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I sense it a sliver of a second before it happens, but not soon enough to just get back in bed and ride it out. The bladder spasm makes my whole pelvic floor seize up and I abort attempts to stand and just half-slide down to the floor. Imagine a pufferfish huffing and puffing itself to full, spiky roundness right between your hips. Full. Inflation. That's a bladder spasm: the alarm with no snooze. Crouching on the floor, I paw for my PAX vaporizer and hope it's been charged and loaded with some of the mercifully high-CBD, low-THC cannabis that helps calm the spasm and lets me peel myself out of bed.
Everyone gives you a sly smile when they hear you're a medical marijuana patient, like you're spending all your evenings on the couch, getting high, the wing place on speed-dial. Sitting on the floor with a pulsing bladder, I'm far from the recreational user profile: I carry an Interstitial cystitis (a chronic bladder issue) diagnosis, permitting my medical use. Lucky for recreational users in my state, Massachusetts has just legalized adult-use marijuana. Less lucky is that, when shops open in June of 2018, medical marijuana patients may feel some undesirable side effects from a pushy industry.
Many Massachusetts residents have integrated marijuana into their routine for a range of reasons, and medical patients mostly expect access without interruption. As the market adapts to the new law, Jonathan Caulkins, former director of the RAND's Drug Policy Research Center and professor at Carnegie Mellon, says that there are three types of users who will make up the market: patients with a disease who believe marijuana is directly treating illness, recreational use, and the wellness bloc that he describes as approaching cannabis "the way that people going to GNC approach food supplements." "They're not treating the disease," he says of both the medical and wellness blocs, "they're treating symptoms."
For some, that's enough. Caulkins says: "One possibility will be that it'll be treated like a "nutraceutical" where the store says 'we're all about health,' but the package never says 'this will cure cancer.'" The thirty billion dollar supplement industry already outpaces regulators so much that it's hard to fathom how the burden of cannabis testing and quality standards could be simply piled on top of the FDA's existing workload.
There is an awareness, though, that regulating cannabis will require hefty resources: In Massachusetts, the legislature created the Cannabis Control Commission to regulate medical marijuana (previously under the Department of Public Health) as well as recreational use. As legislative and regulatory shifts collide with the introduction of a lucrative industry, medical users should brace to make room for the recreational market.
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"Nutraceutical" wellness weed is a long way off due to the precarious status of a federally illegal substance with legal status in some states. The likelihood of success of Cory Booker's recently introduced Marijuana Justice Act of 2017 is low, some experts say. Aaron Lachant, partner at Nelson Hardiman law firm, says the DOJ's review of the Cole Memorandum is expected to come out in the next couple of weeks and "we'll get our first real policy position from the Jeff Sessions Department of Justice on how they look at medical and nonmedical marijuana."
While unlikely under the current administration, "If Cannabis gets removed from the Controlled Substances Act, everything will instantly become prohibited under the FDCA [Federal Food, Drug, and Cosmetic Act] because unambiguously, cannabis meets the definition of a drug under the FDCA," Caulkins says. This would place medical patients in the greatest jeopardy: Dispensaries would be in immediate violation of the FDCA with sales immediately suspended and no backup resources. This threat to medical users is likely at least an administration's term away in the current landscape, but signs of treacherous territory are emerging.
Industry ethics and sales practices are looming public health crises for both recreational and medical users. Vaughan Rees, lecturer on social and behavioral sciences at the Harvard Chan School of Public Health explains: "Marijuana products of today might be considered something like the tobacco products of one hundred years ago—they have a relatively low potential for dependence and limited appeal. With an aggressive industry pursuing high profit, it is likely that the marijuana industry will use marketing to increase public interest in marijuana use, while investing in research to enhance the addictiveness of their products."
Jordan Tishler, a Massachusetts-based emergency physician and regional director of Society of Cannabis Clinicians emphasizes that the concept of a prescription and involvement from medical providers is essential to protect medical users from predatory industry sales pressure. "It's not about controlling you, Ms. Patient, it's about controlling [for example] CVS's ability to upsell or cross-sell you on other products," he tells me. Medical users have to navigate all the products available to them mostly on their own in service of treating a symptom and are vulnerable to manipulation. For many recreational users, this experimentation is the whole point, but Tishler reminds: "The needs of patients are different from those of recreational users."
If it's possible for the recreational industry to introduce some benefit to patients, it will be through product improvements of this kind. If automation becomes widespread, Caulkins says, "The cost per hour of intoxication for a generic or equivalent of Budweiser could be absurdly low," and would drive overall prices down. However, as legalization scoots along glacially and the strongest enticement for municipalities is seductive tax revenue, medical users could still encounter serious financial obstacles.
"I think the thing that kills medical marijuana is taxation," says Lachant, who is the only attorney appointed to the Los Angeles County Advisory Working Group on Cannabis Regulation. He says that it's been observed in states instituting a recreational program after medical legalization is established that "there's no incentive to keep going to their doctor and paying to have a recommendation when you can go to a non-medical store and get similar products at the same price." The danger in this is that patients will be even more at risk for classic upselling from a retailer they should be able to trust, who behaves more like a street dealer maladroitly providing medical advice.
On my last visit to the dispensary to pick up medication, I nearly shredded my skin off with impatience as the woman in front of me argued with the patient advocate about the concept of registration renewal. Upon hearing the price, the woman became agitated and snatched her cards up, taking care to tell the patient advocate "Why would I pay that just to pay for it? I'll just buy it on the street."
Unfortunately for her, recreational legalization will make it impossible to pull the teenager-outside-the-liquor-store routine that she tried on me after I left. Fortunately, it will be unnecessary. When passing the ballot question for recreational use in 2016, advocates in Massachusetts played up the angle that purchasing from a store front will carry less product sourcing and quality uncertainties. With the seeds sown for recreational use, the medical use community should be fully prepared for shortages and wary of business practices adopted by the burgeoning industry.
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