March

3, 2016

To: Honorable Members of the Utah House of
Representatives
Health and Human Services Committee

From: Drug Policy Project of Utah
Board of Trustees

Dear Representative,

The Drug Policy Project of Utah (DPPU) would like to thank
you for this opportunity to comment on Senate Bills 89 and
73, which will be heard by your committee.

DPPU is Utahs largest membership-based drug reform
advocacy organization. As an IRS recognized 501c3
nonprofit organization we are dedicated to providing
research and public policy analysis to all Utahns about drug
policies and the effect of they have on our communities,
families, and individuals. Along with other medical
cannabis advocates, DPPU is in support of creating a
medical cannabis program here in Utah, and we applaud
the incredible amount of time and energy that Senators
Madsen and Vickers have exhausted on crafting the two
medical cannabis proposals before you. DPPU has
organized press and public events, prepared research
documents that compile and analyze gold standard, peerreviewed studies on many of the conditions being
considered for inclusion in these pieces of legislation, and
consistently provided accurate, up-to-date information to
Utahns who are interested in the proceedings surrounding
Senate Bills 73 and 89.

We understand and commend the desire to reconcile the
different approaches of these two pieces of legislation and
have compiled the following suggestions for deliberation as
you move forward with the difficult task of creating an
appropriate and robust medical cannabis program in Utah.
We submit for your consideration the following requests
that we believe will positively pave the way for Utah to
establish a comprehensive medical cannabis program
based on scientific research, national best practices, and
compassion.

1. Adjusting the allowable ratio of CBD : THC

The first evidence that cannabidiol (CBD), a nonpsychoactive component of the cannabis plant, could have
antipsychotic properties was published in 19821. This
initial study investigated the interaction between THC and
CBD in health volunteers. The studys authors coadministrated the two cannabinoids together and found
that when done in closer to equal ratios study participants
experienced less anxiety and paranoia than with THC
alone1. The possible antipsychotic effect of CBD received
further support with a report of a higher frequency of acute
psychotic episodes in patients admitted in psychiatric
hospital after the use of a variety of cannabis strains
virtually devoid of CBD2. These initial results led to a series
of studies that have established, from laboratory bench to
patients, a clear link between CBD and its antipsychotic
activity.

Research on the benefits of THC and CBD in isolation is
becoming more and more established. With THC
demonstrating analgesic, anti-emetic, and antiinflammatory properties, and CBD possessing antipsychotic, anti-seizure, and anti-anxiety properties3-4.
Research on the simultaneous use of a 1:1 ratio of THC to
CBD is still in its infancy, but what is believed to be one of
the first studies on this topic can be traced to Brazil in the
mid-1970s. In this study, patients were given between 1560mg of CBD in conjunction with 30mg of THC, and the
resulting effects were measured5. Subjects reported a more
pleasurable experience and less anxiety with the
combination of CBD and THC than they felt with THC
alone5. Furthermore, a different group of
scientists examined the effects of administering CBD at a
dose six times that of THC6. They found that 73% of study
participants reported a decreased feeling of being high
when compared to THC alone6. Follow-up studies have
demonstrated that the combination of the two
cannabinoids reduced users experiences of increased heart
rate, gait instability, and difficulty in eye tracking
exercises7. These results, plus many others currently in the
literature, support the idea that CBD works to minimize
some of the anxiety-inducing side effects of THC. And in
combination, they exert positive therapeutic benefits to
patients.

2. Inclusion of PTSD unrelated to military service

We are also particularly concerned about SB73s exclusion

of unqualified Post-traumatic Stress Disorder (PTSD) as a
qualifying condition. Many Utahns including law
enforcement officers, firefighters, emergency responders,
and victims of sexual assault or other traumatizing
experiences will be excluded.

PTSD is a DSM-5 anxiety condition in which a prior intense
trauma results in a long-lasting anxious response, with reexperiencing or flashback phenomena, avoidance of
triggers and overall emotional numbing being the hallmark
characteristics of this condition8. There has been a recent
emergence of empirical studies on the effects of cannabis
on the most common symptoms of PTSD, borne primarily
out of the observation that individuals with PTSD report
using cannabis to assist in coping with the difficult
symptoms associated with this condition; specifically,
hyperarousal, negative affect and sleep disturbances9-10.
Much of the empirical work on this topic has consistently
demonstrated that the endocannabinoid system plays a
significant role in the etiology of PTSD, by way of increased
total number of receptors in the brains of those suffering
from this condition when compared to healthy control
subjects11-12. So, in effect, PTSD brains contain more
cannabinoid receptors than non-PTSD brains, leading
researchers to postulate that these patients do respond
differently to cannabis when compared to patients not
suffering from PTSD.

Multiple studies suggest that THC and CBD may actually
exert opposite actions on brain function with several lines
of preclinical work having shown that CBD reduces the
effects of THC on several different behavioral function
tests13-15. In line with this data, CBD has been found to
reduce anxiety and improve overall sensations of wellbeing
when combined with acute, high doses of THC in healthy
volunteers16. More recent studies have demonstrated that
CBD actually reduces anxiety in patients affected by social
phobia17. In this vein, CBD has been shown to elicit antipanic effects through activation of important brain
receptors critical in modulating our emotional reactivity to
stress18. It is with this data, and much more not presented
here, that leading experts are now beginning to realize that
patients suffering from PTSD and other anxiety related
mental health conditions may, in fact, benefit from more
CBD-rich strains of cannabis, but not CBD in isolation.


3. Improving the qualifying conditions list
Both Senate Bill 73 and 89 use a qualifying conditions list to
delineate which medical conditions the program will cover.
We recommend the conditions lists from both proposals be
merged so that a broader range of patients may be included
in the initial program. Medical research supports the list of
conditions included in both bills and SB73s list is
supported by the findings of a significant body of evidence
regarding the efficacy of medical cannabis in the treatment
of patients.

We recommend the following language:
Qualifying illness.
(1) For the purposes of this chapter, the following conditions
are considered a
qualifying illness:
(a) HIV, acquired immune deficiency syndrome or an
autoimmune disorder;
(b) Alzheimer's disease;
(c) amyotrophic lateral sclerosis;
(d) cancer, cachexia, or such condition manifest by physical
wasting, nausea, or
malnutrition associated with chronic disease;
(e) Crohn's disease or a similar gastrointestinal disorder;
(f) epilepsy or a similar condition that causes debilitating
seizures;
(g) multiple sclerosis or a similar condition that causes
persistent and debilitating
muscle spasms;
(h) post-traumatic stress disorder; and
(i) chronic pain in an individual
On or before September 30 of each year, the committee shall:
(a) review the list of conditions described in Subsection (1) to
determine if, based on available medically relevant
information, it is medically appropriate to add a condition to
the list; and
(b) present the committee's recommendation to the Health
and Human Services Interim Committee.

4. Improving the process for adding new conditions
Both SB73 and SB89 offer a pathway to adding new medical
conditions to the original list through either the Controlled

Substance Advisory Committee (SB89) or the

Compassionate Use Board (SB73.)

We are concerned the Controlled Substance Advisory
Committee is heavily reflective of regulatory agencies and
not the medical community. We recommend that language
from SB73 and SB89 be combined to create a hybrid system
for creating a pathway for patients and their doctors to add
disease states that would then be included in the program.
We believe that the Compassionate Use Board in SB73
should be included in the final version of both pieces of
legislation and should either; a) make a recommendation
directly to the legislature, or b) make an initial
recommendation to CSAC which will then make a final
recommendation to the legislature. Both pathways are
agreeable to us and we believe this more balance by
ensuring the program is neither overly restrictive nor
permissive.

We recommend the following language for the
Compassionate Use Board:
Compassionate Use Board.
(1) The department shall establish a Compassionate Use
Board consisting of:
(a) five physicians who currently licensed and practicing in
the state and
certified in one of the following specialties:
(i) neurology;
(ii) pain medicine and pain management;
(iii) medical oncology;
(iv) psychiatry;
(v) infectious disease;
(vi) internal medicine; and
(vii) pediatrics;{ and}
(b) the director of the Department of Health or the director's
;
and
(c) two medical research professionals with expertise in
cannabinoids or a qualifying
illness, including one medical research professional who is
affiliated with a research-based higher education institution.
(2) The department shall appoint at least one member of the
board who has a specialty in addiction medicine.

5. Inclusion of affirmative defense

Emerging legal precedent including a recent Arizona

Supreme Court19 ruling that found that the presence of
cannabis metabolites, which can remain in the bloodstream
for 30 days, cannot be used as valid evidence of
impairment, supports SB73s inclusion of language allowing
for an affirmative defense. The incorporation of this type of
defense does not condone the illicit use of cannabis as the
current statute allows for those who are impaired to be
charged.

We recommend using this following language from SB73:
(3) It is an affirmative defense to prosecution under this
section that the controlled substance was:
(a) involuntarily ingested by the accused;
(b) prescribed by a practitioner for use by the accused; [or]
(c) a cannabis product that was:
(i) not causing impairment; and
(ii)
(A) recommended by a physician to the accused, if the
accused holds a valid
medical cannabis card under {this section}; or
(B) ingested by the accused in another state in which the use
of {cannabis or} a
cannabis product is legal under state law; or
[(c)] (d) otherwise legally ingested.

In closing we want to express our sincere appreciation for
your consideration of this complex issue. We appreciate the
hard work that each of are engaged in.

Please feel free to reach out to our Board President at the
information below.

Thank you,

Turner C. Bitton
Board President
Drug Policy Project of Utah
(801) 564-3860
turner@dpputah.org




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