Cannabis rescheduling: What direction will the Trump administration go?

Federal officials should reject efforts to change laws regarding medical and recreational use of marijuana, according to two scholars who reviewed the current state of science of cannabis as medicine.

“Rescheduling Cannabis — Medicine or Politics?” was a special communication article published by JAMA Psychiatry. Authors Bertha K. Madras, PhD, and Paul J. Larkin, JD, outlined reasons why national health and legal leaders need to rethink their approach on loosening federal regulations around marijuana as a drug.

In the last few years, the U.S. Department of Health and Human Services “failed to adequately address the adverse effects of cannabis use, including the high prevalence of cannabis use disorder among users, risks associated with youth consumption, growing evidence linking cannabis to psychosis, and other significant concerns,” they said.

Only a small fraction of physicians recommend using the drug, and the U.S. Food and Drug Administration does not have evidence from high-quality clinical trials about issues such as cannabis formulations and purity, or dosing guidelines.

“There Is Credible Scientific Evidence Supporting Such Medical Use? That conclusion is dubious,” Madras and Larkin said.

Rescheduling the drug

The administration of President Joe Biden made national news when directing the U.S. Department of Health and Human Services and the Drug Enforcement Administration to examine how marijuana is classified under the federal Controlled Substances Act (CSA). Marijuana currently is a Schedule I drug, with no currently accepted medical use and a high potential for abuse. The Biden administration proposed making it a Schedule III drug, with a moderate to low potential for physical and psychological dependence.

Last year, cannabis proponents were enthusiastic about the federal reconsideration. It was “The Beginning of the End of Cannabis Prohibitions,” said a May 2024 article by Paul Armentano, deputy director of NORML, which opposes marijuana prohibition. He was responding to a proposal by the U.S. Attorney General’s office to reclassify the drug.

In August last, DEA announced it would hold a hearing on the proposal, starting in January 2025. That hearing has been on hold due to legal disputes about DEA involvement as a proponent of the proposed rule, according to the timeline prepared by the Drug Enforcement and Policy Center of the Moritz College of Law at Ohio State University.

Marijuana and MAHA

In the second term of President Donald J. Trump, his administration has made a priority of stopping the flow of illegal fentanyl into the country. Stopping overdose fatalities and preventing illegal drug use are among six priorities published by the White House Office of National Drug Control Policy.

Marijuana was absent from those priorities, and this year cannabis supporters and opponents have been trying to predict where marijuana might fit in the campaign to Make America Health Again, led by HHS Secretary Robert F. Kennedy Jr.

In April, the law firm Vicente published a summary on presidential appointees, their stances on marijuana legalization, and the president’s own statements about the drug. Attorney General Pam Bondi opposes marijuana law reform, as does Terrance C. Cole, the president’s nominee to oversee DEA. FDA Commissioner Martin A. Makary, MD, MPH, has expressed critical views of cannabis use.

Kennedy “advocates for plant medicine reform,” according to Vicente, although he and Makary have expressed support for additional research on therapeutic use of psychedelic drugs.

As for the president, Trump has made public statements in favor of decriminalizing marijuana and reclassifying it, according to Vicente’s summary.

What do physicians say?

Doctors for Drug Policy Reform (D4DPR), a national advocacy organization, has a history that posits racism, not public health, was the foundation of America’s 20th century cannabis policy. That resulted in a war on drugs that has failed.

Regarding patient health, “from a pharmaceutical perspective, botanical cannabis is a very safe drug.” Tobacco, alcohol and opioids kill thousands of Americans each year, but there has not been a single documented case of death by cannabis overdose, according to D4DPR.

The organization acknowledges health risks, particularly problematic use, the chance of persistent psychosis and impaired ability to drive a car.

D4DPR and the American Academy of Pediatrics (AAP) also explain the differences among the plant marijuana, or cannabis sativa; tetrahydrocannabinol, or THC, the intoxicating chemical in the plant; cannabidiol, or CBD, another ingredient in cannabis; and more. AAP advocates that people younger than age 21 should not use any form of cannabis and public health campaigns should explain why it is harmful to young bodies and brains.

What happens next?

Madras and Larkin called for DEA to reject HHS’ conclusions on rescheduling cannabis.

Federal regulators at HHS and the attorney general’s office use an eight-part test when considering scheduling a substance. There is a five-part test for designating a drug as a medicine, Madras and Larkin wrote, citing the CSA and the federal Food, Drug and Cosmetic Act.

FDA’s recommendation in favor of rescheduling cannabis ignored emerging trends in cannabis use, including high prevalence of cannabis use disorder, which has ballooned in states with legalized medical cannabis, along with cannabis poisoning.

Despite advocates’ assertions, the United States has no medical consensus that cannabis is a legitimate medical treatment. Those who recommend it are often not primary care physicians, and many states allow “budtenders” to recommend cannabis for any medical condition without a physical exam or diagnostic tests to certify that it is needed, Madras and Larkin said.

As for medical tests, “the evidence supporting generic ‘cannabis’ as a treatment for medical conditions remains either low quality or nonexistent,” they wrote. A 2017 report by the National Academies of Sciences, Engineering and Medicine found evidence cannabis could be effective in managing chronic pain, but 24 meta-analyses/reviews did not endorse it for chronic pain.

Meanwhile, there are no high-quality studies showing cannabis is effective in relieving anxiety or post-traumatic stress disorder. States vary widely in their guidelines on medical conditions that can be treated with marijuana, many without supporting research.

The authors noted rescheduling cannabis as a Schedule III drug “could grant the FDA greater authority to regulate medical claims and restrict access to dispensary cannabis.” But no one in FDA has indicated that in fact would lead to greater oversight, Madras and Larkin’s paper said.