Over the last 40 years, the legal status of marijuana has been debated vigorously. Proponents of policies that would permit individual possession of small amounts of marijuana argue that it is a safe drug and that criminal sanctions against personal use and possession represent at worst excessively harsh and at best unnecessary penalties. Echoing these sentiments, editors of The Lancet have concluded that "cannabis per se is not a hazard to society but driving it further underground may well be."1 Advocates for legalization also point out that the morbidity, mortality, and economic costs to society associated with alcohol and tobacco use in the United States dwarf those associated with marijuana use.
Those opposing liberalization of current laws counter that marijuana is not a benign drug, especially in light of new psychopharmacologic information demonstrating that marijuana shares many features with other illicit drugs. They also contend that legalization or decriminalization of personal use of marijuana likely would trigger a substantial increase in use, with foreseeable increases in the social, economic, and health costs.
Most recently, the debate has focused on the medical use of marijuana (that is, the use of smoked marijuana to treat a variety of medical conditions). Eight states (Alaska, Arizona, California, Colorado, Maine, Nevada, Oregon, and Washington) have passed ballot initiatives that provide for medical use of marijuana under certain circumstances; one other state (Hawaii) has enacted state legislation permitting medical marijuana use.2 The federal government has opposed vigorously any efforts to permit physicians to prescribe marijuana for medical purposes, an approach characterized by the former editor of the New England Journal of Medicine as "misguided, heavy-handed, and inhumane."3
Controversy regarding marijuana is not limited to the United States. Australia has decriminalized the use of marijuana in some territories, and Canada4 as well as Switzerland and other European countries5 are reconsidering their approach to marijuana. However, the most widely publicized approach to regulation of marijuana is that of The Netherlands. Under a complex system of "law-on-the-books" and "law-in-action," Dutch law permits personal use of marijuana but outlaws possession.6
Pediatricians, too, are not of one mind in their views regarding the legal status of marijuana. In a periodic survey of fellows of the American Academy of Pediatrics (AAP) conducted in 1995,7 only a minority (18%) favored legalization, and 26% believed that possession or sale should be a felony; 31% felt that marijuana should be available by prescription for medical purposes to a certain class of patients, and 24% believed that marijuana should remain illegal but penalties for personal possession should be reduced or eliminated.
Since the periodic survey was conducted, much more has been learned about the psychopharmacologic properties of marijuana. Scientists have demonstrated that the emotional stress caused by withdrawal from marijuana is linked to corticotropin-releasing factor, the same brain chemical that has been linked to anxiety and stress during opiate, alcohol, and cocaine withdrawal.8 Others report that tetrahydrocannabinol, the active ingredient in marijuana, stimulates release of dopamine in the mesolimbic area of the brain, the same neurochemical process that reinforces dependence on other addictive drugs.9 Current scientific information about marijuana has been summarized in the AAP policy statement "Marijuana: A Continuing Concern for Pediatricians."10 Some of the significant neuropharmacologic, cognitive, behavioral, and somatic consequences of acute and long-term marijuana use are well known and include negative effects on short-term memory, concentration, attention span, motivation, and problem solving, which clearly interfere with learning; adverse effects on coordination, judgment, reaction...