OFFICERS January 30, 2018 President Kelly J. Clark, MD, MBA, DFAPA, DFASAM President-Elect The Honorable Shane E. Pendergrass Paul H. Earley, MD, DFASAM Vice President Chair, House Health and Government Operations Committee Margaret Jarvis, MD, DFASAM Room 241, House Office Building Secretary Yngvild Olsen, MD, MPH, FASAM 11 Bladen Street Treasurer Annapolis, MD 21401 Brian Hurley, MD, MBA, FASAM Immediate Past President R. Jeffrey Goldsmith, MD, DLFAPA, DFASAM Re: Opposition to HB268

BOARD OF DIRECTORS Dear Chairwoman Pendergrass and members of the House Health and Directors-at-Large Government Operations Committee, Anthony Albanese, MD, DFASAM Marc Galanter, MD, DFASAM William F. Haning, III, MD, DFAPA, DFASAM On behalf of the American Society of Addiction Medicine (ASAM), the nation’s Petros Levounis, MD, MA, DFASAM Edwin A. Salsitz, MD, DFASAM oldest and largest medical specialty organization representing more than John C. Tanner, DO, DFASAM 5,500 physicians and other clinicians who specialize in the treatment of addiction, and the Maryland-DC Society of Addiction Medicine (MDDCSAM), Regional Directors we would like to take the opportunity to provide our opposition to HB268, Region I Director Jeff Selzer, MD, DFASAM which would allow the state medical cannabis commission to approve certain Region II Director provider applications for patients who have an opioid use disorder (OUD). Murtuza Ghadiali, MD Region III Director With the opioid addiction and overdose epidemic significantly impacting the Kenneth Freedman, MD, MS, MBA, FACP, AGAF, country and Maryland, it is important that patients have access to to the DFASAM Region IV Director clinically proven treatment services that do help people recover. Michael Shore, MD, DFASAM, DLFAPA Region V Director Anika Alvanzo, MD, MS, FACP, FASAM MDDCSAM and ASAM are dedicated to increasing access to and improving the Region VI Director quality of addiction treatment for patients in Maryland and across the Gavin Bart, MD, PhD, DFASAM country. Ensuring that patients have access to all Food and Drug Region VII Director A. Kennison Roy, III, MD, DLFAPA, DFASAM Administration (FDA)-approved medications to treat opioid addiction is a Region VIII Director critical part of our efforts to improve the care and treatment of patients with Miriam Komaromy, MD, FACP, FASAM Region IX Director the disease of addiction. However, we are concerned about allowing an OUD Peter Selby, MBBS, CCFP, FCFP, MHSc, to be a qualifying medical condition for the approval of certain provider DFASAM Region X Director applications for access to the state’s medical cannabis program. Scott Teitelbaum, MD, DFASAM There is no human data on cannabis’s efficacy in treating OUD. Clinical Ex-Officio experience in Maryland and elsewhere has found no correlation between Stuart Gitlow, MD, MPH, MBA, DFAPA, DFASAM Randolph P. Holmes, MD, FASAM cannabis use and remission or recovery from OUD even though cannabis use Todd Kammerzelt, MD, FASAM is common among those in treatment for opioid addiction. In fact, individuals Michelle Lofwall, MD, FASAM Penny S. Mills, MBA with OUD are actually at higher risk for addiction to cannabis given common Aleksandra Zgierska, MD, PhD neurochemical pathways. Given these concerns, we recommend HB268 be

FOUNDING PRESIDENT reported unfavorably by your committee. Ruth Fox, MD 1895-1989 Currently, there are three categories of FDA-approved medications available in the US for the treatment of OUD: buprenorphine, methadone, and naltrexone. Each of these medication categories have been proven to be safe

11400 Rockville Pike Suite 200 Rockville, MD 20852 Phone: 301-656-3920 | Fax: 301.656.3815 www.ASAM.org for the treatment of opioid addiction, and both clinically and cost-effective in reducing drug use and promoting recovery when used in conjunction with psychosocial services. Cannabis, cannabis-based products, and cannabis delivery devices should be held to the same standards as other prescribed medications and be subject to the FDA approval process to ensure their safety and efficacy.i

It is estimated that 9% of people who use cannabis will become dependent on it.ii That number goes up to about 17% in those who start using the drug in their youth and to 25%-50% among daily users.iii Of the 7.4 million Americans with an illicit drug use disorder in 2016, 4 million had disorders related to cannabis use.iv MDDCSAM and ASAM appreciate the state considering all resources available to help patients with OUD and addiction, but for the safety of Maryland’s patients this bill should not be adopted. We ask the legislature to base any decisions regarding the treatment of OUD and addiction on the current scientific and clinical evidence around FDA-approved medications and address ways to further increase access and use of those proven pharmacotherapies along with psychosocial services.

MDDCSAM and ASAM share the state of Maryland’s goal of increasing access to and improving the quality of OUD and addiction treatment services. While we are opposed to this bill that would allow patients to treat their OUD with cannabis through the state medical cannabis program, we are committed to working with the state legislature to ensure Maryland’s addiction treatment system is aligned with the standards and best practices of the addiction medicine field. Please do not hesitate to contact Dr. Anika Alvanzo, at [email protected] if MDDCSAM and ASAM can be of service to you. We look forward to working with you.

Sincerely,

Kelly J. Clark, MD, MBA, DFAPA, DFASAM President, American Society of Addiction Medicine

Anika Alvanzo, MD, MS, FASAM, FACP President, Maryland Society of Addiction Medicine

CC: The Honorable Eric M. Bromwell, Vice-Chair The Honorable Angela Angel The Honorable Erek L. Barron The Honorable The Honorable Antonio L. Hayes The Honorable Terri L. Hill The Honorable Ariana B. Kelly The Honorable Nicholaus R. Kipke The Honorable Susan W. Krebs The Honorable Pat McDonough The Honorable Ric Metzgar The Honorable

The Honorable Marice Morales The Honorable Matthew Morgan The Honorable Joseline A. Pena-Melnyk The Honorable Andrew Platt The Honorable Samuel I. Rosenberg. The Honorable The Honorable Sheree Sample-Hughes The Honorable The Honorable Chris West The Honorable

i American Society of Addiction Medicine. (2015). Public Policy Statement on Marijuana, Cannabinoids and Legalization. Chevy Chase, MD: American Society of Addiction Medicine. Available at http://www.asam.org/docs/default-source/publicy-policy-statements/marijuana-cannabinoids-and- legalization-9- 21-20156d6e0f9472bc604ca5b7ff000030b21a.pdf?sfvrsn=0. ii Lopez-Quintero C, Pérez de los Cobos J, Hasin DS, et al. Probability and Predictors of Transition from First Use to Dependence on Nicotine, Alcohol, Cannabis, and Cocaine: Results of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Drug Alcohol Depend. 2011;115(1- 2):120-130. iii Anthony JC. The Epidemiology of Cannabis Dependence. In: Roffman RA, Stephens RS, eds. Cannabis Dependence: Its Nature, Consequences and Treatment. Cambridge, UK: Cambridge University Press; 2006:58-105. iv Substance Abuse and Mental Health Services Administration. (2017). Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health (HHS Publication No. SMA 17-5044, NSDUH Series H-52). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www. samhsa.gov/data/