[MUSIC PLAYING] RYAN GRIM: Welcome. My name is Ryan Grim. I'm the Washington bureau
chief for the Huffington Post. The panel we're
doing here today is on the science of marijuana, the
implications of legalization.
It's presented jointly
with the Huffington Post. Our program is part of the Dr.
Lawrence H. And Roberta Cohn Forums. Now, Dr.
Cohn passed
away last year. However, we're
pleased to welcome Roberta Cohn on in the
audience today, thank you. This event is streaming live
on the websites of the forum, and on the Huffington Post,
and also at Huffington Post. So, our panelists, starting
with my immediate right, Marie McCormick, who is a-- let me get this correct,
it's a long title-- Professor of Maternal and Child
Health Harvard Chan School, and chair of the committee that
published the recent landmark study "Health Effects of
Cannabis and Cannabinoids: the Current State of
Evidence and Recommendations for Research." We're also joined by Staci
Gruber, Director of Cognitive and Clinical Neuroimaging
Care, Director of Marijuana Investigations
for Neuroscientific Discovery Program at McLean
Hospital, Associate Professor of Psychiatry
at Harvard Medical School.
Vaughan Rees, Lecturer on
Social and Behavioral Sciences, Harvard Chan School, and
addiction specialist. And also, finally, Andrew
Freedman co-founder and partner, Freedman
& Koski, and he's the former Director of
Marijuana Coordination for the state of Colorado. So we're going to do a
brief Q&A towards the end. You can email questions to
the forum@hsph.Harvard.Edu.
You can also submit
them on Facebook towards the end of the forum. We'll take as many of those
questions as we possibly can. We have a clip from
Sean Spicer, who's going to get us started here. [VIDEO PLAYBACK] - I think there's
a big difference between medical marijuana,
which states have a-- the states where it's
allowed, in accordance with the appropriations writer,
have set forth a process to administer and
regulate that usage versus recreational marijuana.
That's a very, very
different subject. - I did want to follow up
on this medical marijuana question. So is the federal
government going to take some action around this
recreational marijuana in some of these states? - Well, I think
that's a question for the Department of Justice. I do believe that you'll see
greater enforcement of it.
Because, again, there's
a big difference between the medical
use, which Congress has through an appropriations
writer in 2014, made very clear
what the intent of-- what their intent
was in terms of how the Department of Justice
would handle that issue. That's very different than
the recreational use, which is something the Department
of Justice, I think, will be further looking into. [END PLAYBACK] RYAN GRIM: OK, thank
you, Sean Spicer. There's nobody here from
the Department of Justice to ask this question,
so instead we're going to treat it
from this perspective.
And now Marie, I did want
to hear your perspective on it, particularly with
regard to the study that was released on January. If the Department of
Justice, or Sean Spicer, were going to take the
scientific evidence into account when making policy,
well, what should they know? MARIE MCCORMICK:
Sure, the reason that this report
was commissioned is a reflection of the
changing landscape of cannabis in the United States. It's changing very rapidly. The report was actually funded
by several federal agencies and several states, actually,
for the National Academies of Medicine to take a look at
the health effects of cannabis.
And if you know
these committees, it took half a morning to decide
between marijuana and cannabis, but it is health
effects of cannabis. And look at the information,
both on positive health effects, as well as
negative health effects. The report has nearly
100 conclusions. But I have to say that boils
down to about half a dozen for which we actually think
we have firm evidence.
And we'll get back to the
rationale for that before. In terms of positive
effects, it's very clear that the literature supports it
some people with chronic pain, muscle spasms from
multiple sclerosis, and the nausea and
vomiting with cancer chemotherapy experience
some relief with cannabis. And we looked at a whole
bunch of other conditions and did not see such evidence. We also found that there
is limited evidence that cannabis actually increases
the use of other drugs.
You may be surprised to know
that it's tobacco and not what you might be thinking. And there is moderate evidence
to support the use of cannabis, and each substance abuser-- substance dependence or abuse,
which is now problematic use under the new DSM. Clearly, acute use
of marijuana leads to decreased impairments
in learning, memory, and attention. And there's some
very limited evidence that this may
persist afterwards.
I think, although-- we could
not determine, actually, the specific effects
on adolescents, evidence from other
substances would suggest-- other substances being
tobacco and alcohol-- that it would be prudent not to
have adolescents using cannabis because they are particularly
vulnerable to the effects of psychoeffective agents. But that's about it out of
100 conclusions and 10,000 references. [AUDIENCE CHUCKLES] RYAN GRIM: Thank you. Stacey, you've been
studying 20 years now, that both recreational marijuana
and medical marijuana now-- on the one hand, we're talking
about different uses here.
On the other in some
ways, we're talking about the precise
same plant just used for different purposes. Yet find some divergent
results depending on who or how it is being used. Can you talk a little
bit about that? STACI GRUBER: Sure. So we actually have
been seeing the impact of recreational marijuana
use for more than 20 years, and for the last two
and 1/2, the effects of medical marijuana use.
And you're absolutely
right, it's very important to distinguish between the two. Most of what we know about
the impact of marijuana on the brain comes from studies
of recreational marijuana users, primarily those
with chronic, heavy use. Overall, as Marie mentioned,
studies typically report differences or
impairments, if you will, in cognitive function across a
number of domains in those who use marijuana compared
to those who don't. In our work, we've noted that
the most striking differences are actually among
those with what we call early onset
marijuana use, that is, used prior to, in our
studies, the age of 16, compared to those who begin
using later, particularly on task for acquiring what
we call executive functions.
These are things like, the
ability to utilize feedback to change your
behavior or to inhibit inappropriate responses. This is perhaps not surprising
since the brain continues to develop throughout
the second and maybe even into the third decade of life. And adolescence into early
adulthood, as Marie alluded to, represents a period
of what we call neurodevelopmental
vulnerability. Increased frequency
and magnitude of use has also been shown
to be associated with worst performance.
And to date, we have
very little data on the potential impact of
what we consider higher potency products, which are growing
increasingly popular. On the other hand,
while recreational users are typically seeking
products very high in tetrahydrocannabinol, or
THC, the main psychoactive constituent with the goal of
changing their state of being, our medical marijuana
patients typically seek treatment in order
to alleviate symptoms rather than to experience
the psychoactive effects. Accordingly, they
often choose but-- not always, but
often choose products that are very
different from products that are very common
among recreational users. They have a different
chemical composition.
So, for example, they
may select products with a range of
other cannabinoids, including things like
cannabidiol, CBD, often touted for its
therapeutic effect, which is not intoxicating, as well as
a number of other cannabinoids. Data from our mind
program, the first project, is a large longitudinal
observational study the, first of
its kind, is really designed to assess
very specifically the impact of medical
marijuana on areas like cognitive performance,
measures of brain structure and function,
conventional medication use and other variables in
patients before they begin using medical marijuana
so we can determine if there's any change, we
follow them for up to two years. In one study, our first
study actually, we recently reported improvements in a
number of areas including cognitive performance, sleep,
and mood between baseline and after three
months of treatment. In addition, patients
reported reductions in their use of
conventional medications, very importantly,
a 42% reduction in the use of opiates.
This echoes what we've seen
from states that have fully legalized medical
marijuana where the number of opiate-related
prescriptions has decreased. So while these findings
are preliminary, so a very small
sample size, we're really just getting started. It certainly provides
evidence that suggests that medical
marijuana may, in fact, be beneficial for a number of
patient groups including those with chronic pain. Further research is
critical but difficult, as I know Marie knows, given
marijuana's current status as a Schedule I substance.
All constituents from
the plant are currently illegal under federal law. So that's another thing we
should probably talk about. RYAN GRIM: That's a
really striking finding that medical marijuana may have
improved cognitive performance. Can you very quickly just
tease out why that might be? STACI GRUBER: It may be that
these folks on the average age of onset of their medical
marijuana treatment is significantly later
than our recreational users in our studies and most of my
colleagues across the country.
Average age in our
study is about 49. And these are people who haven't
used marijuana previously. Or if they did, they have to
be many years post that use. So it may be that they're
beyond, let's say, the period of critical
developmental vulnerability.
They're not necessarily
20s and 30s. They're older. It may also be a function of
what they've selected to use. There are some cannabinoids
that may be protective.
In fact, there's evidence
to suggest that that's true. Some of these cannabinoids
may, therefore, prevent some of the
deleterious effects we see in recreational users. Hard to know yet. RYAN GRIM: Thanks.
Thank you. Vaughan, can you
talk a little bit about how marijuana
policy regulations might be able to both protect and
enhance public health going forward? VAUGHAN REES: Sure. I'm particularly
interested in the changing regulatory environment
for marijuana. And as we've seen the
introduction of laws that have legalized the use
and possession of marijuana and decriminalization
of marijuana use, those have had
important advantages for resolving existing criminal
justice and social justice problems.
So I'm delighted, for
example, that in some states that have had three
strikes laws that there are kids who won't be locked
up in some cases for life for the use of possession
of marijuana and the impact that that may have on
housing availability, educational attainment, and
other important public health measures. On the other hand,
I am concerned that we haven't,
at this point, put in place adequate
regulations to protect the health of the public from
an expected widespread increase in marijuana use, particularly
the perceptions of the safety or the risk of marijuana
use changes among youth. It's important that we put in
place evidence-based strategies to ensure that we don't see a
new epidemic of marijuana use among kids. I come at this from the
perspective of tobacco control.
Most of the work
that I do has been focused on
understanding how to put in place evidence-based
strategies to protect the public from
tobacco-related harms. And we saw it's a
great example of how we might proceed with marijuana. We saw in the 20th century the
rise of a very powerful tobacco industry, a multinational
group of companies that went about
designing products to make them more addictive,
to make them more appealing, and targeting those products to
specific sections of the public who didn't previously
smoke, including racial and ethnic
minorities, women, people from low
income backgrounds, people with mental illness. And we see some of the
highest prevalence of tobacco use these days are among
those vulnerable groups, those with mental illness, those with
other substance use problems, and, overwhelmingly, people
from low income backgrounds.
The tobacco industry
was able to do that by innovating
developing products, providing ways in which
they could deliver nicotine very quickly and in a way
that promoted dependence and promoted appeal. I'm concerned that
we may see, without appropriate
regulations, an advent of a very powerful and very
effective marijuana industry that targets
vulnerable communities and promotes interests in
use, an uptaking marijuana use among adolescents. And to address that,
we have a number of very good
evidence-based strategies which we haven't yet
successfully employed including putting in place excise taxes
in a uniform way across states, limiting promotions
and marketing of marijuana products. I was contacted recently
by a representative of a Native American
community who told me that a medical marijuana
company has sponsored a powwow.
It is the for the Gathering
of Nations Powwow, which is the world's largest athletic
event for Native Americans. And they're promoting
marijuana products among youth at
this kind of event. We're likely to
see a continuation of these sorts of
activities and strategies by an increasingly powerful
marijuana industry. So looking at the
playbook that we've developed using tobacco I
think is an important way that we can proceed to
both optimize the health benefits of marijuana use
among a medical population while reducing
demand for marijuana or an uptake of marijuana
use among youth.
And as we proceed, I'll
be happy to explain some of those specific strategies. RYAN GRIM: Andrew,
what have you learned on the ground on that subject? You helped set up
Colorado's system. What did they get right? What did they get wrong? ANDREW FREEDMAN: Oh,
that's a big question. I would say we're actually
starving for-- yeah, Colorado model in two minutes.
We're starving for public
health information. And I would say that despite
what people might think about government, we actually
do start with data and research and decide what's the
best policies from there. And we would gather once a
week, once every other week, with the heads of the
Department of Public Health, the head of the Department of
Human Services, public safety, and we would pore through
what little findings there were at that time to decide
how to put things together. But I'll tell you
there's a lot lacking.
For instance, the supplement
compliment debate, now we feel very unsure
about what to say about, does this supplement
or complement for tobacco, alcohol,
prescription drugs, and driving while high? We have some date on
driving while high. But I'll tell you that it is
really noisy because we just recently defined what it
meant to drive while high and then trained up
all our officers. And so all of the data we
have is very noisy or absent altogether which,
for government, means your governing with one
arm behind your back. A point you can see that was,
really, the edibles governing.
And so edibles have been around
forever in the medical world. But we didn't really
know what it would look like in the recreational world. And so we didn't
have the information behind overconsumption,
over accidental ingestion, over normalization
to kids when edibles looked like gummy
bears or kids' candy. We've come in with regulations
and public education campaigns in all those places.
But I think those could be both
a lot faster and a lot more nuanced had we had more
information on the onset. I would say, in the absence,
we've done two things. One is we've taken
the best practices that we can find from tobacco,
alcohol, prescription drugs. And second, we've decided
to remain flexible.
I would say that we would
say we're on version 1.0. And we would hope to be
in version 8.0 Three years from now because this is a very
rapidly-changing landscape. I would say, though, that it's
a hard road, a tough road ahead in part because even
the collection of data has become politicized. It's a very divisive
issue right now.
Most of my job-- RYAN GRIM: Everywhere
or Colorado? Because-- ANDREW FREEDMAN: Well-- RYAN GRIM: --you're consulting
with a number of states, right? ANDREW FREEDMAN: Yeah, more so
everywhere else but Colorado. Colorado, there's
at least beginning to become some
acceptance that this is-- RYAN GRIM: Right. ANDREW FREEDMAN:
Everywhere else is arguing, should you legalize marijuana? And the debate we lose then is,
how do you legalize marijuana, regardless of where you
stand on the first issue? So what we found was,
even collecting data, there would be groups that would
take very small pieces of data and run out to the media
to say the worst thing. The sky is falling in Colorado.
And this is the heaven
on earth in Colorado. And what we then didn't
get a chance to do was communicate
agnostic data just to say this is what
we're seeing right now. We're not drawing conclusions. But it's important that we all
understand what we're seeing.
That's really harmful for
a public health discussion and really harmful for creating
good public health policy. I will end with just a
little bit of optimism. I think that, despite
the federal roadblocks and the politicization
of this issue, there is going to
be great chance for short-term public
health research, particularly because we
do track every marijuana plant from seed to sale with the
radio frequency identifier tag. So we know what's being
sold where and in what amounts at what frequency.
And we can overlay that with
driving while high data, school suspension data, a
whole bunch of things that I hope in the
near term will become great use for other states
looking to legalize marijuana medicinally or recreationally. RYAN GRIM: Right. Now, you ran a public
awareness campaign. And we have a couple
of clips from those if we can play maybe
two of those now.
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Only now it gets harder. Now it's stuff
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Get tools and tips at
GoodToKnowColorado.Com. CLIP: You passed. RYAN GRIM: What do we know
about how effective those were? ANDREW FREEDMAN: Our initial
data is pretty good at this, actually. A broad scale of the
public health surveys haven't shown a statistically
significant change in youth consumption since
we've legalized marijuana.
I wouldn't say that we can
pin those to the ads at all. But we do do pre- and
post-surveys of those ads and those actually had
pretty good outcomes. I'd also say that this
was an evolution for us. Our first public health
campaign for youth prevention looked a lot more like this
is your brain on drugs.
And it goes back to the
politicization of this issue and the divisiveness. I feel like that
was a campaign and I. Was a part of that that came out
a lot from the reaction of what would feel good
for an adult who's against marijuana to see on TV. It didn't come from actually
talking to kids in focus groups and figuring out what works and
really pre-testing it and post testing it with
the exact audience you want to go to
in change methods.
I hope that that's an evolution
that carries on to other states and that we actually get
in competitions for who can who can run the best
prevention campaigns. VAUGHAN REES: Yeah,
those are the sorts of strategies that
we've found have been very effective with tobacco. So it's good to see that
states such as Colorado are picking up and
proceeding with that. We're seeing the effect of
those sorts of media campaigns as well as other strategies
in reducing tobacco use.
Nationally, I think
it's worth recognizing that, among 12- to
17-year-olds, the prevalence of current marijuana
use is running at about twice that of tobacco. That is about twice
as many kids have used marijuana in the United
States in the past 30 days have used tobacco. Tobacco is the
drug or the product that's sold in virtually
every convenience store across the country. Yet we've managed to
curtail dramatically the prevalence of tobacco use.
And these sorts
of initiatives are most welcome in terms of
reducing uptake of marijuana among youth. We also need to get information
out there about the health effects specifically on youth
and educate parents and educate kids about that. Because, if we don't, then
the marijuana industry is likely to communicate
these products in very different ways. RYAN GRIM: Andrew,
if you could, I.
Wanted to pick up on
something that Staci mentioned a little bit ago where
she said that some 40 plus percent of people in a small
sample that she had overseen were able to reduce opiate
consumption by substituting medical marijuana for pain. Have you seen any effect on
the opioid epidemic in Colorado or elsewhere where marijuana
has been legalized? ANDREW FREEDMAN: Well, I've
read the research papers that show that states with
legalized medical marijuana have seen an opioid decrease. We're watching closely
what's happened since recreational came online. We have not seen
a sharp decrease.
I think correlation
versus causation here is pretty tricky. So I would give it more time. And I do think that's a
delayed effect, right, that it could take up to five
years for that to show up in your data, if not longer. But we did see some effect
from the medical side when that really turned
broadly available back in 2010.
RYAN GRIM: Staci-- Oh, go ahead. MARIE MCCORMICK: I'm
just going to say that the literature,
however, does not support the use of cannabis
to treat opioid dependence. So you can't use it
to make that better. Whether there's
some substitution in terms of what medication
people are using for pain is one thing.
But we did not find any
evidence that it actually is useful in terms of
getting people off opioids. RYAN GRIM: You did
find evidence that it was useful for pain reduction. MARIE MCCORMICK: Oh, absolutely. Yes.
RYAN GRIM: Can you talk
a little bit about that? MARIE MCCORMICK: Well,
basically, the element there was that it was
found that cannabis-- but I have to say this
isn't, for the most part, not smoking cannabis. This is the other things
that Staci was talking about. Marinol does reduce symptoms
in people with chronic pain. So it can be useful
in that regard.
And although it
was not available when we ended our
data collection, which was August of last year, there
are some emerging effects that it's also useful in
reducing some forms of very severe child seizure disorders. So I think that the data
are accumulating on some of its therapeutic uses. RYAN GRIM: Right. And any suggestions you can
draw from what you found? I mean, if it is the case
that one of the things that can be useful for
is pain, then it does seem like it would
be able to substitute for a lot of people-- STACI GRUBER: Yeah, I think-- RYAN GRIM: --long-term
opiate use.
STACI GRUBER: Absolutely. And I think, again, the
report is so helpful and it gives us
a place to start. We also have lots
of folks who give us a fair amount of anecdotal data. And it's so difficult to
weed through it, right, because-- no pun intended.
But you have to weed
through it because this is what they tell you. They tell you that
they feel better after using these
products and, in fact, they don't need opioids anymore. And people who had problems with
opiate use, separate or apart from pain treatment,
often utilize some kind of step-down programs. We may not have any
data on that yet at all which is what the
report is telling us.
We desperately need that data. We need to take an
anecdotal finding and expand it and blow it
out and see if there really is something to it. RYAN GRIM: Right, and not having
data doesn't mean we don't-- STACI GRUBER: Absolutely. And that's, I mean, the
strength of anecdotal findings.
Some of the greatest discoveries
on the planet come from what? Anecdotal findings
first that we then go to study with clinically
sound, empirically-- RYAN GRIM: Right. STACI GRUBER: --designed trials. RYAN GRIM: So, Vaughan,
in this debate, marijuana, cannabis, is
up against big pharma. On the other side, it's up
against big tobacco, too.
Or maybe it's becoming
part of big tobacco. Can You talk a
little bit about what these big companies are doing
when it comes to cannabis? VAUGHAN REES: Well, we're
seeing an increasing blurring between the marketing of
marijuana products and tobacco products. And we're seeing packaging
of marijuana joints in boxes that look
like cigarettes. We're seeing the
introduction of menthol into marijuana
products, which we know that menthol has helped
to promote the ease of use of tobacco products.
It makes it smoother,
easier to inhale. We're seeing that
being introduced into marijuana products. We're seeing the involvement of
the big tobacco manufacturers in the marijuana industry. And Altria, the world's
biggest tobacco company, has claimed the rights to two
websites, altriacannabis.Com and altriamarijuana.Com,
which raises concerns about the
future involvement in these industries.
RYAN GRIM: It's
pretty suggestive. VAUGHAN REES: As the
power and resources of these companies come into
play with marijuana products, we have serious concerns
about how these products will be developed, designed, and
marketed specifically to youth. RYAN GRIM: Marie, what
was the thing that surprised you the most when
you delved into the research? MARIE MCCORMICK:
How little there is. I think that chapter
after chapter after chapter
basically articulates the flaws in the literature.
Part of this is the
regulatory barriers for doing marijuana
research or cannabis research because of the need
because it is a Schedule I. Drug. That is a drug that
is only addictive and has no therapeutic use. And so the regulatory hoops
of doing research in this area are substantial.
But there are also other areas. And our report deals with these. One of these is that one needs
to develop some uniform measure of exposure to cannabis. The studies range from, have
you ever taken it, yes or no, to very detailed questions
about how much you smoked in the last week.
And there's no standards. So you can't compare
across studies. And even if you got
what you took in 1980, that's 4% tetrahydrocannabinol. If you're taking the
same amount today, it's 13% to 14%
tetrahydrocannabinol.
So you can't really compare
studies now to studies then. And the other biggie which
we've been talking about is other drug use. Most of these studies really
can't tease out cannabis separately from tobacco
and other kinds of drugs that people are taking. So we've actually
recommended that there needs to develop a really
comprehensive science agenda for studying the
short-term and long-term effects of cannabis, that we
need to have the feds sit down and decide how we're
going to measure this, particularly in the absence
of any significant blood biomarkers, that we have
to improve surveillance.
And that means not only in
the states that are doing it. But also putting these questions
into National Health Interview Survey so we know
what's happening across in representative populations. And finally, they really need
to take a look at the research barriers to studying
this, and particularly whether it's still reasonable
to consider this a Schedule I. Drug.
RYAN GRIM: I want to open it
up in a second to questions. But, Andrew, go ahead. And then I want to also ask you
how people at the state level are handling the posture of
this administration, which isn't actually as clear
as what Sean Spicer said. He said they're going to be
very aggressive about this.
But, actually, the
Obama administration said the exact same thing
while they were not doing that and while they were issuing
memos that were contradicting. They would say it's still
illegal federally but x. So how are people handling
this bizarre conflict? ANDREW FREEDMAN: So
let me touch really quickly on-- because I
do think that there's an important point. I agree with everything
on the federal level that we should be demanding
public health research as fast as possible in
a public health level, on the federal level.
I would say, on
the state level, we should be gathering baseline
data as fast as we can in the states that are looking
towards changing everything. And I'll give a
few quick examples. I mentioned before
driving while high is very noisy data right now. And that's because we tend to
use marijuana money to enforce driving while high which creates
a huge observation bias when you come in.
I would really like to do some
great county-specific driving while high research
before legalization so that we can have a better
idea of how legalization affects it. On the Trump question,
it feels like we're building castles on sand. And that's really
difficult when you're talking about good government. It is not dissimilar to the
year before the legalization of marijuana in
Colorado where we really didn't know where Obama
was going to come down.
But then once they came
down, they actually stayed at that position. And that's the most we
can ask for right now. We don't believe our regulators
are committing a crime the way we read the Supremacy Clause. Do you, Trump administration? Because that would
be a big deal for us.
And we need to
know that urgently because these are good people
who are doing government work. They're not
distributing marijuana. They're forcing public health
and public safety regulations. And banks that are keeping
money off the street and providing some level
of additional regulatory oversight, those are the people
that get scared out first.
And the people who are
left in the industry are the people more OK with
risk, which are generally not real, legitimate actors. And so I would say confusion
is not a great thing when you're talking about
public health and public safety. And so it's a new
administration. We hope we'll get clarity soon.
But we're fearful we won't. RYAN GRIM: What is the
banking situation now? ANDREW FREEDMAN: Very quickly--
and this is the only pun I ever do-- it's not an unbanked industry. It's a half banked industry. Thank you.
Thank you. It normally gets groans. RYAN GRIM: It's brutal. ANDREW FREEDMAN: Or I say
it's like an edibles joke.
You'll get it in two hours. And so what we have
found is that people have found I have gone through
rigorous compliance methods. There actually is guidance
on how to bank this. It just requires you to know
your customer like you've never known your customer before.
And we've had third party
compliance companies that have come up
and are able to do that with complex
analytical systems. And that has led to-- I mean, I think we're
well-banked in Colorado. RYAN GRIM: Staci, when it comes
to data, at the same time, what has it been like to
try to collect it and do research without
access to the actual thing that you're trying to cite. STACI GRUBER: So
there is access.
Right now, the only
source that you can use to actually do
studies where you're going to administer cannabis
or cannabinoid-based product, any marijuana comes from NIDA. It's all grown at Ole Miss. And while the drug
supply program has expanded
exponentially at NIDA, it doesn't necessarily
reflect what people for both recreational
medical purposes are actually taking. And so from a
researcher's perspective, as a clinical
researcher, I'm really interested and desperate to
know what are the effects that these patients
are going to experience using their products.
Some of these high-potency
products, for example, run north of 40%, 50%, 80% THC. Is it likely that we're
going to see the same effects from recreational
use of these what we call concentrates,
dabs, shatter, wax, butter versus old conventional
flower products that used to be 4% or 5% and
now about 12% to 13%? Maybe not. In our medical patients, we
should find a way somehow to vet the actual
products patients are using across the country,
submit them for testing, make sure they're
clear and clean, and somehow get them into
some supply program where researchers like me can
study them effectively. That's-- RYAN GRIM: In some
ways, it seems like-- tell me if this is wrong-- telling somebody to go out and
study the effect of Vivitrol by studying a drug
that's similar to it.
So what do you do? What would you
recommend if you could set the policy on research? STACI GRUBER: Well, thankfully
I'm not a policymaker. RYAN GRIM: OK. STACI GRUBER: But, yeah. It's a tough time but, yeah.
RYAN GRIM: Well,
as somebody who has tried to do research
and run up against-- STACI GRUBER: Absolutely. RYAN GRIM: --the shoals of the-- STACI GRUBER: Yeah, I think
we do our best with regard to these observational
type studies. And we have individuals who keep
extraordinarily complex logs and detailed records. And they're online.
We do it electronically, the
old pencil/paper fashion, whatever will work for patients
and recreational users will do. We also have samples from
each one of our folks who are in studies submitted
to a lab for testing. So we know what they're using. But it would be much
better to go the other way and to utilize the
power and the knowledge from places like
dispensaries and growers in states like
Colorado and California who have literally optimized
growth for patients with specific indications
like pain, for example, and understand how they
got to where they are and how their patients are
doing by allowing us to study in an empirically
sound way so we would know not, just
anecdotally, if it really works.
RYAN GRIM: Lisa, do we
have a question from online or should we start
with the studio? LISA MIROWITZ: No, I think
let's start with online. We have a ton of
questions coming in. And we're not going to be
able to take all of them. So please join our live chat.
You can continue
on there as well. We have questions from policy
leaders and the general public. So let's take this one. It's from Edward
Redd, Dr.
Edward Redd, representative in the
Utah House of Rep. He has several questions. He's asking if there
is any evidence to suggest that CBD may
be useful in managing schizophrenia or other
psychiatric disorders. He also asked about
CBD and/or THC.
To treat MS, neuropathy, cancer,
inflammatory bowel disease, Crohn's, and a few
other disorders. So, Marie, maybe
you could comment. MARIE MCCORMICK: We
found no evidence that it was useful in
treating schizophrenia. It was useful for
treating spasms in MS.
For the rest of
the conditions you list, there was no information
that it was useful. That doesn't mean it may not be. It's just that the studies
have not been done. RYAN GRIM: Staci,
any thoughts on that? STACI GRUBER: The
only thought is just, to echo what Marie said,
we have very little data.
There is some data from
other countries suggesting that CBD has been useful
for some symptoms related to anxiety and some evidence
of anti-psychotic effect. But these are very few studies. And there's not much out there. But there's a
little tiny signal.
So I think it's something that
people remain interested in. But it's hard. Again, you have the
definitive report right here. So there's not
much yet to go on.
Yeah, it's right here,
literally right here. I wasn't joking. RYAN GRIM: Yeah. STACI GRUBER: I wasn't joking.
LISA MIROWITZ: Thank you. OK, this is another
one that just came in. Could the panelists
comment on the recent study that came out of the American
College of cardiology? It claims that marijuana
use increases the risk of stroke and heart disease. I would also like to hear their
thoughts on the product recalls that are occurring in many
states due to abnormally high pesticide levels.
Any thoughts on that? RYAN GRIM: Anybody
have thoughts? ANDREW FREEDMAN: I can
start on pesticides. RYAN GRIM: Yeah,
do the pesticides. ANDREW FREEDMAN: Pesticides
were the worst part of my life for about six months. Pesticides is one
other place where not having the federal government
involved is really problematic.
And I would say that both the
regulation and enforcement of pesticides is
almost entirely a game that the EPA plays in the FDA. And we've never had to, as a
state, in-house all of that. That is entirely new. And it's something we decided to
do for marijuana because people were using it.
And, surprisingly,
no other state had done that even with medical
marijuana up and running. We ended up taking-- Pesticides have to be
guilty until proven innocent because there are tens
of thousands of them. And so we ended up taking
a very stringent line and only approving about
25 pesticides that really looked more like oils and soaps
much more often than chemicals. What we ended up seeing
was a lot of people had grows that, due
to their economics, they had to use pesticides
in order to stay afloat.
And so we did find a lot
of people, particularly with Eagle 20 on
their marijuana-- and there's very little
about what Eagle 20 does. But there is some evidence that
it cleaves off hydrogen cyanide when heated to over 400 degrees. And so we thought it best
not to give it to consumers. And so a lot of
marijuana did go on hold.
I will tell you the stuff we
find in seeds from a legal home grows have really bad
pesticides on them. And so it might be one of the
best things that comes out of regulating is
to actually look at how are we growing marijuana,
and can it be a cleaner product? LISA MIROWITZ: Great, thank you. MARIE MCCORMICK: In
terms of the association with heart attack,
stroke, and diabetes, the evidence is
extremely limited. The strongest evidence we found
is that, acutely, cannabis may trigger a heart attack.
But chronic use
is not associated with cardiovascular disease. And the evidence with respect
to stroke and diabetes is extremely limited. By that, it means we
couldn't find very much. LISA MIROWITZ: Great, thank you.
Thank you. I'll take one more
from online and then we can take some from
our audience here. Let's see. This is from Karen Fisher.
Since the marijuana plant
approved for research by NIDA. Has such a low
THC content, is it safe to say we have no idea
about the short- and long-term effects on teens about
use once a week or more of a higher THC content
plants and concentrates? How are we going to
discover these effects? STACI GRUBER: It's
a great question. And, actually, just
to be clear, it's not that NIDA has only
low-potency strains available. Again, they've expanded
their portfolio exponentially over the last several years.
And I think they
now have strains that go up to about 14%. Many states, of
course, on average, exceed 14%, including
many of our folks that come through our
lab at about 16%, 18%. But this is Massachusetts. Colorado is about 19% as well.
So it's a great question. I think what we know about
the effects of marijuana or cannabis on the brain,
especially in early onset folks, kids who are
using during adolescence, comes without much
information about the effect of specific potency,
right, or specific strains. In fact, I'm not
aware of studies that are actually administering
NIDA-based product to adolescents. We don't do that.
We just don't. But the other part
of the question, which is actually a
really, really good one, has to do with infrequent use. As I mentioned,
most of what we know about the effects of
marijuana on the brain come from studies of
fairly regular chronic, consistent users. Although, again, the
definitions, the metrics, are not particularly
well-described.
So one study group's
definition of regular use or consistent use may be
very different from another. Casual could be once a month
or two to three times a week depending on the study group. So we certainly need more data. VAUGHAN REES: I would add that
with understanding marijuana products, we need to look at the
way the marijuana industry is innovating its products.
And we've learned through
many years with tobacco that additives,
certain additives, can increase the temperature
of the burn of coal at the end of the product which
changes the particles that are delivered to the consumer. And that may allow
deeper penetration into the lung, more
rapid uptake of THC. There are additives that make
the smoke easier to consume. There are many ways in which
the product can be innovated.
So it's not just
an issue of potency but a question of the
pharmacokinetics of THC. And how THC can be
better delivered to consume it to increase
the addictive potential of the product while making
it more appealing to kids. STACI GRUBER: The other thing is
that some of those concentrates are literally created by using
things like hexane and butane which, of course, are not things
that we want to introduce. Some are solventless.
But in order to get those
really high-potency products, there's a method that's
used in introducing these other chemicals. So that's another
important consideration. LISA MIROWITZ: Thank
you for addressing that because we had another
question on that as well. RYAN GRIM: Do you want to
take an audience question? And if there are none,
we can go back to online.
LISA MIROWITZ: I think we
have one right back here. AUDIENCE: I actually
have two quick questions. One, is there any studies on
comparison of different ratios of CBD and THC in a product? And the second
question is for Staci. You mentioned that
some cognitive behavior gets improved.
I was wondering what type
of cognitive behavior. STACI GRUBER: So
you want to take it? You want me to take it? It's up to you. MARIE MCCORMICK: Yeah. STACI GRUBER: There are some
studies, very recent studies, that have looked at the
effect of THC-based products and products with higher CBD.
Again, these are
lab-based studies to determine whether
or not there's an increased psychoactivity
with or without CBD on board. These are just starting
to be published actually. I'm only aware of one in the
last couple of months actually. So we're starting
to get this data.
And it does look as
if the presence of CBD. And likely other
constituents on board sometimes mitigates the
negative or less desirable effects of THC. Your second question-- RYAN GRIM: What type of
cognitive enhancements did you see? STACI GRUBER: In our study,
again, a pilot study, now we have more
subjects, thankfully. But when we went to publication,
it was a very small sample.
We had completed visit
one and visit two after three months of treatment. We saw improvements
in executive function, so the ability to do these
complex tasks, faster but without an
accuracy trade-off. So they were doing just as well. So that was very
encouraging to us.
It's something important
to follow up for sure. AUDIENCE: Thank you. I think the comparison with
the drugs is so instructive. I found the tobacco
thing so fascinating.
Could you make a
comparison with alcohol in terms of
physiological effects, good and bad, and the
cultural, legal framework of the whole question? VAUGHAN REES: In terms of the
health effects of marijuana compared with alcohol? AUDIENCE: Health effects, yes. VAUGHAN REES: I think I'll speak
very generally to that point. But I think this is instructive. Again, I'm more interested
in adolescent use.
The earlier the age of
initiation and development of symptoms of
dependence, the worse the outcomes in terms of
severity of dependence, difficulty quitting, and
other life problems associated with use. Those patterns are
similar for marijuana as they are with alcohol. Alcohol, as we
know, can undermine educational attainment. It can undermine
cognitive performance.
It is associated with
increased risk of injury and many other high-risk
behaviors among adolescents. To some extent, some
of those patterns may be true with marijuana,
particularly undermining educational
attainment and impact on cognitive performance. So we see similar
patterns there. We also see that the very
powerful alcohol industry have targeted their
products to youth.
And so we've seen this
play out in previous years. And we need to have, as I
keep saying, regulations to ensure that we
can protect youth from the same outcomes
with marijuana. MARIE MCCORMICK: I think
the comparisons are somewhat difficult. In the
presentation we had from the National
Transportation Safety Board and their effects
of alcohol versus cannabis on traffic accidents,
it turns out, with alcohol, people don't
recognize they're impaired and, therefore, take risks.
It turns out, actually,
people on cannabis realize they're
impaired and slow down. And so it may not be as
straightforward as saying it's just like. RYAN GRIM: That's not a joke. The NTSB actually says that.
MARIE MCCORMICK: Yes. Well, that was their data
they were presenting. They actually-- RYAN GRIM: I
wouldn't dispute it. MARIE MCCORMICK:
--could not come down to say that cannabis
actually increases traffic accidents in part because of the
other things that are going on.
Young men using other substances
are in the traffic accidents. ANDREW FREEDMAN:
So I would say it's an important question
in a different way which is that, regardless of how
it actually lays on top, is a framework from a
public health point of view. From a political point of view
and from a messaging point of view, it is what the
advocates are saying, is that it's safer than alcohol. It's the most common
political framework with which to pass legalization.
And it actually becomes a
criminal justice argument over time, which, in some
ways makes, sense, right? Why would you treat a
marijuana user criminally different than how you
would treat a marijuana user particularly when
the health rate is so much worse for alcohol? In some ways, it becomes
a silly argument over time because sometimes they actually
see marijuana itself as a, hey, you can't treat
marijuana that way. Sure you can. I mean, we can be more
restrictive with marijuana than we are with alcohol
in part because we've learned more from alcohol
about how to do this better. And why would we make
the same mistakes we made in alcohol with marijuana? But people attach the
criminal justice element of treat marijuana like alcohol
to actual marijuana itself.
The second thing I
would say is this is a place where we would love
some more supplement/complement data. I think that we look
in the DUID data. And what we're concerned
about is, do people smoke and drink and drive? And we don't know enough about
that, to be to be honest. RYAN GRIM: What do you know? ANDREW FREEDMAN: Well, this is
where the data is very noisy.
But we do know that,
for the most part, when we're pulling over drivers
for driving while high, they also have another
substance in their system. VAUGHAN REES: I think
there's some evidence that's shown that in states
that have, I think, legalized medical
marijuana that there's a lower proportion
of drivers picked up with opioids on board. ANDREW FREEDMAN: But,
on the other hand, the fatality data in Colorado
does show an increase in people testing positive for
THC, drivers testing positive for THC that have been involved
in roadside fatalities. But it's really messy data.
RYAN GRIM: Which means they
may have smoked at some point. ANDREW FREEDMAN: It
doesn't say causation. MARIE MCCORMICK: At some point. Yes, at some point.
STACI GRUBER: But at some
point could be one hour before. It could be three weeks before. ANDREW FREEDMAN: Weeks, yeah. STACI GRUBER: It
depends on the user.
ANDREW FREEDMAN:
Again, a place that can use some much deeper
study than currently exists. LISA MIROWITZ: We're
getting a lot of questions about the Trump effect,
as people are calling it. So I'll just take one. But we have a lot
along these lines.
This is from Rory O'Connor. What is your best guess as
to precisely what actions the Trump administration
and Jeff Sessions Justice Department will take and
when in terms of enforcement of federal law making marijuana
illegal as opposed to state laws making it legal for
medical, recreational, or both uses? RYAN GRIM: Anybody want that? ANDREW FREEDMAN:
Yeah, I'll take it. STACI GRUBER: [INAUDIBLE], good. ANDREW FREEDMAN: Not to
say I like taking it, but I'll take it.
So my crystal ball
broke on November 8th. And so I will still
give you my best guess. But I have almost
no more insight than anybody else on it. My guess is what will happen
is there will be the Cole Memo which is the
enforcement directive that the entire legalization,
both medical and recreational, is based on.
My guess is they will
actually withdraw that memo. I think a lot of people in
the Department of Justice find the idea that this
exists in memo form to be morally repugnant. And that's much more
on a legal basis than it is on anything else. And my guess is that
they'll continue to enforce much like they
do currently enforce which is with special priorities
and not with a purpose to shut down recreational and
medical licensing systems.
It's also unclear to me,
legally, whether or not-- and I'm a lawyer but this
is not my legal advice-- they actually have the power
to shut down the licensing systems in states. I think they have the
power to go and arrest a single licensee. But our regulators, I
think, have the power to enforce public health and
public safety regulations. And so, in that case, what
they would be left with is, really, you'd have to hire
thousands of DEA agents and hundreds of judges
in order to prosecute the cases of bringing
every licensee through.
And so my guess is
it ends up looking a lot more like the Cole Memo
even without the Cole Memo being there than anything else. But I think there'll
be a lot of confusion. And that will mean a lot
of freezing of industry. RYAN GRIM: And my
sense on this-- I've written a lot
about this-- is that my guess is the DEA
will do as much as it feels like it can get away with.
It is an entity to itself. And so they will
make some moves that may be in violation
of the Cole Memo. They will defend
it as not really in violation of the
Cole Memo because they will have it lawyerly. And they will see if
they get away with that.
And then, if they do, they will
push further and push further until the Department
of Justice pushes back, which they may never
do, which will just create a lot of
confusion over the years. ANDREW FREEDMAN:
I'm in agreement. LISA MIROWITZ: Thank you. We have a lot of questions.
So please, everyone,
go on our chat and we'll put all of
them that were coming in on there as well. RYAN GRIM: So really quickly--
and we have a couple of minutes left-- in about a minute or two,
if we could get one policy recommendation that you would
give to somebody who could be remotely receptive to it. Marie, do you want to start? MARIE MCCORMICK: I think the
main one that we have from our report-- and, by the way,
policy was not in the scope of this report-- is what we've been hearing
all along, that we desperately need more research. And there should be an
absolutely organized approach in doing that.
STACI GRUBER: That
was very fast. RYAN GRIM: It was. You now have-- STACI GRUBER: I was prepping
myself for a minute. RYAN GRIM: --a full two minutes.
STACI GRUBER: I guess I do. I would say that, really,
we're in a situation where our policies outpace science. And despite the single
term, as I mentioned before, that we use marijuana to
describe everything that comes in that plant, it
certainly isn't all the same and probably shouldn't really
be considered the same. We need a lot more
work in this area.
But it's really imperative
that, as researchers and people invested in public
health and policy, we're able to study the
effects, the good and the bad. As scientists, we're supposed
to present unbiased findings, regardless of how you
feel about that issue. You have to report
what the data show you. And in order to
do that, you have to be able to do the research.
So I think that legislation
which eases restriction for clinical
research and provides expanded access to a
wider platform of products already in use with appropriate
oversight, of course, ultimately informs public
health and policy efforts and keeps our consumers with
their recreational or medical patients safe and well-informed,
which is their right. I also think marijuana has been
around for thousands of years. We tend to forget this. We sometimes treat it
as if it's brand new.
It's been around since at least
2700 BC, used across the world by millions of people
not likely to necessarily be going anywhere
despite its legal status. Regardless of where
you go in the world, it doesn't matter whether
it's legal or illegal, people are using it. So our job, again, as
scientists and policy makers and legislators is
really to find out the good, the bad,
and the truth and help people make good,
sound decisions so that they can take the best
care of themselves possible. RYAN GRIM: OK, Vaughan? VAUGHAN REES: I think
those are great points.
And actually I would
respond to that. I think marijuana's
certainly been around for thousands of years. But we're seeing it used
now in ways that we've never seen previously. It's being introduced
into vaporizers, into e-cigarette type devices.
Industry's innovating new ways
to make the product appealing and deliver it to people so
that it optimizes the effects and increases addictiveness. So these are
concerns that I have that I think the landscape
of marijuana products is changing rapidly. And with it may become
an epidemic of use, particularly among
young people, which could undermine their
well-being and the public health in general. So those are my concerns.
And we do have a science base
in which we can draw from. And that is the one that
we've used very effectively with tobacco, which has got
tobacco use rates among youth at half that of marijuana. We need to increase taxes
on marijuana products or at least to adopt a uniformly
high level of excise tax on marijuana to make them
less affordable, less appealing to kids. We need to restrict
promotions and advertising, storefront advertising,
which is used in most states where marijuana is legalized.
It varies from place to place
and allows certain health claims, so certain claims
which may promote interest among youth and reduce
their perceptions of the risk of the product. So these are strategies
which we can fairly quickly and immediately employ to reduce
demand for marijuana products and restrain an
industry which is really targeting youth and targeting
vulnerable populations as we speak. RYAN GRIM: Right. ANDREW FREEDMAN: I'm going to
put just a little bit of meat on the bones of an actual
political next step, too.
Because I agree with everybody. There needs to be a call
towards research in this and not just clearing
the barriers. I think the federal
government should be putting significant
resources into public health and medicinal research
for marijuana. My suggestion would be
the federal government has been stuck in a debate on
whether or not legalization is a good idea for 60 years.
This group, myself maybe
included, but particularly people on this side of
me, has an obligation, I think, to band
together as a coalition and really approach
the federal government in an actual lobbying context
to say we're not here to debate the merits of legalization. We're here to say it's
absolutely bananas that we can't do research
on this because it's happening everywhere right now. And we are not serving
the public good by not doing research on it. And so carve this
out specifically.
This is not about the
legalization of marijuana. This is about good
public health policy. And I think until this
group comes and has its own voice at the table and
its own very specific lobbying policy, it's just going to
be the same noise that's been before which
is pro-legalization versus anti-legalization. And that's not a debate that's
very helpful to America.
RYAN GRIM: OK, and my own
policy recommendation, which nobody has asked
for, is just legalize it. So thank you, everybody,
for joining us. I want to plug-- I want to thank the forum. I also want to plug
an event on Monday.
1:30 Live here is Race and
Policing, State and Local Perspectives. So come back then and join us. I will not be here
but the forum will be. And thank you so much to
our panelists and everybody for the great questions.
SPEAKER 7: If you are interested
in supporting this program and others like this
from the Leadership Studio at the Harvard T.H.
Chan School of Public Health, please call 617-432-1318
for further information..
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