UW ADAI - Symposium - 2022 - Exploring Solutions - Addressing the Risks of High THC Cannabis Products
(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:

• Washington State Liquor and Cannabis Board (WSLCB) Board Member Jim Vollendroff introduced Bia Carlini, a UW ADAI Research Scientist heading up the Cannabis Education and Research Program (CERP) who was also the Program Chair for the symposium (audio - 1m, video).
  • Vollendroff, who came to the board from the behavioral health field, commented that he’d been introduced to Carlini by Representative Lauren Davis and had become "a big fan.” Having seen Carlini be “instrumental in bringing us together and organizing today's event,” Vollendroff acknowledged how Carlini had “been dedicated to understanding the public health impact of…legal psychoactive substances, use, and policies on social and health outcomes.”
    • Davis offered remarks with other legislators earlier during the symposium. She was among the signatories to a January 19th letter to Governor Jay Inslee supporting Vollendroff's appointment to the WSLCB board, which specifically cited his “lived experience as a person in recovery from both mental health and substance use challenges and as a biracial member of the LGBTQ community.”

• Carlini gave a presentation on “How to Address High THC [tetrahydrocannabinol] Cannabis Products’ Risks and Harms: Perspectives of Washington Stakeholders,” sharing survey results of respondents who proposed, and later ranked, policy options for the products (audio - 22m, video, presentation).
  • Carlini focused her remarks on “what Washington stakeholders think about all that that we talked about today.” Through a 2021 budget proviso, she noted legislators appropriated $500,000 to the Washington State Health Care Authority (WA HCA) for UW ADAI“...to develop policy solutions in response to the public health challenges of high tetrahydrocannabinol potency cannabis.” With a final report due by the end of 2022, she said they’d been looking into “what kind of policy works, and in several areas that had similar challenges” and “what local stakeholders think about this issue.” Carlini stated it was “obvious” to many researchers, but she wanted to be clear that “the brightest ideas cannot be implemented, or not be sustainable, if you don't involve stakeholders and hear where they sit on all the ideas.”
    • WA HCA officials were given responsibility for submitting two reports to “the office of financial management and the appropriate committees of the legislature.”
      • An initial report was submitted in December 2021 to “summarize progress made to date, preliminary policy recommendations, and next steps.” Carlini gave an update to members of the Washington State House Commerce and Gaming Committee (WA House COG) on the initial report in November 2021.
      • A final report “must be submitted by December 31, 2022, and shall summarize the analysis conducted by the institute, the process and stakeholders involved, an inventory of relevant cannabis policies in other states, and recommendations for policy changes to reduce the negative impacts of high potency cannabis in Washington state.”
  • In order to arrange the survey, Carlini had found some stakeholders through existing lists, given “30 years of work, ADAI had collected a lot of emails from important stakeholders from all different perspectives” including at WSLCB and the WA HCA Division of Behavioral Health and Recovery (DBHR). Additionally, she said UW ADAI researchers “reach[ed] out to the cannabis industry through journals and associations, and also selected social media.” Through these networks, “we got the main stakeholders we were looking for” who were then divided up into three groups:
    • Communities: “Prevention, social justice and youth-centered organizations, parents, educators and youth”
    • Professionals: “Health care providers, law enforcement, government agencies, researchers”
    • Cannabis Advocates: “Workers, representatives, press, consumers”
  • “We had the two round of questions to the stakeholders in our study,” explained Carlini, who said the first round had stakeholders “come with ideas…How can our laws about high THC cannabis products be strengthened in Washington state to decrease risk to consumers?” This round of questions encouraged a wide range of responses and didn’t require participants to justify them with data, Carlini described, evoking 302 ideas from respondents, caveating that “a lot of them were repeats.” This “brainstorm phase was open for about three weeks” online, she added.
  • Working with Polygon, Inc on the concept mapping methodology, Carlini said the company “consolidate[d] the repeats…and the redundancy to avoid bias” before UW ADAI officials picked “46 unique policy ideas” for a second round of surveying. Respondents were shown the ideas and asked to group them however they liked, she stated, then they were asked to rank whether each idea was “impactful or not on addressing the issue at hand, and second if they were approved” how feasible would successful implementation of each idea be.
    • She typified this as concept mapping, “a way to capture collective thinking to find policy solutions,” indicating it had been employed for “urban development decisions and healthcare services.” Carlini argued this system was “equitable” and could be an approach that didn’t have “a high error key to show when they are participating.” The process kept participants anonymous, she mentioned, observing that it was “very exciting for us to apply” concept mapping to drug policies.
  • In total, she told attendees 109 individuals participated in the first round of surveys, and 160 participants in the second round, with no way for researchers to know how many were repeat respondents. “It's not common to have this amount of participation when you are trying to get people involved on making decisions on policy and giving their opinion,” Carlini suggested, gauging it “a very successful amount of participation for this kind of process.”
    • Carlini acknowledged that participants identifying as a member of the Cannabis Advocate cohort had the lowest participation level in the survey at 23%, but she still felt all three of the groups “participated well in the two phases of our study.”
  • Carlini claimed responses were geographically diverse as well, though most survey participants were from “the most populous areas, yes, had more participation…probably proportional with the demographic distribution.”
    • Carlini’s presentation identified 6 of the 29 counties in Washington. Below is the percentage of Washingtonians residing in that county at time of publication according to federal census data, along with the proportion of survey respondents from that county:
      • King County: 29.1% of population, 23% of respondents
      • Pierce County: 11.9% of population, 4% of respondents
      • Snohomish County: 10.7% of population, 3% of respondents
      • Thurston County: 3.8% of population, 16% of respondents
      • Spokane County: 7% of population, 6% of respondents
      • Whitman County: 0.6% of population, 8% of respondents
  • Carlini then reviewed self-reported demographics of respondents:
    • Round 1 - Solicitation of policy ideas
      • 41% racial/ethnic minorities
      • 54% Female
      • 45% between 21-44 years
    • Round 2 - Ranking of selected ideas
      • 36% racial/ethnic minorities
      • 54% Female
      • 54% between 21-44 years
    • Census estimates from July 2021 for Washington state indicated that 36.2% of the population identified as a racial group other than White, and 49.6% identified as female.
  • Participants were asked to rank their level of concern over “high levels of THC,” Carlini elaborated, with the average ranking of 3.8 out of 5, which she called “pretty high.” The subjective measure of perceived risk could have ranked higher, she explained, but “cannabis consumers themselves have a pretty moderate concern…around 2.8 and the industry was around 1.4.”
    • In the interest of full disclosure, both Cannabis Observer Founder Gregory Foster and I were participants in this survey. Both of our responses were logged as Cannabis Advocates, though several roles in multiple groups felt applicable to me. Carlini reached out and Cannabis Observer provided assistance recruiting survey participants from the cannabis sector as well as patients and consumers.
  • When it came to ranking the 46 ideas that were proposed, Carlini told attendees “there were seven policy areas that they divided in big buckets” and respondents were asked to rate the “feasibility and impact” of risks associated with high concentration products. She described the policy areas as:
    • Empower consumer/public with information
    • Taxation
    • Advertising Restrictions
    • Product and purchase caps
    • Ban High-THC Products
    • Licensing
    • Age Restrictions
    • Do Nothing, for those who thought “things are good as they are.” 
  • Preferred policy solutions landed in a “go zone” described by Carlini as ideas rated as both “feasible and impactful” by most stakeholders. There were lower priority ideas considered feasible but of low impact, she commented, as well as ideas stakeholders deemed “very impactful…but very difficult to implement.” Additionally, some policy ideas had “no importance…or feasibility,” Carlini remarked. Next, using a “mixed method approach,” she said survey data on policy ideas was “plotted” based on the “average impact or feasibility score.” Carlini laid out how the most supportive responses covered four policy areas:
    • Empower consumer/public with information was “firmly in the go zone…and this was supported by all the three groups pretty much equally.” This included ideas like “place public health message at point of sale,” doing “research to determine” proper label readability, or having “warning labels that’s specific to high potency products.” Opinions were slightly less unanimous around “posting store warning about high THC products. And the idea of ‘a dab will do’ would be the education that was like, maintain things as they are, but just teach moderation,” an approach that “community/professionals were not that jazzed about…and put it outside” the go zone even though most stakeholders endorsed it.
    • Three advertising restrictions reached the go zone, Carlini explained, “probably for a very easy reason to understand, because it's already in force” in state law. However, she noted, “‘eliminate all advertising of high THC products’ was also in the go zone when you see all the stakeholders together.”
    • Product and purchase cap policy ideas were “mostly situated on the no go zone or discard zone.” But three ideas were in “the consider zone” which many stakeholders “considered impactful, but just wonder[ed] about the feasibility” of enacting them:
      • “Cap THC by product category”
        • “Professionals were definitely more excited and moved to the go zone capping THC products by category,” Carlini added. 
      • “Cap THC concentration at 10% total”
      • “Limit serving size to five milligrams in all products or limiting to 10 milligrams”
    • The only taxation idea with general stakeholder support: “increased taxes on products with more than 35% THC.” Increases for “products thought to be harmful” or on “total THC by weight” had lower, but significant respondent support. Support varied, with cannabis industry representatives and consumers placing taxation ideas “in the remove option,” whereas professionals ”put it on the go zone.” Cannabis industry respondents did favor decreased taxes for products with cannabidiol (CBD) added.
    • Doing nothing was widely perceived to be feasible but have little impact, which evoked some laughs among the audience.
  • Carlini promised the report to the legislature would include additional commentary, but she interpreted her results as “good news from those that are rallying for population health in Washington state: stakeholders are concerned with high THC products for non-medical use, and they support policy changes.” Some policy ideas stakeholders supported “are in fact backed by science and research,” she stated, with general respondent support for “adding health warning labels and making the labels readable,” advertising bans “specifically for this products, and a tax increase proportional to THC content or concentration for non-medical use.” Carlini insisted other ideas were supported by science, but not stakeholder opinion, which she felt spoke to “the importance of doing more consumer and public education…on this matter.”
  • Thanking participants and those who’d helped conduct the survey and analyze the results, Carlini specified her gratitude to:
    • Jacob Delbridge, Washington State Department of Health (DOH) Policy, Systems, and Environmental Changes Coordinator
    • Kevin Haggerty, Former Director of the UW Social Development Research Group 
    • Gillian Schauer, UW Researcher and Cannabis Regulators Association (CANNRA) Executive Director
    • Michael McDonnell, UW Elson S. Floyd College of Medicine Professor of Community and Behavioral Health
    • Megan Moore, Washington State Public Health Association (WSPHA) Board Member and Co-Chair of the Policy Committee and Kitsap Public Health District Community Liaison
    • Caislin Firth, UW ADAI Research Scientist 

• Attendees asked how the feasibility of policy alternatives was framed and inquired about researcher outreach to the cannabis industry.
  • Moderator Marina Epstein asked Carlini to explain how feasibility was phrased for respondents (audio - 1m, video).
    • She answered that “We clearly asked them to not consider political feasibility” and assume if an idea was “approved by political process, do you think it's feasible to implement.” But, “whether or not people took that at heart” was a “different issue. We could notice that a lot of the comments there were about considerations of the political feasibility,” Carlini reported.
  • A question was raised virtually about outreach “being made by UW to collaborate or partner or at least have conversations with the industry on conducting some of the research that is missing” (audio - 4m, video).
    • Carlini agreed there were opportunities “to research and there are many things missing” but UW was bound by “federal laws, of collaboration…of doing research” and this was “mostly the challenge” of conducting some studies. “We cannot touch, research-wise, the products that they offer in the market,” she told attendees, praising the “creative” workaround offered by symposium speaker Carrie Cuttler, a Washington State University (WSU) Assistant Professor of Psychology, who had her survey participants purchase specific cannabis product types on their own. Carlini recognized University of Washington Center for Cannabis Research (UW CCR) Director Nephi Stella, who researched the “medicinal side and work with the substance provided by the University of Mississippi. That is the DEA [U.S. Drug Enforcement Agency]-approved the material. But for studying the impact of the products that are out there, we are pretty limited.” She talked about working with industry representatives on “exchanging ideas, on disseminating [research], and opening doors.”
      • Check out an April 4th UW CCR presentation on cannabis by Stella.
    • Considering cannabis industry members to be among “my dear esteemed colleagues, and even friends, we do sit on different sides of the interest.” She viewed industry stakeholders as “mak[ing] their living, they have interest on profiting on the products that I'm most concerned about.” Nonetheless, she wasn’t “a person that is on reefer madness, or them as people that don't have preschool” aged children, “but we are definitely sitting in different sides so our questions may differ as well. I invite the industry to do the research to prove their products are safe for consumption.” It was “complicated for us to have to prove that [high concentration cannabis products] are not safe and be questioned all the time in terms of our methodology, or a lack of certainty” which she found was inherent in “doing science.” Carlini stated that “it takes 40 years to be certain of something, and we may change our certain[ty] in the next day. Because we don't have, really, any skin in the game. We are open to the truth as the truth evolves.”
      • U.S. Senate bill S.253, the Medical Marijuana and Cannabidiol Research Expansion Act, was passed by Congress November 16th, and at time of publication reported as on track to be signed into law by President Joe Biden.
        • An October 2022 research article, “The cannabidiol and marijuana research expansion act: Promotion of scientific knowledge to prevent a national health crisis” analyzed implications of the law.
      • WA HCA officials and UW ADAI researchers may not have conflicts of interest around specific outcomes, but they are recipients of State cannabis revenue and may have complicated feelings about their responsibility to influence how cannabis is perceived by the public.
      • As well, the report authors have been beneficiaries of a trend of federal research funding being prioritized to identify cannabis harms and negative outcomes. Validation of cannabis prohibition views and bias in research funding has been articulated by cannabis advocates, the media, and researchers themselves:
        • Federal spending on medical marijuana research is pathetic (2015)
        • The Federal Government's Failure to Support Sound Medical Cannabis Research
        • Why we don’t know much about pot (2019)
        • Cannabis research database shows how U.S. funding focuses on harms of the drug (2020)
        • Federal Obstruction of Medical Marijuana Research (2021)
        • After 50 Years, U.S. Opens The Door To More Cannabis Crops For Scientists (2021) 
        • Evidence in Context: High Risk of Bias in Medical Cannabis and Cannabinoid Clinical Trials Dictates the Need for Cautious Interpretation (2021)
        • Bias in Cannabis Research Focuses on Harmful Effects (2021)
    • Epstein noted there were also areas where “it's not just the industry, the consumers and the industry are very aligned, you know, especially in things like costs.” Carlini felt “they should be, but not as removed from concern as the industry is.”

• Cannabis Observer obtained a draft of the legislative report by Carlini and others which leveraged the survey results and offered legislators potential policy changes to further regulate high concentration cannabis items.
  • A November 1st draft of the legislatively mandated report was acquired via a public records request. At publication time, Cannabis Observer had not encountered more recent language for the report which remained due December 31st.
  • Here are selected excerpts from the draft executive summary:
    • “This report describes the recommendations for state policies based on the perspectives of WA stakeholders, research evidence on public policies designed to mitigate harms associated with non-medical use of high THC cannabis products and other legally commercialized health-compromising products, and cannabis policies that have been considered or adopted in North America…This report recommends a comprehensive package of policies aimed at: 
      • decreasing access to high THC products, 
      • preventing initiation of high THC products
      • empowering consumers and the public with information and education about high THC products.” 
    • “Notably, we are not recommending capping THC content at this time. Capping THC content to allow only low concentrations of THC is an evidence-based policy to be considered in the future, however it received low stakeholder support from all three groups involved in ADAI assessment. This is a policy option that could become more feasible as cannabis education and THC literacy increases in WA, THC testing accuracy improves in our state, and more is learned from caps in other states and provinces.”
  • The draft recommendations to legislators outlined what data researchers had reviewed, what other policies had been studied, and how stakeholder opinion had been incorporated along with International Cannabis Policy Study (ICPS) information.
    • The draft acknowledged that “tribal partners were invited to share their perspectives through a Dear Tribal Leader Letter distributed by WA HCA in January of 2022 and in a presentation at the January 2022 Monthly Tribal Meeting, and nine tribal organizations and indigenous groups were invited to participate in concept mapping. Participation in concept mapping is anonymous, but notably, no one chose “tribal partner” as a primary identity. Therefore, recommendations are based on WA state stakeholder perspectives and further consultations with tribes that may be impacted by changes to state policy should continue to be explored.”
    • “The recommendations made in this report refer solely to public health challenges derived from the availability of high THC non-medical products, recognizing that medical users have specific needs and work in partnership with their clinicians to make decisions that are appropriate to their health (and therefore are out of the scope of this report).”
      • The odds of patients being impacted by recommendations were elevated given the limited supply of medically compliant cannabis products and WSLCB uncertainty about the actual number of compliant endorsed retailers. Research has confirmed patients purchase significant amounts of high concentration products.
    • WSLCB Board members heard from University of Waterloo School of Public Health Sciences Professor and University Research Chair David Hammond about ICPS data related to Washington on November 8th.
  • Seven recommendations were made based on the areas Carlini indicated were generally popular with stakeholder groups.
    • “Decrease access to high THC products
      • Implement excise tax levels proportional to total THC content in products with greater than 35% THC concentration” 
        • The draft emphasized how this policy lacked support from cannabis advocates but inferred this “is consistent with the position of alcohol and tobacco producers who have a financial conflict of interest with such measure.”
        • The draft doesn’t distinguish the view of cannabis consumers on the issue who already pay the highest tax on cannabis of any legal state. Neither the survey ideas, nor draft report contemplated diminishing enthusiasm for high-THC products by lowering taxes on products containing less than 35% THC concentration.
        • Later analysis of whether excise taxes are inherently regressive and inequitable offered a justification that, “like cannabis, alcohol taxes constitute a minor proportion (i.e., 1%) of the tax burden for most people, including those with low incomes,” citing a 2010 study on “The Effectiveness of Tax Policy Interventions for Reducing Excessive Alcohol Consumption and Related Harms.”
        • Other research studies include:
          • Fiscal and Externality Rationales for Alcohol Taxes (2009)
          • Are Alcohol Taxation and Pricing Policies Regressive? Product-Level Effects of a Specific Tax and a Minimum Unit Price for Alcohol (2016)
          • Of Course Sin Taxes are Regressive (2021)
          • Marijuana Taxation: Theory and Practice (2021)
          • Who Pays Sin Taxes? Understanding the Overlapping Burdens of Corrective Taxes (2022)
    • “Prevent initiation of high THC products
      • Prohibit marketing and advertising of high THC products
      • Raise the legal age for high THC products’ purchase to 25 years old
    • Empower consumers and the public with information and education about high THC products
      • Add high THC-specific mandatory health warning labels (HWL)
      • Add standard THC serving unit and total servings to cannabis product labels
      • Require point-of-sale education about high THC products risks, labels, and dosing
      • Fund social media campaigns and public service announcements (PSAs) targeting people at elevated risk for experiencing high THC products negative effects”
  • Other “Evidence-based policies to be considered in the future”:
    • Cap THC concentration
    • Set purchase limits for THC content
    • Education in communities/schools about high THC products risk”
  • Additional recommendations:
    • “Sufficient funding is imperative
    • Patients should not be affected by policies to mitigate the harms of high THC products
    • Place regulation of hemp-derived consumable cannabinoids under WSLCB jurisdiction”
  • And the draft conclusion:
    • “As WA cannabis markets increase production and sales of high THC products, it is extremely likely the negative health effects associated with its use will also increase. WA stakeholders are concerned with non-medical use of high THC products and support policy changes. Now, while the market is relatively nascent, is the time to make course corrections that will protect the health of WA residents from unforeseen harm. Policies that empower consumers to make educated choices, that reduce access for people under 25, and that use taxation to incentivize use of products with lower THC concentration will lead the way in evidence-based cannabis policy that supports a balanced approached to cannabis legalization.”
  • Draft appendices linked included:
    • Appendix B: Assessment of existing high THC products’ policies, programs, and initiatives in North America
    • Appendix D: Stakeholder Groups 
    • Appendix E: Stakeholder Policy Ideas
    • Appendix F: Concept Mapping Methods & Results  
  • On November 29th, UW staff published a press release (“Report addresses mental health risks of high-THC cannabis”) drawing on an interview with Carlini about the impending report and her recollection of the history of I-502.
    • “​​Proponents of the law said people should be able to access cannabis to change their perception of reality and to treat medical conditions without stigma.”
      • As a volunteer organizer for I-502 in the early 2010s, I can’t remember a talking point centered on advocating for people’s right to change their perception of reality.
        • However, a 2015 ruling by the Supreme Court of Justice of the Nation in Mexico found that “prohibiting people from growing [cannabis] for personal consumption was unconstitutional as it violated the human right to the free development of one's personality.”
        • The related concept of “cognitive liberty” subsequently became more prominent in drug policy reform circles and other domains.
      • Also, the medical cannabis community was divided over the initiative as covered in the 2013 documentary, Evergreen: The Road to Legalization.
    • “Because these products lack labeling about a serving size, users can be unaware that they have consumed a chemically synthesized, mind-bending ‘hit’ equivalent to 190-proof alcohol.”
      • Within the regulated marketplace, synthesized cannabinoids were explicitly banned by the WSLCB in July 2021.
      • There are many methods for extracting and distilling compounds into more concentrated forms, some of which do not require the use of chemical solvents.
      • Though comparing impairment from alcohol and cannabis proved difficult for experts gathered by WSLCB in 2021 and 2022, the agency does permit 190-proof alcohol to be sold in Washington.
    • "The cannabis plant's raw flower material can have between 10 and 20% of THC concentration..."
      • The complex and diverse cannabis plant, inclusive of hemp cultivars, can have less than 0.3% THC upwards towards 30% THC by dry weight measurement.
      • Some researchers consider products with more than 10% THC to be “high-THC cannabis.”
  • On Friday December 2nd, WA House COG members planned to host a work session to hear an "Update on Cannabinoid Product Regulation and Enforcement and Summary of Research on High-THC Concentration Cannabis." In addition to a WSLCB panel, the agenda lists Carlini as the sole UW ADAI presenter.