Prof. Kathi Hoke and Network for Public Health Law Eastern Region Lead Cannabis

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In response to sweeping changes to marijuana legislation at the state level, on June 20, 2018, Prof. Kathi Hoke and the Network for Public Health Law Eastern Region held a Cannabis Policy Briefing at the University of Maryland Carey School of Law. Cannabis policy experts discussed the current state of marijuana policy, current gaps in knowledge regarding the health impact of cannabis use, and lessons learned from policy changes across the country.

Speakers included representatives from the CDC, CDC Foundation, NIDA, Association of State and Territorial Health Officials, Network for Public Health Law, and the Maryland Medical Cannabis Commission. Attendees included representatives from Eastern Region States’ medical and non-medical cannabis commissions, state and local public health professionals, tobacco control professionals, medical professionals, and academic professionals.

The briefing began with a “Cannabis 101” overview that provided the historical background on the regulation of marijuana in the U.S. that has vacillated between criminalization and legalization. Dr. Gillian Schauer, Senior Policy Fellow with the CDC Foundation, reviewed marijuana policy in the U.S. and the implications of policy changes on usage over time.

She also highlighted the current state of knowledge regarding the health risks associated with marijuana including increased risk of mental health diagnoses, substance abuse/dependence, respiratory effects and low birthweight. Research on health effects is hampered, however, by marijuana’s status as a Schedule I drug under the Controlled Substances Act, the difficulty of isolating the effects of marijuana given overlap with consumption of other substances, and the fact that frequency and mode of use have not historically been well measured.

Marijuana policy, Dr. Schauer noted, varies widely by state. Some states, such as Colorado and California among others have passed laws allowing for medical and non-medical use. Many others have passed legislation with narrower access to those who can demonstrate a medical need. Other states have adopted CBD-only/low THC policies. This latter group, Schauer noted, often provides little regulatory oversight.

In contrast, states that allow medical marijuana only are typically highly regulated in terms of marketplaces, types of products available, registries and product testing with public health agencies typically serving in the oversight role. Schauer noted that these states vary in the medical indications that permit access and those indications are sometimes not supported by scientific evidence.

Susan Weiss, Director of Extramural Research at the National institute on Drug Abuse provided an overview of the major marijuana studies conducted to date. She emphasized the need for data to inform public health approaches to marijuana use, particularly in light of sharply increased potency of marijuana products and the proliferation of different routes of administration.

Indeed, the need for data was a recurring theme throughout the day. The public health agencies responsible for oversight of medical marijuana have limited scientific data on the long-term effects of marijuana usage to inform their messaging. Surveillance data is also limited but there is some evidence to suggest that there is a decreasing harm perception around marijuana despite risks related to potency and routes of administration.

Dr. Weiss was followed by a panel of policy experts. James Hodge of the Network for Public Health Law – Western Region discussed the changes to marijuana policy at the federal level, namely the January 2018 rescission of Obama-era guidance to decline enforcement of federal drug law in states that have legalized marijuana. That guidance and subsequent clarifications as well as recent court decisions and proposed federal legislation have contributed to continued uncertainty in marijuana policy. He likened the continuing efforts to balance federal and state legislative mandates to a “roller coaster” that shows no signs of slowing.

Andy Baker White from the Association of State and Territorial Health Officials then discussed local level approaches including school policy, employment policy and public consumption laws. While school policy has been settled in several states (i.e. use is permitted in school with valid physician authorization, parent/school nurse administration, etc.), lawsuits have been filed where state laws allow pediatric access to medical marijuana but prohibit its use in schools. In terms of employment policy, states are taking various approaches in providing employment protections to individuals authorized to use medical marijuana. Arizona, Minnesota, and Delaware, for example, have taken an anti-discrimination approach, while others, such as New York, have adopted a reasonable accommodations approach. He also highlighted the equity issues that arise for individuals who live in public housing. While these individuals have a right to use marijuana under state law, that use is prohibited under housing law.

Michael Tynan from the U.S. Centers for Disease Control and Prevention then discussed the production, distribution and regulatory oversight systems that must be established after legalization, using Oregon as an example. He highlighted the challenge that public health agencies face in ramping up prevention efforts post-legalization in the absence of resources for that purpose as well as the critical need for data on use, particularly among youth. He also discussed the overlap between tobacco use and marijuana use in terms of norms regarding public consumption, implications for smoke free laws, and overlap of products (e.g., e-cigarettes such as Juul and Pax Era). He emphasized the importance of public health agencies “having a seat at the table” in order to influence the policy discussion.

Lindsey Greto from the public health department for Seattle & King County, Washington, discussed policy implementation at the local level. She relayed her agency’s experience implementing store siting laws that require that cannabis retail locations maintain a minimum distance from schools, daycares, etc. As originally written, however, the distance required by regulation would result in the placement of all retail locations in underserved and under resourced communities. That led to a policy change decreasing the distance requirement in order to facilitate wider, more equitable disbursement of locations. She encouraged state funding for research especially on the impact of stores on communities and evaluation of alternative distribution models such as delivery. She also reiterated the need for public health presence and credibility in the medical marijuana conversation.

Will Tilburg, Director of Policy and Government Relations for the Maryland Medical Cannabis Commission, provided an overview of the Commission’s work. He urged public health professionals in Maryland to become more involved with the Commission and the policy conversation happening in the state. He then discussed the recent history of decriminalization and legalization of medical marijuana in Maryland as well as the current regulatory framework.

During the discussion after the panel, panelists and attendees discussed the possibility of rescheduling marijuana under the Controlled Substances Act. As Professor Diane Hoffmann and colleagues discussed in a recent post to the Health Affairs blog, based on requirements for rescheduling cannabis currently supported by FDA and DEA, such a change remains unlikely. Panelists also noted the lack of support for FDA-approved marijuana-based medications among the medical marijuana advocacy community.

The tension between federal prohibition and state legalization remains an issue, particularly for states with narrower medicinal use laws. For example, individuals may be consuming marijuana for medicinal purposes but face difficulties when they are admitted to hospitals or hospice care facilities that are highly regulated by both federal and state governments.

Regulation of edibles, food products containing cannabis extracts were another topic of discussion. Edibles are widely viewed by many as “healthier” since they are ingested and not smoked but there is little scientific evidence to support that perception. One serious concern with edibles is the lack of serving size restrictions. A single cookie may contain eight servings but the cookie is not sold in a manner that facilitates consumption by serving size. Further, edibles are not as fast acting as smoked cannabis and consumers may not realize the effects prior to overconsumption. This can lead to overdose or severe toxicity that may result in, among other potential negative consequences, high levels of agitation, anxiety or hallucinations.

A related policy issue is that of pediatric access to medical marijuana. While limiting youth consumption enjoys a broad consensus, for some pediatric patients, there may be therapeutic benefits of medical marijuana. The Network is looking at the existing regulatory frameworks in other states to inform Maryland’s approach to this population.

The afternoon agenda included a round table discussion that provided meeting participants with a rare opportunity to talk with presenters and panelists in a small group setting. At the conclusion of the conference, Network Attorney Mellissa Sager summarized the key highlights of the day’s discussion (1) Public health professionals should not shy away from involvement in the marijuana policy conversation – policy changes are happening and the public health perspective will be critical (2) Regulatory agencies such as the Maryland Medical Cannabis Commission welcome participation in their meetings to help inform the policy discussion (3) Data is limited – some information is available but it will be important to stay updated as the science develops.


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