are more effective. 

Center on Addiction strongly encourages more high-quality research on the medicinal value of cannabinoids to treat health conditions. While administrative and legal barriers (including marijuana’s DEA classification as a Schedule I drug) make it difficult to conduct such research, forgoing FDA review and allowing state legislators or voters to make health care decisions without this centralized review of the evidence poses an unacceptable risk to the public’s health.

The FDA is currently reviewing the medical evidence supporting the safety and effectiveness of marijuana for medical purposes. The FDA’s review may result in a recommendation that the drug be downgraded from Schedule I, which would create more opportunities for research and treatment.  

To protect public health and encourage research on the potentially therapeutic components of marijuana, Center on Addiction recommends the following:

  • The National Institutes of Health (NIH) should develop streamlined procedures to increase research on the utility of cannabinoids for medical use and encourage the development of better THC-based, FDA-approved medications.
  • NIH and the Institute of Medicine of the National Academy of Sciences should convene regular meetings to evaluate research data on therapeutic indications for cannabinoids and, when appropriate, make recommendations to the FDA about approving new indications.
  • State policymakers, physicians and patient advocates should work to encourage or fund research to test the safety and efficacy of marijuana-based and cannabinoid medications.
  • States that have approved “medical marijuana” should:
    • Establish surveillance programs to monitor safety, adverse events and outcomes, and
    • Provide education to prescribers and consumers about the risks associated with marijuana including risks associated with altered sensorium (accidents, inability to work or study effectively, etc.), cognitive deficits, addiction and psychosis.

Medications prescribed by a physician are the most effective, potentially lifesaving, treatment for opioid addiction. Medication-assisted treatment (also called MAT) reduces drug use and overdose rates and helps retain people in treatment longer, which is associated with better outcomes. MAT also reduces criminal behaviors and infectious disease risk and improves occupational, psychological, and family functioning. Studies suggest that combining MAT with therapy yields the best results.  

Unfortunately, there is a widespread misconception among providers, policy makers and the public that “abstinence-based” or “medication-free” treatment – without MAT – is best. Given the evidence supporting MAT’s effectiveness, this philosophy is not supported by research and is potentially dangerous.   

FDA-approved medications to treat opioid addiction include methadone, naltrexone and buprenorphine, which is often combined with naloxone. Naltrexone blocks the effects of opioids so people do not get intoxicated (high) or overdose if they use. Methadone and buprenorphine reduce cravings and withdrawal symptoms and allow individuals to improve their functioning in everyday life. When taken as prescribed, these medications do not cause the feeling of intoxication associated with opioid abuse. Because these medications have different mechanisms of action, different side effects and risks, and are available in different health service locations, the medication that is best for any individual will vary.

Methadone has been proven effective through over 40 years of research. The other medications are newer and therefore are less well studied, but data suggest that they may be as effective for many groups of people with opioid addiction. 

The length of treatment with MAT depends on the duration and severity of the addiction, the patent’s physical and psychological health and preferences, and other factors affecting recovery. People with an earlier stage or less severe form of addiction may benefit from taking medication for a shorter period of time (for example 6-12 months), depending on their treatment progress. For people whose addiction has progressed to a chronic condition, they may need to take medication for many years or even the rest of their lives, just like people who have asthma, diabetes or heart disease. 

The research supporting MAT is strong enough to conclude that MAT is an “evidence-based” treatment, meaning, it has been proven to work. All addiction treatment programs and providers should offer MAT directly or through referral; those that do not should not be considered “evidence-based” providers. Federal and state agencies that pay for addiction treatment services should require that MAT be made available to all patients treated in programs they support. Prohibiting or discouraging the use of MAT or denying reimbursement for this service is unethical, violates parity, and is inconsistent with acceptable medical practice.

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