1. Medical Cannabis in Maryland Presentation to University of Maryland Medical School Quarterly Meeting October 8, 2015 by Deborah Miran Commissioner Maryland Medical Cannabis Commission

2. Medical Cannabis – An Update Milestones of the Twentieth Century 1940- Cannabidiol (CBD) was identified as a constituent of the plant 1964- Tetrahydrocannabinol (THC) identified and synthesized in Israel 1988-1993- Two cannabinoid receptors discovered-proof of endocannabinoid system in body 1992-1995- Two endocannabinoids discovered

3. Function of the Endocannabinoid System Regulation of functions which control eating, sleeping, relaxation, memory and movement Endocannabinoid system is basic to all other systems in the body Evidence that the endocannabinoid system begins to form within days after fertilization.

4. Overview of Endocannabinoid System Cannabinoid receptors – Type 1 -These are the most extensive receptors -Found in the brain, spinal cord, peripheral nervous system, organs, and tissues. Cannabinoid receptors – Type 2 -Found in immune system

7. NIH Statement 2006 In the past decade, the endocannabinoid system has been implicated in a growing number of physiological functions Modulating the activity of the endocannabinoid system turned out to hold therapeutic promise in a wide range of disparate diseases Ranging from mood and anxiety disorders, movement disorders such as Parkinson’s and Huntington’s disease, neuropathic pain, multiple sclerosis and spine cord injury, to cancer, atherosclerosis, myocardial infarction, stroke, hypertension, glaucoma, obesity, and osteoporosis.

9. Patient Experiences In 2015, hundreds of comments have been received from patients Conditions range from ALS, fibromyalgia, epilepsy, multiple sclerosis, neuropathy, cancer, chronic back pain, leukemia, and PTSD Some patients are military veterans who are desperate to reduce their dependency on strong opioid pain killers

10. Safety Profile of Cannabis LD 50 is the Lethal dose which will kill 50% of the population Ibuprofen636mg/kg Caffeine192mg/kg Nicotine 50mg/kg Heroin 22mg/kg CannabisEssentially Zero* *It would take 70kg man to smoke 1500 pounds in 15 minutes. 2013 Data from CDC on drug induced deaths Total – 43,982 Prescription analgesics – 16,235 Heroin - 6,235 Cannabis - 0

11. Cannabis for the Management of Pain Assessment of Safety Study COMPASS Study Dr. Mark Ware J. of Pain September 2015 1 year Prospective Cohort Study among subjects with chronic non-cancer pain. Risk of having at least 1 SAE was not significantly different between groups Risk of having at least 1 AE did not differ significantly between cannabis user & controls Conclusion: Study suggests AES of medical cannabis are moderate and compare to prescription cannabinoids. Results suggest that cannabis at an average dose of 2.5 g/d in current users may be safe as part of a carefully monitored pain management program

12. Evidence of Decreased Opioid Overdose Mortality in U.S. “States with medical cannabis laws had a 24.8% lower mean annual opioid overdose mortality rate.” (Bachhuber, M.A. (2014) Journal American Medical Association)

13. Evidence of Decreased Use of Cannabis by Adolescents American Journal of Public Health and American Academy of Pediatrics California District reported no increased use and actual decreased use in states with well regulated medical cannabis laws.

14. What Makes Maryland Different Growing & Processing Standardization of growing phase Controlling valuables in the process Documentation of the process Validation of the process Testing Independent accredited laboratories Independent sampling required Requirements include testing for potency, purity, and microbiology Inspection & Compliance Extensive pre-license inspection by ASA trained team Requirements for periodic as well as “for cause” inspections. Commission has authority to suspend distribution and request product recall

15. Evidence of Physician Support 2013 New England Journal of Medicine poll of medical use 76% of all votes* favor use of cannabis for medical conditions *1,446 votes representing 72 countries an 56 states and provinces in North America

16. Evidence of Growing Support from the Leukemia and Lymphoma Society “LLS supports the medical use of marijuana by patients with serious medical conditions when it is prescribed by a health-care provider and permitted by state law. In a state where patients are permitted to use marijuana medically for serous and /or chronic illnesses and a patient’s physician has recommended its use in accordance with that state’s law and that state’s medical practice standards, LLS strongly urges that patients should not be subject to federal criminal penalties for such medical use.”