A Cannabis Tweet Storm

I had the privilege of being part of the Advisory Board for the inaugural Cannabis & Hemp conference hosted by Business Insurance on October 24-25 in NYC. The Board's responsibility was to craft a compelling agenda and recruit compelling presenters. Based on survey results from those in attendance (87.5 percent said the content and 79.17 percent said the networking opportunities were very-to-extremely valuable), the collective hard work paid off. It was a unique collection (on the stage and in the audience) of various stakeholders from the cannabis industry, insurance industry, brokers, employers, and risk management (along with attorneys, agencies, a professor - and some skeptics). Attendees were also geographically diverse, coming from 28 U.S. states and three countries. The only thing in common among all presenters / attendees was a curiosity about how legalized cannabis (recreational and medical use) will continue to evolve in the U.S. and a desire to not make a mess while it happens.

There are a number of ways for those that did not attend to learn from those that did:

• Handouts are available for most of the sessions
• "State cannabis laws present medical malpractice conundrum" on Oct 25
• "Concerns over CBD labeling, health claims crop up" on Oct 28
• "Another day, another lesson for insurers in evolving cannabis market" on Oct 29
• Wilson Elser (a founding partner/sponsor) published their "Key Takeaways"

For my part, I documented my observations from the sessions I attended in real-time on Twitter (@RxProfessor) using #BI_Cannabis. Are you ready for the storm?

(this was actually posted to LinkedIn): To kickoff #BI_Cannabis we visited the Manhattan location of Etain Health. My notes: - They have an in-house pharmacist (required by NY, college-educated, worked in retail, has special NY certification for #cannabis). - While doctors can recommend specific dosages (x% THC, y% CBD), their experience has been most leave it up to the dispensary pharmacist's discretion. - The pharmacist engages with the patient to understand their circumstances with Q's such as: * Have they tried #marijuana (medical, recreational before)? * If not, do they understand THC's effect and are they OK with it? * Evaluation of physical presentation, qualifying condition, co-morbidities, medications / supplements they may already be taking - The diagnosis will lead him to suggest a specific product/blend but it's still left up to the patient to determine whether it's working (and if not to try something else) He recommends to "start low" and titrate up if necessary. There is no universally applicable or precise dosing determination - it's all about patient response. I have visited dispensaries in Denver CO and Eureka CA (budtenders not pharmacists) and this was more methodical.

#VapingCrisis Unscrupulous people creating cartridges in their garage and selling online is reason, not nicotine or legit (regulated) THC cartridges.

#VapingCrisis According to speaker, illicit vaping is a $55M per year industry in NYC!

#VapingCrisis According to speaker, it’s about the illicit (unregulated, “black”) market and dangerous additives that come with it. CO has model regulation on the way.

#VapingCrisis Speaker said they’ve only had 1 complaint (respiratory issue from asthma) out of 1.5M marijuana legal/regulated vapes.

#CBD being sold everywhere with no knowledge of what it’s made of is creating a public health issue. No idea what’s in it – Buyer Beware. FDA reacting to the “wild west” response to the 2018 Farm Bill.

FDA and FTC validating #CBD claims (what it treats, what’s in it). USDA issuing regulations on manufacturing/production process but states can do their own. After-the-fact but trying to separate the legit from the con artists.

There are no gaps “at this point” in insurance coverage for #cannabis businesses, from lesser-known to more widely-known insurance companies. They follow normal business practices just like for any other industry.

However, limits are too low and liabilities are too high for some #cannabis insurance coverage which makes premiums / losses expensive.

SAFE Act had 206 sponsors and final vote in U.S. House was 321-103. Deemed non-controversial (“suspension vote”), expect markup by Sen. Crapo by end-of-year. Still TBD whether it makes it into law.

CLAIM Act has had no hearing, nor markup and no obvious future. It may be tacked onto another bill more broadly associated with banking.

Per speaker, Cresco Labs is hiring 120 people/month, mostly in marketing + accounting + finance (i.e. normal business functions).

Medical malpractice is about deviation from the standard of care. But just as important is lack of informed consent (where patient is not advised of benefits AND risks) and where physicians are most vulnerable when recommending #cannabis.

Interesting resource is Society of Cannabis Clinicians that offers accredited CME curriculum regarding endocannabinoid system and medical use education geared towards physicians and nurses.

National Cannabis Industry Association advocates – wants – smart federal/state regulation, standards, transparency, methods for compliance.

NY requires a pharmacist to engage with the patient at the dispensary. So does CT, AR, PA and MN (maybe more). IMO, better than the “budtender” used in states like CO, NM and CA.

Hospitals are on the front line because patients bring their own #cannabis. Because of JCAHO (and others) the patient must self-administer (or via caregiver). Patients know more than doctors about #cannabis applicability to their condition.

Hospitals have to balance patient safety and regulation when a patient brings their own #cannabis. Do they add to medical record/chart? How do the lock-up when patient needs to leave the room (e.g. X-Ray)?

Hospitals can say “no” to #cannabis but lack of access could create medical issues. If they say “yes” then they need to document (somewhere) and be very specific (dose, frequency, formulation) and label as “self-report”.

#HebrewHome (geriatrics) "The Nursing Home With A Medical Cannabis Program The Feds Can Live With"

#HebrewHome (geriatrics) has had “incredible results from the use of medical #cannabis” to simplify regimens (less constipation) and reduce #opioids (which can create drowsiness, confusion, falls – not great for older people).

#HebrewHome (geriatrics) recommends start low with pure CBD, then high CBD/low THC. They never use 1:1 or high THC. Interestingly, they do not monitor toxicity.

#HebrewHome (geriatrics) Patient must self-administer (or via caregiver). For those that cannot procure their own, dispensaries often have free delivery.

Four things for good regulatory framework – support from state executive leadership, govt agencies capable of working together, stakeholder engagement between govt & industry, agencies able to monitor and enforce demonstrated compliance.

Endocannabinoid System primary responsibility is homeostasis (stable equilibrium). CB2 receptors regulates immune system throughout the body. CB1 receptors handle everything else. But there’s more than just CB1 & CB2 that’s part of ECS.

DYK … There are no CB receptors in the brain stem which is what limits toxic effects from #cannabis.

Some dosing suggestions (every individual is different). Top table is for people that don’t need to be awake tomorrow. The bottom table is for those that do.

Because of so many variabilities in biochemistry and receptors and bioavailability (different per route of administration), it is difficult to predict & control dosing. In fact, it’s impossible to predict dose that works.

And then ...

On my walk from #BI_Cannabis to @PennStationNY ... jw @healthybart & @reema_hammoud, is this medical #cannabis? Looks a tad "recreational" to me. Blatant. On a public street. In Manhattan. With no <21 age filter on who walks by.

The responses were enlightening:

• It's not real weed. It's a scam. "What's the Deal With Those NYC Weed Trucks? We Did a Weed Lollipop Taste-Test to Find Out."
• It’s a tourist trap. There is no THC involved with these products. Decriminalized, but still illegal in New York.

I'm already looking forward to the second edition, scheduled for April 2-3, 2020 in San Francisco. Whether you're a skeptic, a believer, or on the fence, stay tuned!