TENNESSEE MEDICINE 8 QUARTER 1 | 2019 PHYSICIAN’S HEALTH PROGRAM MESSAGE

physicians that such prescriptive payors, such as Medicaid, Medicare authority was non-delegable. Dr. Quinn and TRICARE, as well as private health was caught in this crossfire. insurance companies. In addition, Medical Marijuana: Dr. Quinn faced inquiries from the Given the choice of agreeing to a DEA, the hospitals where she held Therapy or an Oxymoron? relatively brief suspension of her privileges; and credentialing boards, license or running the risk of a licensure such as the American Board of Family By Michael J. Baron, MD, FASAM Medical Director revocation following a contested case Medicine, where she held a certification. hearing before the New Jersey Medical Fortunately, no adverse action was Board, Dr. Quinn opted to enter into taken against her by any of those bodies. a consent order. The suspension of her license in New Jersey was only This conscientious and dedicated With the current marijuana legalization tide sweeping the nation, the beginning of a host of problems. doctor spent a substantial amount of the question among medical professionals has to be, “Is medical marijuana Nearly every jurisdiction in which time over the course of three years actually therapeutic, or is it an oxymoron, given there is nothing currently Dr. Quinn was licensed required her responding to the disciplinary ‘medical’ about the way this plant is being handled by our pharmaceutical to report her suspension; a failure proceedings and the resulting inquiries, and medical systems?” to timely do so would be an added and traveling to states where in-person count of discipline and subject the attendance was required for medical This treatise is not meant in any way to alter process is arduous, it ensures that our intermediate compounds along biochemical doctor to additional fines. board meetings or hearings, taking the legal regime applicable to Schedule I prescription pipeline is effective and safe. pathways. The compound that shares the time away from her office and substances. This is purely for educational There is no federal process in place to test, name with the subclass is generally the In addition to reporting the disciplinary part-time practice. purposes and not meant to be a push for guarantee or regulate medical marijuana. most pharmacologically active. action against Dr. Quinn’s license to or against how marijuana is treated by the Individual state testing requirements the NPDB, the New Jersey Medical One can see how easily even a federal government. So let me explain… vary greatly from state to state when they Eight of the 10 cannabinoid subclasses Board reported it to each state in which conscientious practitioner can run are present. begin with the prefix “Cann,” making these Unfortunately, there is more emotion and groups of compounds easy to confuse with she was licensed, thereby triggering afoul of a state’s practice act or entrepreneurship surrounding medical each other. The two classes that do not begin the filing of disciplinary complaints regulations, considering the differences marijuana than research or science. What We Know with “Cann” are the tetrahydrocannabinols. against her in all 20 states. Many state from one state to another. Physicians Currently in the United States, the use and The following is known about medical The following is a breakdown of the boards customarily seek “reciprocal who are similarly licensed in multiple possession of marijuana is illegal under marijuana or cannabis. Cannabis comes 10 Cannabinoid subclasses and their discipline”; that is, to mirror the states would do well to take heed of federal law for any purpose because of the from a flowering plant, native to central medicinal properties: discipline issued by the New Jersey Dr. Quinn’s experience and maintain Controlled Substance Act (CSA) of 1970. Asia and the Indian sub-continent. The Delta 9-tetrahydrocannabinol Medical Board. Fortunately, most of a heightened awareness of the myriad Under the CSA, marijuana is classified as a genus includes three species: cannabis •  (∆9-THC) is the Cannabinoid with those state boards, after reviewing of rules and regulations that apply to dangerous, addictive Schedule I substance sativa, cannabis indica, and cannabis the most psycho-pharmacologic Dr. Quinn’s response to the New Jersey their practice in those states. by the Drug Enforcement Agency (DEA), ruderalis. Each species has different ▪ thereby prohibiting even medical use of quantities of the cannabinoids, the active activity. ∆9-THC was first isolated and Medical Board’s consent order, synthesized in the lab in 1964. ∆9-THC Charles K. Grant, is a shareholder the drug. Individual states have passed medicinal compounds that are unique declined to pursue reciprocal discipline has euphoric, analgesic, antiemetic, in Baker Donelson’s Nashville office bills, referendums, propositions and to the cannabis plant. The cannabinoids and either dismissed the complaints do not contain nitrogen, so they are not antioxidant, and anti-inflammatory where he represents doctors and other amendments to make medical marijuana outright or simply placed Dr. Quinn’s classified as alkaloids, differing them from properties. In higher concentrations it professionals before state licensing legal and available with a doctor’s license on probation until such time recommendation for certain ailments. most other psychoactive plant compounds. has psychotogenic (causing psychosis) boards. For assistance with licensing as the discipline in New Jersey was State laws regarding marijuana now properties. Delta 8-tetrahydrocannabinol matters, please contact Mr. Grant or The leaves and buds of the cannabis plant lifted. However, five medical boards conflict significantly with federal law. is the other non-Cann named are cultivated to sell as medical marijuana. chose to mirror the suspension of her any member of the Baker Ober Health With the results of the November 2018 Cannabinoid subclass and is similar to The cannabinoids can also be extracted license, to be followed by probation, Law practice. election, medical marijuana is now ∆9-THC, only less potent. from the cannabis plant and infused into available in 33 states and recreational fines, and prescribing courses. In New edible products such as brownies. The • Cannabidiol (CBD) is the other main Grant advises physicians to consult marijuana is available in 10 states and York, where her private practice was extracted cannabinoids can also be and medically important Cannabinoid. with a lawyer prior to meeting with an Canada. Marijuana is generally first at risk, Dr. Quinn decided to have her concentrated to very high levels and sold CBD has anxiolytic, antipsychotic, investigator from the State’s health approved by the state as medical case heard on the merits. The New York as “concentrates” with product names such analgesic, anti-inflammatory, department. Doctors and other marijuana, followed by approval of Medical Board dismissed all charges as “shatter.” Marijuana growers are now antioxidant, and antispasmodic practitioners often readily meet with marijuana for recreational use, usually against her after hearing her case. producing strains of cannabis with varying properties. CBD oil has been used within a few years. investigators without fully understanding quantities of the cannabinoids, depending to treat many ailments including the pertinent regulations and full Dr. Quinn’s challenges were not limited States where medical marijuana is legal on the desired content. infantile spasms. Cannabidiol is sold to state licensure, however. She had to ramifications of “admissions.” have circumvented the complex, lengthy by numerous online retailers who The cannabinoids are divided into 10 respond to inquiries from government and expensive process required of claim their products are derived subclasses. The cannabinoids in each pharmaceutical firms by the Food and from industrial hemp and therefore subclass are closely related structures Drug Administration (FDA) to bring a legal. Cannabidiolic acid (CBDA) differing by only a single chemical moiety medication to market. Although the FDA is another compound in the CBD * This article is based on a true account of discipline against a physician’s license. The name of the practitioner and the actual medical boards involved have or so, which indicates they are likely subclass and has antibiotic properties. been changed. We are grateful to “Dr. Quinn” for graciously agreeing to share her story in the hope that other physicians can avoid the problems she faced.

Continued on page 22 PHYSICIAN’S HEALTH REPORT PHYSICIAN’S HEALTH REPORT

Continued from page 9 • Cannabigerol (CBG) and As a rule, the cannabis sativa-dominant test conducted on that strain of Medical pesticides, or other substances that turn purified drug substance derived from Like a contaminated factory that produces Cannabichromene (CBC) strains found in dispensaries have Marijuana within the last six months.” up in the end-product. These heavy metals marijuana. Dronabinol (Marinol®) is unsafe medicinal products, cannabis the compounds have antibiotic, delta-9-tetrahydrocannabinol (∆9-THC) and organic contaminants get extracted a synthetic form of ∆9-THC, not an plant, has numerous safety concerns. antifungal, anti-inflammatory, content in the 18-to-30 percent range, Labeling for medical marijuana infused with the Cannabinoids when processing for extracted compound and is a DEA Let’s make the cannabinoids safe for those and analgesic properties. whereas the cannabis indica-dominant products in Colorado includes: “concentrates and edibles.” These products Schedule 3. Epidiolex is 100mg/ml patients who will benefit from their use.▪ strains have much lower ∆9-THC and like “Shatter,” a popular concentrate which and is dosed starting at 2.5mg/kg oral, Cannabinol “ This product contains marijuana and •  (CBN) has sedative, antibiotic, higher cannabidiol (CBD) content relative contains more than 90 percent ∆9-THC, twice per day. anticonvulsant, and anti-inflammatory its potency was tested with an allowable to C. sativa. are marketed as “healthier” because they If you or someone you know is actively properties. CBN is a degradation product plus or minus 15% variance.” “Medicalizing” marijuana sends a don’t involve smoking. Yet they may contain suicidal, please call Mobile Crisis, of tetrahydrocannabinol acid (THCA). FDA-approved medications have a strength signal that this is a “safe” drug. People “ This product was produced without much higher concentrations of heavy metals a 24/7 response team in Tennessee, listed on the container. For example, flouxetine will assume if it is recommended or Cannabielsoin Cannabinidiol regulatory oversight for health, safety, or other soil extracted compounds. Also, at (855) 274-7471. For less emergent •  (CBE), comes in 10mg, 20mg, and 40mg tablets. prescribed by doctors then it must be Cannabitriol or efficacy.” there is no current standard to extract referral needs, the Tennessee (CBND) and (CBT) are the Medical Marijuana is made from harvested safe to use. Marijuana is currently the remaining subclasses of Cannabinoids Cannabinoids. Manufacturers employ Medical Foundation Physician’s plant varieties of cannabis, some of which Allopathic physicians moved away from second leading cause for entry into a and have properties that have not been potentially harmful compounds like butane, Health Program (TMF-PHP) is a have high concentrations of ∆9-THC and plant therapy decades ago. Physicians drug treatment center. By legitimizing fully isolated or determined. rubbing alcohol, and industrial heptane to physician resource that provides some of which have higher amounts of don’t prescribe willow bark or foxglove marijuana as “medical” we are enticing produce concentrates. assessment and referral information. CBD. Most, if not all, medications have extract or opium latex. Physicians prescribe people to use a product of which they The TMF-PHP can also provide What We Don’t Know an optimal therapeutic amount called FDA-regulated, inspected, and verified To date, Marijuana is a Schedule 1 drug, might otherwise steer clear. monitoring and advocacy when As one can see, many of the known the therapeutic index. Too much of a medications with known strengths listed defined as having no currently accepted appropriate for physicians needing cannabinoids have medicinal properties medication and toxicity occurs; too little on the container such as aspirin, digitalis medical use and a high potential for Let’s Do the Research that level of care. The program exists beneficial to patients suffering with a host and the desired clinical effect is missed. and opioids. abuse. This scheduling also makes It is becoming clear that cannabinoid for physicians struggling with illnesses of inflammatory, infectious, neurologic and We don’t know the ideal therapeutic index human research more difficult. Because compounds are effective in treating that include depression and suicidal painful conditions. So, what’s the downside? for the cannabinoids. That research is still Another reason we moved away from Cannabidiol, a compound with promising certain disease processes. However, thoughts or actions. It is a confidential in its infancy. whole plant therapy is that plants can clinical efficacy, is found in the marijuana administering the whole plant to get one service provided for physicians to The downside is that marijuana — even contain contaminants and compounds plant, it is also considered a Schedule 1 cannabinoid compound is not an effective, improve the quality of healthcare in “medical marijuana” — is a plant that, not The individual states where medical that are harmful when ingested. Our drug and therefore illegal. counting the cannabinoids, has more than marijuana is now legal have their own pharmaceutical industry learned to extract safe, or even practical delivery method. Tennessee. Learn more at e-tmf.org labeling requirements, all different from To confuse matters, the FDA recently or call 615-467-6411. 480 different compounds. We’ve known for the beneficial compound and leave the rest. By studying the properties of the each other. The following are examples of approved Epidiolex,® a Cannabidiol 20 years that marijuana smoke has many Cannabis is an accumulator and is often cannabinoids, we will have a much the Colorado warning label requirements oral solution for Dravet Syndrome and of the same carcinogenic compounds contaminated with heavy metals, pesticides, better idea as to which ones are helpful for medical marijuana: Lennox-Gastaut Syndrome, rare forms contained in tobacco smoke, including bacteria and fungus. or harmful. We need to explore this of epilepsy that emerge during childhood polycyclic aromatic hydrocarbons. “ There may be health risks associated with option to get the best data to help guide Phytoextraction can be defined as the use and can be difficult to treat. In contrast Physicians learned years ago that smoking the consumption of this product.” and educate us. Cannabinoid compounds of living plants to absorb and accumulate to Schedule 1, this new medication is tobacco is hazardous. Inhalation of need to be researched, developed, and “ There may be additional health risks metals from the soil into the parts of the plant classified as a DEA Schedule 5 controlled marijuana smoke, just like tobacco smoke, when found efficacious, put into our associated with the consumption of this that are above ground. Phytoextraction substance, the lowest level, defined as is not a safe delivery system. We have little pharmacopeia through the rigorous product for women who are pregnant, is used to clean up soil that has become having a proven medical use and low knowledge as to what these 480 compounds process regulated by the FDA. do. Are they safe for human consumption? breastfeeding, or planning on becoming contaminated. Cannabis is an exceptional potential for abuse. This is the first The answers are not known because the pregnant.” phytoextractor. Cannabis hyper-accumulates FDA-approved drug that contains a research has not been done, in part because heavy metals such as lead, cadmium, “ Contains Marijuana. For Medical Use Marijuana remains a DEA Schedule I, mercury, chromium, and cobalt present Only. Keep out of the reach of children.” which can curtail research, grant funding in the soil as a result of fertilizer use, and study. pollution, emissions, runoff, and mining. This is also mandated to be listed on the Cannabis also accumulates herbicides and The two main strains, cannabis sativa label in Colorado: pesticides. Some states, but not all, require and cannabis indica, are sold at medical testing for bacteria, fungus and heavy “ A complete list of all nonorganic marijuana dispensaries. The following are metals. When medical marijuana is pesticides, fungicides, and herbicides descriptive compilations found at medical ingested, a host of toxic compounds are used during the cultivation of the marijuana dispensaries: potentially being ingested as well. In the Medical Marijuana. few states that require testing for heavy Cannabis Sativa is typically less potent For each Harvest Batch of medical metals, up to 20 percent of products fail but tends to have higher levels of the marijuana packaged within a container, and are destroyed. psychoactive compound ∆9-THC. Most the medical marijuana center shall people who use cannabis sativa find that it Colorado requires a list of pesticides, ensure the potency of at least the medical increases energy, focus, and creativity, and fungicides, and herbicides used during the marijuana’s THC and CBD is included elevates mood. Cannabis sativa is more cultivation, but that does not include the on a label that is affixed to the Container. cerebral and gives a headier, mind-based soil contaminants that have been extracted The potency shall be expressed as a range high. Cannabis indica strains are more by the Cannabis plant. of percentages that extends from the For assistance or to make a tax deductible contribution to the Physicians Health relaxing and sleep-inducing. They tend to lowest percentage to the highest Program, contact the Tennessee Medical Foundation at 615-467-6411; write to the relieve nausea, stress, and anxiety and give Concentrating ∆9-THC or CBD can percentage of concentration, from every increase the amounts of heavy metals, Tennessee Medical Foundation, 5141 Virginia Way, Ste 110, Brentwood, TN 37027; patients a sense of calm. or visit e-tmf.org to send a confidential email or donate online.