Greetings, everyone, and welcome to a virtual presentation of our APA Accepted Abstract entitled Seeing Through the Smoke, Medico-Legal Implications of Medical Marijuana. I am presenting today with a fabulous group of colleagues, the first of which, who will speak to you, is Maria Lapchenko. She completed a forensic fellowship in Cleveland, Ohio, with the Dr. Knopf Singer, Dr. Resnick team just a few years ago, and it has been a pleasure watching her career blossom. Dr. Saxton completed the fellowship, the same fellowship, just a few years earlier, and it has also been delightful to work with her in Cleveland here over the last handful of years. Who we have finishing up our, or I'm sorry, in the middle of our presentation today is Dr. Chandler Hicks, an absolute rock star of a first-year resident who put this presentation together for us, and finally, myself. I am forensic faculty at University Hospitals in Cleveland, Ohio, and it has been just a delight to work with this wonderful group of people. This was born out of an interest in following up on a presentation that we did at Apple, the Academy, the American Academy of Forensic, excuse me, Psychiatry and the Law, last year, and we are expanding the topic because it has been such a popular, controversial one. With that, I will turn it over to Dr. Lapchenko to take it away. Thanks, Dr. West. So, none of the presenters have any financial interests or relationships to disclose today. We're going to be talking about medical marijuana, but before we do, I'd like to sort of orient you to how the presentation is going to be structured. So I will talk about sort of the historical context of medical marijuana laws. I'll talk about important medical marijuana legislation and case law, and also briefly mention medical marijuana indications and guidelines because there's significant state-to-state variations. Dr. West is going to be talking about the pharmacology, including drug-drug, drug-marijuana interactions, marijuana side effects, toxicity, including the marijuana psychosis-violence link, and she's also going to be talking about cannabis-related DSM diagnoses. Dr. Hicks is going to be talking about issues related to medical marijuana use in the workplace and other psychosocial spheres, including use in schools while participating in sports, driving, and gun ownership. And finally, Dr. Saxton is going to be talking about most clinically relevant stuff, which is issues related to prescribing, including informed consent and potential pitfalls of recommending, including medical malpractice and professional misconduct. So before we get into the meat of the presentation, I'd like to review a few terms. So cannabis and marijuana are two terms that are often used interchangeably. Cannabis is the technical term for the genus of the flowering plant, and there's two popular species that are commonly consumed. Those are the cannabis indica and the cannabis sativa plants. They vary in their THC to CBD ratios. So THC is tetrahydrocannabinol, which is considered the psychoactive component of marijuana. This is in comparison to cannabidiol, which has no psychoactive or intoxicating properties. So cannabis indica tends to have a higher THC to CBD ratio and tends to produce more of the high sensation, whereas the cannabis sativa has a higher CBD to THC ratio. The cannabis sativa plant is also referred to as hemp, because it's used in industry for the production of fabric, fiber, ropes, et cetera. Marijuana is the colloquial term for the smokable plant material derived from the cannabis plant. It generally refers to psychoactive plant material. And so during the presentation, what you'll hear, most of the speakers will probably be using these two terms interchangeably. So there are two main strains, the cannabis sativa and cannabis indica, and they're consumed because of their differing properties, which stem from their THC and CBD contents. And there are also hybrid strains that are crosses between the cannabis sativa and cannabis indica plants, and they're basically crossed to achieve some sort of therapeutic benefit. And all of these are available in medical cannabis form. So I'd like to present some historical context for cannabis laws in North America. These date back quite a long time. And in fact, the first cannabis related law was passed in 1619 in North America by the Virginia Assembly. And this law, it's interesting to note that it was the first marijuana law in North America, and it was mandated that every farmer must grow hemp because of its use in industry and the production of ropes and sales specifically. In the late 19th century, cannabis was a popular ingredient in a number of medicinal products. It was sold openly in pharmacies, and it was sort of touted as the cure-all for what ails you, including everything from stomach pains to gonorrhea to childbirth psychosis, cough, and others. You can see in the picture, there's a formulation called cannabin-bell. It was something that was produced for, quote, mental and physical exhaustion, and its ingredients included both cannabis and strychnine. In the early 20th century, I think public opinions started to change about medical cannabis. It went from being a popular ingredient to something really associated with a large wave of immigration that started to occur in the early 20th century. During this time period, about 900,000 immigrants entered the country legally, many of them from Mexico. It is thought that recreational use of marijuana has been attributed to the influx of Mexican immigrants. Due to anti-immigrant sentiment, it began to be associated with Mexicans, and there were a number of anti-drug campaigns that were launched warning against, quote, the great marijuana menace, the Mexican immigrant. This negative anti-immigrant, anti-marijuana sentiment continued through the 1930s. Of course, during the Great Depression, whenever there's a recession, there needs to be a scapegoat, so the immigrants continue to be scapegoated. There was thought to be a link between marijuana use and crime, and by 1931, 29 states out lawed marijuana, including California, which I believe was the first in 1913. Moving forward, things sort of continued as they were in the 1930s. In 1937, the Marijuana Tax Act was passed. This tax was imposed on both prescribers, so pharmacists, doctors who recommended it, as well as consumers of marijuana. The tax was so high that it basically made marijuana too cost prohibitive to use, either in medicines or in industry. In the 1950s, there were minimum penalties that were imposed, including, and harsher sentences for marijuana-related offenses. Things looked like they were turning around in the 1960s, when the counterculture adopted marijuana as part of their peace, love, and weed movement, but in 1971, with the passage of the Controlled Substances Act by Richard Nixon, this firmly solidified marijuana as an illicit substance with no known medical benefit and high abuse potential. The Controlled Substances Act placed marijuana in the Schedule I category of DEA drugs. It wasn't until 25 years later, in 1996, when Proposition 215, also known as the Compassionate Use Act, was passed in California. This was essentially the first medical marijuana law in the country. That same year, in response to Proposition 215, the federal government issued a policy basically stating that physicians prescribing Schedule I substances was, quote, not in line with the public interest and threatened to revoke their DEA licenses and subsequently prescribing privileges for recommending medical marijuana. It wasn't until 16 years later, from that point, that Colorado, the first state to legalize recreational marijuana, legalized it. Moving forward, this is a pictorial of what the DEA drug classification looked like until 2018. Here you see marijuana in the Schedule I category. Schedule I drugs have high abuse potential and no known therapeutic benefit, according to the DEA. The only change that was made in 2018, when hemp was reclassified. But you can see that marijuana is in the same category as LSD, heroin, peyote, ecstasy, and quail eggs, drugs that physicians certainly do not prescribe and certainly do not advocate use of. This is in comparison to drugs that are cannabinoid-derived. Two drugs, nabalone and dronabinol, are synthetic THC. Both of these drugs are approved for cancer-associated nausea and HIV-AIDS wasting syndromes. These are Schedule II and III, respectively. There's also a medication called epidiolex, approved by the FDA, I believe, in 2018. This is a Schedule V drug, and this is a CBD that's approved for rare seizure syndromes. There's a bit of a disconnect where some cannabinoids are Schedules II, III, and V. Marijuana is still very much Schedule I. There are a number of important legal cases and legislation that dictate how medical marijuana is regulated and recommended in the United States today. The first of these legal cases is Conant v. Walters. This was a case that was filed in federal court in California. It was originally filed in 1997. If you recall from two slides ago, when California passed the Compassionate Use Act, or Proposition 215, in 1996, that same year the federal government issued a policy stating that the prescription of Schedule I substances was, quote, not in line with the public interest. This class action lawsuit was filed just the year following the federal policy. It was a class action lawsuit. The plaintiffs were seriously ill, seriously medically ill individuals, as well as their doctors. These plaintiffs alleged that this federal policy violated, quote, an integral component of the practice of medicine, the communication between a doctor and a patient. The federal government is saying, if you're recommending medical marijuana, if you're talking to your patients about it, we're going to possibly take away your prescribing privileges. The issue at hand was whether the federal policy violated the doctor's First Amendment rights to free speech. Ultimately, the federal court agreed with the plaintiffs and did state that it was a First Amendment violation. It was appealed to the Ninth Circuit Court, who issued the following opinion. They agreed with the lower court that it did indeed interfere with the doctor's First Amendment rights to talk about with their patients what they wished. In the opinion, the Ninth Circuit Court laid out what physicians may and may not do. Physicians may discuss the pros and cons of medical marijuana and may issue oral and written recommendations to use marijuana, but they may not dispense marijuana or aid in the patient purchasing, possessing, or cultivating marijuana. This is the first case. This is a really important case because this is where we derive much of what we do as physicians regarding recommending of marijuana. As a result of Conant v. Walters, physicians do not prescribe marijuana, but they recommend it. The difference between prescribing and recommending is physicians state that someone has a qualifying condition and state whether or not they believe that they could benefit from marijuana. They do not specify the dosage, the frequency of use, or the formulation, which is very different from a prescription. The next piece of legislation, which is very important, is the Rohrabacher-Farr Amendment. This is an amendment to House Bill H.R. 2578, the Commerce, Justice, Science, and Related Agency Appropriations Act. This is an amendment that was initially introduced in 2001. It failed six times before finally being approved in 2014. It's a very important piece of legislation because this is the first time that Congress voted on any medical cannabis bill. The purpose of this amendment is to prevent the use of federal funds to interfere with the implementation of state medical cannabis laws. Basically what this did was prevented state medical cannabis dispensaries from prosecution by DA agents. This is a picture of one of the co-sponsors, a congressman Republican, Dana Rohrabacher from California. The caveat to the Rohrabacher-Farr Amendment is that it needs to be renewed and reviewed annually. It was almost undone under the Trump administration when former Attorney General Jeff Sessions asked to undo it. He believed that marijuana was, quote, only slightly less awful than heroin, but presently it still stands. The next piece of legislation is the Farm Bill of 2018. This is a federal bill, which means that it applies broadly across the country. What this did was it reclassified hemp or cannabis sativa from a Schedule I substance. This allowed for farmers to grow and cultivate it. Much of the CBD oil that is part of the medical marijuana prescribing is derived from hemp. The federal government put a limit on the quantity of the psychoactive component, the THC, that can be included, so it may not be more than 0.3% dry weight. It allows some sort of oversight because the FDA can monitor hemp production. Finally, the last piece of legislation, which has not yet been passed but just introduced, is the Marijuana Opportunity, Reinvestment, and Expungement Act of 2019, or the MORE Act. It was a bill that's sponsored by Kamala Harris and approved by the House Judiciary Committee in 2019. The goals of this act are to remove marijuana from a Schedule I to a lower schedule, to a Schedule III, to require courts to expunge marijuana convictions, and to financially compensate those individuals who were unfairly impacted by the, quote, war on drugs. It is not yet good law because it still needs to be voted on by six House committees as well as both parts of Congress. This is just a brief summary about what I talked about and what we know to be good law in the country. Marijuana is still federally illegal due to the Controlled Substances Act from 1971, though hemp has been reclassified. States are allowed to enact their own marijuana laws, though there is no federal marijuana law because it still remains illegal. State dispensaries are not subject to federal prosecution due to the Rohrabacher Farm Amendment, and legislation to reclassify marijuana is pending but has not yet been approved. This is a map of what the U.S. looks like in terms of their medical cannabis laws. Green and blue states have some sort of law, only three do not, Idaho, South Dakota, and Nebraska. The vast majority of states with cannabis laws allow medical cannabis but not recreational. Eleven states allow both recreational and medicinal. As you can see, there are laws across most states. In comparison, if you look at a map of the world, I was not able to find anything more recent than 2018, though I suspect things have changed since then. Much of the world has medical cannabis laws. Much of Western and Central Europe, Scandinavia, the southern part of Africa, Australia, and Latin America have medical cannabis laws. The U.S. is not terribly unique in that aspect. There's a significant amount of state-specific variations in marijuana laws. Because it's federally legal, there are no federal laws governing marijuana use, marijuana prescribing, so states sort of take it upon themselves to decide how they want to handle their marijuana laws. There's significant variation in what is considered a qualifying condition in the formulation or the form in which medical marijuana can be obtained and used, what is required for physicians, including training, assessment, monitoring, review of the prescription monitoring program, what needs to be included in informed consent, and whether home cultivation is allowed or whether medical marijuana can only be purchased from a dispensary. I'm going to go through these broadly in the next couple of slides. In terms of qualifying conditions, the vast majority of conditions are chronic, painful, and debilitating, and most of them are not psychiatric. Cancer, HIV, AIDS, and multiple sclerosis are the most common ones. Seizures, severe pain, glaucoma, they're all fairly common and approved in most states that have the medical cannabis laws. Ten states do have the provision of, quote, any other medical condition, and what this means is that in those states that have that provision, physicians are able to determine whether a condition qualifies someone for medical marijuana. It is not limited to the list of explicitly stated conditions. In terms of psychiatric, there's obviously significantly less qualifying conditions, though PTSD is the most common, followed by Tourette's. Several states do have a qualifying, and anorexia is a qualifying condition, though it's not specified whether it's anorexia nervosa or anorexia secondary to a medical condition, so it may be sort of open to interpretation. Several states have autism and agitation secondary to autism, and one state contains the term, any debilitating psychiatric disorder, which means that it's at the discretion of the physician who's recommending medical marijuana. There are a number of neuropsychiatric conditions, including Parkinson's disease, Alzheimer's, traumatic brain injury, Huntington's, and one state has CTE as a qualifying condition. States vary in the composition that they allow. Most of the states that have medical cannabis, they allow THC and CBD-containing compounds. About one-third of the states have a limit on how much THC. Remember, THC is a psychoactive component, so a number of states limit how much of the psychoactive component can be present in medicinal cannabis. These are some images that I was able to find online. There's many of them, but some of the formulations that are available for medical cannabis. This is all medical cannabis. It's not recreational. It can be the smokable herb, as you see in the top left corner, edibles, gummies, top right corner, oils, tinctures, creams, et cetera, bottom left corner, and other edibles like cookies in the bottom right. this is all medical cannabis. And states will vary depending on what kind of formulation they allow to be considered quote medical and not recreational. So some states prohibit explicitly the smoking of the herb. It either has to be consumed by some other form or oil has to be vaporized, but it cannot be smoked. So there's significant state-state variation in terms of patient requirements for those who are medical cannabis consumers. Most states do specify that the minimum age to receive a medical marijuana card and to receive medical marijuana is 18, though some states have provisions that individuals under the age of 18 can have medical marijuana, but they need either two physician approval or parental consent, but there's some other sort of stipulation if it's gonna be prescribed to someone under the age of 18. There are possession quantity limits for individuals and this varies from state to state. It could be anywhere from a 30-day supply to a 70-day supply. Some states will specify no more than X number of ounces, whereas other states will say no more than X number of days, very significantly. Home cultivation, as I mentioned in a previous slide, varies from state to state. So some states allow it, others don't. Those states that do allow it generally have quantity limits on the number of immature and mature plants that folks can harvest at home, and it's generally restricted to personal use and you can't grow it for a neighbor or friend. There are registration fees and these vary in how much it costs and then how frequently they have to be paid. From what I've seen, many of these registration fees have to be paid yearly and there are a number of restrictions on use. So there's different state laws about who can and cannot use it and when it can and cannot be used. And finally, so in terms of physician requirements, there's, again, a wide variation in what is required by states. So some states require that a prescriber be an MD or a DO. Other states allow naturopaths and homeopaths. So those states are in the minority. And some states even allow non-physician prescribers like NPs and PAs to recommend medical marijuana. In terms of training, some states recommend or mandate 20 hours of online CME, others mandate four, others mandate no training and you just must have an active DEA and a state medical license. Assessment varies. Some states allow in-person assessments and others allow telemedicine assessments. The monitoring varies. So the number of times that an individual has to be seen in a 12-month period. So some states say only once, so you can give a one-month supply with 11 refills and that's good enough until you see your patient 12 months later. Others say you need to be seen every six months, et cetera. States have different rules regarding the review, the mandatory review of the prescription monitoring program. States do have medical marijuana monitoring and that's a different thing. Medical marijuana monitoring programs, MMPs and then there's a significant variation in what is required in terms of informed consent when informing a patient who you're recommending medical marijuana for about the risks, benefits and alternatives. And so my advice to anyone who's currently doing it or currently considering it, you would have to look at your individual state's medical marijuana laws to make sure that you are in complete compliance because there is such significant state-state variation. And with that, I'll end my piece and turn it over to Dr. West. All right, thank you, Dr. Lapachemko. That was excellent. And I will launch into talking about side effects of marijuana as well as some drug-drug interactions that we might want to consider. Okay, next slide, please. This is just a summary of what we're talking about. We will look at, again, the indications of medical marijuana from a psychiatric perspective and talk about marijuana and psychosis. Next. So Maria touched on this, but we would be remiss to not mention the incredible cultural impact of marijuana in the U.S. These are just a small number of images I pulled up that may be reflective of some of the things that people have come to associate with marijuana in the U.S. We are, especially my generation, Generation X has seen a tremendous shift in the feelings and thoughts about marijuana from the time we were young until the legalization of marijuana in multiple states at this point. Next. So that begs the question, why exactly do people smoke weed? So I'm talking about recreationally, medically, just generally what drives people to pick it up as a recreational substance or to seek it from a physician now that that has become sanctioned here in the U.S. The idea of euphoria, of course, is a big driver. That's dopamine-dependent and is common with other substances that people use recreationally. Some people described heightened senses, feeling colors or seeing, sorry, seeing colors more brightly and hearing sounds more vividly to enhance the quality of their experience. Distorted sense of time, either time slows down or speeds up. Changes in body movement, feeling perhaps paralyzed or leaden, and this may be an appealing feeling to people in the same way that people would use a weighted blanket. Changes in cognition, memory, and learning, of course, can be associated with marijuana and like other substances that are used recreationally, decreased inhibition may be possible too. And people have been using marijuana as pain relief far before it was ever allowed to be prescribed. Next. So I drilled down to medical marijuana in Ohio, where we are all from or trained, and just wanted to echo some of the things Dr. Lapchenko discussed in her presentation. What we're seeing here in green is the psychiatric indications for the prescription of medical marijuana in Ohio. And PTSD is probably the one as a practitioner in Ohio who treats psychiatric patients clinically that I hear the most about, in that people are seeking a diagnosis of PTSD as a justification potentially for getting a medical marijuana card here. Next. So I have borrowed Dr. Lapchenko's slide from 2020 showing the legalization of recreational marijuana in addition to where it is prescribed or legally sanctioned to be prescribed. And that is a significant amount of the country as seen here in blue. I was able to find a study dating back to December of 18. So a little over a year old, and just wanted to highlight how much PTSD is a focus in the prescription of medical marijuana. Because again, I feel as a clinician, that is what I get the most requests for. I myself do not prescribe it, but certainly in the state hospital where I work, I have a number of patients who come in who do have a medical card and are requesting to receive it in the hospital saying that they can get it legally. And there was actually an interesting issue that came up when a patient brought their medical marijuana, which of course was obtained legally, into the hospital, the state hospital, where it is not considered appropriate treatment. And just like any other medication that was obtained legally, but maybe not considered appropriate for people with a history of substance use disorders, we retain the substance and disposed of it, which caused a great deal of consternation in the patient, understandably. So we will move forward. Next slide, please. Okay, we've talked about why people use it. Now let's talk about the meat of what I am discussing today with what can go wrong. So there's some pretty benign side effects, right? We see red eyes, which is a telltale sign that people have been using marijuana, usually one of the first things one can notice in addition to the very potent and recognizable smell. Hyperphagia is a fancy medical term for the munchies with people commonly described to. Xerostomia, a term I got to look up as I haven't seen it since medical school, and that of course refers to dry mouth. Dyspnea or difficulty breathing, not surprising if people are ingesting, or excuse me, using marijuana in a form where they are inhaling it. Tachycardia, common response to any form of marijuana intake. Slowed motor response time and delayed reaction time is another side effect, and one that is particularly concerning when people are either driving or operating heavy equipment. And finally, the psychiatric side effect that we hear most commonly is paranoia. People describe being worried about things or concerned in a way that they normally aren't, and that would be a negative experience associated with marijuana. Next. I wanted to include this timely article released just five days before our presentation regarding COVID-19 and marijuana use. This was published on CNN's website, and the most notable headline quote suggests, even occasional use raises risk of COVID-19 complications. As with everything COVID, I immediately clicked on it and wanted to learn more, and discovered maybe the evidence to support this bold headline wasn't quite as convincing as they had initially made it sound. Some of the reasons that they suggested not using marijuana even occasionally during this crisis is that it may cause airway irritation, as we know, and that may prove to be a confounding variable in diagnosing COVID in that if you're having airway irritation and present to your doctor with symptoms suspicious of the coronavirus, it may simply be related to your use of marijuana. The other is impaired judgment. Again, something that we brought up just a moment ago in the side effects slide, and this was noted to be particularly difficult maybe to manage in this crisis situation, given that you may choose not to follow the current recommendations for social distancing and all the other things that we have been instructed to do to decrease our risk of exposure to COVID. Next slide. So we mentioned short-term side effects that occur simply after using marijuana. There are some more long-term effects that have been linked to chronic marijuana use. The first I was surprised to learn was titled cannabinoid hyperemesis syndrome, also in other realms called cyclic vomiting syndrome, and this was a surprise to me because I understood marijuana to be used as an anti-emetic, particularly in folks who are receiving chemotherapy related to cancer. So the fact that long-term or chronic use could cause a situation where people are experiencing nausea and vomiting more was interesting to learn. Amotivational syndrome is not such a surprise. That's the archetypical picture of the young man who is crashing in his parents' basement on the couch playing video games all day without the motivation or interest in getting up and doing anything or achieving anything in life. There have been noted possible consequences to the fetus during pregnancy and women who smoke marijuana regularly. They describe potential difficulties with brain development and also a lower fetal birth weight. And then the concept of marijuana being a gateway drug is a controversial one. So the fact that there's a prescription and doctors are involved in offering it as a treatment suggests that it is relatively benign, whereas other people put forth that the idea that smoking marijuana introduces individuals to a drug culture where they may be exposed to other potentially more dangerous drugs like cocaine and heroin. Next slide. It is important as psychiatrists, of course, to reference our Bible, the DSM, and I wanted to bring to your attention some of the unsurprising and then more surprising diagnoses that we have listed. Cannabis use disorder, we are incredibly familiar with this. This is the 11 criteria that apply to all substance use disorders that we pretty regularly go through with patients, so no surprises there. Cannabis intoxication is just a nice review of all the effects, side effects that I spoke about earlier. The DSM does note that you can use a specifier to suggest that people are experiencing perceptual disturbances associated with marijuana as, again, a particular specifier for this diagnosis. Cannabis withdrawal. So it has always been my perception of all the substances of abuse that we inquire about as psychiatrists that withdrawal is not something that is commonly experienced with cannabis. I didn't pay it much mind until one day I was testifying on the stand and got asked about cannabis withdrawal. It was brought to my attention that it is indeed a diagnosis in the DSM, and when I reviewed the symptoms, I was interested to find that they are very vague, so it could be associated with just about any disorder that we as psychiatrists diagnose. We're looking at irritability, anxiety, insomnia, low appetite, restlessness, decreased mood, and physical symptoms that are associated with withdrawal. So again, very interesting to find that this does exist in the DSM, even though clinically it's not something that pops up on our radar as psychiatrists very often. And then finally, of course, not a surprise, it's the DSM. There's the unspecified cannabis-related disorder, which is the catch-all category. Okay, next slide. So marijuana and psychosis is something that became incredibly important to me as a clinician. I work in a program that assists in multiple phases and realms. Those who have been diagnosed with a first psychotic episode, usually associated with schizophrenia. Therefore, you can guess that the age of the people in the program is often in their very late teens or early 20s. These are all people who have been exposed to marijuana, and about one quarter of our current 46 patients in the program use marijuana regularly. That's important to me for a number of reasons. One, I find that it poses significant diagnostic difficulties when I'm trying to explain and sort out in my head and then to the family what's going on with the patient. We know that marijuana has been linked to psychosis, and families and patients, of course, find that they want to rely on that as the etiology for the symptoms that might have gotten the young person I'm treating hospitalized and caused the unusual behavior that has concerned the individual and their family so much. So it really does facilitate denial of a true psychiatric disorder, namely a true psychotic disorder like schizophrenia in both the patient and the parents. And finally, I also find some challenges with therapeutic alliance. So I have come to accept that a lot of my folks are using marijuana and kind of passively, though I would never recommend it to my patients, kind of meet them where they're at. So that's really important that I know that, I am open and accepting of hearing the information so I don't alienate my young patients who aren't thrilled to be seeing a psychiatrist at a community mental health center in the first place. Next slide. So this is a guy that I am fortunate enough to work with in the many things that I do in Ohio. His name is Dr. Eric Messamore. He is distinct in that he is both a psychiatrist as well as holds a PhD in pharmacy or pharmacology. And he has really dug deep and drilled into the exploration of marijuana and psychosis. So I am fortunate enough to be able to rely on his very informative slides and present them in a simple way that at least was understandable to me who doesn't like to look at a lot of research. Next slide, please. So we asked the question, can THC cause psychosis? In animal studies, it appears that THC given to rats does cause sensory information processing abnormalities that are also seen in people with the primary psychotic disorder of schizophrenia. Humans in a lab also have demonstrated the same processing anomaly in those who are healthy, not diagnosed with schizophrenia, in controlled conditions in the laboratory setting. Finally, clinical trials run by the FDA, or I'm sorry, reviewed by the FDA state that THC can cause paranoia, abnormal thinking, depersonalization, and hallucinations. Next slide. What's similar between the mental state caused by THC and psychosis as experienced in a primary psychotic disorder? One, we see an increased release of dopamine. Two, we see the decreased effect of glutamate. And then maybe something we're not as familiar with, THC can decrease anandamide, and that is a cannabinoid, endogenous cannabinoid, which is an anti-inflammatory agent, which could, with decreased production, lead to the loss of neuroprotection. Next slide. Percentage-wise, the FDA, kind of a go-to source, suggested that with therapeutic dosing, as Maria indicated in her talk, can be all over the place, as dictated by different states with different opinions. The FDA said that about 3% to 10%, up to one-tenth of people using THC can experience psychosis. And a New Zealand study said that up to 15%, with a fairly large N of 1,000 adults, experience psychosis. Next slide. Okay, so the question that I get asked a lot, back to my first patients and their families, did marijuana cause schizophrenia? If I have a family and an individual who's willing to accept their diagnosis of schizophrenia, the family, of course, wants to know if smoking marijuana led to that. So this really is a chicken-or-egg scenario, because one could also ask themselves, did the symptoms of schizophrenia cause one to smoke marijuana in an effort to solve it? Or did the symptoms of schizophrenia lead to an effort to self-medicate? Next. So what do we know? A 2016 study showed that more exposure to cannabinoids lead to a higher odds of being diagnosed with schizophrenia. And in 2014, there was evidence to suggest that earlier age of onset occurs, especially with products containing a higher concentration of that psychoactive THC. So to further explore this relationship, maybe in a more logistical or circumstantial avenue. We see the THC can potentially lead to decreased compliance with medications, meaning that people may space out and not take the antipsychotics that we know can be helpful to treat schizophrenia. If they do take them, there may be a poor medication response due to some things that we'll talk about in a moment. We see an increased recurrence of psychotic symptoms. And finally, a temporary worsening of positive and negative symptoms, including cognitive impairment. There was also some research to suggest in 2016 that schizophrenia can enhance sensitivity to the effects of THC. Next slide. So CBD is something that comes up. You can find it in a variety of forms. This is simply a very quick Google search for images related to CBD. CBD has been touted as being the kinder, gentler form of marijuana or THC in that it does not typically have psychoactive properties. But of course, we want to think about the possibility of contaminants if not properly prepared, as the FDA does not monitor all these products you see before you. Next slide. What does the FDA have to say about CBD? They suggest that it may cause sedation or suicidal ideation. They say that it may have negative psychoactive effects. Again, we see sedation popping up and then maybe poor sleep quality or decreased appetite. And then finally, other CNS effects include irritability, agitation, aggression, and anger. Next slide. Next slide. Dr. Messamore put together this wonderful slide here that I like to look at the images that he's selected. If you are not interested as much in research and all the ins and outs of it, this is just a quick look at some recent studies that have observed what CBD and schizophrenia, what CBD may do in schizophrenia. We have two seemingly neutral studies to suggest that it didn't help, it didn't hurt. One study to suggest that there was worsening cognition and another study to suggest that it actually may have helped by increasing those anandamide levels leading to a reduced PAM score. Next slide. So as a forensic psychiatrist, I spend a fair amount of my time assessing violent situations that may or may not be the product of mental illness and THC can be a big monkey wrench in that. I testified in a big case recently where there was supposedly chronic marijuana use. So there was a positive level and that had a lot to do with the outcome of the trial. There was testimony from experts regarding marijuana and its impact and what the certain levels mean. So huge focus by the prosecution as a means of discounting potential mental health symptoms that could have had an impact on motive and the actions of the defendant. Next slide. So what's the link between THC and violence? Well, again, looking logistically and situationally at these two components, we think that potentially, and this is common sense stuff, paranoia, anxiety, and panic may lead to conflict with others. Additionally, increased physiological arousal, we know that marijuana causes tachycardia, can lead to increased aggression. Impaired cognition and perceptual disturbances may cause people to interpret the benign actions of others as aggressive, which could lead to combative behavior and fights. And then decreased ability to control aggressive impulses in conflictual situations can, of course, lead to a heightening of the conflict and situations in which illegal drugs are sold, just placing oneself in that situation may increase the potential for violence. Next slide. Okay, so tying this all together, this is marijuana violence and psychiatric illness. The studies really demonstrate mixed results. This is the idea that marijuana may serve to suppress violent activity all the way up to the fact that there may be an almost fourfold increase in the likelihood of violence. An interesting question theoretically that was posed is the idea of violence actually increasing marijuana use, that people are maybe finding their violent activities egotistonic and in order to self-soothe, turn to marijuana to relieve their stress. Of course, any time we look at this many confounding variables, we think about the possibility that any other situational component may affect the outcome of these studies. A few that popped into my head were additional substance use, which comes with a host of other side effects and symptoms, as well as maybe some antisocial personality disorder traits. Next slide. One study that I found that linked THC violence and psychiatric illness with a fairly large N of 1,100 people looked at psychiatric hospital discharges over a period of three years from three different hospitals. They interviewed the individuals discharged five times every 10 weeks following discharge. It did seem in this cohort that persistent marijuana use did lead to an increased risk of violence. And those reported use at each of the follow-up five periods were two and a half times more likely to display violent behavior. Next. And the last thing I wanted to touch on was drug-drug interactions. I have highlighted in green things very relevant to psychiatrists. There are no absolute condor indications for prescribing medications knowing that someone is regularly using marijuana, but a couple of things I wanted to point out. There are some enzymes that metabolize THC, part of the P450 system. Inhibitors of these enzymes, of course, would increase blood levels of marijuana. There are a number of them, some antibiotics and antifungals. And the ones that pop out, of course, to me are the SSRIs, Prozac, and Luvox. So prescribing Prozac and Luvox inhibit these certain cytochrome enzymes, which then increase the potency of marijuana. I found another study to suggest that low-dose alcohol, again, this is still considered under the driving limit, which would be 80. So a low alcohol level, they are qualifying as being around 65, was actually found to increase blood levels of marijuana. And then smoking greater than two joints a week, so we're talking chronic, regular use, caused the induction of a certain enzyme, a certain cytochrome. And this led to increased metabolism of some really important drugs to psychiatrists, including clozapine, Zyprexa, and Thorazine, as well as theophylline, a maybe not so relevant anti-asthma medication. So with Thorazine and theophylline, this induction of the enzyme led to about a 50% reduction in plasma concentrations, which of course is incredibly notable if we are attempting to treat a psychotic disorder with an anti-psychotic. So again, no absolute contraindications, but certainly helpful to note if a patient is using marijuana to know that it may have an impact on the medications we are prescribing as psychiatrists. And with that, I will turn it over to Dr. Hicks. Hello, my name is Chandler Hicks, and the goal of my presentation is to further expand on the ideas presented by Dr. Lapchenko and Dr. West. However, I will focus less on pharmacology and more on social issues. As you all know from the abundance of media and medical coverage, marijuana is at an interesting stage in its development. Due to the discrepancy between federal and state legality, there have been a myriad of issues that have come up. I hope to address and provide clarity on some of these issues. My discussion is by no means all encompassing. However, I believe it provides a thorough base for some of the barriers medical marijuana patients may face. I'll review various topics from driving to travel to school. I'll start by discussing employment concerns. Although typically not considered an issue before recommending most medications, gaining and maintaining employment for medical marijuana users has recently become a hot topic as more states have accepted the utility of medical marijuana. There are roughly over 3 million medical marijuana users with a substantial number of those in the workforce. Making it likely you will eventually encounter this problem. Employment, like most marijuana issues, is delineated at the state level with varying degrees of strictness. The exception to the rule are federal employees which are unable to participate in recreational or medical marijuana due to it being federally illegal. This includes all military personnel. The way I break down employment concerns are first pre-employment issues, then once employed on-duty versus off-duty use. Further discrepancies by employers are made between recreational and medical marijuana. I will start by addressing pre-employment. I picked two states, Nevada and Washington, as case examples due to their contrasting laws. However, I want to point out that although many states are similar in their rulings to Nevada and Washington, each state has slight nuances that should be looked into before making any recommendations to patients. In Nevada, Assembly Bill 132 went into effect January 2020, making it the first state to rule employers cannot refuse to hire candidates who test positive for weed. However, there are some exceptions. So firefighters, EMTs, and federal employees are exempt from this bill and are still required to undergo any testing that the employer may impose. Other states like Arizona and Delaware have ruled employers may not discriminate against medical marijuana users solely based on their cardholder status or positive drug test, unless it would cause the employer to lose money or federal benefits. So we can go ahead and contrast this to Washington. And there are a lot of states that are in line with what Washington has ruled as well. So they took quite a different view than what Nevada has shown. So in 2006, there was an interesting case. There was a female named Jane Rome. She had received her medical marijuana card for migraines. And as she was seeking employment, it took her about four months, but she applied and was offered a position at Teltec Customer Care Management. She accepted the position and it was pending that she would gain employment as long as she was able to pass a drug test. However, it should be noted that that company had a zero tolerance drug policy. So she obviously failed the test due to her marijuana use and Teltec terminated the agreement. The case was brought to the courts where Washington sided with the employer, giving them autonomy over hiring process. So with that, I'll move on to issues when the patient is already employed. So we can break this down first with the on-duty and then next I'll discuss off-duty issues. So with on-duty use, employers are free to fire, discipline or take other adverse action against an employee who uses marijuana at work or shows up to work under the influence of marijuana. However, employers may be asked to acquiesce to the medical marijuana user's disabilities or when they use. So they may be forced, and this is in the case of in Massachusetts and Nevada, where you might have to accommodate your user. So an example of this may be somebody uses at 8 a.m. in the morning for whatever reason, you might be forced as the employer to allow the patient to come in in the afternoon or work on off days when they're not using. There's no specific guideline, but it does say that there are specific recommendations that you need to accommodate this. So it ends up treating it as a disability at the state level. At the federal level though, there was an interesting case in 2012, James v. City of Costa Mesa, where the federal courts ruled that the ADA does not require medical marijuana accommodation. So this is again a discrepancy between federal and state law. So the question then becomes, how do employers know if someone is impaired? Some states only require a positive drug test. Other states like Arkansas, say that a positive drug test alone is not sufficient grounds for punishment. So this is really left up to the employer and at their discretion to determine how they would make the assumption that somebody is impaired at work. So regarding off-duty issues, some states offer no clarity on the issue. Other states are quite different and they are strict and employers may fire employees who test positive for marijuana, even if the use was off-duty and for a medical condition with a valid medical marijuana card. Other states give the medical marijuana user the benefit of the doubt and say they are not allowed to be subject to drug tests or any repercussions secondary to their marijuana use. So I think the most pertinent thing would be to check your company's policy or if you're recommending for patients, making sure you understand what type of job they work. So with that, I'll move on to driving issues. There are currently four modes of testing, urine, blood, saliva, and breathalyzer. The most universal methods are blood and urine. However, the problem remains it is difficult to correlate intoxication with a positive urine or blood screen. Depending on the mode of ingestion, edible versus inhalant, the psychoactive component of marijuana, THC, is released immediately to the brain. Now, if you use an edible, that might take a much longer period than when inhalant. So I'll use inhalant as the example moving forward. So if you smoked weed, that would theoretically cause intoxication within minutes, depending on the amount you use. Obviously, taking one hit versus smoking an entire blunt would be much different. However, the psychoactive component is metabolized within hours, meaning impairment is no longer an issue after three to five hours as the day goes on. The problem is that the non-psychoactive metabolites can remain in the blood and urine for days to weeks, making these metabolites or these modalities a poor indicator of impairment. So a case example you could think of with this situation is you have an individual who's a medical marijuana, they use it chronically, let's say every night. So they finish work, they finish their nine to five job, they go home and to relax for the night, they smoke weed, they have dinner, they go to bed to relax. Theoretically, the person, by the time they would come in the morning, will not have any more psychoactive components in their system and will be fine to drive and go to work. However, let's say they're driving to work at 8 a.m. the next day and they get pulled over, the officer suspects they're impaired and has the person come in for a blood or urine test. The person is gonna test positive regardless, even though they don't have the psychoactive component anymore just because the urine and blood, like I said, can stay in your system for days to weeks. And therefore, it's not a good indicator of actual impairment. Now, some states have recognized this as an issue and some alternatives, one being a breathalyzer. This is not currently in use, but it's being heavily researched in California and Pennsylvania. The idea is not to detect a specific level, but instead the breathalyzer would detect THC particles in the breath for about a three-hour period after use. The breathalyzer would give a warning sign to the officer and give the officer a probable cause for further investigation. The last method currently in use is the saliva test. And that is used currently in Europe, Alabama, Oklahoma, and there are two pilot programs in Michigan and Illinois. And it's being further used across other states as we get more research available. So this method is similar to the breathalyzer and that is a rapid test resulting in about five minutes. It can also test for amphetamines, methamphetamines, opioids, cocaine, and benzos. This works by the office for a swab of the driver's mouth. However, it should be noted that in Illinois, currently the driver has the right to refuse the test. Whereas if you compare that to Michigan, the driver is not able to refuse the test. If they choose to do that, then they could be fined and their medical marijuana card could be removed. So again, the officer is not looking for a specific level but checking for the presence of THC, allowing for probable cause to undergo further testing or arrest the driver. If the swab is positive, then the officer may call a newly developed drug recognition expert to form a filter sobriety test. So a drug recognition expert is a police officer that's undergone specialty training to recognize signs of impairment. So each state has a differing amount of drug recognition experts. So depending on your location, one might be deployed to your area if you got pulled over and to perform increased testing. If you are determined to be impaired or suspected of impairment, you may be arrested and the driver will be brought into the police station for a further workup. There they may do a urine or a drug test, which carries its own set of logistical issues as I talked about. So let's say they wanna do a blood test on you, that would require them to have a phlebotomist on site to complete that. And we also talked about the issue with timing. So perhaps somebody is impaired when they're driving. However, by the time they get back to the police station, we're looking at many hours most likely between that period and the patient may have already metabolized the psychoactive components of marijuana. And so it's kind of a mood issue from that standpoint. So it furthers the idea that urine and blood tests are very poor indicators for impairment. Additionally, there's no current set standard for the level of any bodily fluid that is universally consistent with impairment. Some states have a zero tolerance policy has created many issues for medical marijuana users. There's an interesting case in Pittsburgh, Pennsylvania. That's a good case example of issues with the zero tolerance policy. So Beth Repp, she was a registered medical marijuana patient who crashed her car after suffering a seizure. The police did a blood test following the crash where she tested positive for cannabis. She was subsequently charged with a DUI. As you can imagine, this is contradictory to the idea of allowing medical marijuana. In Pennsylvania and many states, patients are automatically charged with a DUI for any amount of cannabis in the blood. In Pennsylvania, this could mean a year long license suspension, a $5,000 fine and or six months in jail. Some states like Arizona and Michigan have recognized this issue and ruled a positive blood or urine test is not enough to prove intoxication. Rather, the burden of proof is on the officer to prove impairment. So now we'll switch things up and continue to talk about civil liberties. But for patients that enjoy the second amendment as well as smoking pot, then there's some issues regarding gun ownership. So under the Gun Control Act of 1968, any unlawful user of a controlled substance is prohibited from purchasing or owning a gun. The key words being controlled substance. With the Controlled Substance Act of 1970, marijuana was made a Schedule I controlled substance making it illegal for anyone who uses recreational or medical marijuana to purchase a gun. This comes into practice at the gun shop when attempting to buy a gun. There, when you walk in and you say, okay, I would like to purchase a gun, you have to fill out various forms, one of which being the federal ATF form 4473. It's used as a screening tool to determine eligibility and document transactions. On the form, question 11 states, quote, are you an unlawful user of or addicted to marijuana or any depressant, stimulant, narcotic drug or any other controlled substance? Obviously this would rule out, you know, any person that uses medical marijuana. So after you go through these documents, you sign it. If you falsify any answers, that's a felony and it's punishable by up to 10 years in prison plus fines. So it should be noted though, that the gun shops do not have access or at least in most states do not have access to the medical marijuana database. So unless you're upfront and honest about your, you know, that you have a medical marijuana card, they would likely not know. And so it would not be theoretically difficult for you to lie on that. However, there are some grave consequences to that if you are caught. So further restrictions may include issues with travel. This includes flying, trains and buses. TSA is a federal agency at the airports and therefore has a zero tolerance policy regarding weed possession, regardless of medical marijuana status. However, this is very airport dependent and not always put into practice. Some airports may not check at all if you have marijuana on you. Others may allow you to throw it out or place it in the amnesty box, which you can see in the picture. Other places you may be arrested. So regardless of the airport policy, you should check with the airline and what their policy as well. Delta and American have made explicit policies where they bar weed at all on their aircrafts. And this is similar to buses and trains. Now, some states have reciprocity laws, meaning they might recognize your out-of-state medical marijuana card. However, the state's policy is to research if you are planning to travel and you have a medical marijuana card, research what that state's laws that you're going to, say you're going from California to Michigan to look at what is accepted and not accepted. So switching gears, I wanna discuss a few more niche issues medical marijuana users may face. Prior to researching this topic, I would have assumed medical marijuana is not available to individuals on probation. However, in Colorado, this is not the case. There's an interesting example, an individual Alicia Walton, she was a medical marijuana patient who pleaded guilty to a DUI. Unrelated to her marijuana use, she had obtained the medical marijuana card prior to receiving the DUI. After she got the DUI, she was placed on 12 months of probation, told that she is not able to utilize her medical marijuana card. She was obviously upset with this and took it to the courts. And the case was brought up in Colorado and ruling was not made, while she was on probation, it just took too long, but Colorado went ahead and make a blanket statement saying that medical marijuana is allowed during probation. Meaning the prosecutors bear the burden of showing why a person shouldn't be allowed to use medical marijuana while on probation. In a similar concept of loosening of policies, professional sports have become more and more lax on marijuana testing. Under the new collective bargaining agreement, the NFL is no longer suspending players. This is especially notable if you are a Cleveland Browns fan. You might remember a really good wide receiver, Josh Gordon, who played on the team for a couple of years. He was suspended from multiple games and lost multiple years of his career from receiving suspensions from failed weed tests. So if this was to happen today, he would no longer just be suspended. He most likely would have been sent to drug rehab first and would not have lost as many games in his career. Baseball and hockey have taken similar approaches now. They are more so going the route of substance use rather than suspension. Surprisingly, the NBA has the strictest policy. It's a combination of suspensions and fines. However, this does not appear to apply in reality. There are many accounts of players openly discussing using weed prior to games and throughout their career with no repercussions. It's also interesting to note that about 82% of professional teams play where weed is recreationally or medically illegal. So as we contrast professional sports to colleges, there's quite a difference in the stringency of their testing. So colleges take a much harsher stance. It is year round and random urine drug tests across all sports. However, it should be noted that weed testing or weed repercussions for testing positive are less stringent than say if you tested positive for steroids. If you tested positive for steroids, you would automatically get a one year suspension. If you test positive for weed, the first offense is a half year athletic season suspension. If you have second offense, then you miss the entire season. They've also increased the THC threshold over time. So it was originally five nanograms, increased to 15 nanograms, and now it's up to 35 nanograms. Medical marijuana is also not considered an exemption and this comes into play quite often. There's been numerous cases of athletes that would like to use marijuana or CBD oil and have not been allowed to participate by the NCAA. There was a notable case within the last couple of years. There was a football player, CJ Harris. He was attempting to join the Auburn football team to be a part of the 2019 class. He was accepted and was set to join the team. However, as the team doctor was reviewing the documents, it was determined that he was using CBD oil. You know, CJ tried to explain that he has a history of seizures. He'd had a total of 14 seizures over his lifespan and had been on various anti-epileptics with zero reprieve. So he started using CBD oil in 2017. And after the onset of that, had had no seizures. The team was more worried about the consequences from the NCAA and realized that even using CBD, he would not be able to participate. And so therefore he was not allowed to be on the team. You know, there are numerous other examples of how colleges and schools of all levels are in a difficult position because of the discrepancy between state and federal law. There is a big gray area. Most schools receive both state and federal funding, leaving schools worried they will lose funding by disregarding federal law. This is the case at the University of Oklahoma, where it is medically legally in the state, but the school has prohibited any weed on campuses regardless of medical status. This was for students who used to move off campus. Drug testing at schools has further complicated this issue. And there are quite a bit of different case examples. I'll choose one. So Shea Dossier, she's the female noted in the picture. She goes to college at a school in Phoenix, Arizona. She's studying to become a sonographer. Prior to admission to the school, she had obtained her medical marijuana card for polycystic ovarian syndrome. She was treating chronic pain. Prior to applying and when she applied, she told the school that she uses medical marijuana. They told her it was not gonna be an issue. She was subsequently admitted. However, part of the admittance guidelines, she went through a drug screen. She had already started classes when the drug screen resulted and it was obviously positive for cannabis. She was subsequently kicked out of the school and she reacted by suing back. And the case is currently being heard with no resolution yet. However, there are cases that have been resolved. So in Connecticut, there was a nursing student at Sacred Heart University. Similar scenario, she has a marijuana card. She was kicked out of the school after she tested positive. She sued back and it was ruled in her favor because Connecticut law allows medical marijuana and forbids public and private colleges from discriminating against students who use it. So it's interesting how each state is going about dealing with this differently. And some of the states are still dealing with this and coming up with answers to these questions. Florida has another case similar to this that they have yet to move on. Also, high schools are having to start creating policies for administering medical marijuana. You know, there's interesting cases in Florida down in Palm Beach where they're dealing with this issue to allow caregivers to come on campus to administer medical marijuana to patients. Finally, I will close with perhaps the most pressing issue for some patients and that would be cost. Health insurance does not cover the cost of medical marijuana. All payments are made out of pocket. And so you can imagine how that would be a large issue for patients that are more financially strapped. Then in addition, you know, there's various different forms, you know, whether it be going to get a physical or filling out life insurance forms, it's not clear if one should denote if they are a smoker or not. And the effect of that is that can change your rate at which you are given from your life insurance. And as I said, cost may be a large barrier to treatment and may affect your recommendation if you are discussing this with patients. The cost varies by state, depends on supply and demand, the amount the patient wants to buy, the quality of it, the amount of THC content versus CBD content and the methods. So pricing is different if it's an edible versus a topical versus inhalant. It can be further divided by medical versus recreational versus street value. So in Cleveland last year, and I imagine the prices have dropped some now, but I would assume they're still higher than the street value. If we just go by last year's data though, last year, the average cost for an ounce of weed was $472 compared to the street value, which if you average between high and low quality would be around $250. So if you look at somebody who use it chronically on a daily or other day basis, you're looking at thousands of dollars over the course of the year, which might make somebody go the illegal route versus the legal route just because of cost. Recreational marijuana also tends to cost much more due to increased tax rates. And as you can see on the slide, Colorado is a good example of this, the much higher taxation rate compared to medical. Alrighty, so as I finish, I would like to conclude with a fairly obvious statement. Medical marijuana is not like recommending other medications. When we initiate an SSRI, a blood pressure medication, or most medications, we rarely take into account if the medication will affect our patient's ability to travel, work, or drive. We typically focus on the pharmacology and treating symptoms. With marijuana, we have to go a step further because the consequences of oversight can be detrimental. So I would encourage you to first stay up to date on your state's laws regarding marijuana use. Then when evaluating a patient for medical marijuana, we need to put together a thorough social history to evaluate the risk and benefits compared to other treatments. With that, I will end my discussion and turn it over to Dr. Saxton. Thank you, Dr. Hicks. My name is Adrienne Saxton. And in the final portion of our medical marijuana talk today, I'm gonna shift our focus away from users of medical marijuana and onto physicians who decide to recommend medical marijuana to patients. Closely related topic will be the informed consent process. And I'll go through some information about that. When we think about the potential negative consequences associated with practicing medicine in general, they tend to fall into three broad categories. The first is the risk of medical malpractice lawsuits. The second is the risk of disciplinary action by state medical boards. And the third, which is likely less common, but can be pretty significant if it does occur, are criminal charges against physicians related to perhaps egregious care that they provide or fraud or other issues. And then finally, in the area of medical marijuana, there can be the additional consequence of loss of the ability to certify patients for medical marijuana or loss of DEA privileges. I'm gonna focus on the first three today. And I'm gonna start by talking about medical malpractice. Next slide. Can you advance the slide? So in terms of medical malpractice, the good news for physicians who are currently certifying patients to use medical marijuana is that there are no known cases in which a physician was sued under the premise that their recommendation for medical marijuana fell below the standard of care and resulted in damages to the patient. However, despite the fact that there are no known cases, there is some potential that exists in this area, and I'll provide some examples for you shortly. I did wanna take a moment to thank Professional Risk Management Services for providing some information for this talk in terms of some case law and some other data from their company about lawsuits against physicians. Next slide. When a plaintiff sues a physician for malpractice, they need to prove the four Ds of malpractice by a preponderance of evidence. First, the plaintiff needs to show that the doctor had a duty of care toward the patient. Next, the plaintiff needs to show that the doctor deviated from the standard of care, or in other words, that they were negligent in the care they provided the patient. Third, damages had to result. And four, those damages needed to be directly caused by the deviation in the standard of care. So let's think about how this could apply to a medical marijuana case in a hypothetical example. I'll ask you to consider an anesthesiologist or a surgeon who decides to set up a medical marijuana clinic. If they were to see a patient and diagnosed post-traumatic stress disorder, but miss a diagnosis in that same patient of schizophrenia, this could potentially set up some problems for the patient. For example, we know that there is a risk of psychosis with use of marijuana. Studies vary, but somewhere between three and 15%. This patient with schizophrenia is likely at a higher risk of experiencing psychotic symptoms. If the patient goes on to use the medical marijuana and has an exacerbation of psychosis, resulting in psychotic agitation or a delusion in which they seriously injure or kill another individual, this could lead to potential liability for the doctor who recommended the medical marijuana in the first place. So let's break this down. In this case, it's clear that the doctor had a duty of care toward this patient by entering into a treatment relationship with the patient. It's also clear that damages resulted if someone was seriously injured or killed. And then you can argue that direct causation is fairly clear if we could say definitively that this was a substance-induced exacerbation and that that exacerbation of psychosis and the resulting symptoms stem directly from the use of the medical marijuana. So the final area that we need to examine is the standard of care issue. And a lot of times in these cases, standard of care may be argued by both sides. The defense may argue that the conduct met the standard of care and the plaintiff's attorneys may try to show that the conduct of the physician did not meet the standard of care. In this case, it'd be fairly easy to imagine that a plaintiff's attorney could argue that the diagnosis and treatment of mental disorders is generally outside the scope of an anesthesiologist or a surgeon, and particularly if the anesthesiologist or surgeon did not conduct a mental status examination and if they did not request or review past mental health records and if these failures resulted in missing this important diagnosis of schizophrenia, one could argue that their conduct was negligent, resulting in an erroneous recommendation and damages. Now, in this particular example, we're talking about violence to another individual, and an important side note is that many states do have Tarasov limiting statutes that would prohibit liability for acts of violence in the absence of a direct threat. But not all states have these immunity provisions built in for the physician, and they can be variably interpreted by the courts, so you can't count on that being protected. So some of you might be thinking, well, that's pretty rare that the patient would, you know, have this missed psychotic diagnosis and then go on and become psychotic from marijuana and seriously hurt or kill someone. That's fair, it might be relatively rare, but certainly is possible. Another example though, and I could think of this being potentially more common, would be a patient presenting to a similar medical marijuana clinic with a chief complaint of an acute or chronic pain issue in which they're seeking a medical marijuana certification. Some of these marijuana clinics have gotten in the habit of kind of high volume giving recommendations or certifications in a quick and easy format without much workup. If this were to occur in a situation where the doctor failed to work up the acute or chronic pain issue and failed to request records to verify that some examination or necessary diagnostic testing had been completed previously, there's a possibility here of missing a serious issue that's causing the pain issue, for example, a cancerous lesion. So in that case, you could also imagine that there may be some liability for the doctor for failure to conduct appropriate workup, missing a diagnosis, resulting in this recommendation for medical marijuana use. And now the patient's diagnosis of a cancer condition is delayed, treatment is delayed, the cancer has a potential to advance and so forth. Next slide. When we're thinking about malpractice cases, oftentimes the issue really boils down to whether or not the doctor's conduct met the standard of care. I want you to remember that just because marijuana is a legal treatment for various conditions in several states, doesn't mean that the treatment is standard of care. These are two separate issues. Marijuana recommendations being legal just means that the doctor can't be criminally prosecuted for making the marijuana recommendation. However, standard of care is a separate issue. It's a term that's used in medical malpractice cases, and it essentially serves as a benchmark with which to measure the conduct of the physician to see if the care that they provided the patient was negligent or not. And although some laws have built in standards in which a patient does not have to fail a conventional therapy in order for medical marijuana to be recommended, this is again, mainly protection from criminal liability, but I would question how protective this would be against civil liability. Take for example, a patient who presents to a marijuana clinic with a chief complaint of a seizure disorder. And if that patient had not been had appropriate workup or had first-line treatments for the seizure disorder and the doctor agreed to recommend medical marijuana for treatment without advising the patient of potential risks that could be associated with declining more first-line treatments, the patient could go on to have a seizure that could result in serious injury to himself or to others. And I think that it could be argued the doctor may be on the hook there for recommending this treatment, which was not really the standard treatment for that condition. Next slide. We know that these malpractice lawsuits can sometimes get ugly. And a lot of times plaintiff's attorneys will reach for anything they can to try to show that the doctor's conduct was negligent. It would be fairly easy to imagine that a plaintiff's attorney might look toward professional organizations to see what their statement is on recommendation of medical marijuana. And you can see in this slide that I borrowed from Dr. Lapchenko from her 2019 Grand Rounds in Cleveland, that many professional organizations do not recommend medical marijuana due to concerns about insufficient research and potential risks and lack of regulation. So these being brought up in the courtroom would help to support the plaintiff's argument that the doctor's conduct was negligent. Next slide. There are other potential areas of liability in addition to malpractice. One example would be a wrongful death lawsuit. This is a news article from 2011 in which a California physician who had recommended medical marijuana to a 21-year-old college student was sued along with other agencies. In this case, the student was walking on a highway when he was struck and killed by a car. He was intoxicated on marijuana, cocaine, and alcohol at the time of the accident. He had been recommended to use medical marijuana by a physician, and his parents sued that physician for wrongful death under the argument that he should have never been recommended to take medical marijuana because he did not have medical issues. He was a healthy young student. I was not able to find the outcome of this lawsuit, and I imagine in this case it would be difficult to prove causation since he was intoxicated on various substances, not just medical marijuana at the time of this accident. But you could see the potential here if someone took only medical marijuana and became either acutely psychotic or paranoid or intoxicated and got into a similar situation. Next slide. Another area of potential liability that we may think about less often is concern about children gaining access to marijuana products if the patient wasn't informed to safeguard them. Note that there are many edible forms of marijuana which can look very appetizing to children. The picture in the bottom right is that of Stony Patch cannabis edibles, and these are advertised as being sour, then sweet, then stoned. I believe that these were recreational edibles, but there are many medical marijuana edibles that have a similar bright color flavor type of appeal that children could be eager to try to reach out and taste. In the case of the Stony Patch edibles, there was a large raid in New Jersey, and the 27-year-old leader of this company, along with 24 other individuals, were arrested, and the authorities seized millions of dollars' worth of cannabis products and assets, as well as 21 high-end cars, including a Lamborghini and a Ferrari. So this was big business for that company, but it didn't work out very well. They also faced a trademark lawsuit, and although this edible was taken off the market in that area, like I mentioned before, many other edibles look similar. Another area of liability would be for accidents involving driving a vehicle or using heavy machinery while under the influence of medical marijuana. Granted here, there could be an argument that it's common knowledge that marijuana can affect one's ability to safely drive or operate a vehicle, but as physicians, just like we would with any other controlled substance, when there's a risk while driving, while under the influence, patients should be warned of this. Next slide. This is an interesting case in which a physician was sued related to medical marijuana, but not exactly related to the prescribing of medical marijuana. This was a lawsuit against a doctor who worked for Sun Pain Management Clinic, and he had been treating a patient who sought medical marijuana from a separate doctor. The doctor at the pain management clinic elected to terminate care with the patient because he viewed the medical marijuana as clinically contraindicated. However, there is an Arizona statute that indicates a patient's use of medical marijuana does not disqualify them from patient care, and so the patient sued the doctor, arguing that he violated this statute. Next slide. In this case, the trial court dismissed it due to no private cause of action, and it was appealed and the appellate court agreed. However, they did suggest that a possible remedy for this patient, although he couldn't sue under violation of the statute, was instead to complain to the state medical board that the doctor had behaved in an unprofessional manner. Next slide. This is a nice segue into my discussion about medical board discipline. Unfortunately, I wasn't able to find a paper that had statistics about how commonly doctors are disciplined by state medical boards related to medical marijuana recommendations, but we know that in general, nationwide, a little over 4,000 physicians per year are disciplined by state medical boards. This represents less than 1% of physicians with an active license, but in general, the trend is that malpractice suits against physicians are going down over time, but the number of disciplinary actions by state medical boards is increasing. I'm going to review some examples of discipline against physicians related to medical marijuana recommendations from news articles and some case law to give you a sense of the reasons why they were disciplined. Next slide. This is a case from Michigan in which a physician was disciplined by the board of pharmacy and the board of medicine related to his prescribing practices, including medical marijuana, among other things. Specifically, he was accused of certifying medical marijuana without conducting a physical examination. He was unhappy with this discipline and he appealed it to the Michigan Court of Appeals, but the court upheld his discipline and they relied on statements from the American Society of Addiction Medicine, as well as the Federation of State Medical Boards, which had previously put out statements or policies that recommended examining patients prior to certifying medical marijuana. There is a fairly comprehensive guidelines from 2016 put out by the Federation of State Medical Boards, and I'll be touching on those later in my talk. Next slide. This is a case from 2016 in Colorado. Can you go back one slide? This was a case in which four physicians in Colorado had their license suspended related to medical marijuana certifying habits. At the time in Colorado, marijuana patients were allowed to grow six cannabis plants for their own consumption, but doctors could recommend higher plant counts for patients if it was deemed to be medically necessary. An example of a medical need for a higher plant count would include potentially a requirement of the need to make an edible or concentrated marijuana oil, which would require more cannabis than could be gotten from the six plants. However, law enforcement officials had concerns that these high plant counts could just be a cover for illegal diversion of marijuana. In this case, these doctors authorized hundreds of patients to grow 75 or more medical marijuana plants, and the State Board of Medicine there in Colorado came down pretty harshly on them for these recommendations and suspended their license. Next slide. Here we have a fairly egregious example from January of 2019. This was a case in which a naturopath doctor in California lost his license related to medical marijuana recommendation in a child. In this case, a four-year-old boy was brought in by his father, and the naturopath conducted a 30-minute examination. During that examination, he diagnosed the boy with attention deficit hyperactivity disorder as well as bipolar disorder and recommended that the boy's behaviors be treated with marijuana cookies. The doctor of note had faced previous disciplinary action related to the medical marijuana recommendations, and then in this case, lost their license. Next slide. Now we'll go to Pennsylvania, where this picture shows a doctor who titled himself as America's Medical Marijuana Doctor. He ran a clinic called Nature's Way and has a YouTube channel by the same name. On his YouTube channel, he identified himself as a medical marijuana patient and also a recommender of medical marijuana. The article indicates that many of his videos were characterized by long, agitated rants about his relationships with women, his thoughts about the medical profession, and his love of marijuana while smoking a joint. He ended up being referred for essentially a fitness for duty evaluation, it sounds like, and he was diagnosed with a cannabis use disorder for displaying a problematic pattern of cannabis use leading to clinically significant impairment. They thought that his cannabis use disorder was impairing his ability to safely practice medicine, and he had significant restrictions placed upon his license, including that he could not see patients. If you go to his YouTube channel, Nature's Way, you can see some videos about his reaction to that, as well as some of his other videos prior to the disciplinary action against his license. Next slide. For my final discipline case that I'll mention, although this is not comprehensive, there are many other cases out there. This was a case from January 2019 in New Jersey in which a physician had his license suspended related to allegedly running a multimillion-dollar enterprise where he was reportedly indiscriminately recommending medical marijuana to patients that he had not personally treated and did not show a true need for the drug. In his practice, it was said that he hosted conferences at a hotel and he would discuss medical marijuana generally with the group and then sent out his staff members, who were not necessarily trained in the field of medicine, to register large amounts of people into the New Jersey medical marijuana program. The specific problems that the Board of Medicine had with his practice habits included, one, that he did not have a bona fide physician-patient relationship with the individuals he was certifying medical marijuana for, two, that he failed to perform a comprehensive medical history and physical examination to see if the patient actually suffered from a debilitating medical condition that qualified them for medical marijuana, three, he failed to assess the patient's qualifying condition at least every three months as was required in the state at that time, and four, he failed to keep accurate and complete records. He defended himself against these allegations and his attorney referred to him as a trailblazer in his field, but the state medical board did not agree and suspended his license. Next slide. Now I'm going to wrap up this part of the talk with a discussion on criminal charges against physicians related to medical marijuana prescribing or recommending. The criminal charges, again, there was no papers that said how common this was, but I do have a few examples. Next slide. This headline comes from a Michigan case from 2013 in which a doctor was convicted of healthcare fraud and conspiracy to commit an offense or legal act in an illegal manner after a four-day jury trial. In this case, the prosecutor said that the doctor had signed, had sold, signed medical marijuana certificates for $100 each to a middleman, and then the middleman went on to resell them for $250 each at a safe access clinic, which was in an appliance store. They said that more than 300 certificates were sold in this manner, and they said that the doctor failed to establish a patient relationship and failed to gather history, and so ended up facing these criminal charges and was convicted. Next slide. Here we have a 2016 case from Arizona. In this case, a confidential informant for the Navajo County Drug Task Force visited a Dr. Geer in September 2012 undercover to obtain a written certification to use medical marijuana. As part of this evaluation, the patient completed a questionnaire and agreed to have his medical records for the last one year sent to Dr. Geer's office or to bring them to the next appointment. Dr. Geer went on to examine the patient and completed a required form in which he said that he reviewed the patient's medical records for the last 12 months, but he actually had not received them or reviewed them at the time that he filled out that form. So the doctor was indicted on forgery and fraudulent schemes and artifices. The doctor submitted a motion to have this criminal charge against him dismissed because there was a physician immunity provision in the Arizona Medical Marijuana Act that basically prevented physicians from criminal prosecution for recommending medical marijuana based on their professional opinion. The trial court granted the dismissal, but the state appealed, and the Arizona Supreme Court reversed, and they essentially said that this immunity provision wasn't meant to give immunity for lying about reviewing patients' medical records. So this case was able to go forward against the doctor. Next slide. All right, so we talked about several ways in which physicians could face either potential or real consequences related to recommending medical marijuana. It's unclear how common this is, but it does happen, and I have some recommendations for you if you do consider certifying medical marijuana on ways that you can reduce your risk. I would recommend first that you familiarize yourself with guidelines that are out there by various organizations for medical marijuana recommending, and one that I'm going to rely on in my talk is that of the Federation of State Medical Boards, which was put out in 2016. In addition to professional guidelines, you should review your specific state law closely and follow the requirements as outlined in your state. Maintain proper and accurate records and be truthful in those records so that you don't face potential fraud charges, as we've heard of some undercover people going out to kind of investigate the way that these marijuana clinics are operated. Next slide. This slide is for individuals to refer to later if you'd like. It just kind of goes over the basic bullet points on the Federation of State Medical Board guidelines, and I'm going to go ahead and touch on each of these in the coming slides. Next slide. The guidelines first recommend that you establish a bona fide physician-patient relationship before giving a recommendation for medical marijuana. You should not recommend it to yourself or to a family member, and be sure that you actually do an evaluation in a traditional doctor-patient relationship rather than just meeting someone in a hotel or elevator and passing out medical marijuana cards. Next slide. Just like any new evaluation, a thorough patient evaluation is recommended. Next bullet point. History of present illness. You can go ahead and put up the rest of the bullet points. A social history and past medical-surgical history. Looking at the substance use history of the individual with particular emphasis on whether or not they've had signs of a substance use disorder. Looking at family history, in particular, family history of psychotic disorders or substance use disorders. Performing a physical examination. Looking at past treatments that they've had for their condition and whether or not there was an accurate response. And then finally, formulating a diagnosis. Of note, the physical exam was one that has been harped on quite a bit in terms of disciplinary action by state medical boards. Recently, with the COVID-19 crisis, there's been some changes in some states in which telehealth evaluation is now allowed for medical marijuana, but you would need to look at your specific state recommendation regarding that. Next slide. The guidelines also recommend a fairly detailed informed consent process, and as was mentioned before, many states require that certain information is written into your informed consent. Keep in mind that many patients come seeking medical marijuana with the view that marijuana is all natural and essentially very little risk associated, but as we heard in Dr. West's talk, there are numerous potential side effects and you need to make patients aware of those side effects. Patients also need to be made aware of the lack of standards with marijuana products. Keep in mind there is no FDA approval or regulation of these marijuana products. There can certainly be variability in the THC and CBD component that patients receive. Some states do have more stringent regulation of their cannabis dispensaries, whereas others have very little regulation. Then there are states that allow home cultivation in which there's really no testing for the CBD or THC content, so it's really difficult to know what you're getting. Also, there's been concerns about purity as some of these marijuana products have been found to have mass quantities of pesticides, and then patients are taking in these additional substances unknowingly. As part of the informed consent, you should warn your patients about the risk of driving or operating heavy machinery under the influence, as well as the risk of developing a cannabis use disorder. Dr. West talked a lot about the risk of psychosis, and so patients should be made aware of that, as well as other cognitive effects such as memory and concentration difficulties, and even some studies show some lasting mild decrease in IQ. Pregnancy and breastfeeding risks, as well as the importance of safeguarding these products from children and pets. Next slide. The FSMB guidelines recommend a written treatment agreement between the doctor and the patient, and this treatment agreement includes a lot of the informed consent components that sort of weigh the risks and benefits, and also includes consideration of additional diagnostic evaluations or planned treatment. These guidelines recommend that you do not give a duration of treatment for medical marijuana of more than 12 months at a time, although like we mentioned before, some states require more frequent monitoring, and that this treatment agreement should be signed by the patient. Next slide. We talked about how states have variability in what conditions qualify for medical marijuana, so you need to refer to your state law to see if a condition qualifies, and even if the condition does qualify, it's up to your professional judgment to consider the evidence base for the recommendation, and to weigh the risks and benefits of that recommendation with the patient for their specific case. Next slide. The guidelines also recommend ongoing monitoring, seeking outside consultation if needed, and maintaining appropriate records. This includes registering with the state agency for medical marijuana, checking the state prescription monitoring drug monitoring program each time a recommendation is issued, assessing their response, and then changing the treatment accordingly as needed as you would with any other treatment. Outside consultation would include seeking referral for pain management or substance use treatment or other specialists if you think that there's a condition going on that maybe the medical marijuana is not going to be that helpful for, and the patient needs to seek other diagnostic assessment or treatments, and then keeping timely and accurate records. Next slide. I would think that this one would be a no-brainer, but not always. Physicians need to ensure that they avoid conflicts of interest, and therefore they should not have any financial interest in a marijuana dispensary. Final slide. In summary, currently there's a relatively low risk of malpractice against physicians related to medical marijuana recommendations, but there is some potential there in the future. State medical board discipline, although we don't know exactly how common it is, it is a realistic concern. Then it's important to follow professional guidelines and state law carefully because if you're not following those requirements, you're at a higher risk of receiving some type of action. Your informed consent should be written and should be detailed.

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