Social factors in marijuana use for medical and recreational purposes

YEBEH-05105; No of Pages 8 Epilepsy & Behavior xxx (2016) xxx–xxx

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Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh

Review

Social factors in marijuana use for medical and recreational purposes Magdalena Szaflarski a,⁎, Joseph I. Sirven b a b

Department of Sociology, University of Alabama at Birmingham, HHB 460H, 1720 2nd Ave South, Birmingham, AL 35294-1152, USA Department of Neurology, Division of Epilepsy, Mayo Clinic College of Medicine, Mayo Clinic in Arizona, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA

a r t i c l e

i n f o

Article history: Received 27 October 2016 Revised 4 November 2016 Accepted 5 November 2016 Available online xxxx Keywords: Epilepsy Cannabis Marijuana Society Sociology Culture

a b s t r a c t Of all the various treatment options for epilepsy, no other therapy comes close to the polarity that cannabis engenders. The rationale for this reaction is firmly rooted in the social factors that enshroud the use of marijuana for both medical and recreational purposes. In order to best understand how to approach this controversial treatment, it is essential to explore the social, demographic, and historical variables that have led to the current opinions on cannabis therapy and how this has converged on epilepsy treatment. Utilizing a sociological conceptual framework, this review discusses in depth the social, cultural, and historical dimensions of cannabis use in the US for medical purposes and its impact on epilepsy treatment. Moreover, it posits that cannabis therapy and the opinions surrounding its use are products of history and assesses this treatment option through the lens of our current times. This article is part of a Special Issue titled Cannabinoids and Epilepsy.

1. Introduction Marijuana refers to the dried leaves, flowers, stems, and seeds from the hemp plant Cannabis, which contains several compounds known as cannabinoids, most notably the psychoactive (mind-altering) chemical delta-9-tetrahydrocannabinol (THC), as well as other compounds such as cannabidiol (CBD). There are two varieties of cannabis, Cannabis sativa and Cannabis indica. Research has shown that these two species produce different effects, probably due to different concentrations of the main components; C. sativa plants have a higher ratio of CBD/THC while the opposite is true of C. indica plants [1]. Marijuana is the most commonly used illicit drug in the US. Marijuana is smoked in handrolled cigarettes (joints), pipes, or water pipes (bongs); it is also mixed in food or brewed as tea. The short-range effects of marijuana include problems with memory and learning, distorted perception, difficulty in thinking, and loss of coordination. Among youth, heavy cannabis use is associated with cognitive problems and increased risk of mental illness [2]. In 2013, 7.5% (19.8 million) of the US population aged 12 years and older reported using marijuana during the preceding month [3]. Marijuana use is often considered a behavioral problem, but marijuana use is also – and perhaps foremost – a sociocultural phenomenon. Humans discovered marijuana in ancient times, and marijuana has been used for ⁎ Corresponding author. Tel.: +1 205 934 0825; fax: +1 205 975 5614. E-mail addresses: szafl[email protected] (M. Szaflarski), [email protected] (J.I. Sirven).

© 2016 Elsevier Inc. All rights reserved.

medicinal, ceremonial, and recreational purposes by people around the world (see [4,5] for a review). Marijuana is an illegal substance under the current US federal regulations. Specifically, in 1937, the US government made cannabis possession and transfer illegal and punishable by law. However, many states in recent years have legalized or considered to legalize marijuana for medicinal or recreational purposes. Although the public opinion on marijuana legalization is divided, legal restrictions and social attitudes toward marijuana are relaxing, and cannabis products are becoming more accessible [3]. With these changes, there are continuing and increasing concerns in the US about marijuana use among at-risk populations, especially youth [6,7] as well as about the effectiveness of cannabis-based treatments for health problems. In particular, there is a growing body of literature regarding the use of cannabinoids for a variety of neurological conditions, most notably multiple sclerosis [5,8–12] and epilepsy, and clinical trials are under way [13]. These developments call for a closer examination of social factors in marijuana use. So, what are these social factors and how are they associated with marijuana use? The use of marijuana is inextricably linked with the key components of human societies – culture, polity, economy, law and order, and other aspects of social life (population/demographic profile, science, health, social stratification, etc.). Here are potential questions that address the different social dimensions of marijuana and marijuana use: (1) Culture: What are the cultural conceptions of marijuana (what it is, what purpose it serves)? What are the social attitudes toward marijuana use and different types of use? (2) Politics: What is the society's formal position (policy) on marijuana and marijuana use? Is marijuana

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Please cite this article as: Szaflarski M, Sirven JI, Social factors in marijuana use for medical and recreational purposes, Epilepsy Behav (2016), http://dx.doi.org/10.1016/j.yebeh.2016.11.011

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regulated? If so, what aspects and how? Is the political/policy discourse changing and how? (3) Law and order: How are marijuana-related laws and regulations enforced? What penalties are there for breaking the laws/regulations? Who are the offenders and what is their motivation? (4) Economic: How is marijuana produced and distributed? What is the profile of producers, distributors, and consumers? (5) Science and health: What is the scientific evidence regarding recreational marijuana use and as treatment for health problems/conditions? What are the attitudes of patients and providers toward marijuana use for medical reasons? The purpose of this review is to present and organize what is known about the social aspects of marijuana use. Sociological perspectives – social constructionism, post-structuralism, deviance, medicalization, population health, and social determinants of health – will provide a conceptual framework for understanding the place of marijuana in American society. The aim is to delineate directions for future research that considers social dimensions of marijuana use, especially as treatment for medical conditions, including epilepsy/seizure disorders.

in four dimensions (quadrants): 1) cannabis as a poison for the soul, expressed in prohibition and criminalization discourses; 2) cannabis as a remedy for the soul, expressed in ritual and recreational use; 3) cannabis as a poison for the body, expressed in treatment and public policy discourses; and 4) cannabis as a remedy for physical necessities, expressed in medicinal and economic use. In a review of mass media material, Acevedo found that the majority (56%) of media items reflected negative appreciations of the discourse (prohibitionist, criminalistics, and treatment-related), but many also represented more liberal views of cannabis (recreational, medical, and economic use), favoring its reclassification. The news items frequently featured information from interest groups and other “campaigners” (e.g., pharmaceutical companies). Furthermore, the discourses on public policy regarding cannabis focused primarily on explaining the efficiency and costsavings of the reclassification. A similar analysis of cannabis discourses in America would be useful to understand the power interests and “campaigners” for or against cannabis in the US. 2.3. Deviance

2. Conceptual framework Any discussion of social factors in health requires a sociological lens. Several sociological perspectives are particularly useful in conceptualizing, contextualizing, and analyzing cannabis use. We provide a brief overview of these perspectives, which are not fully independent but rather build upon and complement each other. 2.1. Social constructionism Social constructionism is a theoretical perspective grounded in the idea that scientific knowledge and biological discourse about the body, health, and illness are produced by subjective, historically determined human interests which change and are reinterpreted over time [14, 15]. Within this approach, cannabis and other drugs are defined through social constructions that emerge during certain historical periods [16]. In contemporary society, drugs are defined according to existing drug policies and related legal terms. Specifically, ideas about certain drugs tend to be grounded in the concepts of ‘addiction’ and ‘prohibition’ because of how social institutions and social actors have defined these drugs, based on their ‘appreciations’ of these drugs and their use [16, 17]. The opinions of these actors and institutions are supported by relevant knowledge produced in specific historical periods. An analysis of drugs and drug policies from this perspective focuses on the views held by policy makers and social groups regarding drugs and related social and behavioral problems. Social constructions of drugs during a particular historical period can be found in that period's official documents, political speeches, media messages, and statements of individual opinions [16]. Thus, per the social constructivist view, the main question we would ask about cannabis in the US is: What information about cannabis is available in scientific reports, policy statements, legal documents, media messages, and other sources? 2.2. Post-structuralism Social constructions of cannabis in a society emerge within a broader sociocultural context which is supported by a particular social system and power structure [16]. Post-structuralists, such as Michel Foucault (1972), have advocated close examinations of the social system (the links and connections between different components of a social context) in which social constructions emerge. Foucault focused on the different discourses about a particular problem, which he called the “archeological material.” Following this approach, Acevedo [16] examined how discourses (“archeology”) on cannabis evolved in Great Britain in the 2000s (reclassification of cannabis from B to C class of drugs) and what role these discourses played in the drug policymaking process. Acevedo identified eight types of discourses expressed

A common frame for analyzing marijuana and other drug use is deviance [18]. Deviance is defined as non-conformity to social, cultural, or behavioral norms. People who engage in antisocial activities, substance abuse, and criminal behaviors or who otherwise live outside social norms are considered deviant. Sociologists posit that deviance can only be defined in the presence of norms or rules. Strong norms that are linked with social values that are held sacred by a society (e.g., don't kill) are written into a code of law and enforced through the criminal justice system. Laws and other social norms regarding cannabis and cannabis use vary across societies and historical periods and can be weak or strong, resulting in varying forms and levels of social punishment for cannabis use, possession, or transfer. The social construction of drug use as a deviant behavior is typically based on the vested interests and ideologies of those who have power over deviancedefining processes, especially legislative bodies and the mass media [19]. Criminalization of marijuana in the US has been framed as a process of moral entrepreneurship – to send a clear message regarding society's disapproval of marijuana use [18]. 2.4. Medicalization Medicalization is the process by which previously nonmedical problems become defined and treated as medical problems [20]. The transformation of deviant behavior, such as drug abuse, into mental or behavioral disorder, which can be treated within the medical paradigm, is the classic case of medicalization. Medicalization is often linked with evidence that suggests that a certain behavior or condition impacts health/functioning and can be treated using biomedical therapies. Marijuana use has been medicalized in the Western world as a health-risk behavior, and marijuana abuse or dependence can be treated as an addictive disorder. On the other hand, cannabis has medical uses including its current accepted use as an agent for post chemotherapy nausea and vomiting or to increase appetite [21] and has been studied as a viable medical treatment, with addiction and other side effects being a serious concern. This adds another layer of complexity to medicalization of marijuana use. 2.5. Population health Evidence shows that substance use disorders take an immense toll on population health and other aspects of social life (e.g., families, education, and economy) [2]. In the US, drug and health policies are in place to reduce the burden of substance use disorders. Based on these policies, population-level interventions, typically within the domain of public health, are developed to target substance abuse. Among other efforts, the US has extensive surveillance programs in place to track substance

Please cite this article as: Szaflarski M, Sirven JI, Social factors in marijuana use for medical and recreational purposes, Epilepsy Behav (2016), http://dx.doi.org/10.1016/j.yebeh.2016.11.011

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There is long-lasting evidence about social inequalities in health [22] and in epilepsy, specifically [23]. The social determinants of health (SDH) are social characteristics of individuals (e.g., social class, education, and race/ethnicity) and conditions in which individuals live and work (e.g., housing and occupational environment) that determine their health status [14,24]. The SDH relationship to health status is mediated (and sometimes moderated) by behaviors and psychosocial factors (e.g., self-esteem). In relation to marijuana use, one may wonder which social status characteristics are associated with marijuana use. For example, are men more likely users than women because men tend to have higher incomes/social position than women and because drug use among women is more stigmatized than among men, due to patriarchal culture and gender roles? Are youth and young adults more likely users than older age groups because they are going through developmental changes (e.g., experimenting) or are trying to socially “fit in”? Are minority, urban youth at more risk of abuse because of neighborhood structural conditions (poverty, unemployment, crime, etc.)? Marijuana use, as other health behaviors, is most likely to be uneven across the population.

has also documented harmful effects of smoked marijuana as a crude THC delivery system. There are significant concerns about the psychological effects of cannabinoids – anxiety reduction, sedation and euphoria, which can influence the drugs' therapeutic value as well complicate the interpretation of other aspects of the drug's effect. The public opinion seems to follow these scientific interpretations regarding marijuana and its uses. The medical and scientific authorities, as well as policy makers, appear to rule the social constructions of marijuana in the US and Western countries [16]. The debate about legalizing marijuana is often framed within core values (morality framing, morality politics) of/by different groups [28, 29]. While religious or conservative groups might oppose and favor restricting marijuana use as immoral behavior, libertarians have supported individual choice and argued that marijuana should be free to consume. In addition to core values, physical and mental health harms, behavioral toxicity (e.g., school dropout and reduced labor productivity), and crime are often evoked concerns that shape public opinion. However, public opinion has typically favored “medical marijuana,” a term, which Rubens [30] calls an oxymoron – because it contains the words medical and marijuana and because it depicts two sides of a political argument. On the one hand, marijuana is a recreational, illicit drug widely used in the US. On the other hand, smoking of marijuana for medical purposes is expanding and becoming more acceptable. Based on his analysis of political and medical views on medical marijuana and its future, Rubens concludes that the movement of scientific knowledge of medical marijuana has followed an erratic pathway, with three forces – science, social-political acceptance, and laws – shaping the process (p. 121).

3. Current knowledge

3.2. Policy and legal aspects

What do we actually know about social aspects of marijuana use? Below we review the relevant literature and other information that fits into the different social dimensions, such as culture, policy and law, sociodemographic trends, social status determinants of use, and so on.

At the federal level, marijuana is classified as a Schedule 1 substance under the Controlled Substances Act. Drugs in this schedule are considered to have a high potential for dependency and no accepted medical use, making distribution of marijuana a federal offense. There have been calls for rescheduling marijuana. In particular, organized medicine – AMA, IOM, and the American College of Physicians – have argued that the fragments of state laws fail to bring about clinical standards needed for marijuana and that if the drug could be placed under a Schedule II designation, regular evaluation and research by industry would follow [30,31]. In August 2016, the Drug Enforcement Administration (DEA) denied two recent petitions to reschedule marijuana, citing a lack of accepted safety for its use under medical supervision and the high potential for abuse. However, the DEA requested a scientific and medical evaluation and scheduling recommendation from the Department of Health and Human Services (HHS), with guidance from the US Food and Drug Administration (FDA) and the National Institute on Drug Abuse (NIDA). The DEA and FDA claim that “scientifically valid and well-controlled clinical trials conducted under investigational new drug (IND) applications are the most appropriate way to conduct research on the medicinal uses of marijuana” and that “the drug approval process is the most appropriate way to assess whether a product derived from marijuana or its constituents is safe and effective and has an accepted medical use” (https://www.dea.gov/divisions/hq/2016/hq081116.shtml). Despite the federal law, some states have introduced their own laws. California was the first state (1996) to allow for the medical use of marijuana. Currently, a total of 25 states, the District of Columbia, Guam, and Puerto Rico have enacted similar laws. Whereas these states/areas allow for comprehensive public medical marijuana and cannabis programs, 17 other states allow use of low-THC, high-CBD products for medical purposes in limited situations or as a legal defense. “Comprehensive” programs are defined as (1) protecting from criminal penalties for using marijuana for a medical reason; (2) allowing access to marijuana through home cultivation, dispensaries, or some other system;

use and abuse, and public health agencies engage with partners at the community level to develop viable interventions. Thanks to the population-level health efforts, there is a wealth of statistical data and other published research available to understand the sociodemographic and other social patterns and trends in marijuana use. This point brings us to consider the specific social correlates of marijuana use on which we elaborate below. 2.6. Social determinants of health

3.1. Cultural dimensions of marijuana use: science versus morality Cannabis has been around in America for centuries [4,25]. In the 17th century, King James ordered land owners to grow 100 plants of hemp (marijuana plant for industrial use) for export purposes. Through the mid- to late-19th century, cannabis, as the so-called “Piso's Cure,” was used mostly as a medical remedy for various conditions including pain and colds, and was recommended for use in “young and old.” It remained unregulated until early 20th century. Because of documented abuses of the drug, in 1937 the US government made it illegal to possess or transfer cannabis. The American Medical Association (AMA) opposed this action. Media such as the internet, television, and film often provides a mirror on the cultural viewpoints surrounding marijuana usage. Popular films that have used marijuana as an important plot point tends to portray marijuana use as comedy rather than drama. Shows like Cheech and Chong, Harold and Kumar, That 70′s Show, and the Showtime series Weeds have mined this issue for its comedic potential reflecting the broader cultural acceptance of the agent and a sense that there were few dangers. Yet, as an NPR story [26] revealed, the moment that a film uses cocaine or another drug as its major plot point, the story turns dark, reflecting where the culture stands on a given agent. Today, both potentially beneficial as well as harmful effects are broadly accepted, largely based on medical and scientific evidence. The Institute of Medicine (IOM) [27] examined the available research and confirmed potential therapeutic uses of marijuana including the potential value of cannabinoid drugs, especially THC, for pain relief, control of nausea and vomiting, and appetite stimulation. However, research

Please cite this article as: Szaflarski M, Sirven JI, Social factors in marijuana use for medical and recreational purposes, Epilepsy Behav (2016), http://dx.doi.org/10.1016/j.yebeh.2016.11.011

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(3) allowing a variety of strains, including those more than “low THC”; and (4) permitting either smoking or vaporization of some kind of marijuana products, plant material, or extract [32]. With the state-level developments, enforcement of the federal law has been relaxing. In 2009, the Obama administration sent a memo to federal prosecutors encouraging them not to prosecute people who distribute marijuana for medical purposes in accordance with state law. Subsequently, in 2013, the US Department of Justice shifted enforcement efforts to the states while deferring the right to challenge the state legalization laws. States with medical marijuana laws typically have patient registries, which provide some protection against arrest for possession up to a certain amount of the drug for personal use. Regulation of marijuana recommendation, dispensing, and patient registries are the most common policy questions. For example, places that have no dispensary regulation experience a boom in new businesses, which are seeking approvals before stricter regulations are made. Also, growers and dispensaries are often considered as “caregivers” and may be limited to a certain number of plants or products per patient. An analysis of state laws permitting use of marijuana for medical purposes has documented great variability across several law features [33]. First, states vary in the number and types of conditions that are permitted for use of medical marijuana. For example, Illinois allows medical marijuana use for 40 different conditions while some other states (e.g., Washington, Vermont) allow it only for 6–7 conditions. Furthermore, marijuana use for terminal conditions, such as amyotrophic lateral sclerosis, and chronic physical health problems, such as muscle spasms and migraines, was more commonly legalized across states than mental health conditions, such as anorexia or post-traumatic stress syndrome. The analysis also showed variation in cultivation, possession, and restrictiveness levels across the states. For example, California and Washington were among the states with the highest permitted levels of cultivation and possession, while Colorado and Oregon scored the highest on the restrictiveness index. Some states (e.g., Maryland, Massachusetts) had low scores on all three measures. There are speculations in the literature about broader implications of permissive medical marijuana laws. For example, it remains unclear to what extent such laws provide a wider access to marijuana without a prescription, strengthen pro-marijuana views, and lead to greater use and willingness to legalize marijuana for recreational use [33]. So far, the evidence is thin or mixed as to whether medical marijuana laws have led to higher rates of marijuana use in the states that passed these laws [34–36]. Some argue that medicalizing marijuana is a “new culture of crime control” [37] and that, in contrast to criminalization, the legal-medical model offers potent forms of social control at the structural, cultural, and interactional levels of society [38]. There have been a number of legal cases involving medical marijuana stemming from the dispute between the federal and state laws (see examples in [30]). Some rulings have favored the federal government's opinion while others have upheld state laws. Rubens [30] outlines the complex adaptive system theory conceptualization of the forces involved in the legalization of medical marijuana. The system's key components – executive decisions, state laws and policies, federal laws, lack of scientific evidence, lack of research and funding, public opinion, and anecdotal evidence – are intricately connected in a way that reflects a non-linear and discontinuous route to broader legalization. The concern over legalization potentially being used as a cover for illicit drug use hinders the efforts in states without medical marijuana laws to consider such legislation. 3.3. Public opinion According to the Pew Research Center [39], an increasing proportion of Americans favors legalizing marijuana use (survey question: “Do you think the use of marijuana should be made legal, or not?”). A total of 57% of US adults currently supports marijuana legalization versus 37% who

are against it, compared to 32% and 60%, respectively, in 2006. The greatest change in attitudes toward legalization of marijuana is noted for millennials (individuals aged 18–35) – they are more than twice as likely to favor marijuana legalization today (71%) than a decade ago (34%). However, the majority of members of Generation X (ages 36– 51) and Baby Boomers (ages 52–70) also favor legalization now, up from 21% and 17% in 1990. The majority of both genders and people across different educational levels support legalization, but, interestingly, Hispanics are less likely to favor legalizing marijuana than whites or blacks. There are also marked ideological and partisan differences in attitudes toward marijuana legalization: 66% of Democrats favor legalization whereas 55% of Republicans are against it. However, there is a sharp split among Republicans, with 63% moderate and liberal Republicans supporting legalization and 62% of conservative Republicans opposing it. An analysis based on media items, legislative transcripts, elite interviews, and other materials [29] showed that the public debate over decriminalization of marijuana continues to be shaped to a large extent by morality framing. In arguing against decriminalization, critics have used moral, mixed, and non-moral arguments. Those arguing from the moral standpoint have argued that decriminalization sends the wrong message to youth, decreases risk perception, and promotes “normalization.” Other critics have evoked negative effects of decriminalization for families, communities, and society at large (mixed argument), and still others have focused on negative health effects (non-moral view).

3.4. Economic aspects of marijuana Economic aspects of marijuana use are complex and deserve a detailed analysis which is beyond the scope of this paper. Issues range from manufacturing and distribution to taxing, banking, and land use and zoning (e.g., [40–43]). Our goal is to note several economic dimensions of marijuana legalization, which have been highlighted in the literature and government and legal documents. Even before passing some marijuana state laws in 2012, fiscal implications of legalizing marijuana were being discussed [28]. Specifically, experts emphasized the potential for increased tax revenue and decreased enforcement costs that would come with legalization. Taxes were also projected to influence price, and, potentially, discourage marijuana use. The federal response to state laws legalizing marijuana was expected to be driven by trade-offs among three categories of cost: costs of regulation and enforcement; costs associated with use (including health effects and other outcomes); and, consequences of black markets. Researchers also tried to characterize legal marijuana markets in terms of projected prices in states that legalize; effects on prices in other states; and tax collection and evasion [28]. Since 2012, empirical evidence has emerged from experiences of states that legalized marijuana. A legislative brief, Regulating Marijuana: Taxes, Banking, and Federal Laws [44] reports on lessons learned about legal sales and regulations in Colorado and Washington, where marijuana use for recreational purposes became legal in 2012. For example, the states have had to balance keeping tax rates at the appropriate level, generating enough revenue to fund regulation, enforcement and education programs, while keeping them low enough to reduce the black market incentives. Taxing marijuana and cannabis-infused products has also been challenging due to variations in measurement (THC levels versus flower product weight, versus edible products' volume or potency, etc.). Furthermore, for marijuana businesses, taxes are tricky because they must file federal tax returns, but are prohibited from taking the tax deductions available to other businesses. Banking has also been affected. It is challenging to create a banking system that allows operation of cannabis-based businesses because of marijuana's illegal status at the federal level. There is a risk of breaking federal banking laws by processing credit card transactions or accepting cash from the businesses. At the federal level, the Departments of Justice and the Treasury have

Please cite this article as: Szaflarski M, Sirven JI, Social factors in marijuana use for medical and recreational purposes, Epilepsy Behav (2016), http://dx.doi.org/10.1016/j.yebeh.2016.11.011

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clarified how financial institutions can provide services to marijuanarelated business (Cole Memo, Bank Secrecy Act memo). In terms of manufacturing of marijuana in the US, DEA has announced increasing the number of authorized marijuana manufacturers supplying researchers (https://www.dea.gov/divisions/hq/2016/ hq081116.shtml). At present, there is only one authorized supplier, the University of Mississippi, which operates under a contract with NIDA. The new policy will allow additional entities to apply to become registered with DEA so that they may grow and distribute marijuana for FDA-authorized research purposes. In addition, the US Department of Agriculture (USDA) has released a statement of principles concerning provisions of the Agricultural Act of 2014 relating to the cultivation of industrial hemp, a low-concentration THC cannabis plant used for industrial purposes (e.g., fiber and seed). The statement describes the legalized growing and cultivating of industrial hemp for research purposes under certain conditions, for example, in states where growth and cultivation are legal under state law. 3.5. Population-level surveillance Federal agencies, in particular the Substance Abuse and Mental Health Services Administration (SAMHSA), have traditionally been tracking marijuana and other illicit drug use at the national and state levels to understand the extent of behavioral health problems (drug use, abuse, and addiction) in the US population, in particular among youth and young adults. Recently, monitoring marijuana use has also been helpful in identifying changes due to legalization of marijuana for medical or recreational use in some states. The best source of the current information on marijuana use nationally is the National Survey on Drug Use and Health (NSDUH), a large representative sample of the US noninstitutionalized civilian population aged 12 years and older. A recent report provides national estimates of marijuana use based on the NSDUH data for 2002–2014 [3]. Marijuana use was defined as a self-report of using marijuana (pot or grass) or hashish (hash). The screening question for marijuana use was: “Have you ever, even once, used marijuana or hashish?” Six indicators were developed for the study: marijuana use; marijuana initiation; perception of harm risk, approval, and attitudes; perception of availability and mode of acquisition; marijuana dependence and abuse; and, marijuana possession-criminal justice. The results of this study showed that in 2014 the prevalence of past month and past year marijuana use was at 8.4% and 13.2%, respectively. Furthermore, between 2002 and 2014, the increases for past month and past year marijuana use were 35% and 20%, respectively. The increase for past month use was observed across most demographic categories (sex, race/ethnicity, education, employment status, and US geographic region). The prevalence of daily or almost daily use in 2014 was 2.5% (92% increase from 2002) and 3.5% (75% increase) for past year and past month use, respectively. While past year use increased by 7% among individuals 18–25 years old, past year use decreased by 17% among youth aged 12–17 years. A similar pattern was noted for daily and almost daily marijuana use. Among other results, the study showed a decrease in perceived great risk and no risk from smoking marijuana once a month (31% decrease) and once or twice a week (33% decrease). The decrease was noted in all age groups. In addition, there was a decrease in disapproving attitudes toward peers trying marijuana, but only among past month marijuana users aged 12–17 years. Earlier research [34,45–47] has found that perception of risk is inversely associated with prevalence of use, but the current report found this relationship present only among adults and not among youth. The prevalence of past year marijuana dependence and abuse in 2014 was overall low (b2%), but it was approximately 12% among past year marijuana users. The latter actually reflects a 29% decrease in dependence and abuse since 2002 among past year users. The report authors stipulate that either the effect of state-level legalization might not

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yet be observed for youth, who are more limited in availability than older groups, or that those who use marijuana daily for medical reasons might be using strains (e.g., CBD) that pose lower risk for dependence or abuse [3]. In terms of perceived availability of marijuana, 60% of all respondents stated that it would be fairly easy or very easy to obtain marijuana (4% increase from 2002). However, the perceived availability decreased by 13% among persons aged 12–17 years and by 3% among persons aged 18–25 years. The most common modes of acquisition among past year users was purchase (48%) and “got it for free or shared with someone else” (49%); trading it for something and growing it yourself were rare (about 1%). The perceptions of maximum legal penalties for first offense possession of an ounce or less of marijuana for own use have also changed between 2002 and 2014. Compared to 2002, more people in 2014 were in favor of a fine as penalty or no penalty, and fewer people supported probation, community service, and possible and mandatory prison sentence as penalty for first offense marijuana possession. These observable changes cannot be used to infer a causal link to changing state laws. Especially, caution is needed when interpreting the findings regarding marijuana use among youth because the potential effects of increased legalization might be delayed, and there might be other factors responsible for decrease in use, such as communitybased substance abuse programs [3]. Research has also examined trends in registered medical marijuana participation across 13 US states and the District of Columbia [48]. The findings show that registration rates were relatively low and flat from 2001 to 2008 (b 5 per 1000 adults). Significant increases were noted in Colorado, Montana, and Michigan during 2009–2010, but not in other states. High rates are currently observed in Colorado, Oregon, and Montana (15–30 per 1000) with the national average of approximately 7.6 per 1000 adults. The majority (75%) of participants are male, but sex differences have been decreasing. Participants tend to be older (50s); fewer than 1% of registrants are under 18. Whether the size and trend in the population of registered users impacts access, attitudes, and consumption is not fully clear. 3.6. Subcultures 3.6.1. Recreational marijuana use Ethnographic research on youth marijuana subcultures has examined the settings, procedures, and methods of marijuana use, and various populations of users based on social class, racial/ethnic background, and other characteristics [49]. Some of the studies focus on white upper and middle class youth as the largest user group [50]. This contrasts with the popular perception (often reinforced by research) that urban communities of color have the highest rates of use. Marijuana is also the most widely used substance in gang life [51]. It is “a shared group activity and an integral part of everyday life among gang members” (p. 125). Gang members often do not consider marijuana a drug. Self-medication and escape were cited by gang members as reasons for smoking marijuana. African American gang members in the study preferred marijuana to hard drugs because of their drug sale activities and their motto: “Never get high off your own supply” (p. 121). The study authors labeled this attitude as “sensible drug use.” 3.6.2. Medical marijuana use Another ethnographic study has examined grassroots innovations in medical marijuana delivery systems [52]. The study provides an account of the production, distribution, and administration of non-smokable cannabis products in a California health care collective in the late 1990s. The organization had about 200 active members/users and another 70 supporting members (e.g., caregivers) who together cultivated marijuana plants and produced a variety of medicinal products. Instead of paying for their marijuana, the members were encouraged (based on their health) to volunteer hours to the organization's operations as well as to support each other via informal hospice care.

Please cite this article as: Szaflarski M, Sirven JI, Social factors in marijuana use for medical and recreational purposes, Epilepsy Behav (2016), http://dx.doi.org/10.1016/j.yebeh.2016.11.011

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Opponents of marijuana legalization often focus on the harms of smoking marijuana, and some medical marijuana users share this concern. The smoking method was preferred among the users in the California study who had a terminal or debilitating illness, but others living with chronic conditions were concerned about the long-term effects of smoking marijuana. Many members admitted that they had attempted to reduce (or eliminate) their reliance on smoking marijuana in favor of consuming baked goods, tinctures, or soymilk-based beverages, or using a vaporizer. While these alternative forms of cannabis worked for many users, one common concern was appropriate dosing. The users reported that eating cannabis-based products required experimentation to establish an effective but not overpowering dose. The group members taught and learned from each other about alternative methods of ingestion. Through working together, the group invented and improved on the organization's many non-smoked medical marijuana products. The researchers labeled this phenomenon as “grassroots innovations.” 3.7. Marijuana as a treatment in epilepsy A 2013 CNN Special Report by Dr. Sanjay Gupta, Weed, brought to light stories of desperate families with children suffering from debilitating seizures who had turned to CBD as a potential therapy. The documentary centers on a young couple from Colorado, Paige and Matt Figi, whose 5-year-old daughter, Charlotte, struggles with Dravet Syndrome. The family travels across state lines to treat Charlotte with CBD. The results of the treatment are extraordinary – Charlotte goes from having hundreds of seizures a week to only one small episode each month. The documentary presents scientific evidence and interviews with patients/families and experts all over the world to shed new light on the potential of cannabis-based medical treatments. After making Weed, and eventually Weed 2 and Weed 3, Dr. Gupta – once a proponent of an enforced prohibition on marijuana – has revised his thinking, offered a public apology, and recently called for a full-scale “medical marijuana revolution” [53]. The Figi case was also documented in the scientific literature [54]. As part of the report, Paige Figi, Charlotte's mother, provides a personal account of her journey to find treatment for her daughter, which included research (“I spoke with parents, doctors, scientists, chemists, marijuana activists, growers, medical marijuana patients, layers, and dispensary owners,” p. 783), finding producers of high-CBD-strain cannabis (the Stanley Brothers), and obtaining a marijuana use permit in Colorado. Initially, medical professionals discouraged her from pursuing cannabis therapy because of Charlotte's young age and uncertain outcomes. After getting clearance from epilepsy specialists and the state of Colorado, the mother began treating Charlotte via incremental dosing with CBD extract that would become known as Charlotte's Web. After 20 months, Charlotte's seizures dramatically improved, and she began walking and talking. The parents tested various doses with and later without antiepileptic drugs to achieve an optimal outcome. In her account, Paige Figi acknowledges the Stanley Brothers and their nonprofit foundation for helping over 200 patients to gain access to high CBD-content cannabis by early 2014. The paper also reviews the current pharmacological data regarding CBD and draws attention to the importance of autonomy and availability in accessing and using CBD among patients who are pursuing this therapy to address catastrophic seizures. These patients' caregivers face an enormous burden – from daily challenges and emotional toll to the risk of sudden unexplained death in epilepsy (SUDEP) – and are attracted by the potential that cannabis-based treatments offer. In the meantime, the quality of CBD is a serious challenge, as “homemade” versions of the extract emerge and may be linked with cases of status epilepticus and other health problems, per anecdotal evidence. The report calls for “calm … and … thoughtful and thorough pharmacologic and clinical investigation into cannabis … to confirm or disapprove its safety and antiepileptic potential” (p. 785), echoing other experts [4,12].

There has also been an immense and multi-prong effort to mobilize the epilepsy patient communities nationwide to advocate for expanded access to cannabis-based treatments via engaging advocacy groups such as The Epilepsy Foundation [55] and social media outlets like Facebook. The Epilepsy Foundation's 2016 Government Affairs Statement articulates the goal of advocating for “removing federal barriers to research on the connection between cannabis and epilepsy, including supporting the rescheduling of cannabis to increase access to cannabis for research” [56]. Furthermore, the Foundation's 2016 Epilepsy Capitol Hill Message urges the US Congress “to support the Compassionate Access, Research Expansion, and Respect States (CARERS) Act (S. 683 and H.R. 1538), the Compassionate Access Act (H.R. 1774), the Therapeutic Hemp Medical Access Act (S. 1333), and the Charlotte's Web Medical Access Act of 2015 (H.R. 1635), all of which would improve safe, legal access to cannabis for research and for individuals in states with medical cannabis programs” [57]. Examples of social media mobilization efforts include Facebook's Hope 4 Children with Epilepsy, an online community created in 2013 as a political advocacy arm of the Epilepsy Association of Utah, which aims “to educate and advocate for the legal right of Utah parents of children with intractable epilepsy to pursue high-CBD cannabis oil as a treatment option” (https://www.facebook.com/Hope4Children/). Other similar communities are Face of Cannabis (https://www. facebook.com/Face-of-Cannabis-184698938396017/) and CBD Oil for Autism & Epilepsy (Kentucky; https://www.facebook.com/CBD-Oilfor-Autism-Epilepsy-Kentucky-643096525724262/). 4. Summary and conclusion There is an extensive literature about the patterns of marijuana use and related problems in the US population and specific subgroups. There is also an emerging knowledge about the social discourse regarding marijuana use for recreational and medical purposes, but it is dispersed across disciplinary literatures and other sources. Policy and legal studies and government documents have focused on regulation and recent trends in marijuana legalization. Medical researchers have been seeking and weighing scientific evidence on potential benefits and harms of cannabis-based therapies while addiction experts have focused on problems of marijuana abuse and dependence. In addition, epidemiologic and public health research has examined population-level patterns and trends in marijuana use and availability, and sociocultural studies and public opinion surveys have provided a picture of changing – more accepting – attitudes regarding marijuana. However, marijuana use and access as well as related perceptions and attitudes are uneven in American society. Factors like age, socioeconomic status, race/ethnicity, geographic region, or ideological or party affiliation account for individual and group variations. The information presented in this review reflects and extends the conceptual thinking about marijuana as a sociocultural phenomenon. The ways in which marijuana is viewed – (socially constructed) depends on historical time and place. For example, the 20th-century marijuana politics was about prohibition, morality, and social control (per deviance perspective) while the 21st century is marked by scientific advances, evidence-based approaches, autonomy, and access. Those with power to shape the national discourse (per post-structuralist view) such as scientists, politicians, and mass media continue to do so, but there are new forces emerging, notably, patient and consumer advocacy and mobilization supported by virtual communities and social media. Understanding these new developments and forces is currently limited. In addition to basic science and clinical investigations, new research is needed to closely examine how science, public policy, culture, media, and patient/consumer movements intersect to shape the current place of marijuana in American society. Especially, very little has been written about social and cultural factors in the efforts to legalize and implement medical marijuana and CBD programs to treat epilepsy and other neurological conditions; at the same time, basic

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science and medical evidence has been growing. Further information would be useful about the social background of users, inequalities in access, or experiences with cannabis-based treatments over time – from stigma to quality-of-life improvements. As CBD clinical research programs continue to expand, it is now a good time to think about developing research arms or independent studies to tackle the social and cultural issues. A broad portfolio of social science designs and methods can be applied, including quantitative (especially, longitudinal cohort studies), qualitative (e.g., patient narratives), and mixed methods, as well as newer multi-method approaches that are gaining traction such as patient/public-engaged (PPE) research (i.e., studies that from inception to dissemination engage patients/families, providers, and other stakeholders). The controversy and other issues surrounding medical marijuana use and access, including the public and professional mindset, cannot be addressed without a sound knowledge base. That is why we advocate for pursuing social science investigations in addition to basic science and clinical research.

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[11] [12] [13] [14] [15] [16]

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Post-script

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In November 2016, nine states will vote on ballot measures that increase access to marijuana, which would have significant ripple effects [58]. Marijuana could become legal in the entire US West Coast and in additional states (e.g., Arizona and Nevada). This would provide a stronger challenge to the federal government's ban as well as reignite the legalization debate in neighboring countries/region such as Mexico and Latin America. Furthermore, if the largest state economy, California, approves marijuana for recreational use, the recreational and medical marijuana market there is projected to grow from $7 billion to $22 billion. However, the effects of the expanded use of and access to marijuana on children and adolescents remain a big concern. Henry Berman of the University of Washington School of Medicine has pointed out that after the legalization of recreational marijuana in Colorado, the number of emergency room visits by children under 10 for marijuana-related reasons doubled, with a third of those cases requiring intensive care [59]. Thus, the stakes for expanded marijuana access and its potential benefits and harms remain high.

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Funding This research did not receive any direct grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Conflict of interest [36]

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