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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
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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)
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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)
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Recreational (dark), Medical (medium)
+ CBD Research (light green) as of 2015
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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
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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
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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
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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
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7-point assessment tool
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Results
Great variationAverage score was 1.96 (SD=2.17)
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Results
Great variationAverage score was 1.96 (SD=2.17)
Bona fide relationship in 62.5% (N=15)
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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
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Results (N=24)
10 Medicalized programs
Mean score 4.1 (SD=1.4)
14 Non-Medical programs
Mean score 0.43 (SD=0.51)
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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
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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
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Medicalized (yellow) and
Non-Medical (green) Programs (N=24)
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Association between medicalization
and enrollment rates
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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)
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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
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Thank you!
Mark Olfson MD MPH
Silvia Martins MD PhD
June Kim MS
Herbert D. Kleber MD