The document summarizes state medical marijuana programs in the United States. It finds that there is great variation among state programs, with an average score of 1.96 out of 7 on factors reflecting a medical model. Programs enacted more recently through state legislatures in Northeastern and Midwestern states (medicalized programs) tend to be more highly regulated compared to earlier voter initiative programs in Western states (non-medical programs). Medicalized programs have fewer participants, with an average of 58 enrollments per 100,000 residents compared to over 1,000 in non-medical programs. The presentation concludes with a case study of New York's strictly regulated medical marijuana program.

1. Medicalized
Marijuana:
A Review of
State Programs
in the USA
ISSDP // Cannabis Summit
April 17, 2016
Arthur Robin Williams MD MBE
Columbia University
Division on Substance Abuse
Department of Psychiatry
New York State Psychiatric Institute

2. Symbolic Laws 1979-1991
 5 states
 Legalized marijuana with a “prescription”
 Symbolic because federal law prohibits
prescribing a schedule I drug
 Virginia (1979)
 New Hampshire (1981)
 Connecticut (1981)
 Wisconsin (1988)
 Louisiana (1991)

3. MMJ Laws 1996-Current
 23 states and DC (N=24)
 California was first in 1996
 Range of programs
 Initially just protective of possession
 Increasingly regulated
 2009 as dividing line for medical programs
 CBD research programs (15 states)

4. Recreational (dark), Medical (medium)
+ CBD Research (light green) as of 2015

5. The Medical Model:
The role of physicians
 Comprehensive H&P
 Make a diagnosis (in your area of expertise)
 Treatment plan with specific objectives
 Informed consent: risks and benefits
 Longitudinal management
 Seek consultation from colleagues
 Document the rationale

6. The Medical Model:
Pharmaceuticals
 Physician oversees dose
 FDA approved (efficacy and safety)
 Current Good Manufacturing Practices
① Manufacturing regulations and dispensed via
licensed pharmacy (separate party from MD)
② Medication is clearly labeled, consistent
 One month supply, typically not filled early
 Route of administration safest available

7. The Medical Model:
Controlled substances
 More restrictive
 For meds with increased risk/abuse potential
 Certifying MD registered with state (DEA
license)
① Refill limits
② Prescription Drug Monitoring Program (PMP)
③ Physician certification

8. 7-point assessment tool
① Bona fide doctor patient relationship
② Non-smoked cannabis
③ Licensed manufacturing/dispensing
④ Standardized testing/labeling
⑤ 30-day refill limitations
⑥ Link to PDMP
⑦ Physician training/certification

9. 7-point assessment tool

12. Results
Great variation
Average score was 1.96 (SD=2.17)

13. Results
Great variation
Average score was 1.96 (SD=2.17)
Bona fide relationship in 62.5%
(N=15)

14. Results
Great variation
Average score was 1.96 (SD=2.17)
Bona fide relationship in 62.5%
(N=15)
Few with restrictive criteria
2 non-smoked marijuana
3 PMPs
3 physician training

15. Results (N=24)
10 Medicalized programs
Mean score 4.1 (SD=1.4)
14 Non-Medical programs
Mean score 0.43 (SD=0.51)

16. State characteristics by group
Medicalized
(N=10)
Non-Medical
(N=14)
P Value
Legislative Act (%) 90.0 28.6 .004
Mean Years Since
Passage (SD)
2.7 (0.50) 13 (1.18) <0.0001
Region (N) West (0)
Midwest (2)
Northeast (5)
South (3)
West (10)
Midwest (1)
Northeast (3)
South (0)
.13
2008 Population Densitya
(persons/sq land mile) (SD)
1,454.1 (939.9) 146.45 (70.1) .11
State GDP (M)b (SD) 393,429 (113,390) 296,314 (142,521) .62
Mean Enrollment per
100,000 Residentsc (SD)
58 (31.7) 1,030 (160.3) .002

17. State characteristics by group:
 First wave MMJ programs 1996-2009
 Voter initiatives in Western states
 Not consistent with medical model
 Second wave MMJ programs 2009-
current
 Legislatures in Northeast/Midwest states
 More highly regulated

18. Medicalized (yellow) and
Non-Medical (green) Programs (N=24)

19. Association between medicalization
and enrollment rates

20. Enrollment by group (October, 2014):
 Non-medical (N=14)
 1,129,759 participants
 99.4% of participants nationwide
 Medical (N=5)
 7,310 participants
 1/20th rate of enrollment (58 v. 1,030)

21. Case Study: New York
 121 pages of regulations
 Only 20 dispensaries statewide
 $200,000 fee for registered organizations
 Physicians must complete a 4-hour
course
 5 brands with many criteria
 95-105% content of indicated THC and CBD
 Low THC 1:20 and 50:50 brands
 Non-commercial names
 Non-smoked products only

22. Thank you!
 Mark Olfson MD MPH
 Silvia Martins MD PhD
 June Kim MS
 Herbert D. Kleber MD