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Can medical cannabis survive adult-use legalization?

Can medical cannabis survive adult-use legalization?

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Very few medical cannabis advocates are against the full legalization of the plant for all adults. But sometimes one unintended consequence of adult-use legalization is that the market no longer caters to medical patients.

“Medical users, over time, are finding that the products that they want and need — they can no longer find on the shelves, or those products are more expensive,” explains Dr. Ruth Fisher, an economist who specializes in the market dynamics of cannabis. “And so they’re kind of getting squeezed out. And I think that that’s a real problem.”

Dr. Ruth Fisher
Dr. Ruth Fisher

In this episode of The Cannabis Enigma Podcast, host Michael Schaeffer Omer-Man interviews Dr. Fisher about the various ways medical and adult-use cannabis markets interact. For instance, why is adult-use legalization almost always preceded by medical cannabis legalization?

Dr. Fisher, author of the book “The Medical Cannabis Primer,” also discusses how the remaining stigmas surrounding cannabis shape many of the dynamics and barriers facing both the medical and recreational markets. The fact that cannabis has been used in secret and behind closed doors for so long contributes to the ongoing perception of danger many people associate with it, she says.

“If cannabis were used more openly by people, I think that we wouldn’t have a lot of the problems that we’re having today,” Dr. Fischer says.

At the end of the episode, Debbie Churgai, executive director of Americans for Safe Access, discusses the various ways that military veterans — who could very much benefit from medical cannabis — have difficulty accessing it and the ways that the Veterans Administration can address that issue.

Produced by Michael Schaeffer Omer-Man. The Cannabis Enigma is a co-production of The Cannigma and Americans for Safe Access. Music by Desca.

Full transcript:

Michael Schaeffer Omer-Man: Dr. Ruth Fisher, thank you so much for being with us.

Ruth Fisher: It’s my pleasure. Thank you for having me.

MSO: So, just full disclosure, we actually recorded this interview a couple of months ago, but for technical issues, we’re having to do it again. So, it’s great to speak with you again.

RF: Another opportunity. Yes.

MSO: When we did speak the first time, I believe it was pretty soon after the presidential elections, which among everything else political that happened surrounding that. There are two big cannabis related changes and prospective changes that came out of that. The first is that a whole batch, a whole set of states passed legalization measures, the result of which is that once they all come into effect, I believe over a third of the US population is going to live in jurisdictions where cannabis is legal for recreational use, the vast majority of states for medical use, and with one exception, recreational legalization has always been preceded by medical legalization.

I’m wondering if you can give us some insight into why that is. What it is about that progression between the link between the two, that makes it a force? Is it just normalization and exposure that people get? It is coincidental and just a correlation? What is the relationship between medical and recreational legalization?

RF: That’s a really good question. I think medical comes first because it’s kind of a more legitimate use, that people need this as something to improve their health and that’s a legitimate use for cannabis. So, states start there. It’s obviously very heavily regulated. I think one of the problems with cannabis and the stigma surrounding cannabis, is the fact that while the use is probably more prevalent than people believe, or realize, it’s not something that they’ve actually seen other people do. So, we all know that alcohol is out there. And plenty people use alcohol and people can abuse it. But the abuse happens aboveboard. Everyone knows other people who have had problems with alcohol, or have taken it too far, they can see it in proportion that there’s way more people who use alcohol functionally, and recreationally, and without any problems. Because it’s a part of everyday life, and it’s been a part of everyday life for so long, people get it, they understand it, there really is no mystery.

With cannabis, on the other hand, they’ve been told that it’s evil, and they haven’t been able to witness the fact that so many people have used it for so long without any problems. And so, there’s a mystery there with cannabis that you don’t have with alcohol. If cannabis were used more openly by people, I think that we wouldn’t have a lot of the problems that we’re having today.

Regardless, so societies tend to adopt medical first and I think that that helps people see that cannabis isn’t really the evil thing that they’ve been told that it is. And they see that it’s a great source of revenue. It’s a great source of jobs. And I think as importantly, as anything else, that there’s a lot of people really being helped by it. I think that all of that serves as a way to legitimize cannabis, and push people to recognize that cannabis isn’t the evil thing that they thought it was, and that helps validate and lead to the use of cannabis for recreational uses.

So, I think it is kind of more opening the can of worms and seeing that it’s not the problem that you thought it was. So, then going from kind of the initial toe in the water to jumping in, into the deep end of the pool, so to speak.

MSO: That’s on a sort of public opinion and perceptions and stigmas level. What about the economic forces and impacts of medical coming first? I can think that there’s already the infrastructure in place. A lot of the adult use, legalization has built upon the medical dispensary infrastructure, logistical infrastructure, the inspections and laboratory requirements in some states, and I imagine that also the political power of massive industries plays a role in pushing for further advancement. How much of a role does that play?

RF: That’s a really interesting question and that’s something that I don’t think I’ve thought about before. What I would say is, the medical market is fairly well defined and I think it’s it’s easier to control. I think that a lot of the governments, when they’re allowing cannabis, they’re opening up to cannabis, they’re doing so very hesitantly and they want as much control as possible.

As far as the existing infrastructure, I mean, on the face of it, Cannabis, the fact that people are using it for medical care seems to make it a part of the traditional or kind of be able to draw upon the traditional healthcare structure. And I think that that’s been a false assumption that has caused a lot of problems. In particular, it would have been a smoother rollout, in most places, I believe, had the cannabis industry been able to draw more upon the traditional industry. But because of the Federal one classification of cannabis, you have most of the traditional industry have shied away from using cannabis, drawing on the schedule one classification and refusing to deal with it.

So, what you have is, as you mentioned, the labs, the whole testing of the cannabis products to make sure they’re safe. It’s not existing medical laboratories that have now started testing cannabis, rather, its whole new laboratories had to pop up from scratch, because existing labs refuse to put their non cannabis operations at risk by entering into cannabis. And you’re seeing that with every other type of infrastructure that’s needed to support the medical cannabis industry. So, for example, payment systems. There are no payment systems, there’s no banking and cannabis. And so, while it would have been nice to certainly draw upon infrastructure that was already there and supporting the traditional healthcare industry, that absolutely was not the case with cannabis.

I think the idea that they could, I think this is a very insidious problem, because people don’t realize that this infrastructure isn’t there until they get into a position and they realize that they were assuming that it would be there and it just isn’t. I can give you a perfect example. And this has caused a lot of problems, I think, with new medical cannabis users, in that they go to the doctor and they have these certain expectations. And so, they decide they’re going to try medical cannabis and they’re thinking of it as healthcare. And so, they go in with the expectations that their experience with cannabis is going to be very similar to their traditional health care experiences. That’s not the case.

If you consider what happens, you go to your normal doctor, your doctor says, “Okay, I think you should take this medication.” He hands you a prescription and he explains to you how to use it and everything. Then you walk into the pharmacy and you see a pharmacist there and he has a lab coat and you know he’s certified, so you trust that he knows what he’s doing. You see all the bottles of pills on the shelves, but you don’t have to know anything about any of that, you simply hand your prescription to the pharmacist. He decides, goes into the back, he chooses exactly the right bottle for you. He hands you your bottle. If you need any more instructions on how to use your medication, he can answer all those and you walk out. I think when customers go to a dispensary, they’re assuming it’s going to be the same type of experience. However, many customers, new medical cannabis customers are going into the dispensary with a note from their doctor saying you qualify under one of the state conditions that enable you to use cannabis. But the doctor isn’t giving the patient any guidance.

So, the patient walks into the dispensary thinking that he’s going to have this typical pharmacy experience, and it’s only when he gets up to the counter and he actually sees literally the hundreds of different products out there and realizes that he’s the one, the customer now, the patient has to determine or decide which of all those hundreds of products he should buy. And he’s looking at it and all these words are coming out, cannabinoids, THC, CBD, ratios, terpenes, and the customer realizes they have no idea what they’re doing. It isn’t until that moment of realization, I think, that the magnitude of kind of this misunderstanding or lack of appropriate assumptions, I guess, on how to try and deal with the whole medical cannabis experience. I think it’s only at that point that people realize how different the cannabis world is from the traditional healthcare world.

MSO: So much of that has to do with the lack of education among medical professionals, but also the lack of scientific information, saying which cannabis products are good for what symptoms or what conditions and hopefully, we get there one day. But what do we do in the meantime? How do you address that?

RF: Another really good question. So, kind of one of the beefs I have, and I wanted to take a step back and say, I have all due respect for the medical profession in the traditional healthcare industry. My dad was a private practice physician, and I’ve lived most of my life in that world. However, that industry has a very particular perspective on the world and on healthcare, and the way proper healthcare is conducted. And it’s a very distinct view from I think, the way cannabis works. And I think that that’s creating a lot of problems, because cannabis really doesn’t fit into the way that most doctors, or healthcare professionals in general, are used to dealing with health care and medication. I’m sorry, I lost track of your question.

MSO: No, let’s let’s keep going on this. I mean, what is that difference? Why is that a problem?

RF: If you think about the way doctors are trained, it kind of goes back to the way the healthcare industry has evolved. You go back to kind of the 1800s, and this is with the germ theory of disease, and this is with trying to standardize and legitimize the practice of medicine. And so, in the 1800s, there was a lot that was not known, and there was a lot of chaos going on. As the germ theory of disease, people recognize, “Oh, gee. It’s germs that cause disease.” And you get into the whole sanitation measure. But also, you’re gaining a lot more technologies and scientific information just on how things work.

There’s a huge attempt, and I’ve been reading a lot about this, it’s really fascinating. There’s a huge attempt by the industry, especially during the late 1800s, early to mid-1900s, to legitimize the practice of medicine. And so, they’re trying to standardize, trying to make sure that doctors are are generally coming at problems from a similar perspective, and especially they’re coming at treatments from a similar perspective. You have to understand that the healthcare and the doctors, the physicians, that’s a cottage industry, which means it’s evolved as individual doctors hanging out their shingle in practicing private practice. So, you don’t have doctors practicing in large groups where they’re subject to top-down hierarchies. And as a matter of fact, doctors are very kind of unique in the extent that they desire, demand autonomy in what they’re doing. They want to decide what it is that they’re doing. They don’t want other people to tell them what to do.

So, to come in and say, “No, you can’t do it that way. You need to do it this way.” That’s a very difficult ask of society or whoever, to ask physicians to do that. It’s a non-trivial issue. So, you have this attempt to legitimize healthcare and to adopt standards, to do things in a more scientific way, and in a more credible way, for patients and for industry. And so, take for example, aspirin. It’s a new therapeutic that came out around the turn of the century, late 1900s, early 20th century, late 1800s, early 1900s, and that was a big therapeutic that came out at the time.

Now, aspirin had been used for hundreds of thousands of years and that comes from willow bark, and they used to steep the tea and make a decoction out of it. But now for the first time, they could isolate it and that gave them much more control over the ingredients, and the purity of the compounds. And so rather than risking a plant, or in this case, a tree bark, that could have potential other contaminants in it, other bark material or pesticides, I don’t know if they had pesticides back then. But what other toxic material that might be in the bark. Now, instead of using the whole bark, they could focus on just the purified compound, and know that they’re controlling the response, the patient will have as much as possible.

And that gives the doctors a lot more legitimacy, it gives them a lot less risk, more control and more surety over what they’re doing. And this then became established as the way to do things, to work with clean isolates, single active ingredient medications, that could be used to treat patients that gave the doctors that minimized risk and maximized control over the whole therapeutic process.

This is kind of what came to be used as the way that modern medicine is done. That standard has been brought through today. And this is the way doctors see treating patients that we work with a single isolate, and we want to isolate it and make sure it’s pure so there’s no other contaminants in there that could potentially harm the patient. We want to make the experience as predictable as possible. And so, everyone in the healthcare industry is trained under this paradigm and this is how they view the world. Unfortunately, cannabis is messy. It’s a whole plant, and there’s a lot going on, and it just doesn’t fit into this one target one drug paradigm. And really, doctors don’t know what to do with it because, well, most of them, they say that’s not real medicine, that’s not the way we practice modern medicine. And so, they really have a hard time dealing with that dichotomy between whole plant cannabis and the one target one drug paradigm. I think this issue lies at the very heart of kind of the whole cannabis issue.

Now, what’s also very significant is, in addition to having multiple compounds, the other real problem with cannabis is you cannot standardize the dose from batch to batch. And so, the problem there is if you have a patient and you finally find the right combination of ingredients for that patient, if you’re using cannabis, it’s almost impossible to ensure the same dose from batch to batch to batch. And so, it’s mostly I think, the one active ingredient paradigm that’s causing most of the problems, but even if they were to be able to shift over to a multi-active ingredient treatment, I think the fact that you cannot reproduce precisely cannabis dosing from batch to batch, I think that’s the other big problem that most physicians have.

MSO: Yeah, it’s very different. And yet we’re seeing more and more physicians come on board. There’s a lot of issues sort of wrapped up in what you what you laid out there. There’s the one drug, one target, cannabis is multiple active ingredients and acts on multiple targets in the body. We’re not going to get over the fact that there’s not the same sort of clinical trial and that type of evidence for cannabis and cannabis treatments in the very near future for various reasons. But the two things that are becoming more clear, is the safety profile of cannabis that as far as adverse side effects and the possibility of fatal overdose is just increasingly clear that it’s a very safe drug to dispense and that we know that they’re – we know more and more about the mechanism by which it works on the human body and that it is involved and can positively affect so many symptoms and conditions. I’m wondering whether, which of those things if maybe, it’s false equation here, but despite all the difficulties that you laid out, what do you think is behind the positive change that more and more doctors are willing to give it a chance?

RF: Okay, so this all ties back into your previous question which I didn’t answer fully, which is what do we do in the meantime, while we don’t have all of this figured out? And so yes, there is a lot of uncertainty. I think that the discovery of the endocannabinoid system was huge in creating and validating cannabis. I think that its risk profile is another really important thing that no one has died from cannabis. And I think that when you look at, it’s that in combination with what’s going on in the rest of the healthcare system, where you have more and more people who are suffering from chronic disease, and there seems to be a dearth of good alternatives available to treat people, but in other words, the traditional system is, is leaving a lot of people unsatisfied. That’s creating a willingness of many people, both patients and providers, to try something that may work in combination with the relative low risk of cannabis in creating harm.

I think the problem here is, and I always go back to thinking about the doctor, and if I were a doctor, and you’re talking about the endocannabinoid system, which is this system that’s so integral in our bodies. Suppose I were a doctor, I had never heard of this, never learned about this, I wasn’t taught this in medical school, I have no understanding of really how it works. Normally, when doctors are prescribing drugs to patients, they rely on information from the FDA to help them determine which patients would benefit and how to guide them on dosing of those medications. And because there’s very little cannabis activity within the FDA, there’s very little information that doctors can turn to to get guidance.

So, they’re dealing with the system that they know very little about, and they have very little guidance from their traditional sources that they rely upon to become educated to help guide patients. Now, they’re asked under all of this uncertainty to advise the patient, and presumably they care about their patients and don’t want to do them any harm, I think that’s a really difficult position to be in. Especially in the US, if you’re talking about litigation and malpractice, I think there’s a huge liability there as well. In the medical community, what you have is communities of practice. And so, doctors have their cohort, who they turn to, to determine, what’s accepted practice in the areas of health that they’re dealing in. They go to meetings, and they talk with their colleagues, and they see what other people are doing, and they turn to their colleagues to help validate new treatments.

Again, with cannabis, this is probably just starting to the extent that it exists at all. And so, all of these traditional venues that doctors used to turn to, to get guidance to help patients, are blatantly missing in cannabis. And I know that there are people in the healthcare industry that are trying to fill in these gaps, but it makes it very difficult for the physicians. But in the meantime, you have patients who are in really dire straits, they’re in a really bad place. They’re on medications, and a lot of cases, many medications that are just wreaking havoc with their systems, and creating a lot of problems in these patients, they’re going to go somewhere, they’re going to turn to something. And in my belief, it should be cannabis, because of the safety profile, number one. And also because of all of the billions of individual case studies on the fact that it can be very effective.

So, I think while everyone’s trying to figure this out better, I think what we need is more testing to make sure the products are safe, and there’s no toxic materials in the products, more transparency as far as which profiles of ingredients are in each particular sample, and absolutely a start low, and go slow, strategy. I think with that people will muddle through and learn by doing, on both sides, and help inform the science based on human guinea pigs. But I think that that’s the best alternative out there at the moment.

MSO: I want to go back to the whole medical recreational question again. We talked about and the other direction, how medical legalization can bring about recreational or adult use legalization. But what happens to the medical programs and access and probably in ways that I don’t even know what to ask? How does recreational cannabis affect medical cannabis?

RF: That’s a real concern in the industry and that’s a concern that I’ve had. So, as you mentioned, all states but one, is it North Dakota, or South Dakota? North Dakota.

MSO: One of them.

RF: One guy out there, they all start with medical first. And so, the medical program becomes legalized, and patients then have to apply for a medical card from the state. Generally, the medical programs are good at tracking patients, and they’re looking at usage, and what you see over time is an increasing number of medical patients using cannabis. At the same time, an increasing quantity of cannabis per patient over time. So, sales of medical cannabis increase over time, both because the number of patients is increasing, and the amount of cannabis per patient is increasing. And this has been a very regular pattern that we’ve seen across all the different states.

Now, when recreational comes along, the states will implement that in different ways relative to medical cannabis. Some of the states maintain completely separate markets between medical and recreational. But in a lot of states, they kind of combine the two programs. And if you look at say, California, and I believe Oregon, and Washington, and Nevada, what you have is most of the dispensaries who were medical, when recreational comes on board, they become dual licensed. And at the same time, you have a whole bunch of new dispensaries come into the market, and some of them cater to rec only, but a lot of them become dual licensed in both rec and medical.

So, what you see then is over time, as the recreational market starts to ramp up, you’re seeing a lot of the cannabis, the medical cannabis activity shift from dispensaries, shift from rather medical only dispensaries to dual use dispensaries. So, if you look at the patient counts, and this pattern is the same across most states out there, what you see is a large drop off over time in the number of medical cannabis patients because they stopped registering with the state as medical cannabis patients, and instead they just go to the recreational pharmacies. The reason for this, is there’s several different reasons. One is why go to a doctor and pay to have a medical card if you don’t have to pay any of those fees and can go to a recreational dispensary and get the same products.

Now, some states have different tax rates. But it turns out that unless you use a whole lot of cannabis each year, you’re probably going to save more and not having to pay for your doctor’s visit and your medical card, then you will end up paying more in taxes. And also, you have benefits like privacy. The state doesn’t necessarily know that you’re using medical cannabis.

So, for a bunch of reasons, you have this clear pattern where once recreational cannabis becomes legal, that medical patient counts drop off precipitously, because the medical patients are now shopping in the dual use dispensaries rather than the medical only dispensaries. So, now, what you have is you have these dispensaries who are catering to two different sets of patients. There are two different sets of customers. They’re catering to the rec group, and they’re catering to the medical group. And the rec group grows really quickly. They tend to kind of swamp the resources of the dispensaries.

One of the reasons is you have these new dispensaries and most of the people who are staffing the dispensaries come from a recreational perspective. A lot of the people out there are traditional cannabis users. Recreational cannabis is their world and that’s how they see it and that’s how they relate to it. And so, they feel you know very comfortable with people who are coming into the dispensary who are seeking cannabis for recreational purposes. Dealing with medical patients on the other hand is a lot more difficult and it’s a lot more expensive for the dispensary because you need a lot of education. You need to educate the bud tenders or the people working in the dispensary to help deal with medical patients. And again, a lot of these people, for them, they’re coming from the direct cannabis world and they don’t really relate to the whole medical aspect of it. Not that they don’t feel benefits, but they find it hard to discuss and recommend products to medical patients that are really in the best interest of medical patients, because the people simply don’t have the expertise.

MSO: Yeah, or you could make a pretty good argument that they shouldn’t be making such recommendations.

RF: Yes. So, you get this kind of conflict in the dispensaries and I think that it’s just easier for them, in a lot of ways meaning psychologically, but in terms of resources, man hours, to cater to direct customers. And so, what you see is fewer products tailored to medical users, and more products tailored to recreational users become available over time. So, in other words, what you’re seeing is the medical users get squeezed out, and when I say by products catered towards them, if you look at kind of what the rec users are looking for, generally speaking, they want high THC content. They’re using cannabis because they want to get high. So, the strains that are very popular in the rec world are almost exclusively the high THC products.

Medical users, on the other hand, are interested in the therapeutics associated with cannabis. and those are intertwined in – they do want THC, but not just THC. They want also maybe CBD and they want terpenes and they want other cannabinoids in there. And so, the products are much more variable in their ingredients. They’re not just looking to get high, and a lot of them don’t want to get high. So, these same products that the recreational users are looking at almost exclusively, the high THC, which means kind of by definition, there’s going to be very little of anything else in there, is very different from the multi compound products that the medical users are looking for.

So, the medical users over time, they’re finding that the products that they want and need, they can no longer find on the shelves, and or those products are more expensive. And so again, they’re kind of getting squeezed out. And I think that that’s a real problem.

MSO: You mentioned it on the dispensary level. But I imagine, it’s all connected that it also has an effect on like a product development and even cultivation and R&D perspective, if there’s less of a market, if there’s more money to be made on the recreational side, that these products are also not being developed as much, which is probably the biggest shame.

RF: That’s absolutely the case. And as a matter of fact, it I did read one article in particular, it was talking about, so in cannabis, obviously, like anything else, you have a lot of other infrastructure and infrastructure, I mean, like complimentary products and services, which is exactly what you’re talking about. But they were talking about a lot of like cultivators and consultants, who advise medical patients. So, I guess kind of like a doctor who is providing educational medical services to patients. A lot of them simply dropped out of the market because once the medical cannabis dispensaries either closed up or moved to rec, their market essentially died.

So, it’s kind of the self-reinforcing thing, that once the resources start to decrease, then it kind of snowballs. Because everyone needs everyone else to be in the industry in order to support one another, you need the cultivators, you need the product, you need the education, you need the patients, you need them all there together. And if patients aren’t there, then the demand for the cultivators isn’t there or the service providers or whatnot in it goes to pot very quickly.

MSO: It’s something that just struck me right now. And I wanted to talk about the prospect of a federal reform from various levels all the way up to full legalization or decriminalization on the federal level. So much of the cannabis market is hyper localized because of the ban on interstate commerce of any cannabis products. And I was wondering right now, whether opening up to a full national market would actually make it more worthwhile for more medical products to be developed and sold, because you’re increasing the market size that your potential customer base by 10, 20, 30 times depending on what state you’re in.

RF: Yes, I agree that opening up sales across state lines would be huge. Another, what goes hand in hand with that, which would also be huge, is enabling direct supplier to sales cultivator, to customer sales. So right now, in a lot of places, the cultivators cannot sell directly to the customer. And if you think about, most products now what’s happening with the web, is the manufacturers are bypassing the middlemen and having direct relationships with their customers. That’s becoming more and more ubiquitous. In cannabis that’s prevented.

So, if the cultivators could develop a relationship with their customers, they could get a lot more brand loyalty and that would create much more stability. As you said, if you can open up to more different states, then yes, you’re increasing your potential market size. So, I think that will definitely help. But I think that there’s something there that is going to cause a lot of problems. And that’s the fact that because each state is its own market now, it has its own growers, because you cannot import, what you have is millions or billions of dollars being invested in growing in every state that has legalized cannabis, because you have to grow your own cannabis in the state where you consume it.

So, you have all of these growers who are spending a lot of money investing in infrastructure, and a lot of these places aren’t necessarily competitive. Like with anything else, there are going to be certain areas, if you consider this the country nationally, there are certain areas where cannabis just grows better, and if we’re talking about outdoors, and clearly the Emerald Triangle has written about opium wars earlier, the Emerald Triangle in California is just very well suited and they’re certain. Kentucky where the tobacco states and there are certain areas that are very well suited to grow cannabis. I’m not sure that say Oklahoma, or Missouri, or Minnesota would be good growing areas. And in that case, in a national market, they would be importers. But if you’re in Minnesota, for example, and I don’t know this for sure, so maybe for some reason, Minnesota is a great state to grow it. But if we assume it’s not, but if Minnesota is legal, and I don’t know if they’re legal, I assume they’re legal. So, they’re growing their own cannabis now and they’re sinking all this money into infrastructure. Once the state lines become open, and you can now import cannabis, are the special interest in the people who have already invested in the infrastructure in Minnesota, are they going to give it up that easily? Or are they going to work with the regulators in the state to put some sort of regulations or import control on just how much cannabis can be imported to compete with the state suppliers that wouldn’t normally be competitive. They wouldn’t normally be able to survive. And that’s a real big concern that I have.

MSO: Yeah, I mean, there’s actually so much more there that we could dedicate a whole episode to, just talking about some of the the benefits of having such hyper localized markets, is the ability to implement sort of social equity programs and trying to ensure that benefits go to communities that were harmed by the war on drugs and prohibition. And I guess I’m just going to skip over a lot of that. We’re seeing a big discussion about that in Mexico also right now, which is about to fully legalize, and whether to allow major multinational corporations into the industry there.

So, I’m just going to jump over to that, which is let’s assume that cannabis is decriminalized on a federal level, or maybe just the banking bills pass, and all of a sudden, people aren’t afraid to get into the cannabis industry, and a lot of the barriers to operating in that industry start to lower or disappear. We constantly hear about big tobacco and big alcohol. Now, they’ll take over the cannabis industry. Do you think that they’re actually poised to do that? Because there have been some pretty massive companies come up organically, no pun intended within the cannabis industry. Would small farmers and smaller companies, putting aside Minnesota and their unhospitable climate for growing anything, would it be such a massive shift and would it happen overnight like that?

RF: I don’t know if it would happen overnight. I think that they’re going to be big players. And I think what’s going to happen, and I’m hearing this more and more, is the comparison of Budweiser and Coors to the craft beer industry. So, if you look at the big beverages companies that are coming into cannabis, if they’re looking to scale up the way that they want to, they’re talking about isolates and they’re talking about very different products, then someone for health and wellness, or even a seasoned recreational user would want. So, they’re they’re talking about large scale operations, isolates, and just scaling operations and providing mass quantities of very homogenized, uniform products. Again, that’s like a Bud or a Coors and that’s a very distinct product from an IPA, or a homebrew, which also, they have very substantial market share.

One of the things I was just talking to someone else about is the latest market report I saw showed that over the past month, and this is an increasing trend, cannabis users have been upscaling their use. They’ve been shifting from the lower priced product to higher priced product. And so, as people consume more over time, they start to get an appreciation for the quality of the product. And if you’re talking about high quality cannabis, that’s not something that a Bud or a Coors can supply, because simply because you can’t standardize or homogenize a cannabis product at scale, that’s as complex as these higher quality products that people are starting to demand.

So, I think what you’re going to have is a bifurcation of the market, and you’re going to have you know, on one hand, you’re very large industrial producers and suppliers who are going to be catering to a certain type of market, and you’re also going to have the smaller cultivators, the craft growers, who are going to cater to people who are looking for something that’s not a mass market item.

MSO: You mentioned wellness in there. Something that strikes me that I’ve been thinking about lately is the difference between medical wellness and recreational use, and how obviously, if you take the extremes, somebody who’s using cannabis to treat Parkinson’s symptoms, or epilepsy is very different from somebody who smokes a joint before going to bed at night, as a replacement for a glass of wine or something. But there’s a lot of space in between there. The easiest one to think about for me is people who use cannabis because it makes them less anxious. That is a medical condition. Anxiety, that we have pharmaceuticals, doctors prescribe, and that is covered by insurance, and it’s also something that people use cannabis for, were using cannabis long before it was legal. And maybe didn’t even think about it as treating those symptoms, it just made them feel better.

As cannabis becomes more mainstream, and we see this CBD already, that it’s treated for regulatory as well as other reasons as a wellness product. How are those different categories, can they maintain sort of a distinct nature? Can they be different sort of verticals or stay siloed from each other? Or are we going to see more and more blurring between the different types of uses?

RF: I think there’s already a blurring. What you’re asking now is a subject that I just wrote a paper on, hopefully it’s going to be published next month. I think that they’re going to need to separate tracks for cannabis products. So, obviously, the person who’s taking cannabis for Parkinson’s, or epilepsy, or cancer is a very different type of patient than the person who’s taking it for wellness as say, a supplement, which does overlap with many rec users. And so, I think that there’s going to need to be two paths to supplying where, on one hand, you need a much greater amount of regulation to ensure safety and efficacy in products that people are using for serious health conditions. And I think that you need a separate tract for safety and efficacy for people who are using it for less major health problems, maybe you know, arthritis pain, dry skin, anxiety, and wellness as the antioxidant. People who are using it for preventative measures and wellness measures, the antioxidants and whatnot.

So, we have a supplement market, and we have an over the counter market, there’s kind of sort of three. You have supplements you have other over the counter, and then you have prescription. In cannabis, I think that you’re going to continue to have some that are going to be more heavily regulated, they’re going to have greater standards for safety and efficacy for the people who really are using it for the serious conditions, and I think those will also of course, because of more regulation, they’re going to be more expensive, but I think that those are going to be reimbursed by healthcare. And I think there’s going to be a separate regulation that ensures safety primarily, maybe some efficacy, that’s going to have less regulation and thus can have lower prices, but it’s not going to be reimbursed by health care insurance. Just like right now, health care doesn’t reimburse for supplements just because it’s not a tenable economic model. And then, of course, you’re going to have some people who are 100% recreational, but I think most of the people are going to fall into rec and wellness, and some health in there as well. So, I think that you’re going to see three different markets in there.

MSO: You wrote a book called The Medical Cannabis Primer, which is aimed at sort of educating and giving the tools to people entering the medical cannabis world. How did you get into this? What was your background before you started dealing with cannabis and what happened?

RF: It’s been a long, interesting journey. So, I smoked pot in college, in grad school, and decided it wasn’t really my thing. That is a child of the, this is your brain, this your brain on drugs, so even though I tried it, I still kind of bought into a lot of the stigma. In the ‘90s, I was working on a project involving an AIDS drug, and AIDS was one of the first diseases out there that they started using drug cocktails, which is kind of interesting.

So, there was this new drug that came out and they were putting two active ingredients together into one pill, and this is a project that I was working on. So, I became aware of drug cocktails very early on. That was a total coincidence to all of this. But at the same time during the AIDS crisis is when medical cannabis started gaining a lot of credibility and legitimacy to help the AIDS patients who were suffering from nausea and wasting. At the time, I remember hearing that AIDS patients were using cannabis to help relieve their symptoms, and I remember thinking at the time, well, I find it really hard to believe that it would be providing any real medical benefits. On the other hand, if these patients want to get high, then far be it for me to prevent them from enjoying some aspects of life.

So, I didn’t object to the cannabis use, on the grounds that it would help them feel better, but I really doubted that it could be a medical product. And so, I totally disregarded it. However, I do, as I said, my dad’s a doctor, and I have a lot of experience working in the healthcare industry. So, now fast forward to about 2015 or so, and my brother is diagnosed with multiple sclerosis. His disease manifests itself as pain. He gets multifaceted neuropathic pain, that’s just been really devastating, and he’s been on a lot of different drugs trying to deal with it, and his experience with the different drugs has not been wonderful and he still he still needs a lot of relief that he’s not getting.

At some point, in his experiences, one of his doctors, a neurologist said, “You know, I think you might be able to benefit from medical cannabis, but I can’t give you any guidance.” And so, at that point, my brother’s thinking, “Okay, well, you know, yeah, I smoked pot before and how hard can it be? So, yeah, I’ll try it and see what happens.” He kind of went through that whole pharmacy, dispensary experience that I described early, where he got to the dispensary and saw the products and realized he had no idea what he was doing. So, he started playing around with a couple of products and he was actually getting some good results. But he realized that he really didn’t know what he was doing and he hoped that if you knew better, had better information, he could get more out of the cannabis. So, at that point, he turned to me, and he asked me for my help. And I’m like, “Cannabis, really?” I was really doubtful, but I said, “Okay.” Well, at this moment, all I care about is he said that it’s helping. And so, let’s just try and figure out what’s going on here and help them relieve his pain.

So, I dove in with zero understanding of cannabis and a huge amount of skepticism, and just started poking around. It wasn’t long before I learned about the endocannabinoid system, and literally, I fell off my chair. I was just like, “Oh, my god, how can we have this body system that’s as crucial as our immune system or as our neurovascular system or cardiovascular, and I’d never heard of it before.” I was just blown away by that. So, I started learning more and more about cannabis and medical cannabis and how it works on the body, and I’m throwing my brother, these little tidbits saying, “Well, this study says this, or this article says this. Why don’t you try doing this, try doing this?” And he starts incorporating my little tidbits of knowledge and lo and behold, he’s getting better results.

At some point we had, I had done so much research, and together, we had collected so much information, and my brother knew that there are a lot of other people out there who are going through the same problem that he’s going through as well. So, he’s like, “We really got to put all this information together in a book and make it available to other people.” So, what we’re trying to accomplish, with the book, is to help new users, kind of like my brother, although kind of the image we had in mind is your grandma like, and we called her Betty, grandma Betty. Betty is your grandma, and she has cats and she likes to bake. Unfortunately, she has really bad arthritis, or she has some medical problem, and she thinks that cannabis might be able to help, but she’s really scared of it and she has no idea what’s what, and she’s just heard a lot of really bad things, but she’s heard it might work. And so, does she want to use cannabis? And if so, what does she need to know?

That was kind of the the image we had in mind when we’re putting together the book. It’s like, first, how to help people understand what the controversy is and why it’s there, and help them understand and better decide whether or not they think cannabis could help them and be right for them? And if so, what is it that they have to know so that they can go into a dispensary and feel like they can actually participate in choosing a product that’s best for them? So, it was really a patient empowerment project and that’s what we tried to accomplish with the book.

MSO: I’m going to make this next one my last question and then I’ll to let you go. Aside from the almost cliched now answer of hopefully more delivery services will stay open, what do you see the effects of the pandemic being on the medical but any cannabis space and reality for Americans and for the world?

RF: I think COVID, the lockdowns and the move to virtual services, and curbside pickup and whatnot has been tremendous in a lot of ways, and boosting a lot of different types of businesses. But in cannabis, in particular, I’ve heard has been very – and I’ve heard from many different sources, has been detrimental in the sense that the education aspect for the consumer is no longer there with regards to the customer dispensary relationship. So, before the pandemic, people were going into the dispensaries, and they were developing relationships with their bud tenders and their dispensers, and they were becoming educated. And there were some well-educated bud tenders who are really helping, and they were trying to do what’s best for their patients, and they were starting to develop real quality relationships. And this was really the best place for patients to get education, to the extent that the bud tenders were educated themselves.

Now, that the patients are no longer directly interacting with the bud tenders, they’re being forced to get their information online. I mean, it’s good and bad. It’s definitely bad for the dispensers because they’re losing that relationship that they had with the customer. Also getting a problem because are the patients getting the information they need, and it’s very difficult online to put together a coherent picture. And that was one of the reasons we released the book, is I was having so much trouble myself. I’m a seasoned researcher, and I had so much trouble understanding cannabis and how it all works. I think that the services aspect in educating the consumers, I think has been one of the big focuses in the industry, and there have been a lot of groups who are springing up to provide education, either credentialing or just class education or just course information rather.

We also have a lot of hotlines. You have the nurses’ hotline, which is a wonderful thing, and more doctors and telehealth. And I hope that the patients continue to get the education that they need in order to take cannabis effectively and responsibly. Moving forward, I really that’s the part that I think is in most dire need of attention.

MSO: And obviously, if you’re looking for that kind of information, check out our website, The Cannigma, cannigma.com and check out Dr. Ruth Fisher’s book, The Medical Cannabis Primer.

Ruth, thank you so much for taking the time. This has been a fascinating conversation, and I would love to have you back one of these days, again.

RF: Thank you. Wonderful, wonderful. I had a wonderful time. Thank you.


Debbie Churgai (Executive Director of Americans for Safe Access): Despite the fact that 33 states in the United States have reformed their laws to provide for safe and legal access to cannabis for qualifying patients, veterans living across these states still face a confusing system of federal and state laws regarding physician engagement and affordable access.

For example, veterans who rely on the US Department of Veteran Affairs as their primary health care provider are unable to receive medical cannabis recommendations from their doctors, even if they live in a state with a medical cannabis program. And veterans who use medical cannabis to treat their condition must also pay for this medication out of pocket with no financial support or subsidy from the VA.

The roughly 20 million veterans living in the United States experience health challenges ranging from chronic pain, traumatic brain injuries, and post-traumatic stress disorder at a higher rate than the general population. According to the VA, nearly 20% of Iraq and Afghanistan veterans experience PTSD or depression following their service, with 60% of servicemembers returning from duty in the Middle East, with some form of chronic pain. Treatment offered for these conditions by the VA typically includes use of opioid based products, which have well documented addictive and long-lasting side effects, and are killing veterans at a rate twice that of the civilian population due to accidental overdose.

Meanwhile, ongoing research continues to demonstrate the effectiveness of cannabis as a medicine and treating PTSD, neurological issues and chronic pain and in reducing opioid dependency. And two 2020 studies, one conducted by Wayne State University in Michigan and the other by Brazil’s Federal University of Paraná, demonstrate that cannabis can reduce anxiety and adults overwhelmed by trauma as well as reducing and eliminating traumatic memories. And it was recently announced at the Battle Brothers Foundation in partnership with Naya Medic, one approval for a study on the use of medical cannabis to treat PTSD in veterans.

Beyond advancements in research, there is also wide support among veterans for federally sanctioned access to cannabis and education of VA doctors on cannabis as a medicine. Results of this 2017 American Legion study revealed that over 90% of veterans support medical cannabis research, with 80% surveyed also supporting allowing VA doctors to recommend cannabis to veterans. In the same survey, 22% of veterans said they were already using medical cannabis to treat chronic pain, PTSD, agitation and to improve sleep quality.

In addition to VA doctor consultations on cannabis from cannabis education physicians, the Veterans Administration must also tackle the issue of affordability. The affordability of cannabis continues to be one of the greatest barriers to access reported by patients across the country. Veterans who use medical cannabis to treat their condition must also pay for this medication out of pocket with no financial support or subsidy from the VA. The cost of medicine can vary wildly, depending on the state and city in which the patient lives with monthly costs ranging from hundreds to thousands of dollars.

With promising research advancing, abundant legal state access available and one in five military veterans making the choice to use state authorized medical cannabis for treatment, it is time for the VA to reexamine its policies on cannabis. While Congress has demonstrated leadership through important legislation like the VA Medicinal Cannabis Research Act, and the Veterans Equal Access Act, there is much the new administration can do to take action to help veterans with medical cannabis.

The administration and the VA can repeal 3(b) of the Veterans Health Administration directive, 1315, so that cannabis is no longer defined as a drug of abuse. Doing so will enable VA physicians to consult with veterans on medical cannabis and initiate an important process of integrating medical cannabis education and training into the curriculum of VA doctors. Americans for Safe Access stands with veterans in strongly urging the dividing administration to take this important step. And you can too, visit our website at safeaccessnow.org/100days to see what actions you can take to help protect medical cannabis patients and expand access.

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