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?

SUNIL AGGARWAL:  Yes, sir.

LLOYD JESSEN:  Okay.  I'll let you
introduce yourselves and if you -- when you start,
if you could please spell your names for the

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.

LLOYD JESSEN:  Okay.  Thank you.

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

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

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

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

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.

GREG CARTER:  Thank you, Sunil.

So I practice neuromuscular medicine.

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

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

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?

SUNIL AGGARWAL:  130.

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

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

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.

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

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

LLOYD JESSEN:  Thank you.  Any
questions from board members?

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.

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.

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.

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.

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

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

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

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

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:  Thank you, and we wi11
do that.  Thanks.

SUNIL AGGARWAL:  Thank you.

LLOYD JESSEN:  Yes.  Thank you.

SUNIL AGGARWAL:  Thank you and enjoy
your historic building in Iowa.

LLOYD JESSEN:  Thank you.  Bye-bye.

GREG CARTER:  Bye.

SUNIL AGGARWAL:  Bye.

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