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Colin Ward (Host):  Legalization of marijuana is in the news again with state law makers indicating they will not consider passing new legislation in the upcoming session. So, what does that mean for current medical marijuana laws and how does it impact University of Maryland Upper Chesapeake Health? We’ll find out on this edition of the University of Maryland Upper Chesapeake Health Hero Podcast.

Good afternoon. I’m Colin Ward Vice President of Population Health. And with me as always is Lyle Sheldon, the CEO of Upper Chesapeake. Lyle welcome.

Lyle Sheldon, FACHE (Guest):  Colin, good afternoon. It’s good to be with you.

Host:  Lyle our last podcast we learned about E-cigarette use and lung injuries and why so much is still unknown about the dangers of vaping and today, we are going to take a pivot to medical marijuana with the help of Tonya Appleby, a doctorly prepared nurse practitioner and the director of Advanced Practice Hospitalist Service here at Upper Chesapeake. Now this is a particularly complicated issue as we may have patients using marijuana for a variety of ailments but with multiple state and federal regulations seen as being contradictory.

Lyle:  Colin, you’re right. This is a complex topic. Many people don’t know that Maryland actually passed a law in 2013 that allowed the use of marijuana for medical purposes. But that law required academic medical centers to run the programs. The two academic medical centers in the state neither one of them volunteered so the law had to be amended and in 2014 to allow state certified practitioners to prescribe the drug for severe or chronic conditions.

Host:  Okay so we know that people with certain conditions like chronic pain which can sometimes be associated with cancer treatments can legally use marijuana. Why is this such a challenge for hospitals then?

Lyle:  This challenge is that states that have acted to legalize marijuana with a narrow focus on medical conditions, but it remains illegal under the federal government laws.

Host:  And so why is that important at the hospital level?

Lyle:  Because hospitals across the nation could lose their ability to care for Medicare and Medicaid patients by knowingly breaking federal laws which you and I don’t want to do or FDA regulations.

Host:  That’s right and the Medicare Medicaid population, that’s a big portion of the patients we care for.

Lyle:  It’s over 50% of our patients.

Host:  Wow, okay, so there’s a lot at stake here for both patients and medical providers in this area. So, Lyle when we come back, we’ll be joined by Tonya Appleby for a comprehensive look at medical marijuana including the legal issues, the current known patient benefits and the future of cannabis and it's place in medicine.

Welcome back. I’m Colin Ward and I’m pleased to be joined by Tonya Appleby, the Director of the Advanced Practice Hospitalist Service here at Upper Chesapeake. Welcome Tonya.

Tonya Appleby, CRNP (Guest):  Thank you.

Host:  Now before we get started on the legal issues, let’s just talk about what is known about the benefits of medical marijuana? What can you tell us?

Tonya:  Well the research is still limited but the National Academies of Science, Engineering and Medicine came out with a really good book a couple of years ago. It’s kind of like our bible to help us guide us into what medical conditions medical cannabis is good for. Right now we know epilepsy is a big top one. There is a drug known as Epidiolex it’s a schedule 5 drug now. It’s a first of it’s kind that’s made with cannabis to help treat certain forms of childhood seizures.  Chronic pain, MS and muscle spasms due to spinal cord injuries we have seen that medical cannabis has some great benefits. Nausea and vomiting from say chemotherapy, the lost of appetite associated with cancer conditions. Parkinson’s Disease, inflammatory bowel disease and PTSD. And that’s where a lot of our research is focused right now.

Host:  Okay so it seems like there’s a wide variety of clinical conditions that may actually benefit from marijuana.

Tonya:  Indeed. It’s a lot.

Host:  Alright so now you are one of the state certified practitioners so when you are considering treatment options for a particular patient, what would guide you to recommending cannabis for a patient?

Tonya:  Well we have to take a look at their health history and see if they have a qualifying condition. The Maryland Medical Cannabis Commission which guides our ability to be able to certify patients for medical cannabis has some qualifying conditions that allow us to certify patients for medical cannabis. So, just like we talked about chronic pain, nausea vomiting, anorexia due to lose of appetite due to a medical condition or cancer treatments. We look at those conditions to see is they would qualify, and we also look at it to see what have they tried to treat these medical conditions, and did they have a failure of those treatments and then is the medical cannabis really our last effort?

Host:  So, it’s not – it might not be the first treatment option.

Tonya:  Correct.

Host:  Okay. So, can you tell us a little bit about the difference between THC and CBD? There’s a lot of – you can’t walk into a convenience store without seeing CBD oils are for sale here. What’s the difference and help people get oriented to why one is legal over the counter and one is regulated by the state.

Tonya:  Very good question. So, THC and CBD both come from the cannabis plant. There are two types of plants, the sativa and the Indica. When you see THC containing products, they exceed the threshold mandated by the federal government. So, they have more than .3% THC in them. So, those are considered federally illegal. You have to either go to a state where it’s legalized recreationally or have a Maryland Provider certify you for the medical cannabis. THC is going to give you that hallucinogenic stoned kind of effect where as CBD is still pharmacologically active but doesn’t have a lot of the side effects that the THC has. Now to break it down even further, you go into a Walgreen’s CVS and you see CBD oil, oh it’s available for me. It means that it was extracted from a cannabis plant, but it has less than .3% THC in it which makes it legal but the processing of that could be pretty dangerous. Because there is no FDA regulation in some of these products that you are buying from the Walgreens and CVS. So they could have oils, ingredients in them that the FDA is not monitoring that you could be ingesting that could actually be harmful for you.

Host:  And this is the same problem that we see with the vaping pens where there’s seven thousand chemicals and no FDA approval.

Tonya:  Correct.

Host:  Okay. So, now when you have patients that you have certified as being appropriate candidates for medical marijuana and that patient has to come to the hospital for a particular reason; what kind of challenges does that create for our hospitalist team and our caregivers?

Tonya:  Well patient satisfaction is pretty key, and patients do have that self-determination and we want them to take control of their healthcare so when they have been certified for medical cannabis and they can’t bring it into the hospital then they get upset because we’re going to prescribe them something that they know that doesn’t already work.

Host:  And do they know that they can’t bring it into the hospital?

Tonya:  A lot of them don’t. So, when I see patients that come to me for certification for medical cannabis, I go over those rules with them saying you can’t bring it into a hospital. You can’t take it to a public school. You can’t take it to a public place because it’s still considered federally illegal and people don’t want their stuff confiscated so, they’ll have to use other alternative treatments like for pain, for nausea and vomiting when they come into the hospital, but they cannot use their medical cannabis.

Host:  Okay, so you talked about different places where they can and cannot use it. Maybe now is a good time to tiptoe into the legal aspect of this. So, what’s the difference between medical marijuana and the idea of decriminalizing marijuana. What does that mean? Because I don’t – I’m not sure everybody understands there’s a differentiation here.

Tonya:  Right. So, several states have now have medical cannabis laws on the books and several states –

Host:  Most famously Colorado.

Tonya:  Correct. So, you can, anyone from the United States could go to the state of Colorado, walk into a dispensary and purchase cannabis no matter if you are a resident of Colorado or a resident of Nebraska. In terms of legal issues here, we do have decriminalization of the medical cannabis in the state of Maryland, meaning that if you have say for example a small joint on you or an eighth of an ounce on you that you use to smoke in a bowl; as long as you have your cannabis card with you saying that you are a medical cannabis patient, the police cannot prosecute you or arrest you. Can’t say that’s true if you are holding ten pounds of marijuana on you. They probably will try to prosecute you and arrest you and stuff like that.

Host:  And that doesn’t make sense from a treatment perspective.

Tonya:  No, no patient is going to carry around ten pounds of medical cannabis with them. They are going to carry around either their edibles, their small little joints or something like that but I will tell you from all the patients that I have seen, a lot of people don’t want to smoke the cannabis. They want the edibles, they want the creams, they want droplets, they want tablets that are made with THC and CBD to help their medical condition.

Host:  And you can only get those from approved dispensaries, correct?

Tonya:  Correct.

Host:  Okay. So, it seems as though each state, we mentioned Colorado as one but there are other states that have either completely decriminalized or have a different stance on medical cannabis but what is then the difference federally. Why is there so much confusion then? If all the states are saying heh, we’re going to decriminalize or we’re going to legalize medical uses, what’s the hang-up federally? Why the conflict?

Tonya:  Well I think research is still limited about cannabis. It was labeled as schedule one a very, very long time ago and only a few places in the United States are able to study it, grow it and cultivate it. University of Mississippi is one of those. They’ve had an agreement with the federal government for about almost 50 years now to really study and look at growing the plants, studying the plants and look at the plant chemistry of that. That’s where we are lacking and so I think the federal government has still go the hold on it as a schedule one drug to say –

Host:  What – so sorry to interrupt here. but what does schedule one mean for the lay person? What does that mean?

Tonya:  It has absolutely no usefulness in medicine.

Host:  Okay so it’s – it has not been determined that it has usefulness.

Tonya:  Correct and it could be labeled as dangerous and so like your heroine is in the schedule one. So, when you look at these drugs, the federal government still has this hold on it like it’s got to be a schedule one drug and then there’s this still this big debate and a lot of people debating this that it’s still a gateway drug to using other illicit substances.

Host:  Okay so, has the FDA weighed in on this yet?

Tonya:  They are staying quiet. Now, the FDA has weighed on just yesterday letters went out to several companies that are touting the benefits of CBD in the Walgreens and the CVS and your Walmart saying oh CBD is good for sleep, CBD is good for this. These companies cannot make medicinal claims about what their CBD can do and so the FDA instead of going after these businesses they are issuing letters saying they need to redo their packaging. So, you need to be careful when you look at a package that says it’s got CBD or it’s got hemp oil or it’s derived from CBD and THC and it’s making a medical claim, you have to be very careful. Because none of those claims have been substantiated.

Host:  Okay. So, let’s circle back then to the hospital. So, a patient has been cleared, they come to the hospital, they may or may not know that they can not take medical marijuana in the hospital. So, what is the hospital’s policy and how is it governed by the federal regulations?

Tonya:  Well the hospital policy says that patients cannot use their medical cannabis while they are in the hospital. That is a policy.

Host:  Can they bring their medical marijuana to the hospital and just not use it?

Tonya:  They would probably – we would probably ask them to take it home because it’s on our property. I think as healthcare providers when a patient comes into the hospital, if I’m seeing a patient, I need to ask them what prescription medicines are you taking, what over the counter medicines are you taking and are you using any medical cannabis? Sometimes if we don’t ask that question, the patients aren’t going to tell us, so we need to really open the dialog with our patients to ask them what other things that they are taking. We’ve gotten used to asking the patients what vitamins and herbals are you taking and we know that they can have interactions with the medications that we are prescribing them as well. And that’s another shortcoming of the medical cannabis right now. It’s not been studied with other prescriptive medications. So, we don’t know the treatments that we are prescribing our patients in the hospital could have an interaction with the medical cannabis.

Host:  Or their day to day meds. So, their blood pressure control medication or something like that. Okay so we are still new in this field, the research is evolving would you say at this point?

Tonya:  I would say the research is evolving at lightening speed right now.

Host:  Okay. Well thank you Tonya for breaking down this complicated issue. And we’ll be back with more in a moment.

Colin Ward joined again by Lyle Sheldon, the Upper Chesapeake Chief Executive Officer. Lyle we often describe University of Maryland Upper Chesapeake Health as Hope and Healing Close to Home. So how do you see our medical marijuana policies evolving over time? Is this something that the Maryland Hospital Association will help advance or are we really going to need to await future changes in the federal government?

Lyle:  Interestingly enough, just recently, the United States House Judiciary Committee approved a proposal that would decriminalize and tax marijuana at the federal level. Basically it would reverse the federal prohibition by removing marijuana from the controlled substances act while allowing states such as Maryland to set their own rules on Marijuana. This might actually eliminate the conflict between eh current Maryland law and the federal regulations under which Medicare governs hospitals.

Host:  Oh, so that would be quite interesting and something we’re going to have to stay tuned to see how things play out in Congress. Well thanks for joining us as we learn more about medical marijuana and the intersection with hospital medicine. Thanks to our guest Dr. Tonya Appleby from Upper Chesapeake Hospitalist Group. Our next episode will be released in January. For Lyle Sheldon, I’m Colin Ward and we hope you’ll join us in becoming a healthcare hero.