Amended Action Packet - Professions & Public Health Subcommittee (House of Representatives, February 16, 2021)

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Amended Action Packet of the House of Representatives Professions & Public Health Subcommittee for its Tuesday, February 16, 2021 meeting, with Will Robinson as Chair. The meeting notice lists a medical use of marijuana implementation update by Christopher Ferguson, Director of the Office of Medical Marijuana Use, and a briefing on the effects of high-potency marijuana by Bertha Madras, PhD, and says no filed bills or draft legislation will be considered. The packet also contains a letter dated February 11, 2021 to the Joint Committee on Medical Marijuana from physicians giving feedback on smokable cannabis practice standards, including counseling on secondhand smoke and oxygen use, and opposing a 10% THC limit on cannabis flower.

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Professions and Public Health
Subcommittee
Tuesday, February 16, 2021
10:00 AM - 12:00 PM
Webster Hall (212 Knott)

Amended Action Packet

Chris Sprowls Will Robinson
Speaker Chair
Committee Meeting Notice
HOUSE OF REPRESENTATIVES

Professions & Public Health Subcommittee

Start Date and Time: Tuesday, February 16, 2021 10:00 am

End Date and Time: Tuesday, February 16, 2021 12:00 pm

Location: Webster Hall (212 Knott)
Duration: 2.00 hrs

Medical use of marijuana implementation update by Christopher Ferguson, Director, Office of Medical
Marijuana Use, Florida Department of Health

Briefing on the effects of high-potency marijuana by Bertha Madras, PhD, Professor of Psychobiology,
Harvard Medical School

This meeting will be live-streamed on https://thefloridachannel.org/. As no filed bills or draft legislation will
be considered at this meeting, public testimony will not be solicited and seating will be limited to the
Members, invited presenters, and the press. As always, you may contact any Representative prior to the
start of the meeting. Contact information may be found at
https://www.myfloridahouse.gov/Representatives.

NOTICE FINALIZED on 02/09/2021 4:06PM by Osborne.Erin

02/09/2021 04:06:49PM Leagis ® Page 1 of 1
COMMITTEE MEETING REPORT
Professions & Public Health Subcommittee
2/16/2021 10:00AM
Location: Webster Hall (212 Knott)

Summary: No Bills Considered

Print Date: 02/16/2021 03:48 pm Leagis ® Page 1 of 3
COMMITTEE MEETING REPORT
Professions & Public Health Subcommittee
2/16/2021 10:00AM
Location: Webster Hall (212 Knott)

Attendance:

Present Absent Excused

William Robinson (Chair) X
Robert Andrade X
Kristen Arrington X
Anna Eskamani X
Juan Fernandez-Barquin X
Sam Garrison X
Michael Gottlieb X
Sam Killebrew X
Randall Maggard X
Thomas Maney X
Stan McClain X
Michele Rayner X
Alex Rizo X
Bob Rommel X
Tyler Sirois X
Kelly Skidmore X
Carlos Smith X
Kaylee Tuck X

Totals: 16 0 2

Print Date: 02/16/2021 03:48 pm Leagis ® Page 2 of 3
COMMITTEE MEETING REPORT
Professions & Public Health Subcommittee
2/16/2021 10:00AM
Location: Webster Hall (212 Knott)

Presentation/Workshop/Other Business Appearances:

Ferguson, Chris (State Employee) (At Request of Member, Committee or Staff)
Office of Medical Marijuana Use
Director
4052 Bald Cypress Way Bin M-01
Tallahassee FL 32399
Phone: 800-808-9580

Madras, Bertha (General Public) (At Request of Member, Committee or Staff)
Harvard Medical School
Professor of Psychobiology
115 Mill St
Belmont MA 02477
Phone: 617-855-2406

Print Date: 02/16/2021 03:48 pm Leagis ® Page 3 of 3
2/11/2021

Attn: Joint Committee on Medical Marijuana
℅ Florida Board of Medicine
4052 Bald Cypress Way
Tallahassee, FL 32399-3253

Dear Doctors,

I have read and agree with the Smokable Practice Standard
Recommendations as drafted by Drs. Beasley and Gordon.

Respectfully,

_________________________

Physician Name: ________________
License number: ________________
Number of active FL Medical Cannabis Patients:____________
Practice Name: _______________
Practice Address: ___________________________
2/11/ 2021

Attn: Joint Committee on Medical Marijuana
'lo Florida Board of Medicine
4052 Bald Cypress Way
Tallahassee, FL 32399- 3253

Dear Doctors,

We represent a group of over fifty Fl orida Medical cannabis ordering physicians that serve
upwards of fifty thousand medical ca nnabis patients, as well as several Florida MMTC
medical directors. Many of us have met bimonthly over the last six months to discuss both
medical and scientific issues related to medical cannabis. We wou ld like to give feedback
and recommendations related to Smokable Cannabis practice standards.

We understand this committee was tasked in section 381.986, F.S to adopt by rule practice
standards for the certification of smoking as a route of administration. As physicians, we
understand many of you are adverse to recommending smoking of any substance, yet must
provide these standards by July 1,2021 per the current statute.

Whole plant cannabis was labeled in the Florida statute as " Smokable Cannabis". In
actuality, dried flower buds from C. Sativa (hereafter referred to as "whole flowerH) can be
used in forms other than smoking. The composition of whole flower is more complete
compared to other processed forms of cannabis. Flower, when harvested, has on average
500 different components (Dewey, 1986). When processed, many of these components are
inadvertently lost to evaporation or degraded by the use of solvents. Because of the
substantially different chemical makeup, the processed product often does not provide the
same relief that the whole f lower provides . This is known in the cannabis literature as the
Entourage Effect (Ben Shabat, 1998).

Additionally, it is important for this committee to realize the cost difference in whole flower
products compared to other processed forms. Cannabis flower averages $0.04-$0.07/mg
while vaporizer cartridges ($0.12/mg), t inctures ($0 .14/mg), edibles ($0 .25/ mg) and
transdermal patches ($0.75/mg) are much more expensive. With no health Insurance
coverage and many patients on fixed incomes due to retirement or disability, we think it Is
important as physicians to be sympathetic to our patients' financial constraints when
recommending cannabis products.

With the above considerations, our recommendations are as follows:

1. Dosage recommendations- Cannabis dosing between patients can vary widely, and is
not necessarily related to age or body mass. Regardless of route of use, cannabis patients
should always be encouraged to use the lowest effective dose. We recommend products
with both CBD and THC, although ratios may vary. Because whole flower does vary in
potency, even in the same cultivar across ha rvests, we recommend always starting with 1-2
inhalations of any inhaled product. Inhalational methods may require repeat dosing in 2-4
hours, but would suggest PRN instead of scheduled dosing . If a patient is requiring
frequent inhalational dosing (whether smokeable or vapor), we often recommend a
baseline/maintenance oral dose, and then the patient may add an inhalational method for
breakthrough symptoms.
2. Contam inant Risk Whole flower cannabis does have infectious risks that are not present
in more processed prod ucts. Certain molds and mil dews can contaminate cannabis plants
du ring growing, processing, and storage both at dispensaries and in patient's homes. These
contami nants can pose health risks to patients, particularly those immunosuppressed due to
their disease states or their disease treatments. While the State of Florida does require
third-party testing, there is wide variability between MMTCs on the availability of these
test ing results to the physicians and patients. Additionally, there have been Instances
where the contaminated test results do not reach the OMMU for action until after the
product has been sold to patients at the ret ail level. Because of these concerns, we
recommend the OMMU and/or the FAMU's Medical Marijuana Education and Research
I nitiative (MMERI) provide ed ucatton to all MMU registered patients, via email or website
link which would include digital images to hel p the patients learn to identify pat hogens .
Addit ionally we support more consistent, transparent access to 3rd party Certificates of
Analysis for all medical cannabis prod ucts,ideally through the use of QR codes on individual
pr oduct packaging as well as access through the OMMU website.

3.Physicians qualifying patients for medical cannabis should explain the dangers of
secondhand and thirdhand smoke to other household members . Med ical cannabis
patients should be counseled never to smoke cannabis around other family members,
especially child ren. Patients should be encoura ged to smoke outside to allow adequate
ventilation and mitigate dangers of secondhand smoke. Additionally, cannabis should never
be smoked inside vehicles or other small spaces that children will occupy, even if the
children are not present at the t ime the prod ucts are used.(Herrmann, 2015)

4.Physicians qualifying patients for medical cannabis should specifically inquire if
there is any oxygen use in the household, by the patient or other household
members . Those patients using oxygen will be counseled not to use smokeable products,
and those with oxygen in the home will be specifically counseled not to use any smokeable
products in the vicinity of the oxygen use.

s. Physicians qualifying patients for medical cannabis should first ex plain
alternative ways to use whole flower other than smoking before qualifying
patients for the smokeable route . These routes could include use of dried flower in teas.,
extracting the cannabinoids from the flower into butter or other oils,grind ing the dried
fl ower into recipes, and homemade t inctures. The doctor patient relationship remains sacred
and unique, and the opportunity to educate du ring any office visit can have a sign ificant
impact on patient choices . Many patients will be open to t rying non-smoking alternatives if
ed ucated in t hese other options by their physician. Additionally, we wou ld encourage the
OMMU and FAMU MMERI to institute web based or pamphlet education modules to reinforce
these points .

In addition to the above recommendations, we would like to include one suggestion for what
NOT t o incl ude in the committee's smokeable practice standards. In the last two legislat ive
sessions, there have been attempts to lim it cannabis flower to 10% THC. These
recommendations are based on a single poorly designed study that purportedly showed
increased psychosis in ca nnabis products over 10% THC (Diforti, 2019). Despite t he poor
design and lack of reproducible results, t he study is still being used by special interest
groups opposed to medical canna bis to support the 10% limit. There are studies that show
in creased risk of psychosis with higher THC percentages in THC-ONLY concentrates. Whole
flower contains many other cannabinoids, some of which can reduce symptoms of psychosis
and other mental hea lth symptoms. This is another reason why whole flower potency should
not be limited. These components work better together, and can be safer than other
extracted products for mental health (Schubert, 2011 ).

As physicians, we realize that patients often require a certain m illigram dose of med ication
to have physiologic benefit. For example, consider a patient that requires 40 mg of lisinopril
for hypertension control. Assume tablets are $5/tab regardless of potency. If a
pharmaceutical company discontinues 40 mg tablets and only offers 20mg tablets, the
patient's cost has now doubled. This is what decreaS1ng whole flowe r cannabis potency to a
max of 10% THC would do to a majority of Florida cannabis patients.

If the State of Florida artificially limits THC percentage , the state is simply increasing
medicine prices to the patients, likely to be equivalent to a 50% tax, as cannabis flower in
the cu rrent market is often in the 20% range. Medical cannabis in Florida's vertically
integrated system is already more costly compared to most other medically legal states.
There is a certain production price to grow and process cannabis. Decreasing potency will
Increase production costs as more physical space and manpower w ill be required to produce
higher volumes of lower potency products . The patient will be the one to absorb these
costs. As stated above, the medieal canneibis i,etient po~uletion is often on fo:ed ineon"tes
and insurance coverage of these products Is prohibited. In the approximately 22 months
since dried flower cannabis became available in Florida, none of this group's physicians have
had reports of increased adverse events related to dried flower compared to other
modalities.

Thank you for the opportunity to share our experience and recommendations . Please feel
free to reach out to any of us if you have further questions or concerns . We look forward to
assisting your committee and Boards in maintaining a safe,thriving medical cannabis
program for our patients.

Respectfully for the group,

Michelle Gilmore Beasley MD

ME82008 ME124847
References

Ben-Shabat S, Fride E, Sheskin T, Tamiri T, Rhee MH, Vogel Z; Bisogno T, De Petrocellis L,
Di Mano V, Mechoulam R., (1998). An entourage effect: inactive endogenous fatty acid
glycerol esters enhance 2-arachidonoyl-glycerol cannabinoid act ivity. Eur J Pharrnacol.
353(1):23-31. doi: 10.1016/s0014-2999(98)00392-6

Dewey W. (1986) Cannabinoid pharmacology. Pharmacol Rev 38 : 151-178

Di Fortl,M.,Quattrone,D.,Freeman,T., Tripoli,G., Gayer-Anderson,C., Quigley,H. (2019). The
contribution of cannabis use to variation in the incidence of
psychotic disorder across Europe (EU-GEi): a multicenter case control study, The Lancet
Psychiatry, Volume 6, Issue 5, Pages 427-436 . doi https:/Jdoi.org/1 0.1016/ 52:215 -
0 366(1 9}3004 8-3

Herrmann,E.S., Cone,EJ ., Mitchell,J.M ., Bigelow,G., LoDico,C., Flegel,R. , Vandrey,R
(2015) .. Non-smoker exposure to secondhand cannabis smoke II : Effect of room ventilation
on the physiological, subjective, and behavioral/cognitive effects.
Drug and Alcohol Dependence,Volume 151,2015,Pages 194-202

Schubart, C. D., Sommer, I. E., van Gastel, W. A. , Goetgebuer, R. L. , Kahn, R. S., & Boks,
M, P. ( 2.011 ). Cannabis wfth high cannabidiol content Is associated with fewer psychot ic
experiences. Schizophrenia research , 130(1 - 3) , 216-221.
https: //doi.org/ 10.1016/j .schres.2011.04.017

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