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What's next for medical marijuana in Iowa

Following the governor's veto, how will lawmakers approach expansion?

Jacob Roberts swallows a dose of medical cannabis administered by his mother Mary at their home in Coralville, Iowa, on Thursday, Nov. 28, 2019. Jacob takes the medication to alleviate his chronic pain from an inflammatory disease. (Jim Slosiarek/The Gazette)
Jacob Roberts swallows a dose of medical cannabis administered by his mother Mary at their home in Coralville, Iowa, on Thursday, Nov. 28, 2019. Jacob takes the medication to alleviate his chronic pain from an inflammatory disease. (Jim Slosiarek/The Gazette)
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Before they joined Iowa’s medical marijuana program, Mary Roberts’ two children had long histories of taking multiple drugs, including some with “significant side effect profiles,” she recalled.

But since becoming part of the state’s program, both of Roberts’ children have seen significant improvement.

Jacob Roberts, 25, has been able to tamper the pain and seizures as a result of his eosinophilic esophagitis, an inflammatory disease of the esophagus.

Twenty-seven-year-old Kelsey Roberts got in the program earlier this year when autism was added as a qualifying condition. Since then, her behaviors have been negated and symptoms of her obsessive compulsive disorder are better controlled.

“For the first time, I really see her personality,” said Roberts, of Coralville.

Both of Roberts’ children have been diagnosed with the most severe form of autism, meaning they are non-verbal and need a substantial level of support. However, with the medication, she has seen benefits “across the board.”

“I feel like we’re getting much better results with a much better safety profile than what we were seeing with psychotropic medication,” she said.

Roberts, as with many who rely on the state’s medical marijuana program, will be watching as state lawmakers return to Des Moines next month and mull changes to the program. She said she believes more should be done to expand its scope, adding that she feels “strongly that this medication can help a lot of Iowans who currently don’t have access.”

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However, some elected officials have said it’s better to err on the side of caution and ensure these products don’t create unintended consequences for patients. And with Gov. Kim Reynolds’ veto earlier this year of legislation that included a program expansion top of mind, it’s unclear what Iowans can expect.

“I said last year, when I vetoed the bill, that we’re going to continue to work with the legislature and make sure that we look for opportunities to build on the program that we already have in place,” Reynolds said in a news conference last week.

“We want to make sure that it’s safe, reliable and that we’re really maintaining it in a compassionate way while maintaining the health of Iowans.”

What may be ahead

Reynolds and members of the Iowa House and Senate have indicated their willingness to find common ground on legislation related to the state’s program. Most likely, it will revolve around recommendations made by the Iowa Medical Cannabidiol Board, a governor-appointed group that oversees the state’s program.

The board recommended products sold under the state’s program be capped at 4.5 grams of THC — or tetrahydrocannabinol, the psychoactive component of marijuana — over 90 days. Products are limited to 3 percent THC currently, but there’s no purchasing limit.

In the past, board members have said too little is known about cannabis to understand its long-term effects. THC in particular has a potential for harm, said Dr. Stephen Richards, a board member and Spirit Lake pharmacist.

“There’s no question THC has potential for danger,” he said. “There’s no data that shows (THC) is good for treating specific conditions, but I do have data that shows it does harm.”

So before expanding the program, board members have maintained they must have a better understanding and more scientific research to back up the benefits. And that includes a purchasing limit.

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“What we are doing is a medical program and not a recreational program,” Richards said. “We need to keep it controlled and we need to use numbers to keep it safe.”

Iowa Senate Majority Leader Jack Whitver, R-Ankeny, said that a change in how the program handles THC caps is among his priorities for the upcoming session, adding that the cannabis industry nationwide “is an untested and untried industry.”

Cannabis “hasn’t gone through the normal (U.S. Food and Drug Administration) vetting process,” Whitver said. “I think it’s better to roll it out in a controlled manner than to go too far and bring it back. It’s a matter of taking the time and making the best decisions we can.”

But Sen. Joe Bolkcom, D-Iowa City, criticized the medical marijuana program, saying it had become too bureaucratic and too expensive for some. As a result, he is fearful Eastern Iowans may flock to Illinois once the state legalizes its recreational program on Jan. 1.

“If we’re going to continue to rely on a board that recommended this reduced potency, it isn’t worth passing the recommendations,” Bolkcom said. “It’ll make a bad program even worse.”

Inside the governor's office

The lead-up to Gov. Reynolds’ May 24 veto of House File 732 — which included a measure to replace the state’s 3 percent THC cap with a limit of 25 grams over 90 days — came with a barrage of opinions for and against.

Though the bill received bipartisan support in the House and Senate, the Medical Cannabidiol Board voiced frustration that its recommendation to maintain the 3 percent cap had been misrepresented. One member resigned after the House advanced the bill, writing in a letter to Reynolds that lawmakers were not taking the board’s advice seriously.

“It was just there was too much of a disparity in where (the board) was at with the THC level and where the legislation took it,” Reynolds said in an interview last month.

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Starting in late April, the office’s health policy advisers received a torrent of emails from advocates on both sides of the program expansion, according to records obtained by The Gazette.

Representatives from substance-abuse prevention organizations, including the Area Substance Abuse Council based in Cedar Rapids, wrote in with concerns about a potential increase in use of marijuana by younger people if Iowa’s program were to expand.

On the other hand, MedPharm Iowa and Acreage Holdings — the state’s licensed medical marijuana manufacturers — highlighted what they described as the potential for positive patient effects, including a National Institute on Drug Abuse-funded study on the potential for medical cannabis to ease opioid withdrawal symptoms.

MedPharm Iowa also sent a statewide petition with more than 1,500 signatures in support of the proposed expansion.

“I was in an explosion injury and sustained multiple injuries requiring several surgeries and years of physical therapy,” one supporter wrote. “If it wasn’t for CBD and THC, I probably would be addicted to the opioids I was prescribed by my doctors.”

“We patients are not looking to get high but want to be able to live a more active, productive lifestyle,” said another supporter. “... Please, please sign this bill and continue to push for our lawmakers to continue expanding access.”

Iowa’s neighbors

Other Midwestern states have seen growth in its medical marijuana programs in recent years.

Illinois Gov. J.B. Pritzker signed legislation in August to make the state’s medical cannabis program permanent, rather than a pilot program, and to add 11 conditions — including chronic pain, autism and migraines — for a total of 52.

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More than 87,000 patients have qualified for Illinois’ program since its inception, including almost 37,000 in the fiscal year ending June 30.

In Minnesota, state lawmakers in 2019 tripled the maximum receivable supply of each patient’s medical cannabis dosage, from a 30-day supply to a 90-day supply.

Minnesota’s program currently has 14 qualifying conditions, with two more — chronic pain and age-related macular degeneration — under consideration. The program currently has just over 18,000 active patients.

Neither Illinois nor Minnesota’s medical cannabis programs have caps on THC in products. Under Illinois’ program, registered qualifying patients can purchase up to 2.5 ounces, or 70.9 grams, of medical cannabis every two weeks.

Each Minnesota patient’s individual dosage is determined based on consultation with a licensed pharmacist rather than through a product or time period cap — an arrangement that creates flexibility for patients in determining the right dosages, said Chris Tholkes, acting director of the Office of Medical Cannabis at the Minnesota Department of Health.

“People act differently and metabolize medications differently, so having that one-on-one really gives folks an opportunity to see what works for them,” Tholkes said.

Medical cannabis programs with “low THC” are a relatively new development that often are enacted by state legislatures rather than voters, said Paul Armentano, deputy director of the National Organization for the Reform of Marijuana Laws.

“For instance, in Iowa, that is a law that did not come of a voter initiative but came out of the legislative process,” he said. “That process involves a lot more compromise because oftentimes you’re dealing with needing the votes of fairly conservative lawmakers who aren’t particularly comfortable with the idea of medical cannabis access.”

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And state legislatures aren’t guaranteed to expand their medical cannabis programs, even when there is legislative action in neighboring states, said Karen O’Keefe, director of state policies with the Marijuana Policy Project.

“Having a similarly situated state move forward can help, but state legislatures, especially in the Midwest and South, have been very, very slow to act, despite where the public is on this,” she said.

Now what?

Though Lucas Nelson, general manager of MedPharm Iowa, said removing the 3 percent THC cap is “100 percent a step in the right direction,” replacing it with 4.5 grams per 90 days would “be even more damaging” as it would reduce the dosages some patients receive.

Under the proposed limit, patients could receive about 50 milligrams of THC per day at a maximum. Current daily dosages can reach as high as 260 milligrams for some patients with severe cancers, Nelson said.

“To tell a patient, ‘Hey, sorry you found a dosage that works for you, you’re going to have to reduce your dose,’ is not something we want to do, especially in a program based on compassion,” he said.

Iowa could find itself legally liable for any “unintended consequences” that result from expanding its medical marijuana program, said Peter Komendowski, president of the Partnership for a Healthy Iowa.

“This idea that the state of Iowa takes on the role of the FDA, I don’t know what that’s going to mean in terms of long-term liability for public health,” he said.

Komendowski also expressed concern about the possibility of a “THC epidemic” comparable to the current opioid crisis nationwide.

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Armentano, with the National Organization for the Reform of Marijuana Laws, said the debate around medical marijuana too often veers toward “ideology and rhetoric, not science and evidence” — a trend he hopes will change.

“If and when it does change, then I think ultimately we’re going to end up with policies that are far better serving for patients than the sort of arbitrary policies that oftentimes we have now,” he said.

As both sides weigh in on the matter in the upcoming 2020 legislative session, individual Iowans such as Roberts will be watching carefully.

“We would be lost without this particular intervention,” Roberts said.

Rod Boshart and Erin Murphy of The Gazette-Lee Des Moines Bureau contributed to this report.

Comments: (319) 368-8536, michaela.ramm@thegazette.com; (319) 398-8366, thomas.friestad@thegazette.com

HOW WE REPORTED THIS STORY

Governor's Office cites 'executive privilege' to withhold some records

In responding to The Gazette's July 23 open records request, Gov. Kim Reynolds' office provided copies of 217 emails sent or received to date in 2019 by Reynolds, Lt. Gov. Adam Gregg and three health policy advisers pertaining to medical and recreational marijuana.

Michael Boal, Reynolds' deputy legal counsel, told The Gazette his office had located 475 responsive emails. Officials withheld some responsive records based on provisions in Iowa Code that forbid the disclosure of draft documents for policies or decisions not yet adopted and of some personal information of individuals who had received state correctional services.

Boal said the Governor's Office did not provide other responsive records based on “executive privilege.”

He said “numerous courts” have recognized that governors can withhold certain records from public disclosure by citing executive privilege. He cited nine state court decisions between 1952 and 2013, including from Arizona, California, New Jersey and Washington — but not Iowa.

Iowa's open records law does not contain an “executive privilege” exemption, said Randy Evans, Iowa Freedom of Information Council executive director, in an email.

“The positions the governor's office takes are contrary to our interpretation of Iowa's public records law,” Evans wrote. “The Legislature certainly could decide to craft an executive privilege in the public records law — but lawmakers have not done that.”

Pursuing the responsive records through a lawsuit could cost The Gazette or other news media tens of thousands of dollars, Evans estimated.

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