1. Understanding Medical Marijuana Laws: What is and is not considered in past and current state policies Rosalie Liccardo Pacula, Ph.D. Anne Boustead, JD, MPhil and Katherine Pfrommer, MA Research presented here was supported by grants from NIDA (R01DA032693; 3R01DA032693-03S1)

2. Pacula 2 September 2014 What do we mean by medical marijuana? How is it different from other medications? Typical Pharmaceutical Specified Medical Conditions X Clinically established dosage necessary for relieving symptoms X Standardized doses for purchase X Clinically established guidelines regarding frequency of dosage X Clinical limits on durationX Labelling of active (and inactive) ingredients X Clinically preferred mechanisms for delivering X

3. Pacula 3 September 2014 What do we mean by medical marijuana? How is it different from other medications? Typical PharmaceuticalMM Today Specified Medical Conditions XX Clinically established dosage necessary for relieving symptoms X Standardized doses for purchase XX Clinically established guidelines regarding frequency of dosage X Clinical limits on durationX Labelling of active (and inactive) ingredients XX Clinically preferred mechanisms for delivering XX

4. Pacula 4 September 2014 Today’s presentation Discuss how state laws have evolved, with an emphasis on the types of dimensions that are reflected in the laws Draw parallels with other types of medicines, so as to predict how medical marijuana laws may change in the future

5. Pacula 5 September 2014 Five Distinct Periods of Recent Medical Marijuana State Laws Modern Period of MM laws Period Characterization 1972-1996Exploration of medicinal value 1996-2000Protection of patient rights 2000-2009Protection of patient’s access to supply 2009-2013Regulation of access to MJ 2014- presentRegulation of MJ as only medicine

6. Pacula 6 September 2014 1972-1996: Exploration of Marijuana as Medicine

7. Pacula 7 September 2014 1996-2000: Ballot Era CA was the first state to pass what is commonly recognized as a medical marijuana law in 1996 Early state ballot laws protected patients who used medical marijuana and caregivers who assisted in that use –“Medical use” was generally defined broadly to include consumption in addition to cultivation, production, transportation and acquisition These laws generally did not: –Explicitly protect entities that produced or distributed marijuana –Regulate licenses for use or provision of marijuana –Regulate production

8. Pacula 8 September 2014 1996-2000: Ballot Era States

9. Pacula 9 September 2014 Model MM Law in these Early Years Marijuana Policy Project Model Law 2000 Defined activities included in medical use Cancer, glaucoma, HIV/AIDS, disease that causes “pain”, nausea or seizures Registry provisionsStates *may* include registry provisions Legal protections for patients and caregivers Full legal protections available with written certification Amount limitations“Adequate supply”; states may elect to define adequate supply Source of medical marijuana States may opt to include protections for cultivators and production agencies

10. Pacula 10 September 2014 2000-2009: Early Legislative Era Most laws during this period included registry provisions and allowances for home cultivation Few laws at this time included explicit provisions for dispensaries –Colorado 2001 law did not explicitly sanction cooperatives but were implicitly allowed –California SB 420 explicitly allowed for cooperative cultivation of marijuana but did not regulate them – left this up to local governments Regulation was inhibited by uncertainty about federal enforcement of the Controlled Substances Act

11. Pacula 11 September 2014 The Early Legislative Era 2000-2009

12. Pacula 12 September 2014 The 2009 Ogden Memo Clarified the Federal Government’s Position In October 19, 2009, Deputy Attorney General David Ogden released a memo stating that federal prosecutors “should not focus federal resources … on individuals who are in clear and unambiguous compliance with existing state laws providing for the medical use of marijuana.”

13. Pacula 13 September 2014 2009-2013: Late Legislative Era States began enacting more comprehensive (and tightly controlled) distribution mechanisms State regulatory authorities become more prominent: –Regulate hours /licensing of dispensaries –Regulate growers / producers –Labeling requirements on products Still missing from the laws: –Explicit regulations on potency (THC) and other cannabinoids. –Regulations on medical products that can be sold (testing, forms) –Regulations on how it should be consumed (Exception: New York)

14. Pacula 14 September 2014 The Late Legislative Era 2010-2013

15. Pacula 15 September 2014 2014-Present: CBD-only laws Cannabidiol, or “CBD” is a naturally occurring compound in cannbis that has medical effects but does not make people feel “stoned” and can actually counter the psychoactive effects of delta-9 THC Some CBD-only laws have stricter requirements on who can give permission to use CBD –For example, Utah and Iowa both require that CBD use be recommended by a neurologist CBD-oil is generally only allowed for a narrow range of medical conditions –Generally for epilepsy or a seizure condition

16. Pacula 16 September 2014 2014 to the Present: Cannabis as only medicine

17. Pacula 17 September 2014 Model Medical Marijuana Laws Today ASA and MPP model policies include requirements for patients and caregivers to register with the state –Caregiver more carefully defined; sometimes limits on how many people they can care for and relationship to patient Both model policies recognize – and protect – a variety of entities involved in producing and distributing medical marijuana –Not only dispensaries and cultivation centers, but also testing and manufacturing facilities ASA model law includes provisions for testing and labeling medical marijuana –requires the adoption of “product safety standards for the cultivation, processing, manufacturing, labeling, testing, and distribution” of medical marijuana

18. Pacula 18 September 2014 Summary of the Evolution of State Medical Marijuana Laws Modern Period of MM laws Period Characterization 1972-1996Exploration of medicinal value 1996-2000Protection of patient rights 2000-2009Protection of patient’s access to supply 2010-2013Regulation of access to MJ 2014- presentRegulation of MJ as only medicine

19. Pacula 19 September 2014 Likely Next Directions for Medical Marijuana Policies Medical marijuana regulation may begin to more closely resemble regulation of pharmaceuticals –Dosage limits –Labeling and testing requirements –Product restrictions

20. Pacula 20 September 2014 Youth-targeted products sold today in dispensaries – hard to consider this “medicine”

21. Pacula 21 September 2014 Likely Next Directions for Medical Marijuana Policies Medical marijuana regulation may begin to more closely resemble regulation of pharmaceuticals –Dosage limits –Labeling and testing requirements –Product restrictions States may enhance legal protections as different types of entities become involved in producing medical marijuana. Likely to see more of a difference in medical marijuana laws and legalization policies

22. Pacula 22 September 2014 Thank you!!