WA House COG - Committee Meeting
(December 2, 2022) - UW ADAI Work Session

UW ADAI - Presentation - High THC Cannabis Policy Solutions and Stakeholder Survey
[ Event Details ]

Informed by a small survey of stakeholders, a researcher producing a legislative report recommended officials reduce the availability and use of high-concentration cannabis products.

Here are some observations from the Friday December 2nd Washington State House Commerce and Gaming Committee (WA House COG) Committee Meeting.

My top 3 takeaways:

  • University of Washington Addictions, Drug, and Alcohol Institute (UW ADAI) Research Scientist Bia Carlini, leader of the Cannabis Education and Research Program (CERP), reviewed the history of the report and health risks associated with highly concentrated cannabinoid products before members asked about consumer self-titration.
    • First, Carlini made clear that “what we are presenting here is not related to cannabis as a medicine. We strongly believe that cannabis as a medicine is a matter that should be decided by individuals and their health care providers. And also, it does not include unregulated products which had been discussed by” Washington State Liquor and Cannabis Board (WSLCB) representatives before her remarks. Her study of high-concentration tetrahydrocannabinol (THC) products had “been focusing on this product both in terms of the health risk and also what Washington's stakeholders think about products that contain very high concentration of THC” (audio - 2m, video, presentation).
    • Regarding health implications, Carlini noted the consensus statement involved 11 researchers including herself who looked at “research evidence around cannabis concentration,” finding the “greater the potency of cannabis products, the greater the likelihood of adverse health effects…we tried to give examples” throughout the document of “why that is” (audio - 3m, video):
      • “Are high THC products more likely to cause…cannabis use disorder?…We conclude that, yes more THC you have in a product more likely you have the chances of individuals having a really hard time living without consuming on a regular basis the cannabis products…despite of consequences on their family lives, social life, professional life, and…their own health.”
      • “We also look at evidence around who are the people that consume high THC products, we were particularly concerned with inequality and disparities on this matter. And in Washington State we could see that young adults…from 21 to 24, 25, before their brains are completely developed” as well as “people who report mental health challenges and did not have the chance to have higher schooling, and have a lower income, were more likely to consume this high THC products.”
      • “We also were very curious about people being able to adjust their own dose. Should we really be concerned? I mean people may use a very strong product but just titrate, or regulate, and use less, and we could see that the evidence is it depends a lot. Right now, we have very reasonable research showing that healthy people and regular consumers are in fact able to control and regulate their own dose, healthy people mean both mentally and physically, so the researcher is available to show that initially, but there is no data showing that people that struggle with mental health conditions or physical disabilities can do that.”
      • Chair Shelley Kloba asked Carlini if that meant adults could consume less of a high-concentration product, and “might consume less of it than if [they] had a lower THC concentrated product…Sort of adjusting so that I get to the mental state that I'm looking for.” Carlini stated this was “possible if the person [was] healthy, physically and mentally, and if they are already regular consumers.” She stressed it was “not the case from the general population of consumers…and this is initial data that has been documented by Dr. Carrie Cuttler…so [it] is not to be generalized by all consumers.” Carlini further observed that it was “hard to guide policy based on this assumption because this assumption is only possible for a particular set, minority set of consumers” (audio - 1m, video).
      • Representative-elect Chris Stearns wondered "how many people are able to” self-titrate their cannabis consumption. Carlini believed a “very, very small amount of people can do that…around ten or 20%, maybe, of consumers are able to do that because they have been using cannabis regularly.” She additionally noted, during “research…you screen out any people that have issues of mental health and physical disability. So, for these people, which is a tiny amount of people, they can adjust. So for all purposes, to think about policies…this small portion of people it's hard to generalize for, you know, everybody” (audio - 1m, video).
    • Carlini indicated that researchers had also looked at whether “THC potency associated, or related to, the onset of psychotic disorders such as schizophrenia.”Their data indicated the “higher the intake of THC…the more likely that people would develop a psychotic disorder,” she commented (audio - 3m, video).
      • Carlini thanked Kloba for being among legislators attending the UW symposium, highlighting a presentation on "Cannabis Use and Psychiatric Comorbidity: Epidemiology and Association with High-Potency Cannabis Products" by Deborah Hasin of Columbia University. Hasin found that “as you increase the potency of cannabis and the frequency of use you have a very important increase on the risk of developing psychosis,” as well as higher odds of relapse if a consumer “had one episode but not fully developed psychosis,” as well as a “higher risk of not succeeding in treatment.” Carlini said Hasin had called it “reasonable to conclude that today's very high potency cannabis products…confer even a greater risk of psychosis” since her study was “based on considering high-concentration” to be cannabis with THC of “more than 10% and we know the high concentration here is more around 67%.” Carlini’s impression was that Hasin’s findings were “one public health reason” in favor of limiting access to high-concentration items.
  • Carlini then went over a survey of stakeholders that had been conducted to gauge the feasibility and impact of policy options on high-concentration cannabis products before reviewing the statutory and regulatory changes UW ADAI researchers were recommending.
    • “Science is always incomplete, and we invite people to prove us wrong if that's the case,” said Carlini, before describing how researchers had taken a step beyond the “strong evidence” in their consensus statement by conducting a survey on the topic with Washington stakeholders. She described how this had been done through a 2021 budget proviso allocating $500,000 to the WA HCA for UW ADAI “to develop policy solutions in response to the public health challenges of high tetrahydrocannabinol potency cannabis.” Their goal was “to find common ground amongst stakeholders” (audio - 6m, video).
      • Carlini went over the process of conducting the survey, providing information similar to her presentation during the symposium on how respondents self-identified their primary roles, which were divided up into:
        • “Community members, we included prevention advocates, social justice, youth centered organizations, parents of youth”
        • “Professionals from healthcare providers, law enforcement, government agencies, and researchers”
        • “Cannabis advocates that were people that report working [in], being representatives…lobbying professionals, press, consumers and of course…owners of different businesses”
      • Next, Carlini reviewed the concept mapping process by which policy ideas were vetted and organized. An initial cohort of survey respondents suggested policy ideas, she explained. Redundant suggestions, or comments on “medicinal cannabis or delta-8-THC” were removed, and Carlini said the 46 remaining policy options were then ranked by a new cohort of participants based on what they believed was the feasibility and positive impact of each option. Mentioning the demographics of the respondents, she indicated 106 participants engaged in the first stage of concept mapping, and 160 participants ranked the vetted policy options in the second phase, though Carlini mentioned that because this was done anonymously “we cannot assure how many of them were the same” participants in both surveys. There had been concerns that “more than half would be King County only,” but the replies came from around Washington, including a “reasonable, even participation too, of the stakeholders’ big groups.”
        • Carlini’s presentation named the number of respondents for six of 29 counties in Washington, showing the state’s three most populous counties were undersampled according to federal census data at time of publication:
          • 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
    • Talking about the results of the survey, Carlini said that the first question had been “what is your concern about high THC in Washington state. Because we didn't want to then be creating a problem that…we researchers are really concerned, and nobody really cares.” After participants saw a website from UW ADAI that “included a description of the problem, links to additional resources, and a list of the stakeholder groups being asked to participate,” their average response was a concern of 3.8 out of 5, with Carlini reporting that concerns ranged from 1.4 among industry participants, while “researcher and government employees are over four in terms of their concern” (audio - 8m, video)
      • Carlini organized the 46 policy options provided into eight groups subdivided by color, albeit a different configuration than her UW ADAI presentation of the same options:
        • Advertising Restrictions and Age Restriction options, were “pretty much preventing the initiation of use”
        • Taxation; Product and purchase caps; Ban High-THC Products, and Licensing options “related to trying to decentivize [sic] or minimize the use of this products”
        • “Empower the consumer and public with information”
        • “There were several answers too, that was ‘laws and regulations are perfectly fine as they are’ that we called the ‘Do Nothing area.’”
      • Expressing an interest in a “go zone” of stakeholder supported ideas, Carlini’s presentation named “Empower consumer/public with information,” “Advertising Restrictions,” “Taxation,” and “Product and purchase caps” as close to, or reaching a consensus among respondents as more impactful and feasible than not.
        • She mentioned that the cannabis advocates group felt “that [it's] very feasible to do nothing and would have a positive impact,” and that group only supported advertising restrictions for high-concentration products which were already in statute.
        • Carlini noted that Product and Purchase Caps were seen as “research backed, evidence based” and high impact, but a “little low” on feasibility.
        • Backing for taxation changes on cannabis items with “more than…35%” THC was “not very marginal.” Increasing taxes on items with more than 10% THC failed to reach the go zone of stakeholder support, she added, finding “high support on taxes…mostly c[a]me from professionals, healthcare professionals, researchers, and government workers.”
        • Improving informational offerings to consumers was the most popular option (“people loved the idea,” Carlini remarked). She called out responses to some specific ideas:
          • “Warning labels” and “readable labels”
          • “Place public health messages at point of sale”
          • “Maintain availability, but teach ‘a dab will do’”
            • Carlini emphasized “professionals and communities” were “less enthusiastic about this option. It just stays here because of the support of the cannabis industry to do that.”
        • Additional public guidance was also popular, with Carlini’s presentation options grouped as “Earmark cannabis tax for PSAs/ads and social media campaign explaining risks” and “Education in schools and community centers.”
    • Carlini talked about recommendations UW ADAI would make to legislators after incorporating the survey into their consensus statement along with “research evidence” from “North American contacts.” The published draft report featured details “on what has been done up to September” of 2022, even as “none of the policies implemented have been ever evaluated” making them “tangential to our recommendations” (audio - 3m, video).
      • Carlini claimed the survey results showed concern over high-concentration products “for non-medical use, and they support policy changes,” whereas support “to do nothing” was “very, very low.”
      • Several policy options were also “also backed by science and research,” she said, including consumer education, “age-gating, and tax increases proportional to THC content.”
      • She noted that Cannabis Observer had published an observation on an earlier draft of the UW ADAI report the day before her presentation, making her “more than willing to answer any questions you may have about them since now they are in the public domain.” She concluded by thanking her team of researchers, participants, “advisory group members,” and Polygon, Inc for conducting the concept mapping.
      • While the final legislative report was due to be submitted by December 31st, at publication time it was not available on the WA Legislature website nor the UW ADAI website.
  • Legislators had a variety of questions around the published draft report including justifications for the recommendations, potential impacts, and outreach conducted.
    • Kloba noted that respondents in the professionals category “were one of the categories who felt that taxation was a viable choice, but I was wondering…if they had any awareness of the taxation study that LCB did several years ago finding that it didn't seem very feasible?” (audio - 3m, video)
      • Carlini credited Kloba as the legislator that “put forward this idea of having also a proviso to analyze a taxation as an option,” but Carlini asserted that “taxation works for alcohol, tobacco, and [unhealthy] foods really well.” She considered the feasibility study from 2019 to have been focused “on a whole economic outlook, and marginally on public health” while UW ADAI’s goal was to center public health concerns.
      • Kloba commented that “when the rubber hits the road implementation is also a very important concern, so implementability…is key.”
    • Then Kloba inquired about advertising, noting that because WSLCB Director Rick Garza was present, he could share an “overview of advertising regulations as they currently stand” (audio - 3m, video).
      • Garza felt that because there had “been so many changes that you've made over the years,” naming billboard restrictions, he would have to review before being able to share an accurate overview.
      • Policy and Rules Manager Kathy Hoffman joined the discussion to say the board had opened advertising rulemaking in August 2022, the first potential revision “since 2018.” She termed it a “complex area,” particularly since “there are challenges with respect to…constitutional freedoms” around what businesses were allowed to claim. Garza clarified for Kloba that the existing advertising rules on billboards permitted “product…to be advertised and the stores.”
    • Representative Melanie Morgan asked “when the researchers were doing their research in determining…high potency leading to the addiction, was there any comparison to addiction and harms that are caused by alcohol and nicotine? And then, were these research done on different cultural groups” to assess the impact on the “harms and the addictions” (audio - 3m, video).
      • “Research…has been done in different ways,” Carlini explained, but their work focused on comparing cannabis flower and “other more concentrated products.” She argued that other research had been done, but “the user of solely cannabis is a very, very, very rare event” and “most…people consume cannabis plus other products.” In particular, “most people that consume cannabis are…very likely to be tobacco users, are very likely to also consume alcohol,” she insisted. Carlini also believed that regardless of what recreational drugs an individual used, “people that struggle the most with discrimination in society are way more likely to become addicted, or to develop a use disorder, than people that are mainstream and have…decision power, and privilege.”
    • Representative Kelly Chambers returned to the topic of psychotic disorders, inquiring “how can somebody know that they're at risk? Is it...a family history, a diagnosis…certain types of diagnosis?” (audio - 2m, video)
      • Calling mental health “somewhat of a mystery” for professionals and society, Carlini deemed the concept an “intersect[ion] of genetic makeup and environmental conditions, and cannabis is one of these environmental conditions.” She alleged “any other mental health condition, some genetic makeup” could potentially “trigger…a psychotic episode.” However, most research in the field involved those “already hospitalized, or already having the chronic foundation psychotic disorders,” with Carlini indicating schizophrenia was the most studied such condition, though it remained “relatively rare, around one to three percent of people will develop” it.Case control studies compared “people that are already struggling with the disease…and compare with similar people that are not, and you go back in time and you look if they have used cannabis and which potency…in their near past.”
    • Kloba wanted to know if causation of mental health conditions could be established; “maybe there's a little bit of a chicken and an egg problem” since “sometimes undiagnosed mental health disorders” motivated people to be “self-medicated by various substances” (audio - 2m, video).
      • “The only way we could do research on causation,” argued Carlini, was getting a “randomized” group of subjects “then see what happens, do an experiment.” Such subjects would be tracked by researchers for “one to two decades” which she assumed would show those using cannabis “are way more likely to have…schizophrenia, or psychotic disorders, than people that have not.” She knew lawmakers wouldn’t “legislate over people[s’] genetic makeup, but you could legislate over a trigger of this genetic makeup…on not letting this, throughout the years, to trigger psycho[tic] development.”
    • Representative-elect Kristine Reeves hoped to better understand “correlation between the utilization of the substance and its adverse impacts on what I would characterize as underrepresented, or historically marginalized and challenged communities.” She asked Carlini to review the “demographic data in your research in terms of highest impact to particular subsets of the community,” while also addressing “any research outstanding…that shows a correlation between the demographic impacts based on those subsets of the population, and adverse childhood experiences” (ACEs audio - 4m, video).
      • First, Carlini called for “more funds [so] we can work on the granular level of the questions that are being made,” as “adverse childhood experiences is not a variable that has been measured.” She did allow that any “marginalized communities” were at higher risk for substance use disorders “because that's a way they found, most likely to cope with the way society treated them.” Carlini was open to researching the factor specifically in the future.
      • Reeves asked if UW ADAI “would have the capacity” to look at ACEs if requested. Carlini replied that they would before making clear the topic had been studied, but it was “not as clear” whether high-concentration cannabis products impacted the odds of developing use disorders relative to ACEs.
      • Kloba noted she favored more cannabis research funding “because we have fantastic institutes” in UW and Washington State University (WSU).
    • Representative-elect Clyde Shavers asked about the “supply and demand situation, or dynamic. Are consumers demanding greater concentrations of THC, or is it industry…through their entrepreneurship…experimenting with higher concentrations?” He asserted there was some question over whether “using cannabis really lead[s] to other use of harder drugs.” Referencing the cannabinoid briefing earlier in the work session by WSLCB staff, Shavers wondered if their growing market share was the result of consumers after a “better high…and potentially could that lead to other drug use?” (audio - 3m, video)
      • Finding the cannabis sector to be a “very very efficient industry that is keen on innovating,” Carlini asserted this pattern was “typical of industries of any kind that are oriented to grow and make a profit.” She suggested cannabis companies “started experimenting with what was already available” and began making new products.
      • She pointed a finger at social media platforms for being “rampant with advertising, true influencers, and…associating cannabis with very positive” or “desirable lifestyles. Of course consumers start demanding the products.”
      • Carlini noted that “in 2014, [concentrates] were barely seven percent of the market, now they are around 34 to 40% of the market.” She couldn’t be sure whether new product offerings, or a consumer demand for them, was driving the change in consumption, but remained focused on how “these products are not safe for consumption, and they are…exposing people to health risks… particularly people…with a less than privileged life. And we need to do something about it.”
    • Stearns asked about input on the report from sovereign tribal governments across Washington, the majority of which had cannabis compacts with the state (audio - 2m, video).
      • “We cannot consider them stakeholders; they are sovereign nations so they are our partners, not stakeholders,” established Carlini. Through the WA HCA tribal liaison and a “Dear Tribe letter," she reported that tribal governments were contacted and researchers achieved “some connection.” She encouraged any policy change around high-concentration cannabis products to include a chance for tribes to “give their opinion.” Carlini described how UW ADAI staff “​​put our cards out and didn't get too much direction” from tribes, “of course, I think they're interested and they should become partners on negotiating a solution [in] this area.”

Information Set