03/7/23

Marijuana Policy Has Run Ahead of Science

Senate Bill 3 was signed into law by Governor Tom Wolf on April 17, 2016, legalizing medical marijuana in Pennsylvania. The Governor anticipated signing the bill “will improve the quality of life for patients and their families throughout Pennsylvania.” Information on the PA Medical Marijuana Program indicated it would include funding for research to study “the use of medical marijuana to treat serious conditions.” There will also be an advisory committee “that will view these research findings and make recommendations to the legislature for changes to the act.” I’d like to suggest they start with a Harvard-based researcher who is concerned that “policy has outpaced science” when it come to making public health decisions about recreational and medical marijuana.

Staci Gruber is an associate professor of psychiatry at Harvard Medical School and the director of the MIND program (Marijuana Investigations for Neuroscientific Discovery). She has done research on the effects of both recreational and medical marijuana. In an interview with The Harvard Gazette, Dr. Gruber said the science on the health effects of marijuana is not yet settled. “When we think about legalization we always like to have science inform policy. In this particular case, it seems to me that policy has outpaced science.”

She added there is a lot we don’t know about the effects of marijuana. Most of what we do know comes from studies of “chronic, recreational marijuana users.” There are differences between recreational and medical marijuana use, for example with regard to what they use, and how they use. She said there has been well-founded excitement about the potential for medical cannabis use. “[But] there’s a striking paucity of research on the use of medical cannabis.”

Dr. Gruber and her colleagues discussed the findings in a study of theirs, “Splendor in the Grass?” that looked at the impact of medical marijuana on executive functioning. They acknowledged how the growing body of evidence shows recreational marijuana use adversely effects brain function, especially during adolescence, the critical period of neurodevelopment. But they also theorized the use of medical marijuana (MMJ) may not lead to the same adverse neurocognitive effects. Recreational users, seeking a euphoric, mood altering effect, use products with a high THC content. In contrast MMJ users seek medical relief and use products with a markedly different chemical composition than common recreational products. “These MMJ products are often (but not always) high in other cannabinoids, such as cannabidiol (CBD) which has been touted for its therapeutic potential, and which is not psychoactive.”

The study found that after three months of medical marijuana use, patients (who had previously not been exposed to marijuana) experienced some improvement, rather than the well-documented deficits. “They showed some improvements in measures of executive functions. They also had some improvements in sleep quality and some measures of mood and quality of life.” A subset of people who were using MMJ for chronic pain also reported improvements. Although it was a small sample size, there was a 42% reduction in opiate use. When they analyzed samples of their patient’s products, a number of them were using products high in CBD (cannabidiol) and other non-psychoactive cannabinoids.

Gruber thought there was hope for at least adjunctive therapy, “if not substitution therapy,” for cannabinoids or cannabinoid-based products for individuals currently using opioids. “We’ve seen individuals who’ve stopped using opioids altogether.” That won’t work for everyone. “But that doesn’t mean it’s something that shouldn’t be exploited and explored.”

While future studies are needed to further examine the impact of MMJ, research is impeded by a number of federal and state restrictions. It is imperative, however, that sound research, including well-controlled clinical trials of MMJ products, many of which are already widely used by patients, are thoroughly examined. As the “green rush” pushes forward, gaining momentum as states continue to adopt less restrictive policies, we cannot afford for research to continue to lag behind.

Dr. Gruber said her goal as a scientist was to provide truthful information so all people, regardless of their recreational or medical status, can understand what is in their cannabis or medicine. In pursuit of this goal, Dr. Gruber and her colleague Kelly Sagar continued a discussion of their research with “Marijuana on the Mind?” in Policy Insights from the Behavioral and Brain Sciences. You can also watch an archived webinar by Gruber and Sagar on the same subject, “Marijuana on the Mind: A Primer for Policymakers” on the website Social Science Space, where there are also written answers to some of the questions from the webinar. The presentation exists as an independent YouTube video as well. The audio cuts out a few times, but returns if you continue with the video.

In “Marijuana on the Mind?” Gruber and Sagar gave a helpful review of the history of medical use of marijuana, noting how it was included in the U.S. pharmacopeia (a list of medicinal drugs with their effects and directions for their use) until 1942. They also documented several areas of concern with marijuana, including its adverse effects on cognition, especially executive function and memory; brain development among adolescents; and safety concerns related to the frequency and magnitude of marijuana use as well as its potency.

Marijuana (MJ) use negatively effects executive brain functions (EF) such as attention, decision making, risk taking, inhibition and verbal fluency. An earlier age of onset in using MJ appears to be related to greater impairment on EF. “Several investigations have also noted that lower EF appears to predict increased MJ use.” Several aspects of memory are negatively effects by MJ use. Some evidence suggests increased use and higher exposure to MJ are related to slower psychomotor/processing speed.

The formation of grey matter and whiter matter in the brain is adversely effected by MJ use. Grey matter is responsible for information processing and decision-making. White matter has a critical role in promoting efficient communication within and between regions of the brain. Adolescent MJ users are particularly vulnerable to grey matter reductions; minimal further damage seems to occur after early adulthood. Lower white matter integrity is related to higher impulsivity scores, particularly with early onset MJ users.

MJ users with early onset (prior to age 16) reportedly use MJ nearly twice as often and more than 2.5 times as much relative to late-onset users. Overall, frequency and duration of use appear to be key factors in determining the extent of MJ-related impairment.

Safety concerns with MJ use are on the rise due to the increased potency of marijuana and the use of MJ concentrates. The potency of marijuana has risen nearly 200% since 1995. The use of concentrated MJ products, such as dabs, shatter, wax, budder and others can exceed 60% THC. “Furthermore, these products may also contain residual amounts of solvents (i.e., butane, hexane), often used to make concentrates, which are potentially toxic.” There has been very little research done on cognitive performance or measures of brain structure and function in humans with MJ concentrates. “This raises concern that adverse consequences associated with MJ use may be worse now than in the past, particularly among young users.”

Based upon their discussion, policy recommendation given by Gruber and Sagar include:

age restrictions based upon evidence highlighting the developmental trajectory of the adolescent brain;
restrictions on targeting youths in advertisements;
safe packaging guidelines to prevent the accidental ingestion of edible MJ products by children;
place limits on THC potency as well as minimums for potentially beneficial cannabinoids in marijuana, like CBD;
more research on the impact of medical marijuana, which will likely require a lessening of marijuana as a Schedule I substance

As the dialogue regarding legalization of recreational and MMJ continues, perceived risk of MJ use has fallen to an all-time low. Consequently, those with the highest neurodevelopmental vulnerability are using MJ more frequently than in previous years, posing a serious public health issue. A growing body of evidence indicates that relative to non-MJ users, heavy MJ users exhibit poorer performance on cognitive tasks, altered patterns of brain activity, and lower frontal WM coherence, which are highly moderated by age of onset of MJ use. Given the potential therapeutic benefits of MJ, however, it is important to weigh these risks with the benefits. Policy has outpaced science, and eased restrictions allowing citizens to use MJ, in some cases without the benefit of appropriate research. Additional investigation is warranted and necessary to guide informed policy decisions. As states consider legislation for MJ use, it is imperative to determine safe guidelines regarding the impact of MJ on the brain, particularly during critical periods of neurodevelopment.

Dr. Gruber’s research through the MIND program will be extremely helpful for the PA Medical Marijuana Program and state policy makers, such as members of the advisory committee, in making informed public policy decisions with the ongoing availability of medical marijuana in Pennsylvania. The review by Gruber and Sagar of the research relevant the influence of marijuana on cognition, brain structure and brain function in “Marijuana on the Mind?” can be helpful in making future public policy decisions with regard to medical marijuana in the state.

An article cited by Gruber and Sagar, “Cannabis for Medical Use,” should also be reviewed by policy makers, as it is a systematic review and meta-analysis of the benefits and adverse events of cannabinoids. The full text of the systematic review is available. What follows is from the article’s Discussion.

Most studies suggested that cannabinoids were associated with improvements in symptoms, but these associations did not reach statistical significance in all studies. Based on the GRADE approach, there was moderate-quality evidence to suggest that cannabinoids may be beneficial for the treatment of chronic neuropathic or cancer pain (smoked THC and nabiximols) and spasticity due to MS (nabiximols, nabilone, THC/CBD capsules, and dronabinol). There was low-quality evidence suggesting that cannabinoids were associated with improvements in nausea and vomiting due to chemotherapy (dronabinol and nabiximols), weight gain in HIV (dronabinol), sleep disorders (nabilone, nabiximols), and Tourette syndrome (THC capsules); and very low-quality evidence for an improvement in anxiety as assessed by a public speaking test (cannabidiol). There was low-quality evidence for no effect on psychosis (cannabidiol) and very low-level evidence for no effect on depression (nabiximols). There was an increased risk of short-term AEs with cannabinoid use, including serious AEs. Common AEs included asthenia, balance problems, confusion, dizziness, disorientation, diarrhea, euphoria, drowsiness, dry mouth, fatigue, hallucination, nausea, somnolence, and vomiting. There was no clear evidence for a difference in association (either beneficial or harmful) based on type of cannabinoids or mode of administration. Only 2 studies evaluated cannabis.There was no evidence that the effects of cannabis differed from other cannabinoids.

The authors noted there was moderate-quality evidence to support the use of cannabis to treat chronic pain and spasticity. However, the existing evidence suggesting improvements in nausea and vomiting due to chemotherapy, weight gain in HIV, sleep disorders, and Tourette syndrome was low quality evidence. Cannabinoids were also associated with an increased risk of short-term adverse events such as those noted in the above quote. Future studies with large random clinical trials were said to be needed in order to confirm the effects of cannabinoids with issues such as: weight gain in patients with HIV/AIDS, depression, sleep disorders, anxiety disorders, psychosis, glaucoma, and Tourette syndrome. Additionally, the lack of research into the effects and adverse events with cannabis point to the need of future studies in these areas.

Hopefully as medical marijuana becomes more widely available in Pennsylvania, the administrators of the Medical Marijuana Program and other state policy makers will pursue the recommendations suggested in the research reviewed here by Gruber and others who are concerned that “policy has outpaced science” when it comes to lawmakers making public health decisions about recreational and medical marijuana.

Originally posted on March 6, 2018.

08/2/22

The Future of Marijuana Legalization in Pennsylvania

The World Drug Report for 2021 reported that roughly 200 million people used cannabis in 2019, roughly 4% of the global population. North America has the highest number of cannabis users, with an estimated 14.5% of its population use in 2019. The percentage of THC (∆9-THC), the main psychoactive ingredient in cannabis, rose from around 4% in 1995 to 16% in 2019. Although THC is responsible for the development of mental health disorders in long-term, heavy cannabis users, the percentage of adolescents who view regular cannabis use as harmful has decreased by as much as 40% during the same time period. While the potency of cannabis has increased four-fold since 1995, fewer young people see it as harmful.

Such a mismatch between the perception and the reality of the risk posed by more potent cannabis could increase the negative impact of the drug on young generations. Scientific evidence has demonstrated the harm to health caused by regular use of cannabis, particularly in young people. Evidence from surveys suggests a link between a low perception of risk and higher rates of usage. This is the case not only in Europe and the United States, but also in other parts of the world.Aggressive marketing of cannabis products with a high Δ9-THC content by private firms and promotion through social-media channels can make the problem worse. Products now on sale include cannabis flower, pre-rolled joints, vaporizers, concentrates and edibles. The potency of those products varies and can be unpredictable – some jurisdictions where cannabis use is legalized set no limit on THC content – and may be a public health concern.

(See the following charts from the World Drug Report for 2021)

In 2020, 14.6% of high-school students reported past-month use of cannabis. There was a significant increase in the daily or near-daily use of cannabis in the past two years (20919 and 2020). The daily or near-daily use of marijuana was estimated at 4.1% among high-school students in 2020, compared with almost 1% in 1991. In the past few years, the debate about medical marijuana and measures allowing for the non-medical use of cannabis in the United States have led adolescents to perceive cannabis as less harmful than was true in the past.

In the United States, the decreasing perception of risk from occasional or regular use of cannabis is considered to be a spillover effect as debates over measures allowing the medical and non-medical use of cannabis in the states considering those measures extend to other states, and the result of an increase in regular cannabis use, which comes to be perceived as less risky among users, as well as media coverage of the medical use of various cannabis products in many states containing claims of the medical benefits of cannabis products, including those of CBD.

Not only are there concerns for increases in mental health disorders among youth, there are other concerns with how cannabis effects young adults. Cannabis use among adolescents was found to be related to impaired cognition; showing delayed effects on self-control, working memory and concurrent effects on delayed memory recall and perceptual reasoning (ability to think and reason using pictures or visual information). So, exactly what are the risks when individuals, particularly adolescents and young adults, use marijuana? A meta-analysis published in The Lancet Psychiatry suggested the equivalent of one joint can induce psychotic and other psychiatric symptoms in healthy adults with no history of a major mental illness.

In “Psychiatric symptoms caused by cannabis constituents: a systematic review and meta-analysis,” the researchers their findings highlighted the acute risks of cannabis use, as “medical, societal, and political interest in cannabinoids continues to grow.” Significantly, they concluded that CBD (the second most common cannabinoid in cannabis) did not induce psychiatric symptoms; and the evidence that it moderated the induction of psychiatric symptoms was inconclusive. These effects were larger with intravenous administration than with inhaled.

Commenting on the results for Medscape, senior investigator Oliver Howes said “As clinicians, we need to be aware that the medical use of marijuana comes with a risk of inducing psychiatric symptoms, even in people with no vulnerability, and this needs to be factored into decisions to prescribe and to monitor.” Even if the symptoms are short-lived, people need to be aware of them because not only van they be distressing, but they can also affect decision-making and behavior. With regard to the failure of the researchers to find evidence that CBD moderates the psychotic effects of THC, Howes said, “I think it’s fair to conclude there’s a lack of consistent evidence that CBD is protecting against THC’s effect.” The mean age of the subjects ranged from early to late 20s.

An editorial of the study by Carsten Hjorthøj and Christine Merrild Posselt said the finding that low doses of THC can induce psychotic symptoms was “extremely worrying,” because they were similar to those found in medical marijuana. They also said there was no clear evidence that concurrent administration of CBD reduces symptoms induced by THC. “The authors failed to find any clear evidence that concurrent administration of cannabidiol (CBD) reduced these symptoms. Indeed, such an ameliorating effect was observed in only one of four included studies.”

This growing scientific consensus is not reflected in the mainstream public discourses, which have a major effect on the political agenda to decriminalise or legalise cannabis. It also appears that, in many places (eg, several US states), the first thing to be legalised is medicinal cannabis followed by increasing decriminalisation and sometimes complete legalisation of cannabis. It is thus of utmost importance that the public and politicians are informed of the most up-to-date evidence on cannabis. Adding to the state of this evidence is the systematic review and meta-analysis by Guy Hindley and colleagues in The Lancet Psychiatry. The authors demonstrate that Δ⁹-tetrahydrocannabinol (THC) leads to an increase in total symptoms, which was assessed in nine studies, with ten independent samples, involving 196 participants: standardised mean change in scores (assessed with the Brief Psychiatric Rating Scale and the Positive or Negative Syndrome Scale) 1·10 (95% CI 0·92–1·28, p<0·0001). The effect sizes were also large for other symptoms (including general psychiatric symptoms), and were induced even with low doses of THC, somewhat similar to the doses often seen in medicinal cannabis, which we find extremely important and worrying.

The significance of the above research findings should not be lost on Pennsylvania citizens and politicians. As the availability of cannabis increases in the state, as the potency of THC in that marijuana increases, we will see a corresponding increase of psychosis and other mental health-related problems among regular users. This is the future of marijuana legalization in Pennsylvania.

Medical marijuana has been legal in Pennsylvania since April 6, 2016. The first dispensary opened in the Pittsburgh area in Butler PA, on February 1, 2018. But medical marijuana dispensaries continue to spring up like “weeds.” The Weedmaps website indicated there were 39 dispensaries in the Pittsburgh area. Nineteen advertised they provided Curbside pickup.

John Fetterman, the current lieutenant governor of Pennsylvania, is running for the office of U.S. Senator and wants to see Pennsylvania “go full Colorado.” Its governor, Tom Wolf, has publicly supported the legalization of recreational marijuana. There has been legislation proposed by two state senators, the Adult-Use Cannabis Act, to legalize recreational marijuana in the state. See “Should Pennsylvania Go ‘Full Colorado’ With Marijuana?” Part 1 and Part 2.

05/18/18

Marijuana Stepping Stone in PA?

Frank Glover / Stepping stones over the Wharfe / CC BY-SA 2.0

As medical marijuana began to be sold in Pennsylvania I speculated that a prediction by a co-sponsor of Senate Bill 3, that dry leaf marijuana would be sold in PA dispensaries sometime in 2018, was more bluster than reality. But it seems I was wrong. On April 16^th, 2018 Governor Wolf announced that he supported changes to the existing state medical marijuana program that would allow dispensaries to sell dry leaf marijuana. Regulations to enact the recommendations will be available in the Pennsylvania Bulletin on May 12. Were the state legislators who voted for Senate Bill 3 aware a provision in it would permit an advisory board to approve the sale of dry leaf marijuana at a later date, even though the initial bill did not permit it? And were they aware there would be a move to sell dry leaf in dispensaries so quickly? Would they have voted for the Bill if they knew that was the goal?

Rachael Levine, the PA Health Secretary, announced on April 16^th that she approved recommendations from the state’s medical marijuana advisory board to permit the sale of dry leaf “for patients with a qualifying medical condition.” The rationale to permit access to dry leaf marijuana was said to offer a lower-cost option to the concentrate forms. Allegedly the flower form is believed to be more effective in treating some medical conditions with better dosage control than the concentrate form ( a statement made without any supporting evidence). PA law still prohibits smoking medical marijuana or using it in edible form, but plant matter can be legally vaporized, meaning it can be heated, but not burned.

It’s not clear how that rule would be enforced once the marijuana is purchased and taken home. Dr. Levine said patients would be urged to follow the prescribed methods for administering the medical marijuana. “We are not looking for an intoxicating effect. We are looking for a medical effect.”

The Cannabist wrote about the proposed changes to allow the sale of dry leaf or flower marijuana in Pennsylvania. A cannabis consumer advocate said no state law would prevent certified medical marijuana users from buying the dry leaf product and smoking it legally, instead of vaporizing it. “I’m sure patients are going to go home and smoke it, and there’s nothing wrong with it. . . . This is how humans have used cannabis for 10,000 years and it’s how people should have access to it in Pennsylvania.”

In all, there were 21 proposed changes to Pennsylvania’s medical marijuana program. Additional changes included allowing physicians participating in the program to choose to not have their name listed in the public registry to encourage more physicians to participate. The number of qualifying medical conditions is to increase from 17 to 21. One of those additional medical conditions was “the use of medical marijuana as a substitute for treating opioid addiction.” This change barely passed, with six of the 12 voting advisory board members voting in favor and at least one person abstaining (More on this issue later). Another proposed change that would limit a practitioner’s ability to specify the form and dose of medical marijuana a patient should get was not approved. Governor Wolf’s statement said:

My administration is committed to ensuring patients who need and would benefit from this medicine have access to it. The final report of the Medical Marijuana Advisory Board continues to put patients first and will improve the program to give greater access to patients by breaking down financial and administrative barriers. Allowing dry leaf for vaporization will shorten the time it takes to get medication to dispensaries, expand options for the growing number of patients, and hopefully make the program less cost-prohibitive for some patients.

But is this just political rhetoric? Are Pennsylvania’s elected officials being maneuvered into a path toward the eventual legalization of recreational marijuana?

State Senator Daylin Leach predicted at the World Medical Cannabis Conference & Expo, held in Pittsburgh on April 21 and 22 of 2017, that medical marijuana in plant form would be available in dispensaries sometime in 2018. During a panel discussion at the Expo held at the David L. Lawrence Convention Center, he noted State Bill 3 had a section permitting the advisory board to make recommendations by April 2018 about changing the permitted forms of the drug. “But they will, because we’re appointing people to do that.” He believes that full legalization of recreational marijuana in Pennsylvania is inevitable.

State Senator Mike Folmer was another of the primary sponsors of State Bill 3. He said he’s not opposed to legalizing recreational marijuana, but he can’t “politically advocate” for it at this time. WESA said he recalled “how difficult it was to get enough Republicans on board with the medical marijuana program.” I wonder if those unnamed Republicans were aware that their approval of State Bill 3 had a loophole section permitting the advisory board to approve changes to the permitted forms of marijuana? Are they feeling manipulated into approving what was presented as a bill that would restrict the dispensing of dry leaf cannabis?

CBD vs. THC

Another issue with the approval of selling cannabis dry leaf in the dispensaries is making a clear distinction of the kinds of marijuana that will be sold. There seems to be very little effort made when discussing medical marijuana in Pennsylvania—either by the media or government officials—to distinguish cannabis with high levels of THC from strains with high levels of CBD. Tetrahydrocannabinol (THC) is psychoactive, while cannabidiol (CBD) is not. A helpful overview of the differences between THC and CBD can be found in: CBD vs. THC: Main Differences.

Both THC and CBD are present in mature cannabis flower. But different cannabis strains produce different amounts of the compounds. So what strains of cannabis will be sold for medical reasons in Pennsylvania and will they have high concentrations of THC or CBD? Will there be more high THC strains?

Cannabinoids like THC and CBD effect the endocannabinoid system (ECS), which is “named for the plant that inspired its discovery.” Until recently the ECS was an unknown part of the human body’s functions. It helps ensure the proper running of the body’s immune and central nervous system. Its discovery came about through the research efforts of Lisa Matusuda and her team at the National Institute of Mental Health (NIMH) in the early 1990s, where they first identified a THC-sensitive receptor in the brains of lab rats. “The endocannabinoid system is responsible for regulating balance in our body’s immune response, communication between cells, appetite and metabolism, memory, and more.” The cannabinoids in cannabis like THC and CBD interact with the ECS to produce their effects.

Another researcher team was able to identify two of the body’s naturally produced endocannabinoids, anandamide and 2-arachidonoyglycerol (2-AG). 2-AG is a full agonist of both CB₁ and CB₂ receptors. Anandamide is a partial agonist of both receptors and as a result, doesn’t trigger as powerful a physiological response. Cannabinoids like THC and CBD mimic the behavior of endocannabinoids like 2-AG and anandamide. THC activates CB₁receptors, producing the high effect. Although THC also activates CB₂receptors, there it is a partial agonist, meaning it does not have as strong of a physiological effect.

“CBD causes chemical changes by blocking receptors. It tends to have low affinity for both CB₁and CB₂receptors, and instead acts as an indirect antagonist of agonists.” In other words, CBD blocks other chemicals like THC from binding and activating the receptors, as shown in the following graphic in: CBD vs. THC: Main Differences:

By modulating the endocannabinoid system, several diseases and conditions could possibly be treated, including: pain, inflammation, multiple sclerosis, anorexia, epilepsy, cancer, glaucoma, cancer, obesity, schizophrenia, cardiovascular disorders, Parkinson’s disease, Huntington’s disease, Alzheimer’s disease and Tourette’s syndrome.

One of the main obstacles to the acceptance and use of cannabis as a medicine is its potential for psychoactivity from THC. BUT “this issue does not arise in a number of possible approaches to the regulation of the endocannabinoid system.” One way is when a non-psychoactive cannabinoid like CBD is used for therapeutic reasons. Another is when an antagonist to the CB₁ receptor blocks THC from activating it. Are the cannabis strains and medical marijuana products being distributed in Pennsylvania formulated to minimize the euphoric activation of the CB₁ receptor by THC?

Benefits of CBD

Josh Axe, a wellness physician, has listed “8 Proven Benefits of CBD.” On his list are 1) that CBD relieves pain and inflammation; 2) it has antipsychotic effects; 3) it reduces anxiety; 4) helps to fight cancer; 5) relieves nausea; 6) it may treat seizures and other neurological disorders; 7) it could lower the incidence of diabetes; and 8) it promotes cardiovascular health. Dr. Axe cited multiple references to support these claims. He acknowledged several health benefits with THC, including its antispasmodic, analgesic, anti-tremor, anti-inflammatory and appetite stimulating properties. However, there are multiple adverse effects from marijuana use that have been documented in studies primarily of recreational marijuana, which is high in THC. See “Marijuana Research Findings” for more information.

Approving “medical marijuana as a substitute for treating opioid addiction” is a broad and vague addition to the list of approved medical uses of marijuana in Pennsylvania. Does that mean an individual could use medical marijuana as a MAT (medication-assisted treatment) for an opioid misuse disorder? There is reliable evidence for marijuana (THC and CBD) to relieve pain, but that is different than treating opioid addiction.

According to the Chicago Tribune the Illinois Senate recently passed a bill that would allow patients to take an opioid prescription and a signed doctor’s note to a medical marijuana dispensary in order to substitute marijuana for pain relief. “The dispensary must verify approval from a doctor and ensure a patient is not already receiving medical marijuana through another means.” One of the bill’s sponsors said: the bill “keeps people from getting strung out and spiraling down.” The Chicago Tribune commented where that state Senator received at least $8,000 in campaign contributions from medical marijuana interests.

Opponents to the bill said lawmakers were helping medical marijuana dispensaries become profitable businesses by expanding the number of people who can use the drug. One lawmaker said: I just want to make note and remind people that the medical marijuana program was lobbied by people who now own it.” If support for the bill in Illinois was motivated by individuals looking to profit from it, that should be known. However, note again that it was directed to patients with an opioid prescription substituting medical marijuana for the prescription and not the vaguely defined use “as a substitute for treating opioid addiction.”

There was a report on the NPR program All Things Considered on April 2, noting: “Opioid Use Lower In States That Eased Marijuana Laws.” The article highlighted two studies published in JAMA Internal Medicine showing there was a decrease in Medicare and Medicaid prescriptions for opioids in states with liberal marijuana laws. One study found a 14% reduction in opioid prescriptions in states allowing easy access to medical marijuana. The finding was a correlation and thus doesn’t prove marijuana use would result in a reduction in the use of opioids. Nevertheless, “the findings suggest that expanding access to medical marijuana could help ease the opioid epidemic.” Again, this is not vaguely defined use as a substitute treatment for opioid addiction. One of the researchers said:

Like any drug in our FDA-approved pharmacopeia, it can be misused. There’s no question about it. So I hope nobody reading our study will say ‘Oh, great, the answer to the opiate problem is just put cannabis in everybody’s medicine chest and we are good to go.’ We are certainly not saying that.

The authors of the second study said while laws permitting marijuana use have the potential to reduce opioid prescribing in a population segment with a high risk for chronic pain use disorder and opioid overdose, “Nevertheless, marijuana liberalization alone cannot solve the opioid epidemic.”

Another study cited in the NPR report, “Cannabis Use and Risk of Prescription Opioid Use Disorder,” found cannabis use appeared “to increase rather than decrease the risk of developing nonmedical opioid use.” The lead author of the study said there was likely a role “for medical marijuana in reducing the use of prescribed opioids for the management of pain.” But it is a question of balancing risks and benefits, which is hard to do when the current studies are based on broad populations and not the at-risk populations as a whole. And once again, the potential is for individuals with pain issues to benefit from marijuana, not for it to be used as a substitute for treating opioid addiction.

Governor Wolf said he is committed to seeing that citizens of Pennsylvania who need medical marijuana get it. Secretary Levine said: “We are not looking for an intoxicating effect. We are looking for a medical effect.” Hopefully that means cannabis strains and medical marijuana products that are high in CBD and low in THC will be sold in Pennsylvania dispensaries while high THC products will be limited. It is also alarming that such a vague expansion of the permitted treatments, namely to use “medical marijuana as a substitute for treating opioid addiction,” could be included in the revised regulations. Let’s hope the government officials and regulators work to keep marijuana medical in Pennsylvania. But it is also apparent that there are others, perhaps including some of the sponsors of Senate Bill 3, who see the state’s approval of medical marijuana as a stepping stone towards recreational marijuana.

Documents detailing multiple revisions to Pennsylvania’s Medical Marijuana Program were posted online on May 12, 2018. They include permitting the sale of “dry leaf or plant form for administration by vaporization.” This can be smoked like recreational marijuana, although it is illegal in PA to do so. However, there is no clear way to enforce the restriction. As noted above, a pro cannabis activist acknowledged individuals would smoke, not vaporize the dry leaf product saying, “This is how humans have used cannabis for 10,000 years and it’s how people should have access to it in Pennsylvania.”

Also, opioid use disorder is now an approved medical condition to receive medical marijuana. The new regulation is vague and subjective. It seems to provide a loophole for individuals who have an opioid use disorder diagnosis to qualify for a medical marijuana card. The new regulation permitting medical marijuana for opioid use disorder reads: “Opioid use disorder for which conventional therapeutic interventions are contraindicated or ineffective, or for which adjunctive therapy is indicated in combination with primary therapeutic interventions.” The documents describing the amended regulations are available here: http://cannabislawpa.com/updates-resour…/regulatory-updates/

Please share this information with others who may be concerned with the revised regulations so they can voice their concerns. Anyone troubled by these noted changes, or any others within the new guidelines can submit written comments, suggestions or objections regarding these amended temporary regulations to John J. Collins, Office of Medical Marijuana, Department of Health, Room 628, Health and Welfare Building, 625 Forster Street, Harrisburg, PA 17120, (717) 547-3047. The given email address for John Collins was invalid. I will update it here if I locate a valid one.

02/13/18

Keep Marijuana Medical in PA

Western Pennsylvania is about to see medical marijuana sales begin. Two dispensaries are scheduled to open on February 15^th, 2018. It’s been almost two full years since Governor Tom Wolf signed Senate Bill 3, legalizing medical marijuana on April 17, 2016. As the Governor signed the bill, he said: “I am proud to sign this bill that will provide long overdue medical relief to patients and families who could benefit from this treatment.” At the time, the press release expected implementing the state’s Medical Marijuana Program to take between 18 and 24 months, making it right on schedule. Let’s hope that what’s coming sets PA on a different path than California’s original legalization of medical marijuana did in 1996—despite the hopes of two of the sponsors of the new PA law.

When Proposition 215 was about to be approved in California, Senator Diane Feinstein said: “you’ll be able to drive a truckload of marijuana through the holes in it.” The devil is in the details, and she said that particular bill lacked details. A significant difference between Proposition 215 and the Pennsylvania Medical Marijuana Program is that in PA, dried leaves, plant material and edibles are strictly prohibited. Grower/processors can only manufacture the forms of medical marijuana listed in Act 16. These include: 1) a form medically appropriate to administer by vaporization or nebulization; 2) pills; 3) topical forms, including gels, creams or ointments; 4) tinctures; 5) liquids; or 6) oils. A licensed practitioner or medical professional determines which form is appropriate for the patient.

Cannabis products as they are to be sold in PA will provide medical relief to patients and families within the state without the patent medicine aura in dispensaries hocking different kinds of edibles or plant material for what “ails” you, as in states with less restrictive medical marijuana laws (like California). A medical professional (physician, physician assistant or certified registered nurse) has to be present during all hours a facility is open and offering to dispense or consult with a patient. Additionally, they all have to complete a required four-hour training and be registered with the PA Department of Health. Significantly, “a practitioner or physician may not issue a patient certification at the dispensary facility.”

Patients wanting to participate in the medical marijuana program have to visit the online Patients and Caregivers Registry and create a profile in the Department of Health’s patient and caregiver registry. Then they have to obtain a physician’s certification they suffer from one of the 17 serious medical conditions listed in the graphic below. Returning to the Patients and Caregivers Registry, they pay $50 a year for a medical marijuana ID card. Caregivers for minors or patients unable to travel to a dispensary themselves can also participate in the medical marijuana program. Registered caregivers can have up to five patients. See the YouTube video, “Overview of Medical Marijuana in Pennsylvania” on the webpage for more information on the Pennsylvania Medical Marijuana Program linked above.

Look on the website for other resources such as a list of approved practitioners by state region and county, the Patient and Caregiver Registry, and an Information for Patients Brochure. Under certain guidelines, a parent, legal guardian or caregiver may administer medical marijuana to students with serious medical conditions while on school property. See the website for more information on what is required for this process.

The initial guidelines described above will give patients in Pennsylvania access to marijuana for legitimate medical reasons. If the guidelines are followed as described above, they will help the state avoid its new medical marijuana program morphing into what has happened in California since the approval of Proposition 215 in 1996. But Pennsylvania citizens and government officials need to be vigilant. At least two of the cosponsors of the legislation itself want to see the plant form of marijuana available for sale in dispensaries and to eventually to see the state move towards legalizing recreational marijuana.

In April of 2017 at the World Medical Cannabis Conference & Expo held in Pittsburgh, one of the sponsors of Senate Bill 3 (SB 3), State Senator Daylin Leach, said he expected medical marijuana would be available in plant form in dispensaries sometime during 2018. He noted a section of the bill authorizes an advisory board to make recommendations by April of 2018 about whether to change the permissible forms of the drug. During a panel discussion at the Expo, Margaret Sun for WESA reported Leach said the following about the advisory board:

“But they will [approve sale of the plant form of marijuana], because we’re appointing people to do that,” Leach said as the crowd laughed. “They will recommend that at latest by April 17 (2018), which means when dispensaries open, it is likely that they will have whole plant on their shelves from day one.”

Leach’s statement went over well with his listeners, but his ability to make good on his promise is more bluster than reality. What follows is a description of the members of the Medical Marijuana Advisory Board within the State Department of Health are supposed to include. I don’t see him being able to stack this deck:

Members include the Secretary of Health; the Physician General; State Police Commissioner; Chair of the State Board of Pharmacy; Commissioner of Professional & Occupational Affairs; President of the Pennsylvania Chiefs of Police Association; President of the Pennsylvania District Attorneys Association; members to be appointed by the Governor and the four legislative caucuses who are knowledgeable and experienced in issues relating to care and treatment of individuals with a serious medical condition, geriatric or pediatric or clinical research. One member appointed by the Governor shall be a patient, a family or household member of a patient or a patient advocate.

Also, the Department of Health has the final approval on whether to add the smokeable plant form to the program, but as SB 3 is written—and as it is now described on the website—dried leaves, plant material and edibles are not approved. Leach’s words suggest his intentions in sponsoring the medical marijuana legislation was at least partly as a stepping stone to his intent to pursue full legalization of recreational marijuana. Both Leach and another sponsor of SB 3, State Senator Mike Folmer, said they thought full legalization was inevitable in Pennsylvania. Folmer stated he couldn’t politically advocate for legalization just now, as it was difficult enough getting Republicans on board with the medical marijuana program. He said:

I’d like to see our first dispensaries up, I’d like to see the first grower/processors going, and I think then, on my side, we’ll see that the sky isn’t going to fall, dogs won’t sleep with cats, and the sun will still set in the West and civilization will not crumble.

Civilization won’t crumble with the implementation of the existing PA Medical Marijuana Program. But our inability to trust disingenuous politicians who pragmatically use public sympathy for suffering individuals to further their political agendas will crumble our civilization. SB 3 was apparently a backdoor strategy for these two PA State Senators towards their desire to eventually legalize recreational marijuana. Was there ever any real concern for the needs of medical marijuana patients, or was it just rhetoric to get closer to recreational legalization? Leach is a Democrat from Montgomery County and Folmer is a Republican representing Dauphin, Lebanon and York Counties. Remember this if you live in the areas they represent as their term expires.

The Pennsylvania Medical Marijuana Program as it now exists will provide for suffering individuals within the state. And that is a good thing. Other than THC (the psychoactive cannabinoid in cannabis), there seems to be a significant medicinal potential with CBD (cannabidiol). Further research is needed and the federal classification as a Schedule I substance hampers that research from being done. That needs to change.

There are some serious researchers, like Staci Gruber, who are investigating the medical benefits of cannabis without being blinded to its potential adverse psychoactive harms. PA medical marijuana research would do well to partner with researchers like Gruber and her organization, MIND (Marijuana Investigations for Neuroscientific Discovery). Let’s let research and not rhetoric guide the medical uses of the cannabinoids in cannabis. So far it seems there are limited health benefits from THC. See “Listening to Marijuana Research” for more information on this.

Solevo Wellness is set to open its doors for business in the Squirrel Hill section of Pittsburgh on February 15^th. The dispensary’s first shipment is coming from the grower-processor Cresco Yeltrah in Brookville, Jefferson County. Visitors will be greeted by a receptionist and show their necessary legal paperwork to gain access to products and then visit with a pharmacist. “Then they’ll head to a showroom, where cannabis product samples are kept inside glass cases, make a purchase and continue with their day.” The Solevo Wellness dispensary is constantly monitored by security cameras.

CY+ opened its doors with a ribbon cutting ceremony in Butler PA on February 1^st. It will begin selling its products on the fifteenth as well. Larry Clark, the Pennsylvania Deputy Director of Medical Marijuana was there. He said: “It’s a medical experience”; not the head shop approach. Kimberly Geyer, the Butler County Commissioner, said: “It defies all the traditional stereotypes associated with this industry.” CY+ is owned by Cresco Yeltrah, which seems to be a subsidiary of Cresco Labs, a company out of Chicago. Charlie Bachtell, the cofounder of CY+, was at the opening in Butler. Bachtell is the CEO and Cofounder of Cresco Labs. They hope to open their second Western Pennsylvania facility in the Strip district by mid-April.

That’s just around the time Daylin Leach thought the state advisory board could approve the sale of plant product in stores. Given the difficulty it seems there was in getting SB 3 passed not only does that seem unlikely, but it would be political suicide for medical marijuana activists. Dispensing marijuana as a medical product in an environment that has the feel of a medical practice or medicine shop rather than a head shop sets the right tone. Trying to force the so-called progressive cause of legalizing recreational marijuana on the back of the recent approval of medical marijuana could sink them both in PA. But Leach may have other things on his mind since his brash claim last year at the World Medical Cannabis Conference & Expo.

Daylin Leach had an event-filled 2017. He temporarily moonlighted as a lawyer for a Philadelphia law firm that lobbies for the marijuana industry from shortly after Governor Wolf signed SB 3 until he announced a run for Pennsylvania’s 7^th Congressional District in July of 2017. He then announced the suspension of his campaign in December of 2017 in the midst of accusations of a pattern of inappropriate behavior with several former female staffers. He took this step after a story in the Philadelphia Inquirer appeared in which a series of former campaign and legislative staffers accused him of inappropriate behavior. He said he was taking a step back to focus on his family and work with Senate leaders to address these allegations. “I will continue to do all that I can to advance progressive causes in the Senate and represent my constituents with honor.”

Frankly, I think he’s done enough and needs to move on to another progressive cause besides legalizing marijuana. But I suspect the financial lure of cannabis might be too strong for him to resist. So let’s make other PA state legislators aware of wanting to keep marijuana medical in PA.

Faith Seeking Understanding

Charles Sigler, D.Phil.

Tag: Pennsylvania Medical Marijuana Program