NW PTTC - Webinar - The More the Merrier?
(December 17, 2020) - Summary

Public health researchers and prevention advocates discussed a report associating increased health risks with concentrated cannabis products and ways to enact policy change.

Here are some observations from the Thursday December 17th Northwest Prevention Technology Transfer Center (NW PTTC) webinar “The More the Merrier? THC Potency in the Legalization Era.”

My top 3 takeaways:

• Researchers discussed a recently finalized report on Cannabis Concentration and Health Risks adding new insights to remarks from past events.
  • Kevin Haggerty, University of Washington (UW) Professor of Prevention, Director of the Social Development Research Group (SDRG) at UW, and  Co-Director of NW PTTC, provided insight on the report, Cannabis Concentration and Health Risks. He hoped the research perspectives collected in the report would “guide those policy implications” that might be made on the subject (audio - 6m).
    • Haggerty made similar remarks for a webinar during the Washington State Health Care Authority (WA HCA) Prevention Summit on November 4th in which a draft of the report was first made publicly available.
    • Haggerty thanked participating researchers, the University of Washington Alcohol and Drug Abuse Institute (UW ADAI), Prevention Works in Seattle (Prevention WINS), the Center for Rural Opioid Prevention, Treatment and Recovery (CROP+TR), and staff at state agencies for their input.
      • UW ADAI created a High-Potency Cannabis website to accompany the report and findings brief.
    • Haggerty said the research sub-group established by the WA HCA Prevention Research Subcommittee (WA HCA PRSC) to produce the report was “really indebted to” Washington State Liquor and Cannabis Board (WSLCB) Public Health Education Liaison Sara Cooley Broschart and WA HCA Substance Use Disorder Prevention and Mental Health Promotion Section Manager Sarah Mariani “for really instigating this.”
      • Broschart last talked about WSLCB’s prevention role on December 9th.
      • WSLCB hosted focus groups called “Prevention Roundtables” on December 17th and December 18th. When Cannabis Observer asked Broschart for permission to observe the December roundtables we were informed the agency events were a private dialogue with “partners.”
    • Learn more about the history of medical cannabis implementation in Washington statefrom the perspective of the Washington State Department of Health (DOH) from WSLCB, as well as from the legislature.
      • After the passage of SB 5052 in 2015, WSLCB presented to the Washington State House Commerce and Gaming Committee (WA House COG) on the merger and potential medical priority applicants.
      • The Washington State Department of Health and Human Services (DHHS) produced Lessons Learned from Marijuana Legalization in Washington State covering medical implementation in addition to other topics at the 2017 Prevention Summit.
  • Beatriz Carlini, a UW School of Public Health Affiliate Associate Professor, talked about tetrahydrocannabinol (THC) concentration and legalization (audio - 7m). Her comments were similar to her testimony to WA House COG on September 15th.
    • She started off her remarks “by making very clear that while we put together this report [it] was not about medical use of cannabis [but] was only about non-medical use.” High potency was “understood as high THC concentration,” Carlini indicated, but the complexity of cannabis made “potency a complicated discussion.” Referencing a graph of Washington flower THC cannabinoid concentration values over time, Carlini said “low-THC or low-potency cannabis” below 10% THC had a small share of the market when retail stores opened in 2014, and high potency flower was “something between ten and 15% before legalization, you can see it barely exists.” She suggested that cannabis concentrates were “in a very small scale” before Initiative 502 but were subsequently mass produced with “THC levels unheard [of] before.” Carlini felt the current market was “a very different reality” and for concentrate production “we don’t know exactly what it has done because at this point in time the market is not regulated in a way” that consumers can “know exactly what happened” to make the products. She compared it to fruit being turned into processed food that doesn’t “really resemble the fruit anymore.” She felt the public needed a better understanding of how concentrates were processed and packaged, with “complete nutrition[al] facts.” She also reviewed nationwide poison center calls for cannabis flower compared to concentrates which suggested concentrates were more frequently associated with calls where they were the only substance ingested.
      • See Carlini’s 2017 research around cannabis concentrates and use:
        • Beyond joints and brownies: Marijuana concentrates in the legal landscape of Washington State
        • Consumers’ Perspectives on the Function of Marijuana in Their Lives
      • Hashish and hash oil are regarded as cannabis concentrates whose production and consumption have been documented for centuries.
      • The U.S. Department of Justice published a pamphlet on concentrates in Washington state in December 2014.
    • Carlini then talked about disparate health impacts of high potency cannabis products on “historically marginalized populations,” material Haggerty covered during the prevention summit. Carlini conveyed that their report had concluded that “when we look at race and ethnicity, Latinx was way more likely to dab, although they are not as likely as other groups to, to use cannabis, but when they use they tend to dab.” She emphasized dabbing rates for people with no college education, “people who do have lower income and no access to health insurance,” as well as those who had “poor mental health” for at least two of the preceding four weeks. Carlini claimed these groups risked suffering greater harms (audio - 9m).
      • The epidemiological findings Carlini summarized were assessed by UW ADAI Research Scientist Caislin Firth using data from the DOH Behavioral Risk Factor Surveillance System (BRFSS). The sub-group’s report provided the following context on the provenance of these data: “BRFSS surveys use well established methods of data collection from representative samples that enable individuals from diverse backgrounds to report their behaviors anonymously, allowing for fair public policy planning. While BRFSS data does not collected [sic] the exact concentration of cannabis products used, data on modes of consumption and types of products used are a valid — while not perfect — strategy to determine who is more likely to use cannabis in different ways.”
  • Michael McDonell, Associate Professor at the WSU Elson S. Floyd College of Medicine, first talked about symptoms and problems associated with Cannabis Use Disorder (CUD), which “in the old days we would call an addiction.” He said that “most of us, I think, my generation and older folks were raised to think that, you know, you couldn’t really get addicted to cannabis” due to “research that was conducted, mostly in the [19]70s and 80s” using cannabis with less than 10% THC. McDonell asserted that contemporary cannabis products were “very different than what was available before the legalized market” and made the development of CUD symptoms more likely. Additionally, research around tobacco and alcohol had shown potency to be an “addiction liability factor,” McDonell told the group, and that concentrates correlated with an increased CUD risk, particularly for youth (audio - 6m).
    • McDonell provided his perspectives to lawmakers on September 15th.
  • McDonell also discussed research around a relationship between cannabis use and psychosis (audio - 5m) and how concentrate use could impact adolescent development (audio - 6m).
  • Haggerty shared a participant question asking “if we’re seeing increases in THC across the board, are we seeing higher rates of psychosis?” McDonell called it “the $64,000 question” and claimed there was “no way to know yet.”

• A Washington State Department of Health (DOH) staffer and a leading prevention advocate talked about recent cannabis policy developments while suggesting lobbying strategies for advocates and prevention community coalitions.
  • Jacob Delbridge, DOH Policy, Systems, & Environmental Changes Coordinator, said he intended to move the conversation “from research to policy and practice” and think about “why now, and why this is an important issue to address.” He discussed developments in cannabinoid measurement and potency policies in other regions (audio - 11m).
    • Delbridge said “these highly-potent, manufactured products” were “cheaper to make” and “shelf stable, so they’re sold for a relatively lower cost” which was a “major influencing factor for purchase.” He reported that concentrates represented “35% of the Washington state cannabis market” increasing “from about $4 million in 2014 to $311 million dollars in sales in 2017.”
    • Delbridge then reviewed “Policy Efforts around High Potency Cannabis Products” and noted a standard method for testing cannabinoid concentrations in cannabis products would be recommended by the Cannabis Science Task Force.
    • Legislation in Vermont legalizing cannabis sales would limit concentrates and edibles in stores, Delbridge reported.
      • The law sets a maximum of 60% THC for concentrates and five milligrams THC per edible serving.
      • Vermont legalized adult cultivation, possession, and use of cannabis in 2017.
    • Delbridge’s presentation glossed over“attempted regulatory efforts to limit THC concentration of certain adult-use/non-medical cannabis products” in Washington and Colorado.
      • Learn about earlier efforts to limit concentrates at WSLCB and the state legislature.
    • Delbridge noted several states regulated THC concentrations in medical cannabis products, and Illinois was the only state to base their cannabis excise tax on potency:
      • 20% tax for all cannabis infused products
      • 10% tax for other cannabis products with THC content of 35% or less
      • 25% tax for other cannabis products with THC content over 35%
    • He said public health and prevention stakeholders had looked at cannabis use “prevalence” among youth, including “how it’s affected sub-populations and disparities, and in others how it hasn't.” However, Delbridge believed that differences in prevalence were attributable to “the products that youth are using being so different from the products of past generations” and represented “another important measuring indicator.”
    • Delbridge encouraged listeners to utilize the materials on UW ADAI’s High-Potency Cannabis webpage as they were valuable “for messaging.” Haggerty added that he’d already forwarded the findings brief to his state representatives.
  • Liz Wilhelm, Prevention WINS Executive Director, was invited by Haggerty to speak to the utility of the group’s research for “families and communities.” She said she wanted to make the report “purposeful in our communities” and encouraged attendees to make the issue brief available to their elected officials. Wilhelm went through “things that are probably very practical and things that are really familiar to many of you” (audio - 9m).
    • Wilhelm shared a list of general things “parents can do” when talking to their children about cannabis:
      • Correct misinformation
      • Share facts
      • Know the laws and regulations
      • Express concern without shaming, lecturing, or scaring
      • Determine boundaries and rules
      • Network with other parents - use social media well
      • Monitor Internet activity and deliveries/mail. Wilhelm said that there was currently “more opportunity for our kids to get a hold of edible products by ordering them online, and in fact we had that happen in our community.” She explained a minor “overdosed from a high-potency edible” who had “gotten it from a friend who had gotten it from a friend who had ordered it online out of California.” Wilhelm added that it “did trigger some of our...federal partners to look into what’s going on.”
        • The infused candy may have come from an illegal operation in New Jersey that was shut down by that state.
      • Work with your student’s school personnel
      • Report what you find [to WSLCB]
      • Share your concern and stories with policymakers
      • “In our community…” Wilhelm had noticed this phrasing “seems to be something that’s been really practical for the Prevention WINS coalition” since it helped “to remind policymakers that we are talking about our neighbors.”
  • Wilhelm noted that there’d been “some relaxation of some of the allowances around how we can access marijuana products, that we can drive up, get a curbside delivery, that we can walk up to a window...and pick up products. We know that increases access for our kids” and “normalizes” cannabis retail as akin to “picking up toilet paper, it’s like picking up milk and orange juice at the store.” 
  • Wilhelm also talked about the development of regional prevention coalitions as a method of localizing advocacy. She encouraged listening to local prevention supporters’ thoughts on concentrated cannabinoids and finding out “what they need” to communicate with each other, their communities, and their elected officials. Confirming accuracy of “data relevant to the issue” was important as a way to ensure “the narrative matches the data,” Wilhelm explained. Recently, advocates had been focusing on temporary allowances due to the coronavirus pandemic, she mentioned. Wilhelm said it was “really clear” that the 2021 legislative session would feature “a variety of legislative bills around sales” of cannabis and alcohol, but she and others hoped for bills “clearly regulating THC potency” (audio - 7m).
  • She then listed tips for organizations lobbying on concentrated cannabinoids.
    • Share factual information - use social media well
    • Express hope and concern
    • Learn how to critically analyze legislative bills
    • Comment on legislation and policy proposals
    • Join hearings with a well-prepared statement
    • Passion is important and a logically reasoned argument is powerful
    • Lack of strong consistent regulation and availability of high THC products through online purchasing has created a dangerous situation with concerning products for our youth, as well as many adults
      • Selling cannabis and/or vapor products online, or delivering them has been prohibited since passage of I-502 and enforced by the state.
    • Retail marijuana is a commercial industry. Wilhelm felt that “those of us in public health and prevention, you know, our industry is, is supporting people and...creating as healthy a community as we can. That’s really different from what the retail marijuana industry is. It really is about making money and we have to keep that in mind.” She said the differing “bottom lines” and “goals” of the commercial cannabis industry as compared to public health and prevention advocates “doesn’t mean we can’t match up.”
  • Wilhelm concluded her remarks saying that being a prevention advocate “doesn’t mean, you know, that you just say no to things.” She encouraged advocates to “help elevate people’s voices so that we can come to a good policy place.”
    • During his introduction (audio - 6m), Haggerty said “I’m sorry...that Prevention WINS will end its funding on December 31st, but really excited to have [Executive Director] Liz Wilhelm continuing her important prevention work in the state of Washington.”

• Presenters replied to participant questions about cannabis regulation and prospective legislation, and fielded a question about “the cannabis industry pushing back.”
  • Haggerty shared a participant question on “limitations for the percent of THC...should it be restricted for certain people, say teens through 30 years old?” and noted that “it technically is restricted” for those under 21. McDonell wondered “how do we go back from where we are?...Or do we?” He said a new prohibition had the potential to “create another illegal market” and he wasn’t certain “increasing the, you know, age of...makes sense. And if we do it for cannabis the question is should we do it for alcohol or smoking?” McDonell considered it a “complicated question” (audio - 2m).
  • Haggerty asked Carlini to address an attendee question on “the [cannabis] industry pushing back” (audio - 4m).
    • Carlini responded that the September 15th WA House COG work session “felt like [going] back to the tobacco times in terms of all the ways that science was manipulated” although she acknowledged the Washington cannabis sector wasn’t composed of “transnational, big corporations” but was rather a “nascent industry.” She argued that industry representatives only considered the rise in psychosis to be “a slight increase” and that their arguments to lawmakers were a “mistranslation of science.” Carlini explained researchers weren’t “preaching a war on drugs, we’re talking about market forces” related to “for-profit legalization.” She worried that businesses under the influence of capitalism tended “to dismiss science when it goes against profit.”
    • McDonell claimed they wanted “to support the industry” and offered that as he was from St. Louis, “we don’t say anything bad about Anheuser-Busch.” Prevention supporters needed “to advocate for science in this discussion.” McDonell attended cannabis industry conferences with Carlini where “99.9% of the time we have really active dialogue” with cannabis businesses, but the legislative work session was “the first time...where I heard tobacco company talking points.” He said the cannabis industry had never brought “their own scientists and identified them as scientists” as their earlier testimony had “not been that organized of an approach, previously.” Cannabis trade groups were “evolving.” McDonell claimed “the alcohol industry or the tobacco industry is getting increasingly involved” in legal cannabis. Profit-driven consolidation was “something growers talk a lot about” as small operators were “being pushed out of the industry.” He asserted that “some changes in regulations in our state have made that possible.”
    • Carlini returned to the subject of the cannabis industry, saying prevention researchers “want to help the industry become ethical, more ethical” in the face of “the forces of profit.” She wanted “to protect our population against what is more a force, that if it’s not regulated will cause harm” specifically “the explosion of high-potency cannabis” (audio - 2m).
  • Haggerty brought up a question about cannabis products laced with fentanyl (audio - 2m).
    • McDonell said he hadn’t practiced medicine “for the last five years” and had “not personally seen that.” Nonetheless, “cannabis can be laced with anything,” he argued, “and certainly, lacing a joint is not a new thing” because the “black market is still there.” McDonell shared an observation from a former patient: “there’s two kinds of drug dealers. One wears lab coats and one wears jean jackets. And so the industry is somewhere in between.” Moreover, “people are going to take their products and they’re going to modify them on their own. And then there’s this black market that’s still out there” which he believed was “moving to other products like opiates” and fentanyl.
    • Carlini doubted any legal business would add fentanyl to their own products. But as businesses and the industry grew, she felt prevention and public health communities should “try to guarantee that a product that comes to the public are safe.”
    • Haggerty clarified that he was not attempting to suggest legal cannabis businesses had laced any product with fentanyl.
  • Haggerty brought up the MORE Act which was passed by the U.S. House of Representatives on December 3rd (audio - 2m).
    • Haggerty called it a “great opportunity to send the one-pager to your representative” and note that were the bill to become law it would “allow more research to happen.”
    • Wilhelm doubted there would be “movement in the [U.S.] Senate.” She felt “if the motivation was purely to be able to do research” without changing criminal penalties for adults, the bill would “probably make sense.” But, Wilhelm added, “we know who is lobbying for a federal change” and “the majority is not researchers...it is another population. So, intent is important.”
      • A group of more than 100 public health professionals and 16 public health organizations endorsed the MORE Act in a letter to Congress on August 10th.

Information Set