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VIEWPOINT Andrew A. Monte, MD Department of Emergency Medicine, University of Colorado, Aurora; and Rocky Mountain Poison and Drug Center, Denver, Colorado. Richard D. Zane, MD Department of Emergency Medicine, University of Colorado, Aurora. Kennon J. Heard, MD, PhD Department of Emergency Medicine, University of Colorado, Aurora; and Rocky Mountain Poison and Drug Center, Denver, Colorado. |+| Author Reading at jama.com The Implications of Marijuana Legalization in Colorado The legalization of marijuana in Colorado has had incident with other behaviors that contribute to health complex effects on the health of its citizens. Physi-care visits. For example, the combination of marijuana cians have the responsibility to present a balanced plus ethanol increases the risk of motor vehicle colli- perspective, identifying both the potential health sions more than either substance alone. Serum THC con- benefits and risks associated with marijuana use. In centrations are not readily available, so assessing cau- this Viewpoint, we discuss the history of marijuana sality is difficult. policy in Colorado and the expected and unexpected effects of increased marijuana availability. Other states considering marijuana policy liberalization may learn from the experiences in Colorado. History of Colorado Marijuana Policy In November 2000, the Colorado state constitution was amended to allow for the use of medical marijuana by patients with "chronic debilitating medical conditions." Few patients used medical marijuana until October 2009, when the US Attorney General distrib- uted guidelines for federal prosecution of the posses- sion and use of marijuana, ceding jurisdiction of marijuana law enforcement to state governments. The combination of permissive local law and the federal policy change effectively liberalized the sale and use of medical marijuana in Colorado. Anyone with one of the conditions outlined by Colorado law could be issued a medical marijuana license with no expiration date. The number of licenses increased from 4819 on December 30, 2008, to 116 287 on September 30, 2014. In November 2012, Amendment 64, which legal- ized the retail sale, purchase, and possession of marijuana for state residents and visitors older than 21 years, was approved by 55% of voters. During the fol- lowing year, the state legislature appointed policy advi- sors to determine a tax structure. outline dispensarv However, there has been an increase in visits for pure marijuana intoxication. These were previously a rare occurrence, but even this increase is difficult to quantify. Patients may present to emergency depart- ments (EDS) with anxiety, panic attacks, public intoxica- tion, vomiting, or other nonspecific symptoms precipi- tated by marijuana use. The University of Colorado ED sees approximately 2000 patients per week; each week, an estimated 1 to 2 patients present solely for marijuana intoxication and another 10 to 15 for marijuana-associated illnesses. Medical Marijuana Use Patients with some seizure disorders may benefit from the cannabidiol component in marijuana, and several clinical trials will soon enroll patients (NCTO2224690, NCT02224560, NCT02224703, NCT02091375, NCT02224573). Marijuana likely has anti-inflamma- tory effects and may benefit some patients with in- flammatory bowel disease.5 Marijuana may have a safer therapeutic window than opioids for pain control, and an observational study found fewer opioid-related deaths in states with liberal marijuana laws. However, it is unlikely that marijuana is effective for the wide range of health problems approved under Colorado law. Legalization of marijuana has increased opportuni- ties for clinician scientists to study the positive health ef-