In May of 2022, Rhode Island made the decision to legalize adult cannabis use through the passing of the RI Cannabis Act. In this interview, Sarah Hall—BHDDH’s cannabis subject matter expert—discusses the details of this legislation and the history that led up to this point, its influence on cannabis prevention efforts in RI, how the State is working to advance equity and racial justice through the regulated legal cannabis market and why this is such a critical focus, and future goals for the State.
Could you please start by introducing yourself and telling us a bit about your role at the Department of Behavioral Health, Developmental Disabilities & Hospitals (BHDDH)?
My name is Sarah Hall and I work within BHDDH’s Prevention and Recovery Services Unit to provide subject matter expertise around cannabis. I come to this role with an educational background in public policy, and prior to this work, I was engaged in strategic planning as a consultant within the New England and Mid-Atlantic regions, as well as local work throughout RI which allowed me to learn more about the State’s non-profit provider landscape. I also worked for a period of time as the Prevention Coordinator for the town of Westerly, an experience which really helped to deepen my understanding of the prevention field in RI.
My current role here at BHDDH is funded by tax dollars from the state’s regulated cannabis market. I’m focused on monitoring and gathering information about how our legal cannabis market is unfolding and evolving, both from a public and behavioral health perspective as well as a policy perspective. There was a steep learning curve in terms of content expertise needed in this role, and I have spent a lot of time researching and listening to better understand the science, the data, the history, and the social and political context of cannabis.
With the 2022 passing of the RI Cannabis Act, RI became the 19th state in the U.S. to legalize adult cannabis use. Could you provide some background around how we got here, as well as what the current RI landscape looks like in terms of cannabis policy and the entities involved in overseeing it?
Cannabis has been utilized by humans in many ways throughout our entire history, including as a medicine. By comparison, the history of the prohibition on cannabis represents a very short, yet incredibly impactful period of time, and how we got to this place of legalization is really a function of how prohibition began. For most people, our exposure to cannabis has been limited to messages that it is a dangerous social ill. In the U.S. and other countries, we are now beginning to unpack this history, and part of this involves recognizing and taking accountability for the ways in which prohibition was enacted under the guise of public health with racist motivations.
Cannabis was looped into a war on drugs that was aimed at and disproportionately impacted People of Color. Many drug policies began more than 100 years ago as an extension of Jim Crow and aimed at restricting the movement and criminalizing the presence of People of Color, even if there were also public health considerations. This history is well hidden and little understood, although the impacts of it are obvious, particularly for Black and Brown communities. The policy history makes it clear that the propaganda that socialized and rationalized decisions around cannabis was racially motivated. Those messages evolved over time and billions of dollars were thrown behind them, effectively obfuscating the intent and impact.
At the same time, there was a movement to halt research regarding the medical benefits of cannabis, which were well documented until the late 1930s. It was stripped from the American pharmacopeia and the penalties to the medical community for its use were very effective in removing it from the medical toolbox for doctors. While the American Medical Academy fought hard against this early on, government funding has been largely restricted to research on cannabis harms, skewing the information available to the medical community. Movement to decriminalize and bring cannabis back into medical practice began almost as soon as it became illegal, but that history is not well known and was happening in smaller sub-communities in the medical field. So, the movement towards legalization has always been there, but it is only in the last 10-15 years that it has gained wide momentum.
The legislation passed in 2022 established a Cannabis Control Commission whose members were named by the Governor this past June. The legislation also created a Cannabis Advisory Board tasked with informing and advising the Commission in its decision-making processes. The Cannabis Advisory Board (CAB) includes voting members selected by the Governor, Speaker of the House, and Senate Majority Leader, as well as non-voting members comprised of representatives from several state agencies. The Board’s voting members were selected in the fall, and they met for the second time in December. The legislation also provides for this group to create sub-committees focused on public health, public safety, the cannabis industry, market participation, and social equity. At this time, BHDDH does not have a seat on the CAB, but we continue to find ways to provide our support to the group where possible.
As of now, the state’s Cannabis Control Commission is in a transitional period, which means that regulations for the medical cannabis program and regulated adult use market are housed in the Department of Business Regulation under the Office of Cannabis Regulation and through the RI Department of Health. Once the Commission promulgates its first round of rules and regulations, it will become an independent state agency. Right now, they’re working with the Advisory Board to gather the information and analyses needed to create comprehensive regulation. This process may seem like it’s moving slowly, but the decision-makers in this space are focused on doing it right and doing it well in addition to doing it expediently. The process of regulation is never quick, and there are good reasons for that.
Adult cannabis use has now been legalized in RI for over one year. Can you share a bit about how the State monitors and evaluates the impacts of this decision, as well as what some of those initial impacts have been thus far?
The State has many agencies looking at cannabis data through several lenses. For the Behavioral Health Department, much of the data we look at is collected every other year so this doesn’t line up quite perfectly. The data we have available from the Rhode Island Student Survey (RISS) was collected in 2022, so adult use sales would not have begun yet. Overall, however, these indicators have been trending “in the right direction” so to speak. For instance, the most recent RISS results indicate significant decreases in rates of having ever used cannabis and past 30-day use, overall and for high school students in particular. We’ve also seen significant decreases in rates of youth driving under the influence and in cars where someone else is driving under influence, as well as increases in the perception of peer disapproval around cannabis use and a reduction from 20-15% of students who have used cannabis by age 16.
This data tracks with what we’re seeing in many other states that have legalized in that we aren’t seeing an alarming leap in any of the indicators that we monitor closely for youth. Broadly speaking, with a legal market comes a shrinking of the black market with a goal of eliminating it. Since youth have no access to the legal market (our compassion centers have very stringent protocols for entry and purchase only by those aged 21 and older), there are typically fewer opportunities for youth access within a legal market landscape. Additionally, creating a regulated market often entails a focus on supporting informed decision-making, so legalization also tends to coincide with increases in access to education around cannabis and its use.
As we move forward, we’ll continue to collect and monitor these same sources of data, and we’ll also be working to pull in and explore new data sources. The RI Department of Health has hired an epidemiologist in a similar role to mine who is also funded by cannabis tax dollars, and this individual has been working diligently to establish new processes to compile and track relevant information from other data sources, such as data around emergency department visits that are cannabis related. It is difficult to parse out cannabis related hospital data because of the way the system is set up to report these things, so it will take some time to dig in and make sure we’re collecting and monitoring it in a way that ensures its accuracy.
One of the priorities of the RI Cannabis Act is establishing greater equity and advancing racial justice. Can you speak to why this is such a critical focus and how the State is working to advance equity and address the disproportionate impact of cannabis criminalization policies on communities of color through its cannabis policy and prevention efforts?
In recognition that Federal criminalization of cannabis has historically been racially motivated, the RI Cannabis Act, put forth by our legislature, aims to address the legacies of harm that have disproportionately impacted communities of color. One of the ways the legislation aims to do this is through the expungement of cannabis-related criminal records. Another is that it calls for a social equity fund to help mitigate barriers to entry into the cannabis market to ensure that the communities most impacted by the history of criminalization have equitable access to the profits of the legal market. The revenue collected from the regulated market is directed through the legislation to “fund programs and activities related to […] substance use disorder prevention for adults and youth; education and public awareness campaigns, including awareness campaigns relating to driving under the influence of cannabis; treatment and recovery support services; public health monitoring, research, data collection, and surveillance; law enforcement training and technology improvements, including grants to local law enforcement; and such other related uses that may be deemed necessary.”
How is the State currently focusing on cannabis prevention, and how has cannabis legalization influenced cannabis prevention efforts in RI?
Our primary prevention efforts across the state—spearheaded by Regional Directors, Municipal Coordinators, and Student Assistance Counselors—have always included cannabis and still do. The primary objective of these efforts is prevention of or delay in onset of substance use for youth.
To understand the influence of cannabis legalization on prevention efforts, it’s important to consider the full history of legalization and the context of prohibition that precipitated it. This history has had a significant influence on how many currently view cannabis, and we’re now seeing two extreme sides of thinking that have contributed to the spread of misinformation. There is misinformation about the harms associated with cannabis as well as the associated benefits. This makes it quite challenging to get to the truth, which is somewhere in the middle, and gray areas can be very difficult to maneuver. In addition, there is a specific complexity around cannabis and cannabis prevention efforts because of the way cannabis is used as medicine both through the medical program and regulated market sales. What we know about people who use cannabis through the legal adult market is that more than half of them are doing so for medical reasons, so this really shifts the way we need to talk about prevention of this substance. One of my hopes is to better understand, without judgment, what folks use cannabis for, and to use that data to inform prevention messaging. This gives us the ability to expand access to information about how folks can legally use this substance in a way that is safe.
The context of a legal market is asking us to step out of a primary prevention only focus, which is different and can be very tricky. It has moved us into a space where we need to be having conversations about how people of adult age can safely use a substance that has historically been only associated with harm, so it requires a shift in thinking. There is a lack of reliable safe use information available to the public. If we don’t focus on guiding this conversation and sharing information about how to use cannabis in the safest way possible, then we leave that job to our retailers. This is an unfair ask, as they are rightfully focused on solvency in a difficult regulatory landscape. The Federal illegality of cannabis adds another layer of complexity to prevention efforts, because nearly all our prevention work is funded by the Federal government through SAMHSA. As a result, our preventionists work to closely follow their guidelines and best practices, which obviously treat cannabis as a deadly and dangerous schedule 1 substance. It is easy to see how this can be difficult to navigate.
Does BHDDH have a stance on safe use cannabis guidelines for adults over age 21 (similar to alcohol)? Is there any work happening on a state level around this?
I’m currently developing safer use guidelines around cannabis for publication. My hope is that we can make this information available to folks through several channels, including our state’s dispensaries, which is typical practice in other states that have a regulated market. Many of our retailers already have educational information they are providing to their customers. These tools are particularly important for people who do not have much experience with cannabis. As I previously mentioned, there is a gap in public education regarding harm reduction and safer use practices, and retailers are left to fill it. It’s a challenging landscape because states are usually in lockstep with the Federal government on these types of things, but because of the Federal illegality of cannabis, that is impossible here.
There are some adults for whom cannabis is not considered safe. These include pregnant or breastfeeding people and folks with severe mental health challenges such as psychosis or schizophrenia either themselves, or in their immediate family history. It is also recommended to make sure that everyone is informing their health care providers about their cannabis use, as there are some medication interactions that can happen. This is also true for products that contain only CBD. Cannabis also carries a risk of dependence, as does any substance that activates the dopamine reward center in our brains. This is why it is so important that while youth are still experiencing brain development that they abstain from using cannabis. “Just Say Wait” is a tag line I read in a wonderful chapter of Peter Grinspoon’s latest book on cannabis.
For people who don’t carry a risk profile that indicates they should abstain from using, we know that regulated cannabis is safe cannabis, and ensuring this safety is done through strict testing protocols. With vaping, we saw how products that don’t go through regulatory testing can have dangerous additives leading to terrible consequences. Having rigorous laboratory testing requirements is integral to making sure that folks stay safe through our regulated legal market.
Is there any guidance you can share to support substance use prevention providers in thinking about ways of integrating a focus on the intersections of racism and the history of cannabis policy/criminalization in the U.S. within their cannabis prevention efforts and messaging?
I would encourage all prevention providers to look back at the history of cannabis and other drug criminalization because it is disheartening to learn how racially motivated our federal drug policies have been. Further complicating this history is that prevention was born as an arm of the war on drugs, so we must come to terms with the harms done to our country’s communities of color through these practices. It would be helpful to recognize that cannabis prevention was not historically about risks or harms and use that knowledge to inform our prevention efforts. This complex history has left teens and youth in the middle of polarized thinking, encountering one side of messaging that says, “cannabis will destroy your brain,” and another saying “this will cure cancer.” Reconciling this will help us to deliver credible and clear prevention messaging and information around cannabis. I’m using prevention as a term here that refers very broadly to Federal efforts, not to our Rhode Island workforce.
Is there anything else you’d like to share regarding the state of cannabis policy and prevention in RI?
I’d like to underscore that the Regional and Municipal Prevention Coalitions are really the hub of prevention efforts throughout the state. They are the boots on the ground doing great work, so if you’re interested in learning more or helping to support cannabis prevention efforts in RI, I would encourage you to reach out to your local Coalition. I’m also available to offer my support around this, and folks can feel free to reach out to me via email if they’d like to connect (Sarah.Hall@bhddh.ri.gov).
