Medicalized
Marijuana:
A Review of
State Programs
in the USAISSDP // Cannabis Summit
April 17, 2016
Arthur Robin Williams MD MBE
Columbia UniversityDivision on Substance Abuse Department of PsychiatryNew York State Psychiatric Institute
Symbolic Laws 1979-1991 5 states
Legalized marijuana with a “prescription”
Symbolic because federal law prohibits prescribing a schedule I drug
Virginia (1979)
New Hampshire (1981)
Connecticut (1981)
Wisconsin (1988)
Louisiana (1991)
MMJ Laws 1996-Current
23 states and DC (N=24)
California was first in 1996
Range of programs
Initially just protective of possession
Increasingly regulated
2009 as dividing line for medical programs
CBD research programs (15 states)
Recreational (dark), Medical (medium)
+ CBD Research (light green) as of 2015
The Medical Model:
The role of physicians
Comprehensive H&P
Make a diagnosis (in your area of expertise)
Treatment plan with specific objectives
Informed consent: risks and benefits
Longitudinal management
Seek consultation from colleagues
Document the rationale
The Medical Model:
Pharmaceuticals
Physician oversees dose
FDA approved (efficacy and safety)
Current Good Manufacturing Practices① Manufacturing regulations and dispensed via
licensed pharmacy (separate party from MD)
② Medication is clearly labeled, consistent
One month supply, typically not filled early
Route of administration safest available
The Medical Model:
Controlled substances
More restrictive
For meds with increased risk/abuse potential
Certifying MD registered with state (DEA
license)
①Refill limits
②Prescription Drug Monitoring Program (PMP)
③Physician certification
7-point assessment tool① Bona fide doctor patient relationship
② Non-smoked cannabis
③ Licensed manufacturing/dispensing
④ Standardized testing/labeling
⑤ 30-day refill limitations
⑥ Link to PDMP
⑦ Physician training/certification
7-point assessment tool
Results
Great variationAverage score was 1.96 (SD=2.17)
Results
Great variationAverage score was 1.96 (SD=2.17)
Bona fide relationship in 62.5% (N=15)
Results
Great variationAverage score was 1.96 (SD=2.17)
Bona fide relationship in 62.5% (N=15)
Few with restrictive criteria2 non-smoked marijuana
3 PMPs
3 physician training
Results (N=24)
10 Medicalized programs
Mean score 4.1 (SD=1.4)
14 Non-Medical programs
Mean score 0.43 (SD=0.51)
State characteristics by group
Medicalized
(N=10)
Non-Medical
(N=14)
P Value
Legislative Act (%) 90.0 28.6 .004
Mean Years Since
Passage (SD)
2.7 (0.50) 13 (1.18) <0.0001
Region (N) West (0)
Midwest (2)
Northeast (5)
South (3)
West (10)
Midwest (1)
Northeast (3)
South (0)
.13
2008 Population Densitya
(persons/sq land mile) (SD)
1,454.1 (939.9) 146.45 (70.1) .11
State GDP (M)b (SD) 393,429 (113,390) 296,314 (142,521) .62
Mean Enrollment per
100,000 Residentsc (SD)
58 (31.7) 1,030 (160.3) .002
State characteristics by group:
First wave MMJ programs 1996-2009
Voter initiatives in Western states
Not consistent with medical model
Second wave MMJ programs 2009-current
Legislatures in Northeast/Midwest states
More highly regulated
Medicalized (yellow) and
Non-Medical (green) Programs (N=24)
Association between medicalization
and enrollment rates
Enrollment by group (October, 2014):
Non-medical (N=14)
1,129,759 participants
99.4% of participants nationwide
Medical (N=5)
7,310 participants
1/20th rate of enrollment (58 v. 1,030)
Case Study: New York
121 pages of regulations
Only 20 dispensaries statewide
$200,000 fee for registered organizations
Physicians must complete a 4-hour
course
5 brands with many criteria
95-105% content of indicated THC and CBD
Low THC 1:20 and 50:50 brands
Non-commercial names
Non-smoked products only
Thank you!
Mark Olfson MD MPH
Silvia Martins MD PhD
June Kim MS
Herbert D. Kleber MD
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