The Physicians’ Case for Cannabis Legalization

David L. Nathan, MD, DFAPA

David L. Nathan, MD, DFAPA

While physicians continue to debate the merits of marijuana reform, legalization is advancing around the country. Although still prohibited under federal law, medical marijuana is now legal in 29 states, and in eight states cannabis may be purchased by anyone over 21. Federal support of state cannabis laws is critical and all but inevitable, as more than 60% of Americans in both red and blue states now favor full legalization for adults. In this time of contentious divisions in American politics, marijuana legalization has found bipartisan support.

The government’s own statistics explain the decades long, steady shift in public opinion. Every year, the United States makes 575,000 arrests for marijuana possession alone, which is greater than the number of arrests for all violent crimes combined.[1] American blacks are nearly four times more likely than whites to be arrested for marijuana possession, despite similar usage rates between the two groups.[2] Enforcement of marijuana laws has disproportionately affected our nation’s poor and communities of color, contributing to the crisis of mass incarceration. The war on marijuana exacerbates poverty, which is strongly correlated with – among other problems – reduced access to health care. The unjust prohibition of marijuana has done more damage to public health than marijuana itself.

Alcohol Prohibition was repealed after just thirteen years because of unintended consequences: organized crime, increased use of hard alcohol, and government waste.

So, what have we gotten from our eighty-year experiment with marijuana prohibition? Organized crime, increased use of stronger marijuana, and government waste.

And yet, Alcohol Prohibition was a success compared to our war on marijuana. Alcohol consumption decreased during the 1920s, but marijuana use has increased drastically since its prohibition. Today, 22,000,000 Americans use cannabis each month, and even more partake on a less frequent basis.[3]

While evidence shows that marijuana is, by most measures, safer than alcohol for the vast majority of adults, evidence also suggests that both marijuana and alcohol can adversely affect brain development in minors. Studies of underage users show that health effects are worse when kids start younger and consume marijuana more frequently.

But cannabis prohibition for adults does not prevent underage use. For decades, preventive education reduced the rates of alcohol and tobacco use by minors, while underage marijuana use rose steadily despite its prohibition for adults. Since the 1970s, 80-90% of eighteen-year-olds have consistently reported easy access to the drug.[4]

Unfortunately, prohibition sends the message that marijuana is dangerous for everyone, since it is illegal for everyone, and kids know that is not true. If we want our children to believe us when we say that cannabis can be harmful for them, then our laws should reflect the difference in health effects of underage and adult use.

Today, while marijuana regulation in legalized states has not been perfect, it is far better than the prohibition it replaced, and the worst fears of opponents have not materialized. Teen use has remained level in legalized states, motor vehicle accidents and deaths continue to decrease, and state governments have demonstrated a fundamental ability to control the previously untaxed and unregulated cannabis industry.[5] As evidence of these successes, polls show that popular support for legalization remains strong in legalized states.

Times are changing. In 2017, even physicians who oppose legalization generally believe that marijuana should be decriminalized, reducing penalties for users while keeping the drug illegal. Although decriminalization is certainly a step in the right direction, we believe it to be an inadequate substitute for legalization and regulation for a number of reasons.

First, decriminalization does not empower the government to regulate product labeling and purity, which leaves marijuana vulnerable to contamination and adulteration. This also renders consumers unable to judge the potency of marijuana, which is like drinking alcohol without knowing its strength. Moreover, where marijuana is merely decriminalized, the point-of-sale remains in the hands of drug dealers who will sell marijuana – as well as more dangerous drugs – to children.

Contrary to popular belief, decriminalization does not actually end the arrests of marijuana users. Despite New York State decriminalizing marijuana in the 1970s, New York City makes tens of thousands of marijuana possession arrests every year, with continuing racial disparities in enforcement. Finally, under a decriminalized system the government continues to prosecute and constrict the supply chain. This drives up the price of marijuana, making the untaxed illegal market more lucrative, competitive, and violent.

As the legalization of medical and adult use of marijuana spreads across the United States, conscientious and knowledgeable physicians are increasingly voicing support – not for marijuana use, but for effective regulation as an alternative to the failed policy of prohibition.

That is why, along with more than 50 prominent US physicians, we founded Doctors for Cannabis Regulation (DFCR), the first and only national physicians’ organization dedicated to the legalization and regulation of the adult use of marijuana. Asserting confidence in science, reason and the judgment of history, DFCR launched last year with the publication of our “Declaration of Principles.”[6] Since then we have given testimony in numerous state legislatures, met with physician groups, opened free membership to all physicians, advocated for evidence-based regulations in each of the newly legalized states, and begun discussions with members of the new Congressional Cannabis Caucus.

DFCR does not promote cannabis use. Rather, we advocate for the legalization of cannabis for adults, because effective regulation requires a legalized environment. We therefore support a core set of common-sense measures to control the marijuana industry and protect public health. The government should oversee all cannabis production, testing, distribution, and sales. Cannabis products should be labeled with significant detail, including (but not limited to) THC and CBD levels, dosing information and ingredients. There should be restrictions on marketing and advertising of cannabis products. Cannabis packaging and advertising that targets or attracts underage users should be completely prohibited. All cannabis products should have child-resistant packaging. There should be harsh penalties for adults who enable diversion of cannabis to minors. Taxation of the cannabis trade should be used to fund research, education, prevention, and substance abuse treatment, including public information for adults on the use and misuse of cannabis and youth programs that emphasize the risks of underage cannabis use.

Informed physicians may disagree about the specifics of good regulation, but we cannot abstain from the discussion. The cannabis industry now advises lawmakers on cannabis regulation, and doctors must do so as well.

Rejecting the unjust and ineffective policy of marijuana prohibition, the physicians of DFCR are helping to lead the nation on a responsible path to legalization. We invite you to join us. Working together, we can advance public health and protect our children through effective, evidence-based regulation of marijuana in the United States.

Originally published at American Journal of Public Health

David Nathan

David L. Nathan, MD, DFAPA (DFCR Founder, Past President) is a psychiatrist, writer, and educator in Princeton NJ. He is a Distinguished Fellow of the American Psychiatric Association and Clinical Associate Professor of Psychiatry at Rutgers Robert Wood Johnson Medical School. While maintaining a full-time private practice, he serves as Director of Continuing Medical Education for the Princeton HealthCare System (PHCS) and Director of Professional Education at Princeton House Behavioral Health (PHBH). While serving on the steering committee of New Jersey United For Marijuana Reform (, Dr. Nathan was surprised by the absence of any national organization to act as the voice of physicians who wish to guide our nation along a well-regulated path to cannabis legalization. This need was the inspiration for Doctors for Cannabis Regulation.


H. Westley Clark, MD, JD, MPH, CAS, FASAM, is a former Director of the Center for Substance Abuse Treatment, where he led the U.S. Department of Health and Human Services’ national effort to provide effective and accessible treatment to Americans with addictive disorders. Dr. Clark was the former chief of the Associated Substance Abuse Programs at the U.S. Department of Veterans Affairs Medical Center (DVAMC) in San Francisco, California and a former associate clinical professor in the Department of Psychiatry at the University of California at San Francisco (UCSF). In addition to his duties at the DVAMC, Dr. Clark served as a senior program consultant to the Robert Wood Johnson, Substance Abuse Policy Program, a co-investigator on a number of the National Institute on Drug Abuse-funded research grants in conjunction with UCSF. Dr. Clark received a B.A. in Chemistry from Wayne State University in Detroit, Michigan; he holds a Medical Degree and a Masters in Public Health from the University of Michigan, Ann Arbor; where he completed a Psychiatric Residency at University Hospital, Neuropsychiatric Institute. He obtained his Juris Doctorate from Harvard University Law School and completed a two-year Substance Abuse Fellowship at the DVAMC-SF. Dr. Clark is a noted author and educator in substance abuse treatment, anger and pain management, psychopharmacology, and medical and legal issues. He has received numerous awards for his contributions to the field of substance abuse treatment, including a 2008 President of the United States of America Rank of Distinguished Executive Award in recognition of his personal commitment to excellence in government and public service; and a 2003 President of the United States of America Rank of Meritorious Executive Award in the Senior Executive Service for his sustained superior accomplishments in management of programs of the United States Government and for noteworthy achievement of quality and efficiency in the public service. In addition, he was awarded the 2008 John P. McGovern Award from the American Society of Addiction Medicine for his contributions toward increased understanding of the relationship between addiction and society.


Joycelyn Elders, MD is a former U.S. Surgeon General and is Professor Emeritus of Pediatrics at University of Arkansas for Medical Sciences. Born the daughter of poor sharecroppers in Arkansas, Dr. Elders earned a bachelor’s degree at Philander Smith College in Little Rock. She then spent three years in the U.S. Army, after which she attended the University of Arkansas Medical School. She completed her residency in pediatrics, later earning a master’s degree in biochemistry. After rising to the rank of Professor at the University of Arkansas Medical Center (UAMS), she became the first physician in Arkansas to receive board certification in pediatric endocrinology in 1978. Her career in public health gained much traction following her 1987 appointment as Director of the Arkansas Department of Health. In this capacity, she oversaw a tenfold increase in early childhood annual screenings. In 1992, she was elected as the President of the Association of State and Territorial Health Officers. President Clinton nominated Dr. Elders to the position of U.S. Surgeon General in 1993. Once confirmed, she became the first African-American and only the second woman to serve as Surgeon General. Dr. Elders’ tenure is remembered for the controversy generated by her progressive views on drug policy and sex education. During the height of the AIDS epidemic, she was a strong proponent of teaching teens about safe sex as well as abstinence. She also called for research into drug legalization as a means to reduce crime as well as drug misuse. After leaving office, Dr. Elders returned to her professorship at UAMS, while continuing to advocate for comprehensive sex education and drug policy reform. In 2010, she supported California’s Proposition 19, which would have made California the first state to legalize cannabis. The New York Times quoted her as saying, “I think we consume far more dangerous drugs that are legal: cigarette smoking, nicotine and alcohol. I feel they cause much more devastating effects physically. We need to lift the prohibition on marijuana.”

Contributors: All authors contributed to this manuscript, with Dr. Nathan as the principal author.


The authors wish to thank the DFCR Executive Director Brian Muraresku and the DFCR Board of Directors for their assistance in the preparation and publication of this article.


  1. Federal Bureau of Investigation. Uniform Crime Report: 2015 Crime in the United States. New York, NY: 2016.
  2. American Civil Liberties Union. The War on Marijuana in Black and White. New York, NY: June 2013. p. 17.
  3. Center for Behavioral Health Statistics and Quality. Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration, 2015.
  4. Johnston, Lloyd. Monitoring the Future: National Survey Results on Drug Use, 1975-2008: Volume II: College Students and Adults Ages 19-50. Bethesda, MD: National Institute on Drug Abuse, 2009.
  5. Drug Policy Alliance. “So Far, So Good: What We Know About Marijuana Legalization in Colorado, Washington, Alaska, Oregon, and Washington D.C.” October 13, 2016.
  6. Doctors for Cannabis Regulation. “Declaration of Principles.” Washington, DC: April 18, 2016.
Posted in DFCR, Op-Eds / Letters.