UW ADAI - Symposium - 2022 - Opening Remarks
(September 16, 2022)

Here are some observations from the Friday September 16th University of Washington Addictions, Drugs, and Alcohol Institute (UW ADAI) 2022 Symposium on “High-THC Cannabis in Legal Regulated Markets.”

My top 4 takeaways:

• UW ADAI had been a top research body around cannabis since passage of Initiative 502 (I-502) funded in part by revenue from cannabis sales to undertake public health and prevention work resulting in recommendations on concentrated tetrahydrocannabinol (THC) products and “high potency” cannabis flower.
  • Formerly the Alcohol and Drug Abuse Institute, UW ADAI emerged as a key recipient of cannabis excise tax revenue disbursed to the university. Appropriations advised, albeit not mandated, for UW ADAI included cannabis revenue for “the creation, maintenance, and timely updating of web-based public education materials providing medically and scientifically accurate information about the health and safety risks posed by cannabis use.”
    • UW ADAI researchers published an interim Marijuana Research Report in March 2021, as well as biennial reports for 2015-17 and 2017-19.
  • Beatriz Carlini, UW School of Public Health Acting Associate Professor and UW ADAI Research Scientist, had been involved in cannabis policy since 2016 when she became the leader of the ADAI Cannabis Education and Research Program (CERP). She was a member of the Washington State Liquor and Cannabis Board (WSLCB) Cannabis Potency Tax Work Group which produced a work group report in November 2019 summarizing how “transitioning to a potency-based tax for cannabis was not feasible at this time in Washington State. Some work group members from the public health community were in favor of a tax structure that would discourage consumption of high potency cannabis, but did not have confidence that this tax would guarantee those outcomes.”
    • A feasibility study drafted for the work group and WSLCB at that time concluded that “until we are better able to predict consumer responses to, and the health implications of a THC tax, any change in the tax structure would require embracing large known costs and additional unknown costs in exchange for unknown benefits.”
  • In January 2020, Representative Lauren Davis introduced HB 2546, “Concerning the potency of marijuana products,” at a public hearing in the Washington State House Commerce and Gaming Committee (WA House COG) where most attendees present from the cannabis sector were opposed. While that bill wasn’t advanced, an operating budget proviso by state legislators mandated the creation of “Frameworks for Future Cannabis Research.”
  • The next step in suggesting regulations on cannabis concentrations was a “consensus statement” responding to concerns raised by the potency tax work group study and report which was written by the the Washington State Health Care Authority (WA HCA) Prevention Research Subcommittee with members from UW and Washington State University (WSU) “as well as others,” and chaired by Carlini.
    • In December 2020, following the release of the statement, UW and WSU leaders briefed prevention advocates on existing research around health risks related to cannabis dosage that stated “THC content of cannabis products contributes to adverse health effects in a dose-response manner. This increased risk imposed from using higher potency cannabis products is particularly concerning for young users and those with certain pre-existing mental health conditions.” 
    • In 2021, Davis cited the statement when arguing in support of her revised legislation addressing “serious mental health consequences of high-potency cannabis products by regulating the sale of cannabis concentrates.” Carlini testified in favor, emphasizing she spoke in her personal capacity and not on behalf of UW ADAI. That year lawmakers provided $100,000 to the UW Center for Cannabis Research (UW CCR) and WSU to develop research frameworks on “measuring and assessing impairment due to cannabis use” and any “Correlation between age of use, dosage of use, and appearance of occurrence of cannabis induced psychosis.”
  • On March 31st, Governor Jay Inslee signed a supplemental budget increase for UW “going from $263,000 to $325,000 for [Fiscal Year] 2023.”
    • Aside from the money budgeted for the academic institutions to develop research frameworks, UW money for “education materials regarding health and safety risks posed by marijuana use” was increased by 25% to $25,000 under the 2022 supplemental budget.
  • UW ADAI leaders organized the symposium as a way to collect additional research perspectives related to the frameworks budgeted for by lawmakers, with Carlini serving as the symposium Program Chair.
    • Carlini was a panelist at the WSLCB deliberative dialogue on cannabis impairment on June 21st.
    • During the symposium, Gillian Schauer, a UW Researcher and the Cannabis Regulators Association (CANNRA) Executive Director, distinguished between cannabinoid “potency” and “concentration.” She called the latter term a “better marker of what we’re talking about” since, “for me, ‘potency’ means how much of a product do you need to achieve a certain effect,” compared to ‘concentration,’ which indicated “how much THC is in the product.”
      • A 2001 lesson plan for a course at the UW School of Pharmacy on “Understanding expressions of drug amounts” compared concepts of drug ‘potency’ and ‘strength’ in this way: “Potency refers to the relative strengths of medications that can produce the same effect. The drug with the lowest strength to produce the effect is said to be the most potent. Strength is often used interchangeably with potency, but they are not the same thing. Potency starts with the effect and examines the relative strengths of different drugs able to produce that effect, while the word ‘strength’ itself does not imply anything about effect.”

• Chair of UW Psychiatry and Behavioral Sciences Jürgen Unützer welcomed attendees and talked about UW ADAI members working “at the forefront” of cannabis research (audio - 2m, video). 
  • Declaring cannabinoid concentration to be "an area that's really, really rapidly evolving,” Unützer argued that Washington state was “really at the forefront of efforts to regulate cannabis, and to regulate the use of cannabis.” For this reason, UW “has to be at the forefront of the knowledge that we have within this area,” he said. 
  • Unützer told attendees that UW ADAI researchers and guests would speak to “the short-term and long-term risks, how do we prevent them, how do we mitigate them.” He found the topic to be one where “there is a lot more heat than there is light,” but fiery rhetoric was less helpful than illuminating data “and that’s really, what I think our experts at ADAI do very, very well.” Encouraging those present to think “about what do we really know about this area,” Unützer wished everyone a “wonderful, productive day.”
  • In September 2019, Unützer called for doubling the number of mental health service providers in the state.

• UW ADAI Director Susan Ferguson remarked on changes in cannabis research due to legalization policies and shifting demographics of cannabis consumers before warning that products with medical utility shouldn’t be perceived as “harmless” (audio - 5m, video).
  • Ferguson briefed lawmakers about cannabis-related research in September 2020, and on health risks correlated with THC concentrates in November 2021.
  • Enthusiastic about the hybrid in-person and virtual event, Ferguson looked forward to the opportunity to “engage with a very broad audience.” Stating the core mission of UW ADAI leaders was to “reduce the harms of drug use and addiction” by research, outreach, “training, and implementation” activites, she saw an “ongoing, changing landscape” around cannabis consumption following legalization in Washington state and elsewhere starting in 2012. Compared to cannabis prohibition, the challenges she noted with legalization related to the “public perception and stigma" since “when a drug becomes legal, it's often associated with being harmless and we tend to see a normalization of use” by populations not previously associated with cannabis use
  • A “great thing about” cannabis, according to Ferguson, was the varied medical applications. She then mentioned how epilepsy, multiple sclerosis, “nausea and vomiting that is associated with cancer treatments,” appetite loss related to wasting conditions, and “some forms of chronic pain can be treated with cannabis and cannabinoids.” Ferguson further believed there would be “positive implications when we think about opioids and the opioid crisis.” However, she found it “very normal for people to assume that if it’s useful medically, then it must also not be harmful recreationally,” and wanted “balancing” of that impression.
  • Lauding the information made available by UW ADAI, Ferguson said it informed the public through “an evidence-based approach.” She noted the 2021 budget proviso giving money for them to partner with WA HCA “to develop recommendations for state policies related to cannabis concentration and mitigating the detrimental health impacts of this.” Ferguson remarked that the symposium was developed with the UW ADAI CERP led by Carlini to gain knowledge from “perspectives of experts in the fields of public health and policy.” She was thankful for the tax dollars to “rapidly address these timely issues,” as well as the expertise Carlini had around “cannabis use and its potential harms.”
  • Sharon Garrett, UW ADAI Project Director, subsequently went over event logistics before highlighting that “our focus today is on high-THC products sold for non-medical use…in the market that's regulated by" WSLCB. She added that "patients and providers are making their own medical decisions and that’s not within the purview of what we’re talking about" (audio - 2m, video) 
    • While the Washington State Department of Health (DOH) had a distinct classification for medically compliant cannabis products for use by patients, in practice, the medical and adult use markets which were merged by lawmakers in 2015 resulted in the I-502 market being among the only options for patients to purchase cannabis items. 
      • During an August 2021 review of medical cannabis tax preferences by the Washington State Citizen Commission for Performance Measurement of Tax Preferences, staff revealed that for fiscal year 2020 “less than 1% of beneficiary savings for this preference were for purchases identified as DOH compliant product." During a public hearing on the review the following month, one patient alleged an absence of compliant products on the legal market “continues to be a significant problem” and had for years “been cited among patients as the most significant problem in the current system.” That patient also gave critical testimony during a DOH hearing on medical cannabis consultant certifications on February 22nd, claiming a significant number of consultants in endorsed stores were unable to identify medically compliant items.
        • Read a policy statement on “compliant medical products” released by DOH staff in October 2021 subsequent to a WA House COG briefing.
        • Learn more from the Tax Preference Preliminary Report by the commission, as well as the Chair’s Draft Combined Comment form with the group’s October 2021 recommendation to maintain medical cannabis tax preferences.

• Beatriz Carlini, UW ADAI Research Scientist, Cannabis Education and Research Program (CERP) Director, and Program Chair of the symposium, characterized the state’s history of cannabis reforms as experimenting and learning from mistakes (audio - 7m, video). 
  • Carlini seconded Unützer’s assessment that Washington was "at the forefront of progressive policies and responsible policies" due to I-502 and a medical cannabis law passed by voters in 1998. She was “proud” that other officials and experts were looking to the state as “a little bit like the big brother that makes all the mistakes” for other jurisdictions to learn from. Despite whatever mistakes the state made, “we are also good at trying to correct them.” Her example of this was what was being done “for correcting the injustice in terms of equity on the access for cannabis industries and business that didn’t allow for people that were already penalized by the war on drugs to have access” and profit from the cannabis industry.
  • Carlini was among those in the public health field who hadn’t expected THC products would “become more and more and more concentrated and potent” and wanted such items be “attended to” in state law and rule. She insisted that public health interests hadn’t considered this possibility when I-502 was being proposed, suggesting that “now we see from the flower that we are more and more moving into a market that [is] composed by very high, manufactured products with THC going to [60 to 90]%. And we’re trying to correct that, too.” 
    • While concentrates like hashish had existed for centuries, increases in THC concentrations had been a long standing objection to cannabis legalization noted in research literature as far back as Marijuana Research Findings 1980, which noted cannabis was “often in much higher potency than it was 10 or even 5 years ago.” 2012 reporting on data from the U.S. Drug Enforcement Administration (DEA) showed hash oil concentrates containing “80 percent to 90 percent” THC before states legalized production.
    • Many types of concentrates were common as retail stores opened in Washington. Local law enforcement and federal agencies partnered to produce a brochure on the products in December 2014, five months after the beginning of adult use cannabis sales.
    • A 2016 NW HIDTA report compared ‘Hash oil’ concentrations on a national level to the state’s legal market, finding “average THC percentage for useable marijuana based on national samples was 55.45%, as compared to the Seattle store’s average of 72.76%” which included concentrates with “peak levels between 84.6% and 90.8%.” That report identified a trend of increasing cannabis concentration that predated legal cannabis markets by decades.
    • Among the supporters of I-502 in 2012 was UW Professor Emeritus of Social Work Roger Roffman, who offered a public health view of youth messaging on cannabis legalization, even when he was criticized for acknowledging that cannabis wasn’t “harmless.”
      • Roffman was also the author of Marijuana Nation.
  • Carlini called attention to virtual and in-person attendees from WSLCB, WA HCA, elected members and staff of the state legislature, WSU, representatives of local governments and tribal associations, in addition to members of the Cannabis Alliance and “many other owners of stores, processing firms, and so what."