1. MEDICAL MARIJUANA MINNESOTA Central Medical Clinic, 2015 Alfonso Morales, M.D., DABPM

2. The Problem of Undertreated Pain World Health Organization has said that undertreated pain is the number one health problem in America Number patients with chronic pain in the USA exceeds, diabetes, heart disease, and cancer combined National Center for health statistics. Health, United States, 2006 with Chartbook on Trends in the Health of Americans, Hyattsville, Maryland; US Department of Health and Human Services; 2006: 68-71

3. Dual Public Health Crises Undertreated Pain –USA today/ABC –News/Stanford University survey Prescription drug abuse –Whitehouse ONDCP –DEA

4. Paradigm Shift in Opioid Prescribing Competing Public Health Crises –Undertreated Pain –Prescription Drug Abuse Increasing Need for Safe and Effective Pain Management –Decreased barriers to appropriate opioid use –Increased safety in opioid use

5. DEA Facts on Prescription Drug Abuse Nearly 7 million Americans are abusing prescription drugs –More than the number for abusing cocaine, heroin, hallucinogens, ecstasy, and inhalants, combined. –80% increase in just 6 years Prescription pain relievers are new drug users’ drug of choice, vs., marijuana or cocaine Nearly 1/10, high school seniors admits to abusing prescription painkillers

6. Three 2010 MJ Related Bills Pending in US Congress H.R.2943: The Personal Use of Marijuana by Responsible Adults Act H.R.2835: The Medical Marijuana Patient Protection Act H.R.3939: The Truth in Trials Act

7. No Pot for Pain, High Court Says Many court rulings on MJ 2 supreme court rulings Restrict physicians and patients www.potdoc.com

9. Medical Cannabis What are the Facts? –In 2010, there were ~17.5 million monthly users 5.7% of the population (vs 68% for alcohol) –Cannabis is the most widely used illicit drug in the world. Among those who use cannabis ~9% met DSM- IV criteria for cannabis dependence. –In 2010, the most common primary drug of abuse in adolescent drug abuse programs was marijuana (75%)

10. Medical Cannabis Cannabis “Addiction”: Lifetime risk of dependence is 9% for marijuana, 15% for alcohol, 17% for cocaine, 23% for heroin, and 32% for nicotine. –The risk of dependence is essentially for those 25 or less. It is extremely rare for a new user older than 25 to become dependent. –Vs Cocaine where risk continues until ~45. –In those less than 18 who smoked reported smoking marijuana in the last year, ~26% had a use disorder.

11. Medical Cannabis Marijuana and Pain: –Reviews consistently show that cannabinoids are well- tolerated and “modestly” effective in neuropathic pain. The best evidence in MS-related pain. –Very little evidence to support its use in chronic low back pain. –In the trials, there was a large number of adverse cognitive/perceptual disturbances. 30-80% of naïve users reporting psychosis-like issues.

12. Medical Cannabis Marijuana and Pain: Marijuana is not more effective for pain relief than any other available compounds The most evidence for the use of marijuana for pain is for HIV-neuropathy and spasticity due to MS. –Review of California prescribing data show only 3% filled medical marijuana prescriptions are for these diagnoses.

13. Medical Cannabis Marijuana and Pain: Glaucoma is not a painful condition (acute angle closure is) Studies in the 1970’s showed that smoking marijuana decreased IOP for 3-4 hours. –NEI research studies from 1978-1984 –To adequately control pressure, would have to smoke 8- 10x/day. AAO reports multiple superior options, therefore this is no role for marijuana.

14. Medical Cannabis What about Minnesota? Starting June 1, 2015, health care practitioners will be able set up an account to certify patients who qualify for medical cannabis.

15. Medical Cannabis Did you know that Minnesota is the First State Program in the Country to offer only Smoke- Free Medical Cannabis? -No Smoke -No Plants -Only Pill, Liquid, or Oil.

16. Medical Cannabis Introducing the Minnesota Medical Cannabis Program Under the Minnesota Medical Cannabis Therapeutic Act of 2014, a system has been established for certain patients to pursue access to medical cannabis that is legal under state laws.

17. Medical Cannabis The Minnesota Department of Health's Office of Medical Cannabis (OMC) oversees this legislation

18. Medical Cannabis A health care practitioner that has registered as such in the Minnesota Medical Cannabis Registry does not prescribe medical cannabis of any kind. The health care practitioner’s role in the program is to determine, in the health care practitioner's medical judgment, whether a patient suffers from a qualifying medical condition, and, if so determined, provide the patient with a certification of that diagnosis certifying that a patient has a qualifying condition.

19. Medical Cannabis A health care practitioner certifies a patient’s qualifying condition and the patient has registered and been approved in the Medical Cannabis Registry. The patient will visit one of eight Cannabis Patient Centers where a licensed pharmacist will incorporate the qualifying condition, current medical conditions and medication taken by the patient as well as other information provided on the patient’s self-evaluation report to determine the form, dosage and frequency of the medical cannabis to be taken by the patient.

20. Medical Cannabis

21. Two Manufacturers: 1)LeafLine Labs, LLC 2)Minnesota Medical Solutions, LLC - Authorized -Regulated -Inspected

22. Medical Cannabis Three types of practitioners: doctors, physician assistants, and advanced practice registered nurse can certify that patients have a qualifying condition for medical cannabis. MDH will not maintain or publish a list of practitioners who are certifying these conditions.

23. Medical Cannabis Qualifying Conditions: –Cancer associated with severe/chronic pain, nausea or severe vomiting, or cachexia or severe wasting. –Glaucoma. –HIV/AIDS. –Tourette Syndrome. –Amyotrophic Lateral Sclerosis (ALS).

24. Medical Cannabis Qualifying Conditions: –Seizures, including those characteristic of epilepsy. –Severe and persistent muscle spasms, including those characteristic of multiple sclerosis. –Crohn’s Disease. –Terminal illness, with a life expectancy of less than one year, if the illness or treatment produces severe/chronic pain, nausea or severe vomiting, cachexia or severe wasting

25. Medical Cannabis Possible Qualifying Condition: –Intractable Pain Definition of Intractable Pain Intractable Pain is definited in the 2014 Minnesota Statutes. Recent History 1997 152.125 New 1997 c 124 s 1 152.125 INTRACTABLE PAIN.

26. Medical Cannabis § Subdivision 1.Definition.For purposes of this section, "intractable pain" means a pain state in which the cause of the pain cannot be removed or otherwise treated with the consent of the patient and in which, in the generally accepted course of medical practice, no relief or cure of the cause of the pain is possible, or none has been found after reasonable efforts.

27. Medical Cannabis Qualifying Conditions Your health care practitioner must certify that you have one of the nine qualifying conditions prior to enrolling in the system. You must also be a Minnesota resident.Qualifying Conditions Registration Process Find out if you have a qualifying condition, how to get certified, how to register, and how to get your medication.Registration Process Locations Medical cannabis will eventually be available at eight cannabis patient centers across Minnesota.Locations Costs All patients with a qualifying condition must pay an annual registration fee in order to be eligible to purchase medical cannabis.Costs Medical Cannabis Program: A Guide for Patients Overview of the program.Medical Cannabis Program: A Guide for Patients

28. Medical Cannabis Locations Medical cannabis will eventually be available at eight cannabis patient centers across Minnesota.Locations Costs All patients with a qualifying condition must pay an annual registration fee in order to be eligible to purchase medical cannabis.Costs Medical Cannabis Program: A Guide for Patients Overview of the program.Medical Cannabis Program: A Guide for Patients

29. Medical Cannabis Annual Registration Fee Full fee: The annual fee is $200. Reduced fee: Patients on Social Security Disability, Medical Assistance, CHAMPVA or Medicaid are eligible for the reduced fee of $50. A copy of your Social Security Disability, CHAMPVA, Medical Assistance or Medicaid ID card must be provided during registration. Payment: the registration fee is paid online via credit/debit card or check at the USBank website once you login to the Registry.

30. Medical Cannabis In addition to the registration fee, there will be a fee for the medical cannabis you need, payable at the cannabis patient centers. No insurance companies in Minnesota currently cover medical cannabis treatment.

31. Medical Cannabis "As a practitioner, am I protected?“ The legislature has amended Minnesota's medical cannabis statute to address patients' use of medical cannabis in health care facilities, such as hospitals.

32. Medical Cannabis "As a practitioner, am I protected?“ Under the amendment, protections and immunities are extended to employees of health care facilities to possess medical cannabis while carrying out their employment duties, including providing care to or distributing medical cannabis to a patient who is registered in the Minnesota Medical Cannabis Patient Registry and is actively receiving treatment or care at the facility.

33. Medical Cannabis "Do I have to participate?" No; participating in the Minnesota Medical Cannabis Program is optional

34. Medical Cannabis "What is my role in the Program, and what are my responsibilities?" –To use medical cannabis, all patients must register with the Program and have their condition certified by a qualified health care practitioner. (Patients must renew this certification annually with a qualified health care practitioner.)

35. Medical Cannabis "What is my role in the Program, and what are my responsibilities?" –In your role as a health care practitioner in the Program, you do not prescribe medical cannabis to patients. Instead, you are expected to assess your patient's health and:

36. Medical Cannabis "What is my role in the Program, and what are my responsibilities?" –Certify if your patient has a qualifying medical condition; by doing so you attest that you: –Have sufficient knowledge of your patient's history, physical findings and test results to make the diagnosis –Are available for ongoing management of your patient's medical condition

37. Medical Cannabis "What is my role in the Program, and what are my responsibilities?" –Indicate if your patient has a disability that prevents him or her from accessing or self-administering medical cannabis (in this situation, your patient would require a caregiver) –Acknowledge a legitimate medical relationship with your patient

38. Medical Cannabis “Where can I learn more?” For your convenience, Program-related resources including the latest legislative news, fact sheets and clinical research, are available in the website: mn.gov/medicalcannabis

39. Medical Cannabis “I thank everyone who worked together to craft and pass this legislation. I pray it will bring to the victims of ravaging illnesses the relief they are hoping for.” Governor Mark Dayton

40. Medical Cannabis If you have additional questions, please call the Office of Medical Cannabis or send an e- mail: health.cannabis@state.mn.us. Office of Medical Cannabis P.O. Box 64882 St. Paul, MN 55164-0882 (651) 201-5598 Metro (844) 879-3381 Non-metro

41. Medical Cannabis Which of the following has the most evidence for long term treatment of pain?: a.Acetaminophen b.Duloxetine c.Marijuana d.Opioids

42. Medical Cannabis Which of the following has the most evidence for long term treatment of pain?: a.Acetaminophen b.Duloxetine c.Marijuana d.Opioids

43. Medical Cannabis For which pain condition does “Medical Marijuana” have the most evidence? a.Arthritis b.Back Pain c.Glaucoma d.HIV Neuropathy

44. Medical Cannabis For which pain condition does “Medical Marijuana” have the most evidence? a.Arthritis b.Back Pain c.Glaucoma d.HIV Neuropathy

45. Medical Cannabis Comments?