Get­ting ready for pot

Med­i­cal cannabis law pushes state in new di­rec­tions

Northwest Arkansas Democrat-Gazette - - FRONT PAGE - DAN HOLT­MEYER

“It may not work as well as you hope, just like any other treatment we have. It’s go­ing to have its ben­e­fits and its bur­dens.” — Dr. Juan Lombeida, a sup­port­ive care provider with High­lands On­col­ogy Group

“We do have a long way to go, but it is an ex­cit­ing time be­cause a lot more peo­ple are in­ter­ested in pur­su­ing the sci­ence.” — Ziva Cooper, an as­so­ciate pro­fes­sor of clin­i­cal neu­ro­bi­ol­ogy at Columbia Uni­ver­sity Med­i­cal Cen­ter in New York

The changes med­i­cal mar­i­juana brings to Arkansas will likely be less wide­spread than ad­vo­cates hope or op­po­nents fear, at least at first, re­cent his­tory and re­search sug­gest.

The voter-ap­proved con­sti­tu­tional amend­ment al­low­ing med­i­cal mar­i­juana use will soon fall into place. The state plans to start tak­ing li­cense ap­pli­ca­tions for shops to dis­trib­ute mar­i­juana prod­ucts and cul­ti­va­tion fa­cil­i­ties in July. The peo­ple who qual­ify to use and pos­sess those prod­ucts could be able to ap­ply for the nec­es­sary state cards even sooner.

The amend­ment le­gal­izes mar­i­juana use in Arkansas for the first time in al­most a cen­tury, though it’s still against fed­eral law. Sup­port­ers say the drug will mean com­fort in­stead of mis­ery and po­ten­tially less risk than other med­i­ca­tions for some pa­tients.

“It truly felt like a mir­a­cle,” Fayet­teville res­i­dent Emily Wil­liams said last fall, de­scrib­ing mar­i­juana’s im­me­di­ate sooth­ing ef­fect on her chemo­ther­apy-in­duced pain and re­lent­less nau­sea other medicines failed to al­le­vi­ate.

But how many pa­tients will want it, how many doc­tors will al­low it and how many mar­i­juana busi­nesses will suc­ceed re­main open ques­tions. Ex­perts worry about un­in­tended side ef­fects of le­gal­iza­tion, such as less­en­ing the over­sight of doc­tors over their pa­tients’ med­i­ca­tions, or want more study into the drug.

“The sit­u­a­tion’s look­ing a lit­tle rough,” said Storm Nolan, founder of the Arkansas Cannabis In­dus­try As­so­ci­a­tion, point­ing to the in­abil­ity of mar­i­juana busi­nesses to get many bank loans and other is­sues. “There are a lot of un­knowns, and I know that’s scar­ing away a good num­ber of peo­ple.”

THE PA­TIENTS

Arkansas in some ways is play­ing catch-up. Peo­ple have used mar­i­juana’s medic­i­nal prop­er­ties for about 5,000 years at least, ac­cord­ing to a 2013 re­port in the sci­en­tific jour­nal Phar­ma­cother­apy. Twenty-nine states have le­gal­ized its med­i­cal use, start­ing with Cal­i­for­nia 21 years ago.

Thou­sands of stud­ies since 1999 have found ex­am­ples of mar­i­juana or in­di­vid­ual com­pounds found in the plant pro­vid­ing re­lief from pain, mus­cle spasms as­so­ci­ated with mul­ti­ple scle­ro­sis and nau­sea in­duced by chemo­ther­apy, an anal­y­sis from the Na­tional Academies of Sciences, Engi­neer­ing, and Medicine con­cluded this year.

Re­search also has found mar­i­juana use can im­pair learn­ing and at­ten­tion and in­crease the risk of de­vel­op­ing some men­tal health dis­or­ders and of be­ing in a ve­hi­cle ac­ci­dent, ac­cord­ing to the anal­y­sis.

Mar­i­juana’s ac­tive com­pounds, called cannabi­noids, work much like other medicines or drugs, hitch­ing onto spe­cific molec­u­lar key­holes on the outer sur­face of the body’s cells and chang­ing the cells’ be­hav­ior. The re­cep­tors that fit cannabi­noids largely ap­pear on nerve cells and cells that fight dis­ease.

How long it takes for cannabi­noids’ ef­fects to be­gin can de­pend on how the plant, its ex­tracts or its syn­thetic equiv­a­lents are in­gested.

They can be quick and pow­er­ful, based on ac­counts from some who have used it.

A Spring­dale res­i­dent and vet­eran with tremors from Parkin­son’s dis­ease, chronic pain and post-trau­matic stress said he smokes mar­i­juana ev­ery few hours to hold the symp­toms at bay. The sub­stance helped him half his use of opi­oids, painkillers such as oxy­codone that can be­come ad­dic­tive and kill tens of thou­sands of Amer­i­cans each year from over­doses, ac­cord­ing to the U.S. Cen­ters for Dis­ease Con­trol and Pre­ven­tion.

No over­dose deaths from mar­i­juana have been recorded, ac­cord­ing to the U.S. Drug En­force­ment Ad­min­is­tra­tion.

Mor­phine and other med­i­ca­tions caused se­ri­ous nau­sea and “hate­ful” mood swings and left him curled up in a chair for hours, said the Spring­dale res­i­dent, who spoke on con­di­tion of anonymity be­cause his mar­i­juana use is still il­le­gal and of­ten stig­ma­tized. Mar­i­juana al­lows him to play sports with his child. He looks for­ward to be­ing able to take the sub­stance with him dur­ing longer trips away from home with­out fear of ar­rest.

“There’s a lot more of us than you know,” the man added, re­fer­ring to or­di­nary peo­ple who use mar­i­juana for medic­i­nal rea­sons. He said he’ll be the first one in line once the state starts tak­ing ap­pli­ca­tions for med­i­cal use. “I prom­ise you that.”

Tra­di­tional pre­scrip­tions for fed­er­ally ap­proved drugs treat­ing a va­ri­ety of ill­nesses have fallen in states al­low­ing med­i­cal mar­i­juana or its ex­tracts, ac­cord­ing to a study of re­cent Medi­care Part D data pub­lished last year in the jour­nal Health Af­fairs. Pa­tients with pain medicine pre­scrip­tions in par­tic­u­lar filled 1,800 fewer doses per physi­cian per year.

A 2014 study found opi­oid over­dose deaths went up re­gard­less of a state’s med­i­cal mar­i­juana law, but those al­low­ing mar­i­juana’s use saw a slower in­crease.

Nolan, the state cannabis as­so­ci­a­tion founder, said his mother was a suc­cess­ful at­tor­ney who died three years ago be­cause of an opi­oid ad­dic­tion and its side ef­fects. He and his fam­ily watched “a very sad and slow de­cline” that in­cluded months in the hos­pi­tal and a re­ha­bil­i­ta­tion fa­cil­ity, where her life ended.

“We would have tried any­thing,” Nolan said, call­ing mar­i­juana “just so much more hu­mane.”

THE DOC­TORS

Adult pa­tients and care­givers can reg­is­ter for med­i­cal mar­i­juana with the Depart­ment of Health only if their physi­cians cer­tify the pa­tients have one of 18 qual­i­fy­ing con­di­tions and the ben­e­fit of mar­i­juana out­weighs its pos­si­ble draw­backs.

The lat­ter point might be a high hur­dle to clear. Arkansas Chil­dren’s Hos­pi­tal and the state sur­geon gen­eral op­posed the mar­i­juana amend­ment, and sev­eral area physi­cians and health sys­tems de­clined or didn’t re­spond to re­peated re­quests for com­ment on their stance.

Mercy North­west Arkansas

said the de­ci­sion would be be­tween doc­tors and pa­tients, as with any treatment.

Some health care providers said they have mul­ti­ple con­cerns about us­ing the drug. Dr. Juan Lombeida, a sup­port­ive care provider with High­lands On­col­ogy Group, said he would treat med­i­cal mar­i­juana with the same cau­tion as any other med­i­ca­tion, weigh­ing side ef­fects and whether an­other treatment would do the trick.

High­lands On­col­ogy some­times pre­scribes Mari­nol, a U.S. Food and Drug Ad­min­is­tra­tion-ap­proved syn­thetic ver­sion of the cannabi­noid THC that can help with nau­sea and ap­petite, Lombeida said. He called it a “back pocket” op­tion if other med­i­ca­tions aren’t ef­fec­tive. Mar­i­juana it­self has helped a few pa­tients, but made no worth­while dif­fer­ence for oth­ers, in his ex­pe­ri­ence.

“It may not work as well as you hope, just like any other treatment we have,” he said. “It’s go­ing to have its ben­e­fits and its bur­dens, and you need to be aware of those and be will­ing to make a change if needed.”

Ev­ery mar­i­juana plant and dis­pen­sary can be dif­fer­ent from the next, so dosages and other de­tails typ­i­cally de­ter­mined long be­fore a reg­u­lar med­i­ca­tion goes on the mar­ket re­main hazy, Lombeida added. Even if the drug’s work­ings were clear, a doc­tor won’t be giv­ing a pre­scrip­tion with ex­act in­struc­tions.

“I think we are do­ing this whole thing kind of back­wards,” Lombeida said, re­fer­ring to the re­search that’s catch­ing up with wider mar­i­juana use.

The Arkansas Gen­eral As­sem­bly passed a law re­quir­ing dis­pen­saries to hire a li­censed phar­ma­cist as a con­sul­tant to bring more med­i­cal ex­per­tise to the process. Scott Pace, a phar­ma­cist and CEO of the Arkansas Phar­ma­cists As­so­ci­a­tion, said the law will help make sure mar­i­juana doesn’t in­ter­act badly with other med­i­ca­tions.

How mar­i­juana’s dozens of cannabi­noids achieve their ef­fects and how well they can work are still ques­tions miss­ing many of their an­swers, said Ziva Cooper, an as­so­ciate pro­fes­sor of clin­i­cal neu­ro­bi­ol­ogy at Columbia Uni­ver­sity Med­i­cal Cen­ter in New York. She was an au­thor of the na­tional academies re­port.

Stud­ies might look at use of the plant, spe­cific cannabi­noids or their syn­thetic ver­sions, and find­ings in one cat­e­gory don’t nec­es­sar­ily fol­low in an­other, Cooper said. Re­search that’s de­signed to re­veal the dif­fer­ence those sep­a­rate cat­e­gories make and what in­di­vid­ual cannabi­noids are do­ing are still rel­a­tively un­com­mon, she said.

She and other re­searchers partly blame mar­i­juana’s clas­si­fi­ca­tion by the Drug En­force­ment Ad­min­is­tra­tion for the short­age of in­for­ma­tion. It’s held in the same cat­e­gory as heroin and LSD, and re­search into the drug re­quires re­peat­edly get­ting special li­censes and ap­provals that can add dif­fi­culty and months of pa­per­work to a study.

Study none­the­less goes for­ward around the coun­try. Dr. Greg Sharp of Arkansas Chil­dren’s Hos­pi­tal is do­ing three stud­ies ex­am­in­ing the cannabi­noid called cannabid­iol and its ef­fect on sev­eral seizure dis­or­ders. The stud­ies’ re­sults won’t be known un­til they fin­ish.

Cooper is work­ing on two stud­ies, in­clud­ing one also look­ing at cannabid­iol. Some ev­i­dence sug­gests cannabid­iol can soften THC’s high, though “the jury’s still out on that,” she said.

“We do have a long way to go, but it is an ex­cit­ing time be­cause a lot more peo­ple are in­ter­ested in pur­su­ing the sci­ence,” Cooper said. “I ex­pect over the next decade there’s go­ing to be a lot of good data.”

THE BUSI­NESSES

Once peo­ple with the req­ui­site med­i­cal con­di­tions get their doc­tors’ cer­ti­fi­ca­tions and their state cards, they’ll be able to buy from a mar­i­juana dis­pen­sary, ba­si­cally some­thing be­tween a pharmacy and a health sup­ple­ment shop. The mar­i­juana amend­ment al­lows up to 32 dis­pen­saries sup­plied by five cul­ti­va­tion fa­cil­i­ties around the state.

Other states’ in­dus­tries of­fer a preview of what could be for sale, com­monly fea­tur­ing dozens of va­ri­eties of plant ma­te­rial, oral so­lu­tions or pills, food prod­ucts and car­tridges for va­por­iz­ers such as e-cig­a­rettes. Busi­nesses of­ten de­velop types heav­ier in THC or cannabid­iol or try to bal­ance the two, de­pend­ing on the de­sired ef­fect.

“We’re con­stantly work­ing with our pa­tients to un­der­stand what works bet­ter for peo­ple with cer­tain con­di­tions, but it is very per­son­al­ized,” said Ari Hoff­nung, CEO of Vireo Health of New York.

Hoff­nung said the com­pany uses re­search from the U.S. and other coun­tries to tai­lor cap­sule and oral so­lu­tion for­mu­las that are all state-tested for qual­ity. Cus­tomers usu­ally meet with a li­censed phar­ma­cist when they first come in.

Other states also of­fer caveats for Arkansas’ mar­i­juana entrepreneurs. Bank loans and ac­counts are dif­fi­cult if not im­pos­si­ble to se­cure across the coun­try be­cause of mar­i­juana’s fed­eral clas­si­fi­ca­tion as an il­le­gal drug, and other ven­dors are some­times re­luc­tant to get in­volved. Health in­surance and pub­lic pro­grams such as Medi­care gen­er­ally won’t cover pa­tients’ mar­i­juana, which typ­i­cally costs $200 or more per ounce or bot­tle of pills in other states.

Nolan wants to start a dis­pen­sary and cul­ti­va­tion op­er­a­tion in Fort Smith with his brother and step­fa­ther. Good re­la­tion­ships with lo­cal banks af­ter years sell­ing real es­tate were fruit­less when it came to mar­i­juana, he said.

“As soon as they bring it up to the FDIC (Fed­eral De­posit In­surance Cor­po­ra­tion) reg­u­la­tors, they say, ‘So sorry, we’re not go­ing to be able to help you,’” Nolan said. The fam­ily is fi­nanc­ing the li­cense ap­pli­ca­tion and po­ten­tial busi­ness alone, in­clud­ing state fees and re­quired bonds for dis­pen­saries and cul­ti­va­tion fa­cil­i­ties adding up to more than $2 mil­lion.

State reg­u­la­tions and other fac­tors can also limit the mar­i­juana cus­tomer base. New York, for ex­am­ple, didn’t in­clude chronic pain as a qual­i­fy­ing con­di­tion un­til re­cently, Hoff­nung said. Re­ports from Colorado and other state gov­ern­ments show pain is of­ten what qual­i­fies the ma­jor­ity of med­i­cal mar­i­juana users.

Vireo, its sub­sidiary Min­nesota Med­i­cal So­lu­tions and other mar­i­juana com­pa­nies have yet to turn a profit since le­gal­iza­tion in those two states in 2014, ac­cord­ing to Hoff­nung and me­dia re­ports. The states’ reg­istries for mar­i­juana use in­clude sev­eral thou­sand peo­ple out of a com­bined pop­u­la­tion of 25 mil­lion.

“Cer­tainly many busi­nesses are not prof­itable dur­ing the early phase of their ex­is­tence,” said Hoff­nung, who’s also pres­i­dent of the New York Med­i­cal Cannabis As­so­ci­a­tion. “With that said, a busi­ness can­not ex­ist in­def­i­nitely with­out turn­ing a profit, and it is wor­ry­ing.”

Arkansas reg­u­la­tions com­pared to other states’ are more strict in some ways and less in oth­ers. Arkansas al­lows fewer con­di­tions to qual­ify than Min­nesota and Cal­i­for­nia, for ex­am­ple, but joins Delaware and Rhode Is­land in al­low­ing res­i­dents of other states who are reg­is­tered for mar­i­juana at home to buy from dis­pen­saries here if their ill­ness qual­i­fies.

Un­der the amend­ment, the Arkansas Med­i­cal Mar­i­juana Com­mis­sion sets other rules for busi­nesses, and Al­co­holic Bev­er­age Con­trol will in­spect them.

Arkansas leg­is­la­tors this year took other steps to limit mar­i­juana use in some ways. Smok­ing in pub­lic or by any­one younger than 21 is banned, and prod­uct pack­ag­ing must be child­proof and not be ap­peal­ing to chil­dren.

“It’s not go­ing to be a slam dunk,” Nolan said of the in­dus­try’s suc­cess in Arkansas, but he thought the state’s rules struck a rea­son­able bal­ance. “Ob­vi­ously we’re mo­ti­vated per­son­ally, but we also think there’s a de­cent shot of it be­ing fi­nan­cially fea­si­ble.”

State Rep. Robin Lund­strum of Elm Springs pushed un­suc­cess­fully to ban the smok­ing of med­i­cal mar­i­juana. She said the state will have to wait and see if its rules are enough to keep Arkansans safe.

“This is go­ing to be a process, and it’s not go­ing to be pretty at times,” she said.

Some are more op­ti­mistic. Brian Faught, a telecom­mu­ni­ca­tions con­trac­tor in cen­tral Arkansas, is look­ing to move to Fayet­teville and open a cul­ti­va­tion fa­cil­ity and dis­pen­sary and said he has the re­sources to power through the bumpy early years.

Fayet­teville’s City Coun­cil this month ap­proved sell­ing 5 acres to Faught for the busi­nesses if his state ap­pli­ca­tions go through.

“I don’t even smoke the stuff, but it’s a real prod­uct and it’s a real in­dus­try,” he said, cit­ing mar­i­juana’s medic­i­nal power and mon­ey­mak­ing po­ten­tial as his rea­sons to jump in. “I can’t wait to be a part of this in­dus­try.”

AP/RICHARD VO­GEL

Care­tak­ers over­see a grow room for med­i­cal mar­i­juana at ShowGrow, a med­i­cal mar­i­juana dis­pen­sary in Los An­ge­les, in this April 20 photo. Arkansas’ mar­i­juana amend­ment al­lows up to 32 dis­pen­saries sup­plied by five cul­ti­va­tion fa­cil­i­ties around the state.

AP/DON RYAN

Tyler Kennedy (right) smells a mar­i­juana sam­ple from Noah Si­ialata at Can­naDaddy’s Well­ness Cen­ter mar­i­juana dis­pen­sary in Port­land, Ore. Thou­sands of stud­ies since 1999 have found ex­am­ples of mar­i­juana or in­di­vid­ual com­pounds found in the plant...

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AP/RICHARD VO­GEL

A pa­tient takes ad­van­tage April 20 of special deals cel­e­brat­ing the 4/20 hol­i­day at ShowGrow, a med­i­cal mar­i­juana dis­pen­sary in Los An­ge­les. Arkansas’ voter-ap­proved con­sti­tu­tional amend­ment al­low­ing med­i­cal mar­i­juana use will soon fall into place. The...

AP/RICHARD VO­GEL

Bud­ten­ders help cus­tomers at ShowGrow, a med­i­cal mar­i­juana dis­pen­sary in Los An­ge­les. Arkansas’ amend­ment le­gal­izes mar­i­juana use for the first time in al­most a cen­tury, though it’s still against fed­eral law. “It truly felt like a mir­a­cle,”...

AP/RICHARD VO­GEL

A bud­ten­der weighs out mar­i­juana for a cus­tomers at ShowGrow on April 15. Arkansas in some ways is play­ing catch-up. Peo­ple have used mar­i­juana’s medic­i­nal prop­er­ties for about 5,000 years at least, ac­cord­ing to a 2013 re­port in the sci­en­tific jour­nal...

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