Meeting Packet — Professions and Public Health Subcommittee, House of Representatives (February 16, 2021)
Summary
Meeting packet for the Professions & Public Health Subcommittee meeting on Tuesday, February 16, 2021, at 10:00 am. It opens with the committee meeting notice listing a marijuana implementation update by Christopher Ferguson and a briefing on high-potency marijuana by Bertha Madras, PhD. The packet then reproduces an Office of Medical Marijuana Use presentation dated February 16, 2021, covering medical use, qualifying conditions, qualified physician requirements and physician certifications. A program-update section states that there are currently 2,708 qualified ordering physicians and that, from October 1, 2019, through September 30, 2020, there were 664,779 active physician certifications. The packet closes with a list of cited research references on cannabis.
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Professions and Public Health
Subcommittee
Tuesday, February 16, 2021
10:00 AM - 12:00 PM
Webster Hall (212 Knott)
Meeting 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
OMMU Presentation
FLORIDA DEPARTMENT OF HEALTH (DOH)
Office of Medical Marijuana Use
Low-THC Cannabis & Medical Marijuana
Florida’s Official Source for Responsible Use
Florida’s Official Source for Responsible Use.
Office of Medical Marijuana Use
Medical Marijuana Program Update
Christopher K. Ferguson
Director
Office of Medical Marijuana Use
February 16, 2021
2
Medical Marijuana in Florida
2014: Medical marijuana was January 3, 2017:
first legalized in Florida under Amendment 2, which
June 23, 2017: Senate
the Compassionate Medical created Article X,
Bill 8-A, which 2019: Senate Bill 182,
Cannabis Act of 2014. The act 2016: The 2016 Right to Try section 29 of the Florida
implemented Article X, which authorized
authorized a low Act allowed patients with Constitution, went into
section 29 of the Florida qualified physicians to
tetrahydrocannabinol (low- terminal illnesses access to effect. Amendment 2
Constitution by creating recommend marijuana
THC) and high cannabidiol low-THC cannabis and expanded access to
a unified regulatory in a form for smoking
(CBD) form of marijuana for medical cannabis. both low-THC cannabis
structure, went into for qualifying patients.
medical use by patients and medical marijuana
effect.
suffering from cancer or for a larger list of
seizures. medical conditions.
3
Medical Use of Marijuana
UNAUTHORIZED USE AUTHORIZED USE
• Marijuana that was not purchased or • Medical marijuana and low-THC
acquired from a MMTC. cannabis under 381.986., F.S., for
all qualifying conditions.
• Use in a manner inconsistent with the
qualified physician’s certification. • Medical use is the acquisition,
• Transfer of marijuana to a person possession, use, delivery, transfer,
other than an authorized qualified or administration of marijuana
patient or the qualified patient’s authorized by a qualified
caregiver on their behalf. physician.
• Cultivation by anyone other than an • Medical marijuana is only provided
approved MMTC (no home grow).
through an approved MMTC.
4
Medical Use of Marijuana
Medical use means the acquisition, possession, use, delivery,
transfer, or administration of marijuana authorized by a physician
certification. The term does NOT include:
Use in a Use in a state Use on the
Use in a school
Use on any qualified correctional grounds of a The smoking of
Use in any bus, a vehicle,
form of public patient’s place institution, as preschool, marijuana in
public place, an aircraft, or a
transportation, of defined in s. primary an enclosed
except for low- motorboat,
except for low- employment, 944.02, or a school, or indoor
THC cannabis except for low-
THC cannabis except when correctional secondary workplace as
not in a form THC cannabis
not in a form permitted by institution, as school, except defined in s.
for smoking not in a form
for smoking his or her defined in s. as provided in 386.203(5)
for smoking
employer 944.241 s. 1006.062
5
Qualifying Medical Conditions
• Cancer
• Epilepsy
• Glaucoma
• HIV
• AIDS
• Post-traumatic stress disorder (PTSD)
• Amyotrophic lateral sclerosis (ALS)
• Crohn’s disease
• Parkinson’s disease
• Multiple sclerosis (MS)
• Medical conditions of the same kind or class as or comparable to those above
• A terminal condition diagnosed by a physician other than the qualified physician issuing the physician certification
• Chronic nonmalignant pain caused by a qualifying medical condition or that originates from a qualifying medical
condition and persists beyond the usual course of that qualifying medical condition
6
Qualified Ordering Physicians
• Qualifying physicians must:
• Have a clear/active license under
Chapter 458, or 459, Florida
Statutes.
• Complete the required course and
examination provided by the Florida
Medical Association, and Florida
Osteopathic Medical Association.
• Find a qualified physician using the
online search tool:
• https://knowthefactsmmj.com/
7
Qualified Physician Requirements
• Conduct a physical examination while physically present in the same room as the patient,
conduct an assessment of the patient’s medical history, and diagnose the patient with a
qualifying medical condition.
• Determine that the medical use of marijuana would likely outweigh the potential health
risks for the patient. If a patient is younger than 18 years of age, a second physician must
agree with this determination.
• Determine if the patient is pregnant. A physician may not issue a physician certification,
except for low-THC cannabis, to a patient who is pregnant.
• Review the patient's controlled drug prescription history in the Prescription Drug
Monitoring Program database.
8
Qualified Physician Requirements
• Review the Medical Marijuana Use Registry and confirmed that the patient does not have
an active physician certification from another qualified physician.
• Register as the issuer of the physician certification for the qualified patient in the Medical
Marijuana Use Registry and enter the contents of the physician certification into the
registry, including: the patient’s qualifying condition, dosage, the amount and forms of
marijuana authorized for the patient, and any types of marijuana delivery devices needed
by the patient for the medical use of marijuana.
• Conduct an evaluation at least once every 30 weeks.
9
Physician Certifications
• A qualified physician may not issue a physician
certification for more than three 70-day supply
limits of marijuana or more than six 35-day supply
limits of marijuana in a form for smoking (210
days).
• Contents of a Physician Certification:
• Qualifying condition
• Type: low-THC cannabis, medical marijuana
• Route: Oral, edible, topical, sublingual,
inhalation, suppository
• Daily Dose: CBD, THC, Ounces of whole
flower
10
Identification Card Process
11
Florida’s Medical Marijuana Industry
MMTCs are vertically integrated, which means that each MMTC must cultivate, process, and dispense
medical marijuana and low-THC cannabis
• MMTC Licensure Rolling Expansion:
• By July 3, 2017, DOH must license any entity that holds an active, • MMTCs must receive authorization from DOH to begin cultivating,
Dispensing Organization (DO) license under former processing, and dispensing.
Compassionate Use Act and which meets the requirements of s. • As of April 1, 2020, there are no statutory limitations on the maximum
381.986. number of dispensing facilities allowed.
• By August 1, 2017, DOH must license any applicant whose • MMTCs with dispensing authorization may deliver statewide.
application was scored but denied a license by DOH under the
Compassionate Use Act, and which had an ongoing administrative
or judicial challenge as of January 1, 2017, or had a final ranking
within one point of the highest final ranking in its region.
• DOH must license up to 10 MMTCs, including those licensed
under bullet 2, one of which is a recognized class member
of Pigford v. Glickman or In Re Black Farmers Litigation.
• Upon reaching 100,000 patients in the registry, and for each
additional 100,000 patients thereafter, DOH must license 4 more
MMTCs within 6 months.
12
MMTC Authorization Phases
Each MMTC is
authorized to operate:
Fulfillment
Cultivation Processing Dispensing
and Storage
Facilities Facilities Facilities
Facilities
Prior to commencing operation at any facility, request an inspection and receive written approval
from the Office of Medical Marijuana Use.
13
Office of Medical Marijuana Use
Program Update – By the Numbers
14
Qualified Ordering Physicians
• There are currently 2,708 qualified ordering physicians statewide.
• 2021 Data Review - Physician Certification Pattern Review Panel.
• Statewide from October 1, 2019, through September 30, 2020, there were 664,779 active
physician certifications.
• 1,625 physicians issued certifications for 443,888 patients.
15
Medical Marijuana Use Registry Patient Adoption
Total Patient Adoption, per Year: 2016: 1,562 2017: 62,451 2018: 146,599 2019: 214,088 2020: 249,106
Total Patient Adoption through December 31, 2020: 673, 806
16
Active Medical Marijuana Patients
Total Active Patients at
2017: 41,295 2018: 167,758 2019: 299,744 2020: 461,599
the End of Each Year:
17
Comparison of New Patient Enrollment
Total Patient Enrollment, per Year: 2016: 1,562 2017: 62,451 2018: 146,599 2019: 214,088 2020: 249,106
18
Total Initial and Renewal Applications Approved
During 2019 the OMMU Approved 306,015 Patient / Caregiver Initial and Renewal Applications
During 2020 the OMMU Approved 476,119 Patient / Caregiver Initial and Renewal Applications
19
Breakdown of Initial and Renewal Applications Approved
2019 Total Patient Initial Applications Approved: 202,865
2020 Total Patient Initial Applications Approved: 240,864
2019 Total Patient Renewal Applications Approved: 98,371
2020 Total Patient Renewal Applications Approved: 228,605
20
Comparison of Physician Certifications Created
Total Certifications Issued 2019: 564,562 Total Certifications Issued 2020: 725,298
21
Growth in Physician Certifications for
Medical Marijuana Use
This table summarizes the growth in number of physician certifications, individual patients, and qualified physicians.
Patient counts reflect distinct individuals; patients may have more than one certification in each time period.
2019 Report 2020 Report 2021 Report Percent
9 months 12 months 12 months Increase
January 1, 2018 October 1, 2018 October 1, 2019 (2019 to
through through through The greatest number of certifications were issued by a
2021)
September 30, September 30, September 30, small percentage of qualified physicians. This ratio has
2018 2019 2020
been increasing.
Certifications 169,573 460,469 664,779
292%↑ • 2019: 41% of certifications were issued by 4% of
qualified physicians.
• 2020: 61% of certifications were issued by 9% of
Individual 232%↑
113,847 291,865 443,888 qualified physicians.
Patients
• 2021: 71% of certifications were issued by 12% of
Qualified qualified physicians.
Physicians 56%↑
1,039 1,487 1,625
with
Certifications
All Qualified 47%↑
1,838 2,556 2,700
Physicians
22
Trends in the total number and percentage of qualifying conditions reported in each data set.
Conditions listed in bold are the top three qualifying conditions reported by physicians.
2019 Report 2020 Report 2021 Report
9 months 12 months 12 months
January 1, 2018 through October 1, 2018 through October 1, 2019 through
September 30, 2018 September 30, 2019 September 30, 2020
Qualifying Condition Number Percent Number Percent Number Percent
(a) Cancer 16,602 9.8% 36,749 6.9% 51,420 4.6%
(b) Epilepsy 4,197 2.5% 8,698 1.6% 15,625 1.4%
(c) Glaucoma 3,319 1.9% 7,867 1.5% 10,834 1.0%
(d) Positive status for human immunodeficiency 1,624 0.9% 3,861 0.7% 7,490 0.7%
virus (HIV)
(e) Acquired immune deficiency syndrome 279 0.2% 626 0.1% 1,661 0.1%
(AIDS)
(f) Post‐traumatic stress disorder (PTSD) 40,005 23.6% 128,030 23.9% 406,542 36.3%
(g) Amyotrophic lateral sclerosis (ALS) 223 0.1% 408 0.1% 9,564 0.9%
(h) Crohn’s disease 3,312 1.9% 7,931 1.5% 23,006 2.1%
(i) Parkinson’s disease 2,824 1.7% 4,888 0.9% 8,192 0.7%
(j) Multiple sclerosis (MS) 3,499 2.1% 6,760 1.3% 134,245 12.0%
(k) Medical conditions of the same kind or 46,434 27.4% 135,088 25.2% 273,979 24.4%
class as or comparable to those
enumerated in paragraphs (a)‐(j)
(l) A terminal condition diagnosed by a 427 0.3% 870 0.1% 2,717 0.2%
physician other than the qualified physician
issuing the physician certification
(m) Chronic nonmalignant pain 46,873 27.6% 193,941 36.2% 175,904 15.7%
Total qualifying conditions reported: 169,618 535,717 1,121,179
Total number of certifications: 169,573 460,469 664,779
Total number of patients: 133,847 291,865 443,888
Total number of orders for Medical Marijuana,
by route, in all certifications in each data set.
Edibles as a route of administration became available August 27, 2020.
2019 Report 2020 Report 2021 Report
9 months 12 months 12 months
January 1, 2018 October 1, 2018 October 1, 2019
through September 30, through September 30, through September 30,
Route 2018 2019 2020
Edibles _ _ 199,677
Inhalation 340,199 407,855 1,837,293
Oral 295,170 376,350 1,827,093
Sublingual 46,303 98,005 1,027,120
Suppository 878 7,592 140,161
Topical 91,111 292,757 1,726,214
24
Comparison of New Physician Accounts Created
Physicians create their own accounts by self-registering. Physicians are only allowed to add patients and
certifications if their license and education credentials are verified by Medical Quality Assurance.
25
MMTC Product Offerings
Product Landscape
COUNT OF: RANGE IN POTENCY
PRODUCT TYPES PROCESSED PRODUCTS TO THC CONTENT AS A % OF VOLUME
MARKET
Lower Threshold Upper Threshold
Balm 6 0.4% 0.9%
Body Oil 18 0.7% 1.2%
Capsule 67 0.5% 3.0%
Concentrate 72 63.0% 90.0%
Flower Cup 17 15.0% 28.0%
Inhaled (Crumble) 13 80.0% 90.0%
Inhaled (Rosin) 10 80.0% 90.0%
Inhaled (RSO) 18 60.0% 90.0%
Inhaled (Sauce) 3 80.0% 90.0%
Inhaled (Shatter) 17 80.0% 90.0%
Inhaled (Wax) 4 80.0% 90.0%
Inhaler 3 60.0% 87.0%
Kief 9 70.0% 85.0%
Lotion 24 0.3% 0.8%
Oil (Tincture) 108 1.3% 4.0%
Powder 3 95.0% 100.0%
Pre-roll 30 15.0% 28.0%
Resin 5 80.0% 90.0%
Suppository 9 1.3% 3.0%
Transdermal Patch 18 11.1% 90.0%
Vaporizer Cartridge 216 60.0% 87.0%
Vaporizer Disposable 20 75.0% 87.0%
26
Whole Flower 63 10.0% 28.0%
Physician Certifications
Top five physicians with the highest number of certifications in each dataset.
2019 Report 2020 Report 2021 Report
9 months 12 months 12 months
January 1, 2018 October 1, 2018 October 1, 2019
through September 30, 2018 through September 30, 2019 through September 30, 2020
UID Number of Number of UID Number of Number of UID Number of Number of
Certifications Patients Certifications Patients Certifications Patients
AU 4,888 4,114 AU 8,838 6,147 AY 16,604 7,022
J 4,405 2,854 BA 8,763 6,059 AZ 12,971 8,192
CF 3,173 2,906 J 5,665 3,390 BA 12,724 8,932
CG 3,046 2,012 AX 5,608 3,025 CY 6,412 4,777
AX 2,642 2,432 AV 5,184 4,035 BB 6,272 4,492
27
Medical Marijuana: Edibles
Top five physicians with the highest Average Daily Dose (mg).
2021 Report
12 months
October 1, 2019 through September 30, 2020
UID Average Daily Dose (mg) Number of Orders
AP 8,449 184
AO 3,500 2
DF 2,900 30
DK 2,500 3
DH 2,000 2
Average with no outliers: 175 mg/day
No data for Edibles in 2019 or 2020 Reports.
Edibles as a route of administration became available August 27, 2020. 28
Medical Marijuana: Inhalation
Top five physicians with the highest Average Daily Dose (mg).
2019 Report 2020 Report 2021 Report
9 months 12 months 12 months
January 1, 2018 October 1, 2018 October 1, 2019
through September 30, 2018 through September 30, 2019 through September 30, 2020
UID Average Number of UID Average Number of UID Average Number of
Daily Dose Orders Daily Dose Orders Daily Dose Orders
(mg) (mg) (mg)
A 362,231 235 A 593,778 302 X 25,290 6
Q 72,000 5 AT 127,216 6 DC 21,000 1
P 34,400 3 O 35,000 2 AJ 14,000 3
D 26,750 4 BD 21,000 3 AL 13,073 11
U 13,200 4 X 14,497 15 AA 11,635 23
Reported average: 1,098 mg/day Average with no outliers: 193 Average with no outliers: 225
mg/day mg/day
29
Medical Marijuana: Oral
Top five physicians with the highest Average Daily Dose (mg).
2019 Report 2020 Report 2021 Report
9 months 12 months 12 months
January 1, 2018 October 1, 2018 October 1, 2019
through September 30, 2018 through September 30, 2019 through September 30, 2020
UID Average Number of UID Average Number of UID Average Number of
Daily Dose Orders Daily Dose Orders Daily Dose Orders
(mg) (mg) (mg)
A 384,592 235 A 575,251 302 AU 142,889 14,023
Q 72,000 5 P 93,132 28 AJ 14,000 3
BV 16,820 20 AT 22,480 6 AA 11,635 23
U 8,500 4 AA 14,000 3 A 10,000 6
BW 6,000 22 Q 12,158 29 DH 9,657 26
Reported average: 1,157 mg/day Average with no outliers: 148 mg/day Average with no outliers: 197 mg/day
30
Medical Marijuana: Sublingual
Top five physicians with the highest Average Daily Dose (mg).
2019 Report 2020 Report 2021 Report
9 months 12 months 12 months
January 1, 2018 October 1, 2018 October 1, 2019
through September 30, 2018 through September 30, 2019 through September 30, 2020
UID Average Number of UID Average Number of UID Average Number of
Daily Dose Orders Daily Dose Orders Daily Dose Orders
(mg) (mg) (mg)
A 504,500 235 BE 55,909 34 DH 25,000 2
BW 20,000 22 A 55,223 302 AJ 17,500 2
BL 5,600 15 AA 14,000 3 A 10,000 6
BX 4,800 12 BD 9,650 3 DC 10,000 1
BF 3,655 43 BF 4,326 78 DD 7,000 3
Reported average: 630 mg/day Average with no outliers: 140 Average with no outliers: 189
mg/day mg/day
31
Medical Marijuana: Suppository
Top five physicians with the highest Average Daily Dose (mg).
2019 Report 2020 Report 2021 Report
9 months 12 months 12 months
January 1, 2018 October 1, 2018 October 1, 2019
through September 30, 2018 through September 30, 2019 through September 30, 2020
UID Average Daily Number of UID Average Daily Number of UID Average Daily Number of
Dose (mg) Orders Dose (mg) Orders Dose (mg) Orders
BY 19,998 530 U 2,400 3 AQ 4,800 4
BZ 2,000 21 BG 1,450 331 DI 3,500 2
CA 1,400 480 C 1,420 420 DF 2,750 12
CB 1,086 148 BH 1,350 350 DJ 1,750 6
CC 1,000 20 BI 1,200 31 U 1,620 5
Reported avg dose: 164 mg/day Average with no outliers: 168 mg/day Average with no outliers: 173 mg/day
32
Medical Marijuana: Topical
Top five physicians with the highest Average Daily Dose (mg).
2019 Report 2020 Report 2021 Report
9 months 12 months 12 months
January 1, 2018 October 1, 2018 October 1, 2019
through September 30, 2018 through September 30, 2019 through September 30, 2020
UID Average Number of UID Average Number of UID Average Number of
Daily Dose Orders Daily Dose Orders Daily Dose Orders
(mg) (mg) (mg)
A 709,991 235 A 558,287 302 DH 20,800 10
CD 280,000 3 X 50,400 15 AJ 17,500 1
BK 20,275 445 BD 20,600 3 A 10,000 6
U 9,000 4 BJ 10,599 128 AT 9,600 6
CE 4,661 93 U 8,400 3 AK 6,006 272
Reported average: 1,336 mg/day Average with no outliers: 129 Average with no outliers: 148
mg/day mg/day
33
Count of Dispensations
MMTCs may only dispense the products a physician orders for their patient if the patient has an Active Medical Marijuana Use Registry ID Card
34
MMTCs: Currently Licensed
Original Applicant Current MMTC Licensee d/b/a Authorization Status
Costa Nursery Farms, LLC Curaleaf Florida, LLC Curaleaf Dispensing Authorization
Chestnut Hill Tree Farm DFMMJ Investments, LLC Libery Health Sciences Dispensing Authorization
Knox Nursery, Inc. Spirit Lake Road Nursery, LLC Fluent Dispensing Authorization
Alpha Foliage Inc. Alpha Foilage, Inc. Surterra Wellness Dispensing Authorization
George Hackney, Inc. Trulieve Inc. Trulieve Dispensing Authorization
San Felasco Nurseries, Inc. San Felasco Nurseries, Inc. Harvest House of Cannabis Dispensing Authorization
McCrory's Sunny Hill Nursery, LLC McCrory's Sunny Hill Nursery, LLC GrowHealthy Dispensing Authorization
Tornello Landscape Corp 3 Boys Farm, LLC One Plant Dispensing Authorization
Loop's Nursery and Greenhouses, Inc. VidaCann, LLC VidaCann Dispensing Authorization
Plants of Ruskin, Inc. Plants of Ruskin, LLC AltMed Florida Dispensing Authorization
Sun Bulb Company, Inc. Better-Gro Companies, L.L.C. Columbia Care Florida Dispensing Authorization
GST Enterprises, Inc. MME Florida, LLC MedMen Dispensing Authorization
Keith St. Germain Nursery Farms, LLC KSGNF, LLC GTI Florida, LLC Dispensing Authorization
Nature's Way Nursery of Miami Inc. Acreage Florida, Inc. The Botanist Dispensing Authorization
Spring Oaks Greenhouses, Inc Spring Oaks Greenhouses, Inc The Source Dispensing Authorization
Redland Nursery, Inc D&D Accounting Services, LLC - Processing Authorization
Dewar Nurseries, Inc Sanctuary Medicinals LLC - Dispensing Authorization
Tree King-Tree Farm, Inc Tree King-Tree Farm, Inc Cookies Florida, LLC Initial Licensure
Perkins Nursery, Inc Perkins Nursery, Inc - Dispensing Authorization
Bills Nursery, Inc Bills Nursery, Inc The Flower Dispensing Authorization
Deleon's Bromeliads, Inc Mount Dora Farms LLC Green Dragon Dispensing Authorization
Hart's Plant Nursery, Inc Hart's Plant Nursery, Inc Revolution Florida Dispensing Authorization
35
MMTC Dispensing Locations
Each MMTC is vertically integrated and must MMTC (Map 1)
cultivate, process, and dispense medical One Plant
marijuana. The Botanist
Surterra Wellness
Columbia Care Florida
TOTAL FACILITIES The Flowery
Processing F&S Dispensing Cultivation Curaleaf
D&D Accounting Services, LLC
27 20 313 36 Liberty Health Sciences
Revolution Florida
• Cultivation Facility - Any area designated to be used for GTI Florida, LLC
cultivation of marijuana. GrowHealthy
MedMen
• Processing Facility - Any area designated to be used for
processing of low-THC cannabis and medical marijuana.
• Fulfillment and Storage Facility (F&S) - Any area MMTC (Map 2)
designated, which is not open to the public, to be used for Green Dragon
order fulfillment, shipping, transportation, or storage of low- Perkins Nursery, Inc
THC cannabis, medical marijuana, and marijuana delivery AltMed Florida
devices. Harvest House of Cannabis
Sanctuary Medicinals LLC
• Dispensing Facility - Any area designated to be accessible Fluent
by the public and where usable product and marijuana The Source
delivery devices will be dispensed at retail. Trulieve
VidaCann
36
Certified Marijuana Testing Laboratory
381.986 (8)(e)11.d., F.S., requires an MMTC to test Currently five Certified Marijuana
processed marijuana using a marijuana testing Testing Laboratories (CMTL) licensed
laboratory before it is dispensed. Testing results must pursuant to section 381.988, Florida
indicate that: low-THC cannabis meets the statutory Statutes:
definition; THC potency meets statutory requirements;
THC and CBD are labelled accurately; and the • Kaycha Davie
marijuana is safe for human consumption and • Kaycha Gainesville
free from contaminants that are unsafe for human • ACS
consumption. • Modern Canna Science
• Green Scientific
Three additional applications are
pending before DOH.
37
Rules Implementation
The Office of Medical Marijuana Use (OMMU) is charged with writing and implementing rules for medical
marijuana. Currently, the OMMU has the following rules in effect:
Emergency Rules, Chapter 64, F.A.R. Chapter 64-4, F.A.C.
CMTL Emergency Rules MMTC Emergency Rules • 64-4.001 Definitions
• 64ER20-1 CMTL Definitions • 64ER19-3 Pesticide Use on Medical • 64.4.002 Initial Application Requirements
• 64ER20-3 CMTL Testing Marijuana • 64-4.004 Revocation of Dispensing Organization
• 64ER20-4 CMTL On-Site Inspection • 64ER19-8 Renewal Application Approval
• 64ER20-5 Suspension and Revocation Requirements for MMTCs • 64-4.005 Inspection and Authorization
of CMTL Certification • 64ER20-16 MMTC Marijuana Waste Procedures
• 64ER20-6 Standard Operating Management and Disposal • 64-4.009 Compassionate Use Registry
Procedures • 64ER20-17 MMTC Transition to Testing • 64-4.011 Medical Marijuana Use Registry
• 64ER20-7 CMTL Testing Methods by Certified Marijuana Testing Identification Cards
• 64ER20-10 Quality Control Samples Laboratories • 64-4.013 Pesticide Use on Medical Marijuana
• 64ER20-11 CMTL Calibration Standards • 64ER20-31 Definitions • 64-4.023 Medical Marijuana Treatment Center
• 64ER20-12 CMTL Certificate of Analysis • 64ER20-32 MMTC Packaging and Variance Procedure
• 64ER20-14 Requirements for CMTL Labeling • 64-4.202 MMTC Inspection Procedures
Certification and Application • 64ER20-35 Standards for Production of • 64-4.208 MMTC Background Screening
• 64ER20-15 CMTL Background Edibles • 64-4.210 MMTC Fines, Suspension, and
Screening • 64ER20-36 MMTC Regulatory Revocation
• 64ER20-38 Submission of Product for Compliance Testing
Testing • 64ER20-37 MMTC Remediation
• 64ER20-39 CMTL Sample Testing
38
Annual Regulatory Plan
The OMMU expects to initiate rulemaking, not including emergency rulemaking, by July 1, 2021, to implement sections
381.986 and 381.988, F.S. The OMMU’s 2020-2021 Annual Regulatory Plan contains the following rules:
64-4.001 Definitions 64-4.300 Certified Marijuana Testing 64-4.XXX CMTL Renewal
64-4.XXX Application for MMTC Licensure Laboratory Definitions 64-4.XXX Marijuana Delivery Devices
64-4.013 Pesticide Use on Marijuana 64-4.301 Requirements for CMTL 64-4.XXX MMTC Authorization Procedures
64-4.XXX Dosing for Low-THC Cannabis and Medical Certification and Application 64-4.XXX Bonds and Financial Assurances
Marijuana 64-4.302 Testing 64-4.XXX MMTC Harvest Failure Procedures
64-4.XXX Medical Marijuana Treatment Center Change of 64-4.303 On-Site Inspection 64-4.XXX CMTL Audit Procedures for MMTCs
Ownership Applications 64-4.304 Suspension and Revocation of 64-4.XXX Qualified Patient and Caregiver
64-4.XXX Caregiver Background Screenings Certification Suspension and Revocation
64-4.XXX Medical Marijuana Treatment Center Advertising 64-4.307 Standard Operating Procedures 64-4.XXX Seed to Sale Tracking System
and Signage 64-4.308 Testing Methods 64-4.XXX MMTC Procedure for Recalls and
64-4.XXX Pigford and Black Farmers Class Application for 64-4.309 Submission for Product Testing Destruction of Marijuana Failing CMTL Testing
MMTC Licensure 64-4.310 Sample Testing 64-4.XXX Food Safety Good Manufacturing
64-4.201 MMTC Licensure Renewal 64-4.311 Quality Control Samples Practices Inspection Requirements and Renewal
64-4.205 Standards for Production of Edibles 64-4.313 Certificate of Analysis 64-4.XXX MMTC Website and Social Media
64-4.206 Low-THC and Medical Marijuana Packaging and 64-4.XXX CMTL Background Screening Advertising
Labeling 64-4.XXX MMTC Transition to Testing by 64-4.023 Medical Marijuana Treatment Center
64-4.207 MMTC Marijuana Waste Management and Certified Marijuana Testing Laboratories Variance Procedures
Disposal 64-4.XXX CMTL Fines 64-4.009 Compassionate Use Registry
64-4.209 Low-THC and Medical Marijuana Solvent Based
Extraction and Related Products
64-4.211: MMTC Supplemental Licensure Fee
39
Thank you
40
Dr. Madras Presentation
Bertha K. Madras, PhD
PhD, Professor of Psychobiology, Harvard Medical School
Biography
Bertha K. Madras, PhD, is a professor of psychobiology in the Department of Psychiatry at Harvard Medical
School, with her office and laboratory at McLean Hospital. She is former Deputy Director for Demand
Reduction (prevention, treatment) in the White House Office of National Drug Control Policy, Executive
Office of President, a position unanimously confirmed by the US Senate. She served as one of six
Commissioners (Gov. Chris Christie (NJ), Gov. Roy Cooper (NC), Gov. Charlie Baker (MA), former
Congressman Patrick Kennedy, former Attorney General Pam Bondi (FL) on the President’s Commission
on Combating Drug Addiction and the Opioid Crisis.
Her research focuses on addiction biology, and other neuropsychiatric diseases, with a recent focus on
the developing adolescent brain. She holds 19 U.S. and 27 international patents for novel brain imaging
agents and candidate therapeutics. In public service, she has delivered over several hundred public
presentations globally, and developed a museum exhibit and a CD (licensed by Disney), with the Museum
of Science, Boston. She is the recipient of, among others, an NIH MERIT award, The Innovator Award, NIDA
Public Service Award, National Leadership Award, American Academy of Addiction Psychiatry Founders’
Award. Her brain imaging agent altropane, was listed by The Better World Report in 2006 as “one of 25
technology transfer innovations that changed the world”.
Bertha K Madras,
Professor
Harvard Medical School
nee of Cannabis U r 15-19 y
.-~ - = -
.
-
0 400 600 800 1,000 1,200 1,400 1,600 1,800 2,000 2,200 2,400 2,600 2,800 Hall et al 2020
Cannabis use disorders among 15-19-year-olds in 2017 (cases per 100,000)
Why Does Potency Matter?
OH
What Does Marijuana Potency Mean?
O
Public Health Consequences: Known
Consequences to be determined
Why Does Potency Matter?
Higher potency, more drug effects, tolerance, addictive potential, others
Powder Cocaine.HCl
“Crack” Cocaine.NaHCO3 Crystal Meth.HCl
What Does Marijuana Potency Mean?
Cannabis Sativa Contains Many Chemicals
▪ Plant: ~104 Phytocannabinoids, 200-300 terpenoids, flavenoids
▪ Synthetic cannabinoids: 1,000’s made by chemists
▪ Endocannabinoids: Made by brain, body
D9-TetraHydroCannabinol (THC) in marijuana is key:
OH THC
THC
• psychosis, cognitive impairment, euphoria, intoxication,
O
motor impairment, addiction
Huestis et al., 2001 Blockade of effects of smoked marijuana by the CB1-selective cannabinoid receptor antagonist SR141716. Arch Gen Psychiatry 58, 322-8.;
Justinova et al., 2008; Blockade of THC-seeking behavior and relapse in monkeys by the cannabinoid CB(1)-receptor antagonist rimonabant.
Neuropsychopharmacology 33, 2870-7. Carlini Kramer C. Effects of Cannabis sativa (marihuana) on maze performance of the rat. Psychopharmacologia. 1965 7, 175-
81; Carlini et al., Effects of marihuana in laboratory animals and in man Br J Pharmacol. 1974;50:299–309; Masur et al., Effects of acute and chronic administration of
cannabis sativa and (-) delta9-trans-tetrahydrocannabinol on the behavior of rats in an open-field arena. Psychopharmacologia. 1971;19(4):388-97.
Made by the brain Made by marijuana
Models from BK Madras, W Mascarella: Museum of Science, Boston Exhibit
Legalization Arguments Made by Marijuana Lobby and Reality
1. Regulations will Reduce Youth use: states with legal marijuana
• past-month youth use is 40% higher
• past-year youth use is ~30% higher
• first-time youth use 30% higher compared to illegal states
2. Marijuana will be less potent: potency has risen dramatically
• Producers/retailers have incentive to increase %THC to reduce prices, increase profits
• Decreased prices, increased potency, more socially acceptable, increased users
• increased risks for adverse consequences
High THC Potency
Wax, dabs, shatter
New Products
flower, high-potency extracts, edibles (gummy
bears, candy, chocolates), infused beverages
New Delivery System
Vaping
1970’s 1980’s 1990’s 2000’s 2010-
Potency: Greater High
__%THC weight__ 20-90%
More users More
dry weight THC
Addiction
5%
MORE PROFIT!
THC
8%
1-3% THC
THC 3-5%
THC
Plant Resins
Freeman TP, Craft S, Wilson J, Stylianou S, ElSohly M, Di Forti M, Lynskey MT. Changes in delta-9-tetrahydrocannabinol (THC) and cannabidiol
(CBD) concentrations in cannabis over time: systematic review and meta-analysis. Addiction. 2020 Nov 7.
14% THC 3% THC
Forms of
marijuana Sinsemilla or skunk Herbal marijuana
4% THC 69% THC
Hash or resin Marijuana concentrate
Wilson J, Freeman TP, Mackie CJ. Effects of increasing cannabis potency on adolescent health. Lancet Child Adolesc Health. 2019
Feb;3(2):121-128. © Reproduced with permission from David Potter and Tom Freeman.
Washington State: Marketing of concentrates
• No cap for THC potency, or tax based on %THC
• Industry views concentrates as business op
• Farmers no need to produce appealing bud
• No mildew; more shelf stability than flower
• Delivery devices include vape-pens and dab-rigs
• Consumers choose wax, shatter, BHO, CO2
• MJ advertised print, websites/social media, search engines
Carlini BH, Garrett SB, Harwick RM. Beyond joints and brownies: marijuana concentrates in the legal landscape of WA state. Int J Drug Policy. 2017;42: 26–29
Sale of extracts rise • 70% +THC (21% of all sales in some states)
High potency • preference of daily users (who account for most sales)
Cap %THC or tax based on • to reduce incentive, but no US state has adopted policy
%THC
Increased access to potent • likely to increase frequency of use
marijuana at low price
Profit-seeking legal
• Goal is to increase demand, users, frequent use
industry
Public Health Consequences: Known
Specific to Youth General
• Continued high frequency use • More addiction
• Addiction • Psychosis
• Psychiatric symptoms • Hospitalizations
• Use of other drugs • Traffic accidents
• Childhood exposures
10
9
Concentrates
8
7
• Highest risk of
6
5
continued use
OR 4
3
2
• Highest risk of
1 high frequency
0 use
Blunts Eating Vaping Burning Concentrates
Barrington-Trimis, JL, Cho J, Ewusi-Boisvert E, Hasin, D, Unger JB, Miech RA, Leventhal AM. Risk of Persistence and Progression of Use of 5 Cannabis
Products After Experimentation Among Adolescents. JAMA Network Open January 24 2020
8th-, 10th-, and 12th-graders:
• 33% reported lifetime marijuana use
• 24% reported lifetime concentrate use
• 74% of all lifetime cannabis users had used concentrates
Compared with adolescent non-users or cannabis users not using
concentrates, concentrate users were more likely to:
• Smoke
• Use e-cigarettes
• Use alcohol, other drugs before age 17
• Use other drugs
• Experience more risk, fewer protective factors for substance use problems
Meier MH, Docherty M, Leischow SJ, Grimm KJ, Pardini D. Cannabis Concentrate Use in Adolescents. Pediatrics. 2019
Sep;144(3):e20190338.
Youth More Vulnerable to Marijuana Addiction
25
10.9% 15.3% 17.7% 20.6%
20
15
5.6% 7.1% 9.9% 10.5%
10
5
0
1st year 2nd year 3rd year 4th year
12-17y 18-25y
Han B, Compton WM, Blanco C, Jones CM. Time since first cannabis use and 12-month prevalence of cannabis use disorder among youth and emerging adults in the United States. Addiction. 2019 Apr;114(4):698-707
12-month prevalence of cannabis use disorder among US youth aged 12-17 and emerging adults aged 18-25 varied by time since first cannabis use. (n=100,000 12 -25; Past 12-
month cannabis use disorder was assessed using DSM-IV criteria
2.5
• Psychiatric symptoms associated use of
combustible, edible, vaporized marijuana 2
1.5
• Psychiatric symptoms higher in poly- 1
product use
0.5
0
Conduct Depressive Anhedonia Sensation
problems symptoms seeking
Leventhal AM, Bae D, Kechter A, Barrington-Trimis JL. Psychiatric comorbidity in adolescent use and poly-use of
combustible, vaporized, and edible cannabis products. J Psychiatr Res. 2020;124:91-98.
90
80
High potency vs low potency
70
60 • More regular marijuana use
50
• More use problems
40
30
• More use of other drugs
20
10 • More tobacco dependence
0
Regular Mj Use Problems Other illicit Tobacco AUD • More alcohol use disorder
Use drugs dependence
High potency Low potency
Hines LA, Freeman TP, Gage SH, et al. Association of High-Potency Cannabis Use With Mental Health and Substance Use in
Adolescence [published online ahead of print, 2020 May 27]. JAMA Psychiatry. 2020;e201035.
THC THC+CBD
20
THC (ng/mL)
15
10
5
0
Blood Cereb Occ Ctx
Withey SL, Bergman J, Huestis MA, George SR, Madras BK. THC and CBD blood and brain concentrations following daily
administration to adolescent primates [published online ahead of print, 2020 Jun 18]. Drug Alcohol Depend. 2020;213:108129.
▪ Corpus callosum (CC), rich in CB1 cannabinoid
receptors during neurodevelopment
▪ CC is critical for connecting left-right
hemispheres of the brain
• Frequent high-potency marijuana use is
associated with disturbed callosal
microstructural organization in users
with or without psychosis
Rigucci S, Marques TR, Di Forti M, Taylor H, Dell'Acqua F, Mondelli V, Bonaccorso S, Simmons A, David AS, Girardi P, Pariante CM, Murray RM,
Dazzan P. Effect of high-potency cannabis on corpus callosum microstructure. Psychol Med. 2016 Mar;46(4):841-54.
• % THC rose from 8.6% to 20.4% (2000 to 2004), fell 15.3%
In U.S.
2015
Higher potency marijuana products associated with increasing marijuana use disorder
• First-time cannabis admissions (per 100 000 inhabitants)
Higher potency
rose from products
7.08 to 26.36 increase
from 2000 risk
to 2010, fordecreased
then progression from use to marijuana use disorder
to 19.82 in 2015
Adolescents: Past-year marijuana use disorder significantly increased
• %THC was positively associated with treatment entry 0-9
years, with the strongest association at 5 years
In adults 26+, past-month marijuana use and past-year daily or almost daily
• Conclusions: 16-year observational study, time-dependent
marijuana
associations use significantly
between increased
changes in cannabis in adults aged 26+ (NSDUH, 2019)
potency and
first-time cannabis admissions for drug treatment.
Freeman TP, van der Pol P, Kuijpers W, Wisselink J, Das RK, Rigter S, van Laar M, Griffiths P, Swift W, Niesink R, Lynskey MT.
Changes in cannabis potency and first-time admissions to drug treatment: a 16-year study in the Netherlands. Psychol
Med. 2018 Oct;48(14):2346-2352
Problems Associated with Use of Butane Hash Oil
(~ 50-60% THC) Among College Students
before adjusted OR
4.5
4
3.5
3
OR 2.5
2
1.5
1
0.5
0
BHO User
Use frequency Edibles Binge drinking Smoking Other drugs Physical dependlumn1 Impaired control Academic problems
Meier MH. Associations between butane hash oil use and cannabis-related problems. Drug Alcohol Depend. 2017 Oct
1;179:25-31.
10
9
A “Tale” Of 3 Cities
(Actually 11 Sites) 8
Di Forti et al 7
Lancet Psychiatry 2019
May;6(5):427-436. 6
5
4
3
2
1
0
Dose-response:
• van Os J, et al 2002;
London Amsterdam Paris
• Henquet C, et al 2005;
• Moore THM et al: 2007;
• Haney and Evins, 2016; Never used Rare Use <10% Rare Use 10%
• Marconi et al 2016; Use THC <10% >1x/week Use THC >10% 1 x/week Daily THC <10%
Daily use THC >10%
High THC Potency Associated With Higher Risk for
Psychosis
Lower age of schizophrenia
Impaired brain function, driving
Use of other drugs, other effects
More use, higher risk for addiction
30
25
% YOUTH 12-17 USING MARIJUANA
20
15
10
Mother
Father
5
0
Never used Lifetime (NPY) <52 days >52 days
FREQUENCY OF PARENT MARIJUANA USE
Marijuana • abuse and dependence
Mental illness • marijuana-related code increased 5X faster than mental illness
without marijuana code 2012 - 2014
Largest increases • diagnoses of schizophrenia, other psychotic disorders, suicide
and intentional self-harm, mood disorders
Motor vehicle accidents, injuries • related to cannabis abuse data mixed
Head injuries • due to falls
Hyperemesis • 46% increase in the incidence of cyclic vomiting was reported
between 2010 and 2014
Childhood poisonings • exposures to candies, pastries
Severe burns • users who tried to extract THC from cannabis oils
16
Marijuana before 18
14
Marijuana use before Age 18 is Mental illness
Highest Risk for Opioid Use Disorder Drug seller encounter
Age
12
Health
% CONTRIBUTION TO DEVELOPING OUD
Easy access
10 Income
Education
Employment
8
Alcohol before 18
Race
6 Obesity
Disability
4 Gender
Risk of trying heroin
Probation
2
Risk of weekly heroin
Parole
0
Adway S. Wadekar. Understanding Opioid Use Disorder (OUD) using tree-based classifiers Drug and Alcohol Dependence 208 (2020) 107839
Lower. . Risk Cannabis Use Guidelines (LRCUGs)
• Abstain from cannabis use if possible
• Choose low-strength: lower THC content or higher CBD: THC.
• Do not use synthetic cannabis products
• Avoid smoking cannabis
• Avoid deep inhalation
• Don’t drive or operate machinery after using cannabis
• Avoid cannabis if pregnant or a personal or family predisposition
toward psychosis or substance abuse
• Avoid combining the risky behaviors listed
Fischer et al., Am J Public Health. 2018;108(5):e2]. Am J Public Health. 2017;107(8):e1–e12.
sand
(Pas 12 mon h us )
0 0 0 0
0 0 0 0
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0 O O 0
0 0 o 0 0 o O O 0
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mrr-,...0'> 0 O O O 0 0 O
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('()
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. (D l()
Smokes Age of Uses any Uses Drove after Use among Synthetic
cannabis itiation <16 high-THC cannabis annabis use t-risk groups annabis use
(~50°/o yea rs reduct s daily in past 12
months
•Canada U.S. illegal states • U.S. legal states • Total
Goodman S, Fischer B, Hammond D. Lower-Risk Cannabis Use Guidelines: Adherence in Canada and the U.S. Am J Prev Med.
2020 Dec;59(6):e211-e220.
30
25
20
15
10
5
0
Smoke Binge Alcohol Heavy Alcohol Illicit Drugs
NO YES
Data from Dupont, Han, Shea, Madras. Preventive Medicine 113: 68-73, 2018. [Graph prepared by BK Madras] Past month use of alcohol, tobacco and illicit drugs,
among youth aged 12-17, by marijuana status (past month unadjusted prevalence; n = 17,000; data from Table 1). Y-axis: past month prevalence in %)
Consequences to be determined
Consequences high potency?
• Workplace?
• Car accidents, fatalities?
• Fetal development? heightens the health risk of vulnerable groups associated with
sensitive landmarks in brain development, pregnancy, children, adolescents, young
adults
• Impact on cognitive impairment of older adults
• Impact greater with concurrent use of marijuana, alcohol?
• Heavy smoking may increase cardiovascular disease risk in young or middle-aged
men?
Deficits
Cognition
Psychiatric
Addiction Amotivation diseases
Short term Safety
Brain memory loss
IQ decline Higher school
Decreased
changes drop-out Psychosis
reaction time
Poor school
performance Depression Impaired motor
coordination,
Anxiety
• In 2019 Surgeon General Jerome Adams warned the risks of physical
dependence, addiction, other negative consequences increase with exposure to
high concentrations of THC and younger age of initiation
• Higher doses of THC are more likely to produce anxiety, agitation, paranoia,
and psychosis.
• “These harms are costly to individuals and to our society, impacting mental
health and educational achievement and raising the risks of addiction and
misuse of other substance.”
Stuyt E. The problem with the current high potency THC marijuana from the perspective of an addiction psychiatrist. Mo Med 2018;
115(6):482-486; Chandra S,et al., New trends in cannabis potency in USA and Europe during the last decade (2008-2017) Eur Arch Psychiatry
Clin Neurosci. 2019; 269(1): 5-15.; Smart et al., (2017) Variation in cannabis potency and prices in a newly legal market: evidence from 30
million cannabis sales in Washington state. Addiction, 112: 2167– 2177; Morean et al., Predictors of Adult E-Cigarette Users;
Office of the Surgeon General, U.S Surgeon General’s Advisory: Marijuana Use and the Developing Brain. Available
at:hhs.gov/surgeongeneral/reportsandpublications/addiction-and-substance-misuse/advisory-on-marijuana-use-and-developing-
brain/index.html
Brain is maturing • Cannabinoids unsafe for fetus, adolescent,
until mid-20s to 30 young adult, especially potent marijuana
High Potency Marijuana • “New” marijuana poses a greater risk than old
marijuana; no evidence it is necessary
High potency marijuana
• Associated with more brain changes,
addiction, psychosis, hospitalizations
• Evidence is weak that it reduces opioid use
Marijuana and Opioids
• States put opioid users at risk by endorsing MJ
• Limit % THC
% THC • Tax on basis of % THC
Kowal, et al., (2015). Cannabis and creativity: highly potent cannabis impairs divergent thinking in regular cannabis users. Psychopharmacology (Berl),
232, 1123–1134.
Morin et al., P. 2018. American Journal of Psychiatry 176(2), 98-106.
Silins et al. Young adult sequelae of adolescent cannabis use : an integrative analysis. Lancet Psychiatry. 2014 ; 1(4) : 286-293.
Hasin DS, et al. Time trends in US cannabis use and cannabis use disorders overall and by sociodemographic subgroups: a narra8ve review and new
findings. Am J Drug Alcohol Abuse. 2019; 45(6):623-643.
Wu LT, et al. Trends in cannabis use disorders among racial/ethnic population groups in the United States. 2016. Drug Alcohol Depend. 2016; 165:181-
90.
DiForti et al., 2009. High-potency cannabis and the risk of psychosis. Br. J. Psychiatry 195, 488-491. https://doi.org/10.1192/bjp.bp.109.064220.
National Academies. (2017). The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. The
National Academies Press: Washington, DC.
NIDA. Vaping of marijuana on rise among teens. National Institute on Drug Abuse website.https:www.drugabuse.gov/news-events/news-
releases/2019/12/vaping-of-marijuana-on-the-rise-among-teens. June 4, 2020. Accessed June 18, 2020.
Pistis M, Perra S, Pillolla G, Melis M, Muntoni AL, Gessa GL. Adolescent exposure to cannabinoids induces long-lasting changes in the response to
drugs of abuse of rat midbrain dopamine neurons. Biol Psychiatry. 2004;56(2):86-94.
Cadoni C, Pisanu A, Solinas M, Acquas E, Di Chiara G. Behavioural sensitization after repeated exposure to Delta 9-tetrahydrocannabinol and cross-
sensitization with morphine. Psychopharmacology (Berl). 2001;158(3):259-266.
Olfson M, Wall MM, Shang-Min L,Blanco C. Cannabis use and risk of prescription opioid use disorder in the United States. Am J Psychiatry, 2018.
175(1):47-53.
SAMHSA’s Annual Mental Health, Substance Use Data Provide Roadmap for Future Action, https://www.samhsa.gov/newsroom/press-
announcements/202009110221
Montanari et al., Cannabis Use among People Entering Drug Treatment in Europe: A Growing Phenomenon? Eur Addict Res 2017;23:113-121
Levy S., Weitzman ER. Acute Mental Health Symptoms in Adolescent Marijuana Users. JAMA Pediatr. 2019; 173(2): 185-186.
Hanke et al., The cost of mental illness: Massachusetts Facts and Figures. Available at: bhecon.org/wp-content/uploads/2017/11/MA-
Chartbook-2017.html https://www.cdc.gov/media/releases/2015/p0707-heroin-epidemic.html
Jones et al. Prescription Opioid Misuse and Use of Alcohol and Other Substances Among High School Students-Youth Risk Behavior Survey,
United States, 2019. US Department of Health and Human Services/Centers for Disease Control and Prevention, MMWR. Aug 2020. Vol. 69,
No. 1.
Agrawal A, Neale MC, Prescott CA, Kendler KS. A twin study of early cannabis use and subsequent use and abuse/dependence of other illicit
drugs. Psychol Med. 2004;34(7):1227-1237.
Wadekar A. Understanding Opioid Use Disorder (OUD) using tree-based classifiers. Drug Alcohol Depend. 2020; 208: 107839
Chan GCK, Becker D, Butterworth P, Hines L, Coffey C, Hall W, Patton G. Young-adult compared to adolescent onset of regular cannabis use: A
20-year prospective cohort study of later consequences. Drug Alcohol Rev. 2021 Jan 26
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consequences. Drug Alcohol Rev. Jan 26.
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JAMA Netw. Open 3, e1919792.
Fontes et al., 2011. Cannabis use before age 15 and subsequent executive functioning. Br. J. Psychiatry 198, 442–447.
Hall et al,, 2020. Daily cannabis use during adolescence is associated with cannabis dependence and poor cognitive function, which may affect
educational attainment and occupational choice.
Daily use of highly potent cannabis is associated with more severe psychological symptoms, such as psychoses, mania, and suicidality.
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