Friday General Session

Texas Law on Medical

Susan Hays Attorney Law Office of Susan Hays Austin, Texas

Educational Objectives By completing this educational activity, the participant should be better able to: 1. Discuss use according to Texas law. 2. Identify what is permitted legally and what is not. 3. Discuss what family physicians who want to prescribe need to consider.

Speaker Disclosure Ms. Hays has disclosed that neither she nor members of her immediate family have a relevant financial relationship with an ineligible company.

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I. Introduction & Opening Questions Texas Law on Medical Cannabis: II. What is Cannabis? Policy, science, and the regulatory III. Texas Medical Cannabis Laws: disconnect in a rapidly growing industry Overview Evolution and Current Status that is leaving medicine in its wake IV. Practicing Cannabis Medicine Susan Hays, Law Office of Susan Hays, P.C.

(214) 557‐4819, [email protected] V. Looking Forward & Q&A

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Speaker Background Disclosure I. Introduction • BA Univ. of Texas at Austin; JD & Opening Georgetown University Law Center Ms. Hays has disclosed that neither she nor members of • Bd. Cert. in Civil Appellate Law by Tex. her immediate family have a relevant financial Questions Bd. Legal Certification relationship with an ineligible company. • Counsel and lobbyist for and medical cannabis companies • Worked as the general counsel of a publicly traded cannabis company as Nevada developed and implemented adult use regulations in 2017

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Educational Objectives Getting Our Terms Straight

By completing this educational activity, the participant should • Cannabis = L. the scientific term for a be better able to: genus of plants 1. Discuss medical cannabis use according to Texas law. • Hemp v. Marijuana = An arbitrary legal line in the sand 2. Identify what is permitted legally and what is not. • “Hemp” = <0.3% delta‐9 tetrahydrocannabinol (THC) by dry weight 3. Discuss what family physicians who want to prescribe • “Marihuana” = >0.3% delta‐9 THC by dry weight need to consider. • In popular language: • “Hemp” = Industrial hemp cultivated for fiber and other utilitarian uses • “Marijuana” = Growing it for its bioactive effects/to get high with a word adopted by the law to vilify the plant then most known as used by jazz musicians and Mexican refugees and laborers

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1 Audience Polling Question #1: Audience Polling Question #2: Have your patients ever asked you about Do you routinely ask your patients about cannabis (CBD)? use, including illicit use?

1. Never 1. I ask on my intake form, but rarely talk about it 2. Occasionally 2. I ask and routinely discuss cannabis use with patients 3. Often, but I don’t know what to tell them 3. I just ask about the use of “alternative medicine” 4. Often, and I feel competent to counsel them 4. I don’t ask and don’t tell

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Audience Polling Question #3: Texans’ Cannabis Use What percent of your patients would you estimate • 12.4% of 18+ and 10.9% of 12‐17 y.o. used marijuana in the past year have used cannabis in the last year (any form)? (National Survey on Drug Use and Health 2018‐2019) • 2.4 million adult Texans used in past year; 1.6 million in the past month • Approaching the dropping level of cigarette use nationally (in Texas 18.4% of 18+ 1. < 1% and 16.7% of 12‐17) 2. 1% – 2% • Nationally 14% use CBD (July 2019 Gallup Poll) • Use more prevalent in the West and among younger people 3. 2% – 10% • Most common uses: 40% for pain, 20% for anxiety, 11% for sleep/insomnia, 8% for arthritis, 5% for migraines/headaches 4. 10% – 20% • Texas Compassionate Use Program (TCUP): <1000 before 2019, now more than 4500 and growing by a few hundred a month (, Fig. 1) 5. 20%+ • More than 1300 CBD retailers registered with DSHS

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Audience Polling Question #4: Have you ever heard of “the entourage effect”? • What is in cannabis? II. What Is • The “entourage effect” Cannabis? • Strains and chemotypes 1. Yes • What patients and physicians 2. No need to know about cannabis products • Pharmaceutical cannabinoids

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2 What Bioactive Molecules are in Cannabis? The “Entourage Effect” • Cannabinoids, and not just delta‐9 THC and CBD, e.g., • A variety of “inactive” metabolites and closely related molecules • Cannabigerol (CBG) markedly increased the activity of the primary endocannabinoids, • Cannabichromene (CBC) anandamide and 2‐AG (Ben Shabat et al. 1998) • Cannabinol (CBN) • Explains how botanical drugs are often more efficacious than their • Tetrahydrocannabivarin (THCV) isolated components (despite the single molecule model remaining • Tetrahydrocannabinolic acid (THC‐A) dominant for pharmaceutical development) (Russo 2019) • Terpenes • E.g., CBD + THC more efficacious for pain than just THC (Russo 2019 • E.g., Myrcene, limonene, linalool, caryophyllene, pinene citing Johnson et al. 2010) • Flavonoids • Consider the terpenes as well . . .

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Audience Polling Question #5: Audience Polling Question #6: Have you seen inside a cannabis dispensary in a If you have, did you think it looked like: legal state? 1. An Apple computer store 1. Yes 2. My favorite record store back when there were 2. No record stores 3. The sketchy place where I bought a fake ID in college 4. An appropriate place to dispense medicine and counsel patients, with private spaces for patients to obtain sage medical advice

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Strains and Chemotypes: Lingo v. Science Better to Use Chemotypes: What is the Chemical

• What the guy at the dispensary says: Output? • Sativa – the old school skinny‐leaf brain high • Indica – thick‐leafed couch‐lock body high • Type I – THC dominant, THC > 0.3% (typically 10%+); CBD < 0.5% • Hybrids – anything you can make up (“marijuana” a.k.a. “drug type”) • Your “Blue Dream” is not my “Blue Dream” • Type II – Mixed CBD/THC with a ratio ~ 1:1 (“marijuana”) • Nevada medical cannabis dispensaries tests of 2662 samples showed only three • Type III – CBD dominant THC < 0.3% (“hemp” – maybe) chemovars and twelve genotypes reflecting low medical diversity. Further 396 breeder‐ reported names imply a false sense of diversity. (Reimann‐Phillip et al. 2019) • Type IV – Cannabigerol (CBG) dominant CBG > 0.3% (“hemp”) • Type V – Undetectable cannabinoid levels (“hemp”) fiber‐type Strain names are meaningless in this nascent and • (Aizpurua‐Olaizola 2016; Pacifico 2007; Russo 2019) historically unregulated market that engaged in heavy cross breeding over the last fifty years.

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3 Patients/Consumers and their Physicians Should Forms and Delivery of Cannabis (Legal & Illicit) Know the Full Content • Oils and tinctures – Maybe useful (dominant form in TCUP) • Marketing names for types of CBD (Warning: Not used consistently) • Full spectrum – all the cannabinoids, terpenes, and flavonoids in the plant; less • Edibles: Pills, mints, gummies, etc. – Useful (delayed onset but long processed than isolates, a.k.a. “pure spectrum”. Warning: Contains THC lasting); TCUP adopting • Broad spectrum – full spectrum with THC removed (theoretically) • Isolate (theoretically just CBD + inert medium) • Topicals, transdermal patches, etc. – Useless/little bioactivity • But what did that batch test out with? • Vaporizing flower – Preferred (quick onset but shorter duration) • Full spectrum testing? • ‘Vaping’ oils – Dangerous, especially black market/unregulated (EVALI) • Third party, independent testing lab? • Easy consumer/patient access to specific batch’s test results? • Smoking flower – Safer to vape it/same benefit • 84 CBD products purchased online were tested. Results: 26% over‐labeled • Dabbing concentrates – Absolutely no use/likely harmful (less CBD than advertised), and 43% under‐labeled (more CBD than advertised), and 21% had THC (Bonn‐Miller et al. 2017)

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Pharmaceutical Cannabinoids

• Synthetic cannabinoids • Marinol – Dronabinol, a synthetic form of delta‐9 THC, FDA approved in 1985 • Evolution and Current Status for chemotherapy‐induced nausea and anorexia related to weight loss in AIDS III. Medical patients (2.5, 5, & 10 mg) • History & Legal Context • Syndros – Dronabinol, FDA approved in 2017 Cannabis Laws • Cesamet – Nabilone, FDA approved in 1985 for nausea and neuropathic pain, • Texas TCUP synthetic similar to THC (1‐2 mg 2‐3x/day) • Plant‐derived cannabinoids • Farm Bill & Hemp • Epidiolex – A CBD oral solution approved by the FDA in 2018 for Lennox‐Gastaut • Texas TCUP revised syndrome and Dravet syndrome for children 2 years and older (10 mg/kg/day) • Sativex – Nabiximols, not FDA approved. Oral spray of 2.7 mg THC + 2.5 mg CBD for spasticity and pain. Approved in Europe and Canada. • What of the entourage effect?

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Cannabis Legal History: Law Ignores Medicine Cannabis Legal History: Law Ignores Medicine • 1970 –The Controlled Substances Act classifies drugs in schedules based on the potential for • 1914 – El Paso outlaws “marihuana” after a policeman in Juarez is murdered by a abuse, harmfulness, and known level of medical utility giving the power to schedule a drug to man allegedly in a marihuana‐induced frenzy becoming the first U.S. jurisdiction to do so. the Attorney General rather than to the Department of Health, Education, and Welfare. • 1972 – Presidential Commission on Marihuana and Drug Abuse (The Shafer Commission) • 1919 – Texas outlaws “marihuana” after the Mexican Revolution prompts a wave of concludes marijuana “carries minimal risk to public health,” is not a gateway drug, while immigrants who more widely disseminate marijuana use in Texas. tobacco and alcohol are, and concludes marijuana should not only be rescheduled but • 1937 – American Medical Association legal counsel Dr. William Woodward testifies decriminalized. to Congress that marijuana is not the danger law enforcement describes but is • 1976 – Robert Randall sued the federal government for the right to use cannabis to treat his ignored; Marihuana Tax Act passes. glaucoma, and — backed by science — wins. But the government will not let him grow his own supply, instead launching the Compassionate Investigational New Drug Program. • 1944 – New York mayor Fiorello LaGuardia asks the New York Academy of Medicine • 1979 – Texas enacts a “Therapeutic Research Program” — which to study marijuana; it concludes that marijuana does not lead to addiction, crime, or use of narcotics nor does it induce violence, sex crimes, or insanity. passes out of the House on the consent calendar — to allow participation for cancer and glaucoma patients in the federal Compassionate Investigational New Drug Program. The • 1951 – The Boggs Act, initially directed at heroin addiction, lumps marijuana in with program appears to have never been implemented by the health department but is codified opioids, despite the testimony of Dr. Harris Isbell, the research director at the Public at Health & Safety Code §§ 481.201‐.205. Health Service Hospital’s “narcotics farm.”

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4 Federal Medical Cannabis Détente Thawing Current National Medical Cannabis Status

• 2013 – Cole Memorandum declares that Department of Justice (DOJ) will defer to state and local law enforcement to address marijuana 15 legal states (34% pop.) issues in states with “strong and effective regulatory and enforcement + 21 comprehensive systems to control the cultivation, distribution, sale and possession of medical cannabis (37% marijuana” allowing medical marijuana programs to continue. pop.) = 36 states (71% pop.) • 2018 – U.S. Attorney General Jeff Sessions rescinds the Cole Memorandum, but the Rohrabacher‐Blumenauer Amendment 10 “low THC” states continues to prevent the DOJ from spending any funds to interfering including Texas (27% pop.) with state‐legal medical cannabis programs or participants. • Today – (1) Federal budget riders continue to prohibit enforcement Only 3 complete within state‐legal programs. prohibition states left with only 2% of the population (2) Biden administration expected to expand cannabis regulations. (3) Senate majority leader Charles Schumer drafting a legalization bill. National Conference of State Legislatures, https://www.ncsl.org/research/health/state‐medical‐marijuana‐laws.aspx

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Audience Polling Question #7: Texas 2015: Texas Compassionate Use Act (TCUP) Do you know what “intractable epilepsy” is? (Original Law) • Only for “low‐THC” cannabis with <0.5% THC and >10% CBD (20:1) 1. No • Only for “intractable epilepsy”: “a seizure disorder in which the patient’s seizures have been treated by two or more appropriately chosen and 2. Well, I know what epilepsy is, and I know what maximally titrated antiepileptic drugs that have failed to control seizures” intractable means • Only physicians certified in epilepsy, neurology, or neurophysiology 3. Yes, it’s a diagnosis I am familiar with • Must determine the risk of use is ”reasonable in light of the potential benefit to the patient” • A second specialist must concur • Texas Department of Public Safety (DPS) regulates it and runs a registry of physicians, patients, and prescriptions

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Texas 2015‐2019: A Slow Start Texas 2019: HB 1325 Hemp & CBD • HB 1325: Implements the Farm Bill’s hemp program for Texas • DPS issues draft regulations in December 2015, but does nothing for several months, issuing revised regulations in • Texas Department of Agriculture (TDA) regulates farmers and October 2016 handlers • Department of State Health Services (DSHS) regulates • DPS accepts applications in 2017 but only issues three licenses processing and sale of consumable hemp products (i.e., CBD) (despite having determined that twelve would be necessary for • Every crop must have a preharvest test sample taken by an “reasonable statewide access” as the law requires) independent, third‐party accredited testing lab to ensure the • TCUP registers less than 1000 patients delta‐9 THC potency is not > 0.3% (Certificate of Analysis or • 2018 low‐THC MMJ finally available, but in December 2018 the COA) U.S. Farm Bill legalizes “hemp” and CBD • Third degree felony to use a false lab test with an intent to deceive

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5 HB 1325: Filling CBD Regulatory Void Texas 2019: HB 3703’s Tiny MMJ Expansion

• Consumable hemp products must be tested by an accredited testing lab • Dropped the floor on CBD allowing different CBD/THC ratios, but for cannabinoid concentrations and the presence of contaminants kept THC cap • Packaging must have batch ID and date, names of product and • Dropped second specialist requirement manufacturer, test results, and a certification that the delta‐9 THC level is • Adds “exclusive” list of eligible conditions, symptoms, & diagnoses: <0.3% OR a QR Code or url linking to this information • Any epilepsy (not just “intractable”) • Processing and manufacture of consumable hemp products for smoking • A seizure disorder or vaping is prohibited by statute; distribution and retail by rule BUT • Multiple sclerosis court injunction keeping this provision from going into effect • Spasticity • Amyotrophic lateral sclerosis • TDA will license “producers” (i.e., cultivators or farmers) • Autism • DSHS will “register” retailers and “license” manufacturers • Terminal cancer • Law enforcement can inspect and take samples for testing anytime • An “incurable neurodegenerative disease”

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What is an “incurable neurodegenerative disease”? Who May Prescribe in TCUP?  whatever DSHS’s says it is! • A licensed physician • Rulemaking issued a lengthy list (25 T.A.C. § 1.61) (eff. Dec. 5, • Who is also “board certified in a medical specialty relevant to the 2019) treatment of the patient’s particular medical condition by a specialty • Both Adult‐ and Pediatric‐onset Neurodegenerative Diseases board approved by the American Board of Medical Specialties or the • E.g., Muscular dystrophies, Huntington’s disease, tauopathies, Bureau of Osteopathic Specialists”; and Parkinson’s, Lewy Body disorders, dementias, mitochondrial • “Dedicates a significant portion of clinical practice to the evaluation and conditions, creatine disorders, neurotransmitter defects, etc. treatment of the patient’s particular medical condition” • And physicians may request a condition be added • What is ‘significant’?  open to your judgment • Simple one‐page form to request: • Remember that the goal of the law was to expand access! https://www.dshs.texas.gov/chronic/default.shtm • NB: There is no restriction on the age of patients, but they must be • DSHS may request more information to make a determination Texas residents.

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Audience Polling Question #8: What HB 3703 Did Not Do: Do you think you qualify to prescribe low‐THC cannabis in TCUP? • Raise the 0.5% THC cap – or get rid of it and let doctors practice medicine 1. Yes, I have a certification relevant to a qualifying condition and I •  ”Hemp” is 0.3% so why would you bother with TCUP? dedicate a significant portion of my clinical practice to treating •  Licensee now has a 1:1 THC:CBD oil, but still <0.5% THC/lots of oil that condition • State the cap in a medically useful way such as by milligrams 2. I’m not sure. I have the certification, but I treat a lot of conditions including many that are not on the list • Require third‐party independent testing of medical cannabis products (standard in legal states) 3. No, but I treat patients for conditions on the list • Carefully match the research to the conditions list 4. No, nor do I think I should have to have it to advise and treat my patients • Autism added, but not pain (for which there is a great deal of research) or Tourette’s (for which cannabis is quite effective)

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6 TCUP in Context of Other U.S. States Potential 2021 Legislation

• 2014 Farm Bill allows cultivation of hemp in research programs • Almost 10 legalization bills prompting rash of ”low‐THC” medical cannabis laws including TCUP in • Almost 20 decriminalization bills 2015 • 20 medical cannabis bills • TCUP intended to be a “CBD oil” law, but statutory language does not require “oil” • HB 1535 (Rep. Klick – Fort Worth) • Raise THC to 5% • 2018 Farm Bill moves CBD from “marijuana” to “hemp” – including any • cannabinoid BUT delta‐9 THC & removes research requirement Add acute or chronic pain if a physician would otherwise Rx an opioid • Add PTSD – but for veterans only • FL, MS, MO, OK, UT & VA change “low‐THC” to comprehensive MMJ • Remove requirement that cancer be terminal • TX 0.5% THC level lower than most of the 11 “low‐THC” states which • Any “debilitating” medical condition DSHS designates by rule range up to 5% for the eighth most restrictive laws in the country • Allow research with special cannabis IRBs – but only in partnership with licensed dispensaries – for any condition the IRB approves

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Audience Polling Question #9: Audience Polling Question #10: Do you see any issues with HB 1535? If so, what issues do you see:

1. Yes 1. Having an IRB partner with a dispensing organization 2. No 2. Capping THC by % rather than mg 3. Picking and choosing among conditions 4. Picking and choosing among types of patients 5. All of the above

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Becoming a TCUP Physician

• Simple online registration • TCUP IV. Practicing • Go to: https://www.dps.texas.gov/rsd/CUP/index.htm#physicians • The physician‐patient relationship Cannabis • Then to Licensing and Registration • Patient safety • Name, address, TMB license #, specialization diplomate or certificate # or Medicine in scan • Research Texas • Up to 10 business days to process, then you get an online log in for • Dosing the Compassionate Use Registry of Texas (CURT) • Only 65 physicians registered in May 2019; 270 as of Feb. 2021 • HB 3703 allows TCUP physicians to unpublish their names

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7 How Do You Prescribe in TCUP  CURT Should I Worry About “Prescribing” Cannabis? Recommending It? • You will enter your prescriptions in CURT (Note: “prescription” in TCUP does not mean the same thing as in common use.) • Before the Cole Memo and the federal budget riders many • Available 24 hours a day state MMJ laws allow a “recommendation” of medical • If your patient was already the patient of another TCUP physician, cannabis to avoid fears of irritating the DEA, threats to DEA that physician will have to have the “relationship terminated” in registration, medical licensing, or even criminal liability CURT (really a software design issue DPS is aware of and will • DEA laws regulate Rx of controlled substances, including address if the original physician does not respond) “marihuana”, but the Farm Bill whittled “marihuana” down • The dispensing organizations will then look in CURT to fill the • Texas has “prescribe” in the TCUP law but defines it differently patient’s prescription as an “entry in the compassionate use registry,” i.e., the Rx is • Questions? Check the FAQs on the DPS website or call Regulatory entered into a separate system from DEA Rx. See Tex. Occ. Services (512) 424‐7293 Code § 169.003.

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Physician‐Patient Relationship Patient Safety & Efficacy Considerations Confidentiality & Ethics

• You can freely counsel a patient (See 1st Amd.). Also state law: • What’s a reliable source of CBD? • Communications and records are confidential and privileged. Tex. Occ. Code § • Certificate of analysis of batch‐specific test? 159.002. • Identification of the manufacturer and the testing lab • Exceptions: Legal proceedings brought by a patient, suits over fees, criminal proceedings against physicians, criminal proceedings where a patient is the • Pharmacokinetics of CBD? victim, witness, or defendant BUT cannot use to investigate a patient and must • Counterindications with Rx? have judge review in camera beforehand. Tex. Occ. Code § 159.003 • “An integral component of the practice of medicine is the • Dosing? communication between a doctor and a patient.” Conant v. Walters, 309 • Mg F.3d 629 (9th Cir. 2002) • THC v. CBD ratio • See AMA Code of Medical Ethics Opinion 1.2.11 Ethically Sound • Assoc. of Cannabis Specialists Innovation in Medical Practice

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Medical Cannabis Research How to Read Cannabis Research

Myth: There’s no (or not enough) research • Cannabis research should be read critically given the wide  24,000+ cannabis and 35,000+ marijuana articles in PubMed range of cannabis products used and how they are used • There would be more and higher • What form of cannabis was tested? quality but for the federal • THC isolate? government’s roadblocks: • Whole plant? • DEA can veto NIDA studies and has • Marinol? with great dedication • 10‐years of federal litigation to make • What was its content? (was it tested for an accurate one study happen description?) • Then forced to use NIDA’s substandard Christopher Ingraham & Tauhid Chappell, Government marijuana looks nothing like the real stuff. See for yourself, Wash. Post, Mar. • What dosage? product 13, 2017. • How was it administered? (bioavailability) • See NAS 2017

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8 Audience Polling Question #11: Audience Polling Question #12: Do you have any idea what dose of CBD you Where would you look for reliable should recommend to patients? information about medical cannabis dosing?

1. Yes 1. PubMed 2. No 2. Relevant professional society such as the Association of Cannabis Specialists 3. A medical cannabis company website 4. A 22‐year‐old “budtender” at a marijuana dispensary

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Dosing 19th C. and Modern Advice: Why not use Epidiolex instead of CBD? Start Low and Go Slow Or whole‐plant extract?

135 Lancet 635 (1890) • Insurance coverage? • Quality control? • Costs? • Isolate v. whole plant? • Sensitivities and allergies to additives, flavorings, etc.? • What other considerations?

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Audience Polling Question #13: Which regulatory lane does cannabis belong in?

• FDA regulation? 1. FDA‐approved Rx only IV. Looking • Next legislative session? 2. As a supplement, like fish oil and St. John’s Wort Forward • Q&A? 3. As a food 4. Like cigarettes and alcohol 5. Depends on whether you can have fun taking that particular formulation

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9 Resources Sources • Aizpurua‐Olaizola et al., Evolution of the Cannabinoid and Terpene Content during the Growth of • Association of Cannabis Specialists www.cannabis‐specialist.org Cannabis sativa Plants from Different Chemotypes, J. Nat. Prod. 2016, 79:324‐331 • Epocrates Alt Meds (in the app) • Ben Shabat et al. An entourage effect: inactive endogenous fatty acid glycerol esters enhance 2‐ • National Academies of Sciences, Engineering, and Medicine, The Health Effects of Cannabis arachidonoyl‐glycerol cannabinoid activity. Eur. J. Pharmacol. 353, 23–31 (1998). DOI: 10.1016/S0014‐ and Cannabinoids: The Current State of Evidence and Recommendations for Research (2017), 2999(98)00392‐6 available at • Bonn‐Miller et al., Labeling Accuracy on Cannabidiol Extracts Sold Online, JAMA 318:17, 1708‐09 (2017) • https://www.ncbi.nlm.nih.gov/books/NBK423845/pdf/Bookshelf_NBK423845.pdf de Meijer, Etienne P.M. et al., The Inheritance of Chemical Phenotype in Cannabis sativa L., Genetics 163:335‐346 (Jan. 2003) • National Cancer Institute, Cannabis and Cannabinoids (PDQ), Health Professional Version, • Johnson et al., Multicenter, double‐blind, randomized, placebo‐controlled, parallel‐group study of the available at https://www.cancer.gov/about‐cancer/treatment/cam/hp/cannabis‐pdq/ efficacy, safety, and tolerability of THC:CBD extract and THC extract in patients with intractable cancer‐ (updated Aug. 16, 2018) (surveying medical literature) related pain. J. Pain Symptom Manage. 39, 167–179 (2010). doi: 10.1016/j.jpainsymman.2009. 06.008 • American Academy of Cannabinoid Medicine, Article Library, available at • Pacifico, D. et al., Time course of cannabinoid accumulation and chemotype development during the http://aacmsite.org/article‐library/ (selected articles grouped by topic) growth of Cannabis Sativa L., Euphytica (2007) • Russo, Ethan B., Clinical Endocannabinoid Deficiency (CECD): Can this Concept Explain • Reimann‐Phillip, Ulrich, et al., Cannabis Chemovar Nomenclature Misrepresents Chemical and Genetic Therapeutic Benefits of Cannabis in Migraine, Fibromyalgia, Irritable Bowel Syndrome and Diversity; Survey of Variations in Chemical Profiles and Genetic Markers in Nevada Medical Cannabis other Treatment‐Resistant Conditions?, NEUROENDOCRINOLOGY LETTERS, 2004; 25(1/2):31‐39. Samples, Cannabis and Cannabinoid Research (2019) DOI: 10.1089/can.2018.0063 • Russo, Ethan, The Case for the Entourage Effect and Conventional Breeding of Clinical Cannabis: No ‘Strain,’ No Gain, Frontiers in Plant Science, 9:1969 (Jan. 2019)

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Thank you for reviewing this presentation!

• Jordan Tishler, MD, President, Association of Cannabis Specialists, President/CMO, InhaleMD, Instructor of Medicine, Harvard Medical School, Boston, MA • Ogadinma Obie, MD (”Dr. Olga”), Bd. Cert. Emergency Medicine, Houston, TX • Meera Beharry, MD, Bd. Cert. Pediatrics, Adolescent Medicine, Temple, TX

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10 Notes