UW ADAI - Webinar - Addressing the Risks of High THC Cannabis - The Public Health and Legislative Saga
(April 20, 2023)

Here are some observations from the Thursday April 20th University of Washington Addictions, Drug, and Alcohol Institute (UW ADAI) Webinar titled “Addressing the Risks of High THC Cannabis: The Public Health and Legislative Saga.”

My top 4 takeaways:

• UW ADAI Research Scientist and Cannabis Education and Research Program (CERP) Director Bia Carlini went over some of the background and early attempts to change regulations around cannabis products based on the group’s research into “high-potency” tetrahydrocannabinol (THC).
  • UW ADAI Researcher Sharon Garrett introduced the presenters and described the CERP as “a group of investigators and program staff who's come together to collaborate on research and dissemination activities in response to the emerging needs of the community in the context of legalized cannabis” (audio - 1m, video).
  • Carlini first said that her remarks and work were centered on adult-use cannabis, rather than medical cannabis patients, and “does not address issues related to medical use or hemp-derived THC.” She planned to talk about THC concentration “in the landscape of legalization and health risks” (audio - 6m, video, presentation).
    • THC levels “ha[d] become stronger, and stronger for a long time. It's been a while, and it's not necessarily directly related to legalization” as THC concentration had been increasing nationwide, Carlini explained. A more significant concern for her was the “process that existed before but became a very high operation when legalization came, so it was the fact that cannabis became…something different than a plant.” She noted newer forms of “highly manufactured cannabis that came after legalization” had begun to be “produced in big quantities,” naming “shatter, wax, crumble, butter” specifically. These products existed before legalization but “had a very small share in the market.” 2020 data suggested concentrates constituted “more than a third of the market in Washington,” she told the group.
      • The University of Waterloo International Cannabis Policy Study (ICPS) contracted with WSLCB to publish and analyze data on consumer trends, and School of Public Health Sciences Professor and Research Chair David Hammond told the board in November 2022, that the types of products sold in Washington had been “similar to what we've seen overall in the U.S.,” with “a little bit more of a decrease in dried flower.”
    • “And of course the question that started…coming up is ‘are these products riskier than cannabis flower?’” Carlini reported. She indicated there were multiple ways to demonstrate risks which were outlined in a 2020 “collective work” of the WA HCA Prevention Research Sub Committee. That consensus statement concluded, “the greater the potency of cannabis products, the greater the likelihood of adverse health effects,” she said, emphasizing “this impact is particularly concerning for young users and those with pre-existing mental health conditions” and would have “disproportionate impact [in] marginalized populations.” Carlini and the researchers saw an “urgent need for policy considerations” to reduce the impacts of cannabis use disorder (CUD), “developing psychotic disorders,” cannabis hyperemesis syndrome (CHS), and potential “acute episodes of anxiety and panic.”
    • Carlini’s remarks were similar to those she gave at a September 2022 UW ADAI symposium she chaired on “Exploring Solutions - Addressing the Risks of High THC Cannabis Products,” and those she made to lawmakers that December.
    • Though some concentrates have existed for centuries, only newer types have been refined enough to have over 80-90% THC. While not covered by the UW ADAI report, regulators and lawmakers had been increasingly concerned about cannabinoid content of hemp products which, unlike adult-use products, were available without age restrictions.
      • A request bill by the Washington State Liquor and Cannabis Board (WSLCB) strengthening THC regulation was approved on April 17th, and at time of publication awaited action by Governor Jay Inslee.
  • Turning to the legislative history, Carlini called it “reasonable to assume the [Washington State Legislature] would…attempt to regulate these products above and beyond the regular plant.” In looking at “four legislative attempts to regulate concentrates in Washington State…what I'm particularly gonna…focus on today is what have been their arguments against specific regulations and policies.” She took a moment to review the legislative process (audio - 2m, video).
    • Carlini stated the first attempt to alter concentrate regulations was in 2019 after WSLCB leaders were asked to establish a Potency Tax Work Group looking into “varying the marijuana excise tax rate based on product potency.” She acknowledged the resulting feasibility study from BOTEC Analysis which concluded the tax approach was “not feasible at this time.” A final report by the work group was drafted by then-WSLCB Researcher Trecia Ehrlich. Carlini counted herself among “work group members from the public health community” whom the report noted were “in favor of a tax structure that would discourage consumption of high potency cannabis.”
      • In December 2022, Carlini thanked Representative Shelley Kloba for securing the budget proviso that funded the work group.
    • Carlini remarked that beyond WSLCB staff and public health stakeholders, the work group was mostly “people involved in the business, cannabis producers, processor, retailers, laboratory operators, software vendors, also consumer groups and the Department of Revenue and [Washington State Department of] Ecology.” She’d wished BOTEC staff had “reversed the questions and try to see what would be the price of doing nothing,” but wasn’t surprised this group found “until we are better able to predict consumer response 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 known benefits.” Nonetheless, this was the “beginning of a process, and out of this first attempt nothing happened” (audio - 4m, video).
      • The list of task force members named at the group’s August 2019 meeting identified 26 individuals, 16 of whom represented either a state, local, or tribal government; a state university, or a substance prevention association, while eight worked for a cannabis licensee and/or trade association. Gregory Foster, Cannabis Observer Founder + Citizen Observer, was also part of the work group.
    • The first bill on the topic was introduced by Representative Lauren Davis in 2020, Carlini explained. HB 2546 would have restricted any cannabis with THC “greater than 10 percent” with ”medical reasons excluded.” Carlini summed up a plan for all concentrates and some cannabis flower to be capped “back to what cannabis was in 2015…three years after the voters approved the legalization of the plant” which she thought “seemed a very…reasonable request.” However, there was significant critical testimony in a public hearing on the bill, which “never left the committee” (audio - 1m, video).
      • The average THC concentration of cannabis flower in 2015 was 13.88% according to the federal data in Carlini’s presentation.
    • In 2021, HB 1463 was the next bill by Davis which Carlini described as being “a little more flexible since the flower is already at 20% [THC], let's try a new cap, and cap THC products at 30%.” She considered this to be another “very reasonable request…to the new reality of the stronger plants.” Again, the bill wasn’t advanced past an initial public hearing (audio - 1m, video). 

• Carlini picked out several themes from prior legislative testimony in hearings on capping THC content made by some cannabis sector opponents (audio - 3m, video).
  • “First argument was that…capping these products will be going back to prohibition,” Carlini said, displaying a slide containing quotes from Ramsey Doudar, Patients and Users for Reasonable Policy Founder, testifying against HB 1463 in 2021.
  • “Second [argument was] consumers w[ould] migrate to illegal market,” she said, featuring a quote from Yoko Miyashita, then-Leafly General Counsel (at time of publication, their CEO), speaking against HB 2546 in 2020.
    • Carlini said her team had spoken with health economists who argued “without prohibiting the whole product [it was] way more likely that people would migrate, as BOTEC analysis also point[ed] out, to products that are not capped…or taxed differently.”
  • Carlini framed a third argument, “youth education is the answer,” with comments from Lukas Hunter, Harmony Farms Director of Compliance and Government Affairs, offered during testimony about HB 1463.
  • Fourthly, “the science that’s being presented was not credible,” Carlini illustrated with responses from both Micah Sherman, Raven Co-Owner, and A.C. Braddock, then-Cannabis Alliance Vice President (at time of publication on their Board of Directors) and Eden Labs CEO, during testimony and a committee member question on HB 2546.
    • “The studies [Braddock and others were] mentioning [during the hearing] is one of the best studies ever done…a multicenter…case control study,” she indicated, evidence of “very clear increasing risk as you increase the potency and increase the frequency of use.”

• CERP staff went over the history of stakeholder outreach and concept mapping for a 2022 legislatively mandated report, and offered some new details about how responses were interpreted and categorized.
  • Another budget proviso in 2021 set aside $500,000 specifically for the Washington State Health Care Authority (WA HCA) to contract with UW ADAI “to develop policy solutions in response to the public health challenges of high tetrahydrocannabinol potency cannabis.” This funded the September 2022 symposium Carlini chaired, who additionally served as the lead organizer on the final report to lawmakers that she presented in December, speaking to a draft of the report.
    • Cannabis Observer published the draft report obtained via public records request ahead of the December presentation, which was picked up by Bloomberg News.
  • In the webinar, Carlini described the report as being about “what other stakeholders think” outside of the cannabis sector, which she felt had “been very vocal” in prior attempts. She argued the report she’d organized had “actually listen[ed] to all stakeholders in a very systematic way…to find areas of consensus” (audio - 2m, video).
  • Research Coordinator Lexi Nims talked about reviewing existing policies in North America, stakeholder interviews, and concept mapping, as well as reviewing “evidence-based practices within the research for cannabis, alcohol, tobacco, and unhealthy foods.” Nims spoke about mapping process benefits and stakeholder recruitment in ways similar to Carlini’s presentation at the symposium and with lawmakers at the end of 2022, albeit with some new details (audio - 7m, video):
    • Nims noted several outreach methods, and that participants were encouraged to pick a primary stakeholder role before being divided into “community, professionals, and cannabis advocates.”
    • “We encouraged people to provide at least three ideas, but people could provide as few or as many as they pleased,” she remarked, adding “stakeholders did an amazing job of generating ideas and we had 302 total” which were narrowed down to 46 concepts presented during “phase 2, the grouping and rating…open from May 11 through June 12, 2022.”
    • Respondents had an “optional question to provide open-ended responses to any implementation or equity barriers that they foresaw with any of the policies,” Nims said.
  • Garrett went over specific concepts and how stakeholder groups had rated them, covering areas previously addressed by Carlini, but with new specifics (audio - 11m, video).
    • Garrett highlighted how 97 stakeholders generated ideas, which were then rated and organized based on feasibility and impact by 149 respondents in phase 2, “It's very likely that many people participated in both phases, but because we did this anonymously,...we're not sure exactly how many were duplicates.”
    • She argued there had been “fairly good representation” across stakeholder groups and regions of the state, “participation was lower from cannabis advocates, then we'd hoped…we made some special efforts towards the end to try to reach this group” and ended up with “24% cannabis advocates, 36% professionals and 40% community. So, not too bad.” Garrett described “about a third” came from King, Pierce, and Thurston Counties, along with “good representation from Spokane County from Whitman County, Clark County and smaller representation, but a wide variety of other counties participated.”
    • When discussing organizing the 46 ideas that were mapped, Garrett reviewed the concept map structure: “We went through a process for keeping the best clusters [of policy] solutions, starting with four clusters, and we evaluated whether adding an additional cluster improved performance statistics, and more importantly did it improve the value for interpretation,” she told attendees, settling on “seven policy areas, plus do nothing.” A “go zone” with ideas deemed feasible and impactful indicated several policies in the following topics had some support from each stakeholder group, and a few ideas respondents felt were impactful, but not feasible:
    • “Do nothing” 
      • “Cannabis Advocates, however, felt that doing nothing was both feasible and impactful,” she mentioned, calling that “consistent with readings from industry indicating a low concern about high THC products.”
    • “Empower consumer / public with information”
      • “Education in schools and community centers” was the most highly rated idea “across all groups.”
      • “Ideas like ‘maintaining availability, but also teaching a dab will do’” was “a harm reduction thought that you still have these products available, but you do use consumer education to change how consumers use the products. Communities and professionals tended to rate that particular item lower, it fell out of the go zone for them…probably because it started with ‘maintain availability,’ and those two stakeholder groups tended to be more supportive of policies that limited availability.”
    • “Advertising Restrictions”
      • Several of these topics were in the go zone, though “restricting where advertising of high product is allowed” was the only idea showing cannabis advocate support.
    • “Taxation”
      • “Tax based on total THC by weight…was close to the go zone and there's a lot of discussion between whether to tax on concentration versus weight,” as Garrett understood the “concern being that if it's concentration in an effort to try to be below whatever the cutoff is, producers will need to add a bunch of other stuff into their products and what they add could potentially be harmful, too.”
      • Garrett pointed out that cannabis advocate and professional groups disagreed on the impactfulness and feasibility of this topic, with advocates only backing “reducing taxes on items products that had high levels” of cannabidiol (CBD), which “potentially could reduce some of the harmful effects.”
    • Garrett relayed that their interpretation of structured input from at most 246 people was that “most stakeholders in Washington are concerned about high THC products, and they support policy changes.” She mentioned research supporting restrictions on advertising and required warning labels for tobacco products.
    • “Our mandate was to identify areas of common ground and consensus, among stakeholders and this wasn't quite achieved” as cannabis advocates and consumers remained supportive of “the status quo with the exception of…empowering people with information.”
  • Carlini next talked about efforts to turn those UW ADAI report recommendations into law, ideas which had stakeholder backing “with the exception of the industry.” Davis again sponsored legislation based on the report, HB 1641, "Addressing public health challenges of high-potency cannabis products," which also featured language “increasing purchase of these specific products to age 25, which was not supported by all stakeholders, but supported by professionals only.” The bill was granted a public hearing by the Washington State House Regulated Substances and Gaming Committee (WA House RSG on February 2nd (audio - 6m, video).
    • Although HB 1641 "almost immediately leveraged" their recommendations, she reported how "the result was the same” and WA House RSG members decided against moving the bill. Carlini said of the opposition to the measure that, “except for the taxes, all other parts of…this comprehensive package was ignored,” without mention of “even the education” component.
    • She shared more comments by Hunter in his opposition to HB 1641 which she labeled as an example of how opponents "Misinterpret science,” taking issue with a research paper cited that didn’t find significant evidence of a difference between “State Cannabis Legalization and Psychosis-Related Health Care Utilization” based on U.S. “Commercial and Medicare Advantage claims data” between 2003 to 2017. Carlini stressed that this report didn’t study cannabis consumers, was based on “ecological design,” and it “wasn't the purpose to address cannabis use.” Nevertheless, she called attention to the finding that in “exploratory secondary analyses, rates of psychosis-related diagnoses increased significantly among men, people aged 55 to 64 years, and Asian beneficiaries in states with recreational policies compared with no policy.”
    • Another tactic deployed against the bills she framed as “point responsibility to someone else” which she decorated with a quote on HB 1641 from comments by Ezra Eickmeyer, Producers Northwest Executive Director. Carlini stated “of course, education and prevention matters, but it is not by far the only thing…and not the most important thing” to impact use of cannabis concentrates.
  • Carlini felt regulations and taxation levels were too similar between concentrates and cannabis flower, though she recognized that possession limits were seven grams, or one quarter the limit for flower. She translated this amount to “350 doses” based on “​​mimicking the ten milligram…serving size of a edible.” Carlini compared cannabis industry representatives with the alcohol sector, where studies had shown leaders making questionable and unsubstantiated claims to government officials (audio - 2m, video).

• Various questions were posed to Carlini around next steps for policymaking to limit prospective public health impacts attributed to THC compounds, such as having future legislation heard by a different committee, and participants sought specific advice for parents, healthcare providers, and expectant mothers.
  • Asked why researchers weren’t pushing for more caps on THC products, Carlini said “nobody's proposing [caps] at this point” partly since “I don't think there was a cap being proposed by [WSLCB] on alcohol.” However, she noted State alcohol taxation was higher for liquor (audio - 1m, video).
  • Carlini didn’t have a new strategy for advancing legislation on the topic, pointing out “that's the way public health works…it takes a long time to put a dent” in some issues. “If you look at Tobacco 21” which was “relatively recently approved in our state,” she believed it had taken about five years for passage, whereas advocates concerned about THC had devoted “three years, four attempts.” Carlini insisted that, even after backing several bills in her personal capacity, “we are scientists; we don't do bills but we want to support public health-backed science and we'll continue to do that” (audio - 1m, video).
    • Carlini didn’t mention that the 2023 operating budget included another $500,000 for UW ADAI staff to “continue cannabis and public health impact research,” specifically to create “resources regarding the connection between first episode psychosis and cannabis use.” The proviso had been included in the first version of the House operating budget published on March 26th, the House striking amendment to the Senate version of the operating budget on April 4th, and the conference committee version of the operating budget published two days subsequent to this event which was passed by the Legislature on April 23rd.
  • Lora Jasman, a “physician in Spokane, that treats addiction,” asked whether the lawmakers hearing the bills held “a conflict of interest,” as she assumed “the opinions of the committee would kind of match the opinions of the group that were surveyed if the committee was…open to all comers.” Carlini recognized that WA House RSG was formerly the Washington State House Commerce and Gaming Committee, alleging “among legislators that are in the public health domain, there is a strong movement to try to move cannabis out of a committee that is originally concerned with commerce towards health, and that would probably give a different flavor on how this bill would have fared.” She wanted a situation where “all the elected state representatives could look at our arguments and vote against, or in favor,” yet the committee overseeing the adult-use cannabis market “has been a very major barrier” (audio - 3m, video).
  • When questioned on whether the State promoted warnings about consuming cannabis products while pregnant, Carlini answered that there was a package “warning for…all cannabis products about using during pregnancy” (audio - 1m, video).
    • WSLCB also required retail signage warning about consumption while pregnant.
  • Jennifer Mackender, Colorado Consortium for Prescription Drug Abuse Prevention External Relations Strategist, wanted to know about advice for parents on high-concentration cannabis items. Carlini replied “they are not very different from” what was in the UW ADAI report, and argued “the issue is less about the parents” and more about the “availability, the price, and the regulation of what is out there.” Parental communication was “extremely important,” she added, but still had “very limited…power” compared with the “suite of prevention and policy methods that is going to make a dent.” Speaking as a parent, Garrett perceived a “burden” of having to be responsible for conversations with youth was lessened “when the risks aren't as readily available in the environment” (audio - 2m, video).
  • A final question about the role of healthcare providers in educating patients was called “extremely important” by Carlini, who commented such an “encounter with a health provider is a less frequent than we would like, and…a lot of people don't have insurance, and don't see health care providers, particularly young adults and males…and they are the most vulnerable, and the highest percentage of users of this product.” She wanted to keep educating medical professionals and raise awareness about the topic. Garrett summed up that “there's also a lot of research that shows the kids do listen to their parents, even if they don't seem like that's what they're doing.” Carlini still found this a “very limited approach from a society perspective” (audio - 2m, video).