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It is now about ten to eleven, and
we're still a little bit of ahead of schedule. Is
Dr. Hertko here?
ED HERTKO: Anyway, my name is
Dr. Edward Hertko, and I've been a physician in the
state of Iowa for the past 50 years. Before I
start my paper -- and I'll read it, and the paper
is called "Deja Vu. Medical Marijuana, Where Are
You?"
Let me explain. Back in 1979, I
appeared before a legislative forum who at that
time then referred the problem of marijuana to the
pharmacists. Now we're doing it in reverse. We're
going to the pharmacists to refer it to the
legislature.
However, being a student of the Bible,
this also brings me to mind in the book of Genesis
where the Jewish nation was going to the promised
land. They wandered around in the desert for
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40 years. And then they got to the promised land.
and they sent 13 spies into the promised land, and
they came back. Eleven people said "Oh, my God.
You cannot go in there. The people are huge.
They're probably over 5 foot 7."
And two people said "Go in. Do it."
And they were Caleb and Joshua. But they went back
out into the wilderness for 40 years, turned around
and came back. When they got there, Moses saw the
promised land. He died, but Caleb and Joshua got
in.
So here we are with this position now
because I'm back here 30 years later with the same
problem. So I don't know whether I'm Moses and
going to die or whether I'm Caleb and Joshua who
are going to be able to see something happen.
And with that, I'll read my paper,
which I called "Deja Vu. Medical Marijuana, Where
Are You?"
Ladies and gentlemen of the Iowa Board
of Pharmacy, thank you for allowing me to address
you regarding this subject. I did the same thing
30 years ago to the Iowa legislature. I will focus
only on the medical use of marijuana, not its
recreational use. The people who need recreational
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marijuana already know how to get it.
A bill was approved on June 1, 1979,
which appropriated $247,000 to the Board of
Pharmacy Examiners which was contingent upon the
Board of Pharmacy Examiners establishing a
therapeutic research program within 90 days of the
effective date of that act.
The board was mandated to organize a
physician advisory group to advise the board on the
structure of the program which was never
operational. Today therapeutic research program
laws are no longer effective because of federal
obstructionism.
The dual scheduling scheme still
exists in the statute. But the language for the
therapeutic research program Administrative Code
620-12 was active October 1, '79, to June 30, 1981.
And then it eventually was removed in 1987, and it
is now currently just symbolic.
Should suffering patients be
criminalized? There were approximately
830,000 arrests, 99 percent by local, not federal,
officials in the United States in 2006. 89 percent
of these were for possession, not sale or
manufacture, of marijuana.
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Even if only 1 percent of those
arrested were using marijuana for medical purposes,
then there are more than 7,000 medical marijuana
arrests every year.
Here we are 30 years later in Iowa,
and the marijuana debate continues unceasing
regarding marijuana and its use in medical spheres.
Since 1979, and especially since the mid-1990s,
there have been numerous studies that have shown
that many patients suffering from AIDS, cancer,
multiple sclerosis, epilepsy, Lou Gehrig's disease,
severe or chronic pain, severe nausea and vomiting
secondary to chemotherapeutic drugs, severe or
persistent muscle spasms, and other debilitating
illnesses that find that marijuana provides some
relief from their symptoms.
Available prescription drugs often
come with far more serious side effects than
marijuana. And many patients -- That doesn't
count, does it? And many patients who find relief
from marijuana simply do not respond to other
prescription medications.
In 1999 the Institute of Medicine,
which you already mentioned, showed there was great
relief for -- for marijuana. In 1988 after
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reviewing volumes of evidence on marijuana's
medical use, the Department of Enforcement Agency
chief administrative law judge, Francis Young,
found that maintaining marijuana as a Schedule
drug would be unreasonable, arbitrary, and
capricous and that marijuana in its natural form
is one of the safest therapeutically active
substances known to man.
Last year in 2008, the American
College of Physicians, of which I am a member -- I
have been a fellow of the American College of
Physicians since 1968 came out with a position
paper on the therapeutic role of marijuana in
certain conditions but also -- came out with a
pardon me. I skipped a line -- which stated the
conclusion evidence not only supports the use of
medical marijuana in certain conditions but also
suggests numerous indications for the cannabinoids.
Additional research is needed to
further clarify the therapeutic value of the
cannabinoids and determine optimal routes of
administration. The science on medical marijuana
should not be obscured or hindered by the debate
surrounding the legalization of marijuana for
general use.
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The position paper of the American
College of Physicians also stated, quote, given
marijuana's proven efficacy at treating certain
symptoms and its relatively low toxicity,
reclassification would reduce barriers to research
and increase availability of cannabinoid drugs to
patients who have failed to respond to other
treatments.
Since 1996, 13 states have enacted
laws that effectively allow patients to use medical
marijuana despite federal law. Those state laws
have removed criminal penalties for patients who
use and possess medical marijuana with their
doctor's approval or certification. These laws are
working well, enjoy popular support, and are
protecting patients.
Data have shown that any concerns
about these laws increasing youth marijuana use are
unfounded. Eleven of the thirteen medical
marijuana approved states that have produced before
and after data have reported overall decreases in
teen marijuana use exceeding 50 percent in some age
groups. It has been said that it is easier for a
teenager to buy pot than a six-pack of Coors.
Right now under Iowa law, it's illegal
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for seriously ill patients to use medical marijuana
under the supervision of their physician. If the
patient with one of the devastating diseases stated
earlier desires the use of marijuana, they then
must grow it illegally or buy it on the criminal
market.
Therefore, cash goes into the purses
of drug dealers or drug gangs instead of into the
coffers of the State through manufacture,
distribution, registration, and taxation of
marijuana which could add up to hundreds of
thousands of dollars yearly.
If a patient is charged with a
possession of marijuana, is it possible to use
medical necessity as a defense? Yes. It is
possible for -- it was possible for a judge to
allow an individual to raise a medical necessity
defense based on the state having a symbolic
medical marijuana law, and in Iowa, that happened.
An Iowa judge ruled that a medical marijuana user's
probation could not be revoked for using marijuana
because the Iowa legislature had defined marijuana
as a Schedule II drug with, quote, currently
accepted medical use, unquote.
Of note, Iowa moved marijuana into
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Schedule II in 1979 when it enacted a therapeutic
research program. The research program expired in
1981, bue marijuana schedule remains in place. A
2005 national Gallup poll found that 78 percent of
Americans support making marijuana legally
available for doctors to prescribe in order to
relieve pain and suffering.
For over a decade, polls have
consistently shown that 60 to 80 percent support
for legal access to medical marijuana. Prominent
health and medical organizations including the
American Academy of HIV Medicine, the American
Nurses Association backed it in 2003, American
Public Health Association, Leukemia/Lymphoma
Society, Lymphoma Foundation, and like I stated
earlier, American College of Physicians.
At the present time, marijuana is a
Schedule I drug which means A, the drug has a high
potential for abuse. This is not true when
compared to other drugs such as Valium, Xanax,
sleeping pills, and other opiates which are much
more addictive and are not Schedule I drugs. Beer
and tobacco are much more addictive.
The drug has no currently accepted
medical use in treatment in the United States.
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This is not true. Just read the medical
literature.
There is lack oE safecy for the use of
the drug under medical supervision. This is not
true. Francis T. Young, chief administrative law
judge, said on September 6, 1988, quote, marijuana
in its natural form is one of the safest
therapeutically active substances known, unquote.
It is time to legalize the passage of
a law in Iowa allowing doctor-advised medical use
of marijuana. Let physicians certify deserving
patients with debilitating conditions which have
been previously mentioned to receive the medical
benefits of marijuana which likely outweighs the
risks. Drug abuse is bad. But drug wars are
worse.
One thing that I have also is where is
the harm in drugs? And one of the things you have
to do is when you talk about a drug, you have to
bear in mind, what is the harm? Reducing the harm
of marijuana is a public health philosophy that
seeks to lessen the dangers that marijuana abuse
and policy causes to society.
Reduction in the harm policy is a
comprehensive approach to drug abuse and drug
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policy. Harm reduction's complexity lends to its
misperception as a drug legalization tool.
Reduction in the harm of marijuana rests on several
basic assumptions.
A basic tenet of harm reduction is
that there never has been, is not now, and never
will be a drug-free society. A reduction in harm
strategy seeks pragmatic solutions to the harm that
a drug -- in a drug policy causes. It has been
said that harm reduction is not what's nice, but
it's what works.
What does that say on that?
ED HERTKO: Five minutes. Good.
A
harm reduction approach acknowledges there is no
ultimate solution to the problems of drugs in a
free Society and that many different interventions
may work. These interventions should be based on
science, compassion, health, and human rights.
A harm reduction strategy demands new
outcome measurements whereas the success of current
drug policies is primarily measured by the changes
in use rates. The success of a harm reduction
strategy is measured by the changes in rates of
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death, disease, crime, and suffering.
Because incarceration does little to
reduce the harm that any ever-present drug causes
to our society, a harm reduction approach favors
treatment of a drug addiction by health-care
professionals over incarcecation in the penal
system.
Because some drugs such as marijuana
have proven medicinal uses, a harm reduction
strategy not only seeks to reduce the harm that
drugs cause but also to maximize their potential
benefits. A harm reduction strategy recognizes
that some drugs such as marijuana are less harmful
than tobacco, cocaine, alcohol, methamphetamines,
and many others.
Harm reduction mandates that the
emphasis on intervention should be based on
relative harmfulness of the drug to society, a harm
reduction approach that advocates lessening the
harms of drugs through education, prevention, and
treatment.
Harm reduction seeks to reduce the
harms of drug policies, dependent on an
overemphasis on interdiction such as arrest,
incarceration, establishment of a felony record,
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lack of treatment, lack of adequate information
about drugs, the expansion of military source
control intervention efforts in other countries,
and an intrusion on personal freedoms.
Harm reduction also seeks to reduce
the harms caused by an overemphasis on prohibition
such as increased purity, black market adulterants,
black market sale to minors, and black market
crime.
A harm reduction strategy seeks to
protect youth from the dangers of drugs by offering
factual science-based education and eliminating
youth black market exposure to drugs.
Finally, harm reductlon seeks to
restore basic human dignity to dealing with the
disease of addiction. Thank you.
LLOYD JESSEN: Thank you, Dr. Hertko.
And thank you for summarizing the history that this
board has had with this issue, which I think is
something the public is not generally aware of.
I do have a couple questions for you.
The board has been following what's happening in
other states that have medical marijuana such as
California and Colorado. I assume you follow that
as well?
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ED HERTKO: Oh, yes. I followed
this
last week in the paper. The amount of money that
they're going to gain, and I'm thinking Iowa needs
money. Why don't we legalize it and tax it? Like
one guy says, legalize it and tax the hell out of
it.
LLOYD JESSEN: The question I have
for
you is, if medical marijuana was approved in Iowa,
would you have a recommendation on how distribution
of marijuana occurred here given the fact that it
happens in different ways in different states?
ED HERTKO: The only way that I would
be in favor of it is the same way when I was in
practice. I would write prescriptions for
Phenergan, for morphine, for codeine, for any of
the drugs and so forth, and I would do the same
thing here, that I would write a prescription,
which is a legal document which then would take it
to a legal dispensary for a pharmacist who has been
brought up to date on how to fill that thing so
that you have some idea of who is getting it, and
it all has to be legal.
LLOYD JESSEN: Thank you. Some states
use what they call a compassionate care center, and
another alternative would be to have licensed
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pharmacies dispense the marijuana. How do you feel
about that?
ED HERTKO: If I were going to do
that, the first place I would do is I would go to
California because they're the ones whose law
when you're dealing with 13 states, like I've read
the articles from every one of the states, and some
of them are really to the -- far to the left or
whatever you want to call it, and over in
California, I think they've gone a little bit too
far, and some of the stuff they're doing, it almost
sounds like they're doing like a Neverland. You
can just walk down the street and buy marijuana and
hashish and so forth, and you buy it just the same
as cigarettes. But I think that's a little much.
I think at this point in time I don't
think we're quite ready for that sort of a
situation to arise. I would be favor of legalizing
it, but it has to be legally dispensed through a
prescription from a practicing physician or
practicing health physician. I don't know what the
law would be.
But hopefully, though, we will take
this and just add it to the aramatarium that
physicians and other people and health
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professionals can go ahead and use it because I
personally think that marijuana does have a place
and a legal place. As far as the recreational, as
I said earlier, those people already know how to
get it.
LLOYD JESSEN: So in your opinion,
would you favor dispensing by a pharmacy rather
than what other states call compassionate care
centers?
ED HERTKO: No. I would first
go with
that. I don't think -- I don't think -- that came
later because they've been doing that for years in
California. I don't think they did all that
compassion centers -- I don't think that was Day 1.
I think that came later.
I would go with the legal part
through -- legally dispensing it through a pharmacy
and go with that, see how it runs, and then if you
want to change it later to something else or add
something else, but I'd first -- I'd go out to
California and find out how they're doing it and
figure out "Oh, I ain't going to do that to start
with."
LLOYD JESSEN: Any other questions
from board members? Thank you, Dr. Hertko.
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If I could please ask the audience, I
know you're enthusiastic about many of the comments
that are being made, and if you could please just
hold your applause until each speaker has finished.
I'm just worried that if we get a lot of people who
want to speak throughout the rest of the day, we
want to be sure we have time for them, and if we
have to pause every time we have applause, that's
going to slow us down. So I appreciate the fact
you want to applaud, but if you could please just
applaud when each speaker has finished, that would,
I think, be fair to everyone who might want to
speak today.
Let's take a five-minute break so that
our shorthand reporter can have a little rest, and
we'll be back in about five minutes.
(Short recess.)
LLOYD JESSEN: Okay, everyone.
We're
ready to start again, and we have two doctors from
Washington State, and I believe -- are you fellows
with the College of Medicine there?
LLOYD JESSEN: Okay. I'll
let you
introduce yourselves and if you -- when you start,
if you could please spell your names for the
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SUNIL AGGARWAL: Okay. Thank
you,
Lloyd. My name is Sunil Aggarwal. I am a medical
scientist training program trainee at the
University of Washington School of Medicine.
I have completed a Ph.D. in medical geography
studying the medical geography of cannabinoid
botanicals in Washington State.
I'm currently a fourth year medical
student at the University of Washington. And my
name is spelled S-u-n-i-l A-g-g-a-r-w-a-l.
GREG CARTER: Okay. Hi.
I am Greg
Carter, G-r-e-g C-a-r-t-e-r. I am a professor of
rehabilitation medicine at the University of
Washington. I was a part of Sunil's doctoral
committee, and we have done research together on
what he referred to as cannabinoid botanicals, just
so you know what we're talking about. And I have
been at the University of Washington for 15 years.
I've got over 120 peer-reviewed journal
publications.
And I have a website if you're
interested in my full qualifications. You just
Google my name, and the University of Washington
has a bio page that pulls everything up for you.
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SUNIL AGGARWAL: Did you want
us to
talk, or do you want to ask questions? I'm not
sure how you want to do the format.
LLOYD JESSEN: Thank you for
introducing yourselves. We'd just like you to make
whatever comments you want to make, and then we
might have questions for you.
SUNIL AGGARWAL: Okay. Great.
Well,
thank you again for inviting us to speak, and I
want to commend the Iowa Board of Pharmacy members
for taking this -- this step to look at the science
and current practices around cannabis.
I would -- I would suggest that we do
discuss this plant as its scientific name, which is
cannabis, just -- just like we talk about other --
other drugs and substances with their scientific
name rather than their slang name when we talk
about medicine, so you don't want to put, you
know -- you don't want to put your pediatric
patients on ice. You put them on amphetamine or
methamphetamine derivative, and you know, you don't
use blow in your nasal surgery. You use cocaine.
So it's important that we don't use
this slang word because oftentimes, that gets
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associated with a lot of the sort of prevailing
social mythologies around -- around cannabis.
So my comments, basically what I want
to center around, a couple of the issues that the
board is considering with regards to the current
medical use of cannabis in the United States and
some of the science around that.
So as you know, there are 13 states
now in the United States that have active medical
cannabis programs. Roughly, I'd say between 7 and
8,000 physicians in those 13 states have authorized
the use of cannabis for their patients, maybe about
400,000 or so now.
You all know there are four patients
in an active federal program that's been going on
for three decades. One of the federal patients, as
you know, lives in Iowa. They receive a supply
from Mississippi, and that Mississippi program has
supplied cannabis to -- in at least 33 clinical
trials conducted in the United States with smoked
cannabis for the treatment of a variety of
conditions.
I sent Mr. Jessen a list, a huge list,
of -- what do you call it? -- publications that
have come out with that supply of cannabis. What's
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interesting is that there has been about ten gold
standard placebo-controlled trials conducted with
what we call cannabinoid controls where your
control group is oral THC pills.
About ten trials have been conducted
since 1990 -- since, I think -- excuse me -- since
2001. And all ten trials have shown significant
improvement in the cannabis group compared to the
control.
These studies were conducted at major
medical centers such as UCSF, UC Davis, UC San
Diego, Columbia University, University of Chicago,
and they were all published in pretty mainstream
medical journals such as the Annals of Internal
Medicine, Neurology, Journal of Acquired
Immunodeficiency Syndrome, Psychopharmacology,
Anesthesiology, et cetera, the Journal of Pain, and
it's also important to note that we also have one
constant style systematic review and meta-analysis
evaluating the use of cannabis in
chemotherapy-induced nausea and vomiting.
And one meta-analysis that combined
18 studies of cannabis or cannabinoid versus
standard NTC meds showed a statistically
significant difference in patient preference for
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cannabis preference for one of the studies in
favor of cannabis or its components.
So this is what's called Level 4
evidence, which is the highest form of evidence
that's part of the standards of evidence-based
medicine.
So as far as -- as far as the question
posed whether cannabis has an accepted medical use
in treatment in the United States, that is a --
that's what I hope my comments would address.
The question about whether there's an
accepted safety for use in treatment in medical
supervision, I've also sent to Lloyd a study that
was called a Comprehensive Review of the Adverse
Effects of Medical Cannabinoids, which was a
systematic review of all controlled studies,
clinical studies, that have been conducted with
cannabis and cannabinoids and demonstrated that
shows that there were absolutely no adverse
serious adverse events that had taken place in the
trials that have been conducted thus far. And that
was published in the Community of Medical
Association Journal in 2008.
I guess in general comments, I should
mention that cannabis is a very old substance that
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was evolved 37, 38 million years ago and has been
used widely in many indigenous medical traditions
around the world before it came to the United
States.
The chemicals in cannabis, there's
maybe 500 or so, and there are about a hundred or
so cannabinoids in cannabis which interact with the
body's endogenous cannabinoid system, which is
300 million years old in biology, and in recent
years, recent decades, people were trying to come
to understand that the cannabinoid system played a
vital role in regulating appetite, mood, memory,
inflammation, pain, muscle relaxation, even bone
formation, and so it's the -- the system that has
impacted cannabis has been validated through our
understanding of the mechanism of action of this
plant through the endocannabinoid system, and more
research is continuing and hopefully will continue
to determine the different varieties of cannabis,
how they have various impacts in various disease
models and conditions.
So I'll pass it over to my colleague,
Dr. Carter, and we can talk more. Thank you.
So I practice neuromuscular medicine.
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That's my specialty, and my interest in cannabinoid
medicine dates back probably 15 years when I first
came up to the University of Washington. There was
some other folks that were looking at cannabinoids
as neuroprotectants.
And I take care of patients with Lou
Gehrig's disease or amyotrophic lateral sclerosis,
which you folks are probably familiar with. It's a
very bad disease. It presents a unique set of
clinical symptoms that's hard to manage.
And I started looking at some of the
properties of cannabis, initially looking at the
neuroprotective role and thinking maybe it was a
disease-modifying agent but then looked more at
what actually that produces pharmacologically
including drying up the mouth, relieving pain,
relieving muscle spasticity, improving appetite,
perhaps improving mood. I said, well, this might
really help ALS patients, and that's what I've been
studying.
Actually, it does, and I published a
first paper on that in 2001. We've had a couple of
follow-up papers. I still think it also does have
some significant potential as a disease-modifying
agent or agents, cannabinoids in ALS, and there was
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one mouse study done here at the University of
Washington where we were able to show that the -- a
model of ALS, which is a superoxide dismutation of
a mutant mouse, lived 50 percent longer, and
actually the process of the disease was delayed
significantly in mice that were pretreated with a
mix of cannabinoids.
From a practical standpoint, because I
think that does count for something, I've probably
taken care of upwards of maybe 4 to 500 patients
over the years that have been actively using
cannabis.
It's important for you to know I never
recommend -- I never recommend to my patients to
smoke cannabis. I always have them in a vaporizer.
The cannabinoids are oil based, 21 carbon terpene
compounds that are easily vaporized, aromatized at
about 2, 300 degrees Fahrenheit which is
considerably cooler than combustion, which is
around a thousand degrees Fahrenheit, so you can
aromatize the cannabinoids and just inhale them
through a hot mist with a device called a
vaporizer.
They also are quite active with oral
injection. In fact, the half-life has been
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slightly longer. I can -- I think Sunil might have
some stuff on that he actually included in part of
his thesis as well, but dosing versus -- you know,
an inhaled versus oral metabolism.
I think it's important as a group of
pharmacists to realize that we now know pretty
factually how the cannabinoids work. We have CB1
receptors in our peripheral -- I'm sorry -- central
nervous system and CB2 receptors in our peripheral
nervous system.
They are a -- probably mediated at
least in part through cytokine pathways, but it's
getting more and more delineated exactly how
cannabinoids produce their effect. Clinically
speaking, they have about a three- to four-hour
half-life if inhaled and maybe a six-to eight-hour
half-life if eaten.
Sunil just reviewed a substantial part
of my clinic population as part of his thesis, and
that was 150 patients?
GREG CARTER: 130 -- well, even that
criteria, that did not include my ALS patients
actually because we had to get a separate IRP for
that, but there was no -- no dropouts, no
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significant adverse reactions.
It didn't work for everybody, but it
worked for the vast majority of people, and
certainly my argument has been all along that the
federal government schedules dronabinol which is
100 percent THC as a Schedule III, and then it
turns around and takes a natural plant which has
maybe 20 to 25 percent THC at best and makes it a
Schedule I. That makes no sense whatsoever.
And it turns out that THC, which is
dronabinol, 100 percent dronabinol, 100 percent
pure THC, that is the most psychoactive
cannabinoid. Many other -- cannabidiol,
dronabinol, those compounds do not -- have not been
shown to have significant psychoactive effects.
Our government really is -- you know,
will allow physicians to phone in a prescription
for the most -- 100 percent of the most
psychoactive compounds in cannabis, but it turns
around and makes the natural plant a Schedule I.
Now, again, and I've argued with folks
from the DEA and what have you, and they say "Well,
it's a raw fruit plant." Now, I would argue that,
first of all, my personal opinion, I think our
country has been taken over by the pharmaceutical
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companies.
In the state of Washington last year,
accidental overdose deaths from prescribed opiates
surpassed deaths from motor-vehicle accidents.
Now, there wasn't a single death -- there's never
been a single death reported from the overdose of
cannabis.
So if you want to look at this thing
from a historical perspective back from the Reefer
Madness days, Harry Anslinger was the first drug
czar. He was in power at that time, and it was
that man and his cronies that really led us on the
path to opiate-based medicines instead of
cannabinoid-based meds. That cost the lives of
untold number of people.
I mean opiates -- at least in my
practice where I deal with chronic
neurodegenerative conditions, opiates cause
constipation, respiratory suppression. You could
get easily dependent on them, hyperallergies.
They're very hard to work with.
Whereas cannabinoids, the dosage
schedule is easy. Patient can self-titrate for an
effect. There's very little physical dependency.
You can, of course, get psychologically addicted.
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In my practice I'm not too worried about people
with ALS getting addicted to anything, but the
concern over addiction -- and I've debated with
addictionologists -- well, sure, there's a point
with that.
Unfortunately, you know, a certain
percentage of our population is going to be
addicted to any substance at any given time, and
that's been around since the dawn of man. It
exists in the animal world too. I mean creatures
that have receptors and can modulate their
perception of reality will use substances to alter
their perception of reality. That's just the way
it works in nature.
No matter what we do, there's always
going to be a certain percentage of the population
that's addicted, and the addictionologists will
always have jobs, unfortunately. Prohibition has
never been an effective strategy, never ever.
Didn't work for alcohol. It's not working for any
drugs.
I mean sadly to say, I think the
abject prohibition of marijuana, at least in
Washington state now, is to buy heroin for cheaper,
and heroin and methamphetamine are considerably
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cheaper than cannabis.
So I used to try to stay out of the
recreational argument, but I just -- that's my two
cents worth as a father of four kids. So I'll
leave it at that.
LLOYD JESSEN: Thank you for all
of
those comments. I have a question for you. Based
on your professional medical opinion, do you feel
there is current scientific evidence to support the
use of cannabis medically?
GREG CARTER: Yeah. I want
to be -- I
want to be perfectly clear about that, and I will
state my reputation, my professional license, my
DEA registration number on that.
With my right hand in the air, my left
hand on my heart, I will state that in my
professional opinion as a physician practicing over
20 years now that the scientific evidence to
support the medicinal use of cannabis is
overwhelmingly in favor.
SUNIL AGGARWAL: I also would
like to
concur with that opinion. This is Sunil Aggarwal
again. I've actually reviewed the literature in a
recent paper that I was first author on in the
Journal of Opioid Management and the International
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Pain Management Journal.
BOARD MEMBER BENJAMIN:
This is Verne
Benjamin. I am chairman of the Board of Pharmacy.
During your talk, I heard -- it seemed like I heard
you say that your preferred way of using this drug
would be through inhaled rather than burned usage
because of the temperature differential?
GREG CARTER: Yes, yes. Let
me
clarify that again. So the vast majority of
cannabinoids are found on the flower of the female
plant, and they're oils. They are easily
aromatized oils like most organic compounds.
They're 21 carbon terpenes.
And you can at about 200 degrees
Fahrenheit, they will go into a mist, kind of like
aroma therapy. People who do that in spas and
such, they'll put lavender and things and other
essential oils into a mist.
You can do the same thing with
cannabis, and that -- Donald Tashkin out of UC San
Francisco actually looked at pulmonary function
testing, and actually he looked at it with smoke as
well.
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It turns out smoked cannabis really --
I don't like to recommend people smoking anything,
but smoked cannabis turns out to be not terribly
bad, but I just don't like the idea of telling my
patients to smoke. I'm very anti-tobacco and it
just puts me in an awkward situation, so vaporizer
completely gets around that. There's no smoke.
There's no odor, minimal odor.
And these devices are readily
available.
SUNIL AGGARWAL: And sir, I just
-- I
sent a paper to Lloyd which is a study of the
vaporization modality published in the Journal of
Pharmacology, an experimental therapeutic.
It was -- it's an FDA-approved drug
delivery device and has been studied in clinical
trials, and that's one paper I've sent,
characterizes the benefit of using this drug
delivery device.
And it should be noted, though, some
patients do smoke, and combustion -- combustion of
cannabis does not produce the same effects on the
body as combustion of tobacco. We just can't seem
to find the epidemiological link between exposure
and cancers as can be found with tobacco smoking.
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You also can't find a link to COPD or
emphysema, and these studies have been published in
major cancer prevention journals, and the author
that Dr. Carter mentioned, Dr. Tashkin did a very
large retrospective study in the Los Angeles area
showing that no link can be found, and a recent
study published showed there was actually a
decreased risk of cancer that they had in those who
smoked cannabis for 10 to 20 years. That was
published in Cancer Prevention Journal. I'll be
happy to send the references.
But this also makes sense because we
know carmabinoids have anti-apoptotic properties.
Sorry. They have pro-apoptotic properties for
carcinogenic cells and anti-apoptotic for
noncarcinogenic cancer cells.
So the science -- there's a lot of
interesting science on the cancer end of things,
but the risk of smoking, of course, is soot and
bronchitis and respiratory irritation, and we would
rather circumvent those potential risks for our
patients and recommend vaporization.
LLOYD JESSEN: Thank you.
There
appear to be a lot of problems with programs in
states like California and Colorado.
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If either of you are familiar with the
programs in those states, could you respond to
that, and do you have a recommendation as to how
you think distribution of cannabis should occur if
it is approved in a state?
GREG CARTER: Sure. Well,
this is
Greg Carter. I can address that. As a physician,
it often is somewhat awkward when I give this
diatribe on the benefits of cannabis, and then
there's the elephant in the room about, well, where
do we get the cannabis?
In Washington state we have co-ops
that have websites, and so it's actually relatively
easy. However, I've pushed hard to get the
Department of Health here to take over. In my
opinion, as a physician, I would like you all to be
involved. I'd like to have the pharmacists on
board.
I'd like to have state-authorized
distribution where we can send our patients, and
they would get, you know, quality cannabis -- and
you can measure the content of cannabinoids. You
can measure the THC content very easily, and now
it's even easier to measure the content of other
cannabinoids.
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We haven't really gotten into the --
So let me answer your question by saying I'd love
to see the government, state government, involved
in that, and I would love to see pharmacies
involved in that.
So the physician makes a specific
authorization. The patient takes that to a
state-authorized dispensary, and a pharmacist
distributes the medicine in a medicine bottle with
a label on it, just like we do other medicines.
And that does occur to an extent. The
co-ops out here put it in a -- in a medicine
bottle, but there's no pharmacist involved, which I
think is wrong. I think pharmacists do play a huge
role.
I prescribe a lot of dangerous drugs.
I have basically hospice and palliative-level
patients, so I'm unfortunately also prescribing a
lot of opiates, and I have made good friends with a
lot of pharmacists around here, and I depend on you
guys to tell my patients, again, "Hey, this is a
dangerous substance."
And I don't think cannabis is
particularly dangerous, but it's always good to
have a pharmacist go over again what they're
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getting and how it's used.
And right now that doesn't exist
because the patients go to a co-op. Now, some of
these people in the co-op, have to say, are
peasant pharmacists, I guess you would call them,
people that have picked up quite a bit of
biochemistry and pharmacology just from doing this
over the years, but I would -- I would be much in
favor of, you know, the State controlling this just
like it does, you know, State Board of Pharmacy as
you all are controlling. Here's Sunil.
SUNIL AGGARWAL: Yeah.
New Mexico and
Rhode Island are probably the nicest cases to look
at. And both of their legislatures have approved
state licensing of their medical cannabis
dispensary.
Unfortunately, California being the
flagship state, '96, did not actually address
distribution of cannabis. Neither has Colorado.
So what has happened is kind of a
local -- local-level recommendation, and some
places are better regulated than others. There was
no attempts made at state-level regulation of
distribution or what I call delivery sites.
Though that being said, there are some
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places in California that don't get a lot of press
but do an excellent job. For example, the City of
Oakland has licensed just a certain number of
dispensaries in their state -- I mean in their
city. Excuse me.
And one dispensary called Harborside
actually tests all their samples for mold and any
other pesticides and does do gas chromatographic
testing of their samples and labels the contents
with the percentage of THC and in some cases a
percentage of CBT, another important cannabinoid.
So they've been able to sort of
self-regulate, but we can't always solely rely on,
you know, the -- the goodness of dispensers to do
this, and I think we should look at states like,
like I mentioned, Rhode Island and New Mexico.
New Mexico has already started -- you
can contact New Mexico Department of Health if
you're a patient, and they will refer you to a
state-licensed dispensary where you can go, and
they even have a physician on staff as part of the
board of these dispensaries. I don't know what
role pharmacists play, but I'm sure they play a
significant role.
Other countries, of course, have been
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doing this for quite some time. Holland, the
Netherlands has had a federally -- federally run
prescription program where patients can go to
pharmacies and fill their cannabis medical
prescriptions.
Unfortunately -- their program is
quite successful, very safe, but unfortunately
patients prefer to go to the coffee shops because
of -- likely probably because of access issues and
availability.
So there are some models to follow,
and California gets a lot of press, mainly because
of the hundreds of dispensaries in Los Angeles, and
now the City of Los Angeles is trying to kind of
cut down the number of the dispensaries and trying
to take out some of the real profiteers.
Colorado, I haven't heard that many
problems about, but I'm aware that they also have
no state-licensed system, but they have a few
openly operating dispensaries, and they get
thousands of patients, so they're trying to solve
the problem as well.
LLOYD JESSEN: Well, thank you
very
much for all of your comments. I think that will
be helpful to what we're doing, and I'll check to
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see if either of our board members have other
questions.
We don't have any more questions.
Thank you very much for calling us today.
GREG CARTER: Sure. I just
want to
close by saying you're more than welcome, Lloyd, if
you could give the board members there our e-mail
addresses, certainly I know Sunil and I will be
happy to answer any other questions.
And I always seem to think of
questions about 20 minutes after the conference, so
if there are further questions, we'd be happy to
address them by e-mail.
LLOYD JESSEN: It is now noon,
and
we're going to break for an hour lunch, and we'll
be back at 1 p.m., and we have about -- I think 20
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to 25 speakers who have indicated they want to talk
to us after lunch, so we will see you in an hour.
(Lunch recess.)
LLOYD JESSEN: Okay, Welcome back,
think we're ready to continue, and our next
scheduled speaker is Gary Young from the Iowa Elks
Association. Gary, are you here?
GARY YOUNG: It's really set up to
address the audience, not the board. Who would you
prefer I speak to?
GARY YOUNG: My name is Gary Young,
and I retired about two and a half years ago after
a 35-year career with the Polk County Health
Department. I worked as an environmentalist, and I
continue to maintain national professional
registration as an environmental health specialist
emeritus.
I'm here today representing the Iowa
Elks Association as a volunteer. The Iowa Elks
Association is an association of 33 local Elks
lodges in Iowa with about 12,000 members.
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The Benevolent and Protective Order of
Elks nationally has the largest volunteer youth
drug awareness program in the nation. We are
committed to help our youth make informed choices
about drug, alcohol, and tobacco use.
Recently the Iowa legislature banned
tobacco smoking in public places. This action was
to protect employees and the public from the
harmful effects of secondhand smoke.
Redefining smoked marijuana as a
medicine would allow users to smoke in places where
tobacco smoking is currently prohibited. If
someone is taking medicine, you cannot prohibit
them from where and when they take it.
A study published in 2001 in the
British Journal of Psychiatry stated "Actions on
specific brain receptors cause dose-related
impairment of psychomotor performance with
implications for car and train driving, airspace
piloting, and academic performance. Other
constituents of cannabis smoke carry respiratory
and cardiovascular health risks similar to those of
tobacco smokers."
The study concluded "Cannabis is not,
as widely perceived, a harmless drug but poses