Stirring the pot - medical marijuana policy considerations for health systems in Ohio
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OSHP Annual Meeting 2019 Stirring the pot – medical marijuana policy considerations for health systems in Ohio Indrani Kar, PharmD Drug Policy/Formulary Pharmacist University Hospitals, Cleveland, Ohio Acknowledgement: Kacie Cassell, PharmD and Hannah Buehrle, PharmD (UH St. John PGY1 residents) May 6, 2019
Pharmacist/technician learning objectives
• Define state and federal legislation for marijuana
• Explain considerations important for health systems
• Construct a policy for your institution
2
Audience polling
• Does your institution have a medical marijuana policy in place?
– Yes
– No
3
Introduction
4
Introduction
• Cannabis – broad term to describe organic products (cannabinoids,
marijuana, hemp) derived from the Cannabis plant
• Cannabinoid compounds in cannabis include Δ9-
tetrahydrocannabinol (THC), cannabidiol (CBD), many minor
cannabinoids and terpenoids
• Species of Cannabis
– Cannabis sativa
– Cannabis indica
– Cannabis ruderalis
• National Academies of Sciences, Engineering, and Medicine. The health effects of cannabis and cannabinoids: The current state
of evidence and recommendations for research. National Academies Press; 2017 Mar 31. 5
• Nature. Scientific Reports. 2018;8:4519. DOI:10.1038/s41598-018-22755-2. Available:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5852027/pdf/41598_2018_Article_22755.pdf
CBD vs THC
• THC has psychoactive,
anti-inflammatory, and
analgesic properties
• CBD is non-psychoactive
and may mitigate THC’s
effects
https://mothernature.com/2019/01/the-benefits-of-cbd-cannabis-oil-for-pain-mental-illness-anxiety/
• Medical Marijuana. Pharmacist’s Letter. 2017. 231; 1-17.
• Your guide to CBD [Internet]. Mother Nature. [Cited 2019 Mar 29]. Available from: https://mothernature.com/2019/01/the- 6
benefits-of-cbd-cannabis-oil-for-pain-mental-illness-anxiety/.
Hemp vs marijuana
Medical, Recreational use
(THC) (THC)
Low percent CBD Variable
• Hemp vs marijuana: the difference explained [Internet]. Accessed 2019 Mar 29]. Available from: https://medium.com/cbd-origin/hemp- 7
vs-marijuana-the-difference-explained-a837c51aa8f7.
Hemp uses
• Hemp (Cannabis sativa plants) is grown for industrial uses
Hemp 101: what is hemp, what’s it used for, and why is it illegal? [Internet]. Malawi Hemp Association. [Updated 2018 Aug 8;
Cited 2019 Mar 29]. Available from: https://malawihemp.org/article/hemp-101.
• Epilepsy & Behavior. 2017;70:288-291.
• Industrial Hemp [Internet]. United States Department of Agriculture. National Institute of Food and Agriculture. [Cited 2018 Oct 18]. Available from:
https://nifa.usda.gov/industrial-hemp 8
• State Industrial Hemp Statutes [Internet]. National Conference of State Legislators. Washington, DC. [Updated 2018 Aug 8; Cited 2018 Oct 18]. Available
from: http://www.ncsl.org/research/agriculture-and-rural-development/state-industrial-hemp-statutes.aspx.
Objective 1
Define state and federal legislation for marijuana
9Federal law
• Prohibits all possession, sale, and use of marijuana
• Schedule 1 classification (Controlled Substances Act/CSA)
– High potential for abuse
– Has no current accepted medical use
– Lacks accepted safety for use under medical supervision
– Included hemp until December 2018
• Medical Marijuana. Pharmacist’s Letter. 2017. 231; 1-17.
10Department of Justice stance
• 2018 Attorney General rescinds Department of Justice (DOJ)
ruling to not interfere with states where medical marijuana is legal
– Prior Attorney General 2011 memo stated “it is likely not an
efficient use of federal resources to focus enforcement efforts on
individuals with cancer or other serious illnesses who use
marijuana as part of a recommended treatment regimen
consistent with applicable state laws, or their caregivers.”
• Controlled Substances [Internet]. DEA Diversion. [Updated 2018 Oct 1; Cited 2018 Oct 18]. Available from:
https://www.deadiversion.usdoj.gov/schedules/orangebook/c_cs_alpha.pdf.
• Memorandum for all United States Attorneys. Marijuana Enforcement [Internet]. Office of the Attorney General. Washington, DC. [Posted 2018 Jan 4; Cited 2019 Mar 29]. Available
from: https://www.justice.gov/opa/press-release/file/1022196/download.
11
• Memorandum for United States Attorneys. Guidance Regarding the Ogden Memo in Jurisdictions Seeking to authorize marijuana for medical use [Internet]. Office of the Attorney
General. Washington, DC. [Posted 2011 Jun 29; Cited 2018 Oct 19]. Available from: https://www.drugpolicy.org/sites/default/files/DOJ_Guidance_on_Medicinal_Marijuana_1.pdf12
Controlled Substances Act
• Cannabidiol, most common component in medical marijuana,
(considered from “resin” under CSA) is extracted from any part of
the plant, including the “exempted parts”
– Cannabidiol is considered marijuana and is Schedule I
• Certain parts of cannabis plant and preparations made from them
are exempt from CSA’s definition of marijuana (stalk, fiber, and
sterilized seeds)
– Hemp products can be made from these exempted parts
• Epilepsy & Behavior. 2017;70:288-291.
• Industrial Hemp [Internet]. United States Department of Agriculture. National Institute of Food and Agriculture. [Cited 2018 Oct 18]. Available from: https://nifa.usda.gov/industrial-hemp
•
•
State Industrial Hemp Statutes [Internet]. National Conference of State Legislators. Washington, DC. [Updated 2018 Aug 8; Cited 2018 Oct 18]. Available from: http://www.ncsl.org/research/agriculture-and-rural-development/state-
industrial-hemp-statutes.aspx.
DEA internal directive regarding the presence of cannabinoids in products and materials made from the cannabis plant [Internet]. U.S. Department of Justice. Drug Enforcement Administration. [Updated 2018 May 22; Accessed
13
2019 Mar 29]. Available from: https://www.deadiversion.usdoj.gov/schedules/marijuana/dea_internal_directive_cannabinoids_05222018.html.Federal Agriculture Improvement Act of 2018
• Removes hemp from the federal definition of marijuana and creates
new definition
– “the plant Cannabis sativa L. and any part of that plant, including
the seeds thereof and all derivatives, extracts, cannabinoids,
isomers, acids, salts, and salts of isomers, whether growing or
not with THC concentration of not more than 0.3 percent on a
dry weight basis” (Section 10113)
– Removes the following from Schedule 1 under the Controlled
Substances Act (Section 12619)
• Hemp
• THC in hemp as defined in the Farm bill and grown under
conditions set forth
• 112th United States Senate, 2018. Agriculture Improvement Act of 2018 - Conference Report. United States Senate Committee on
Agriculture, Nutrition, & Forestry. [Accessed February 11, 2019; Cited 2019 Mar 29]. Available from: 14
https://www.agriculture.senate.gov/imo/media/doc/CRPT-115hrpt1072.pdf.State law
• 33 states, the District of Columbia, and Guam have legalized
programs for therapeutic use of marijuana via authorized
professionals recommendation
• 10 states allow the recreational use of marijuana
• 15 states have decriminalized the possession of small amounts
• Medical Marijuana. Pharmacist’s Letter. 2017. 231; 1-17.
• Map of marijuana legality by state [Internet]. DISA Global Solutions. [Updated 2019 Mar; Accessed 2019 Mar 29]. Available 15
from: https://disa.com/map-of-marijuana-legality-by-stateMarijuana legalization per state
• States Where Marijuana is Legal [Internet]. Business Insider. [Posted 2019 Jan 4; Cited 2019 Feb 12]. Available from: 16
https://www.businessinsider.com/legal-marijuana-states-2018-1.State law – CBD/low THC product laws
• State medical marijuana laws [Internet]. National Conference of State Legislatures. [2019 Mar 5; Cited 17
2019 Mar 22]. Available from: http://www.ncsl.org/research/health/state-medical-marijuana-laws.aspx.Ohio – marijuana and hemp
• In Ohio, both marijuana and hemp fall under the marijuana
definition (ORC 3719.01) as of 4/4/2019
• Hemp could be made from the exemption components (doesn’t
include CBD oil which is made from resin), but in Ohio hemp
cannot be cultivated
• Ohio Revised Code - Controlled Substances Definitions. 2015 (Qid) s 3719.01. http://codes.ohio.gov/orc/3719.01v2
• Essman E. The 2018 Farm bill, industrial hemp, and what it means for Ohio [Internet]. Ohio’s Country Journal. [Updated 2019 Jan 3; 18
Accessed 2019 Mar 29]. Available from: https://www.ocj.com/2019/01/the-2018-farm-bill-industrial-hemp-and-what-it-means-for-ohio/Impact of Hemp Farming Act (2018) in Ohio
• New hemp language in the Farm Bill allows states to be more
restrictive with hemp than the federal government
– Possibility of legal hemp cultivation in the future if Ohio’s General
Assembly removes hemp from the Ohio marijuana definition
– Senate Bill 57
• The state cannot stop the transportation of hemp across the state
borders as hemp is federally legal.
• 112th United States Senate, 2018. Agriculture Improvement Act of 2018 - Conference Report. United States Senate Committee on Agriculture, Nutrition, & Forestry.
[Accessed February 11, 2019; Cited 2019 Mar 29]. Available from: https://www.agriculture.senate.gov/imo/media/doc/CRPT-115hrpt1072.pdf.
• Ohio Revised Code - Controlled Substances Definitions. 2015 (Qid) s 3719.01. http://codes.ohio.gov/orc/3719.01v2 19
• Decriminalize hemp and license hemp cultivation Senate Bill 57 [Internet]. The Ohio Legislature 133 rd General Assembly. [Accessed 2019 Mar 29]. Available from:
https://www.legislature.ohio.gov/legislation/legislation-summary?id=GA133-SB-57.Ohio’s medical marijuana control program
• HB 523 - Established Ohio’s Medical
Marijuana Control Program (Sept. 8,
2016)
• Permits use to treat 21 qualifying
conditions, pursuant to a physician
recommendation
• Regulations for cultivating, processing,
testing, providing medical marijuana,
patient registration, and physician
certification to recommend
• No reciprocity with or from other states at
this time
• No specific exemptions for CBD
• Clarification on cannabidiol (CBD) oil [Internet]. State of Ohio Board of Pharmacy. Columbus, OH. [Posted 2018 Aug 27; Cited 2019 Feb 8]. Available from:
https://www.pharmacy.ohio.gov/Documents/Pubs/Special/MedicalMarijuanaControlProgram/Clarification%20on%20CBD%20Oil.pd 20
• Ohio Medical Marijuana Control Program [Internet]. [Cited 2019 Feb 8]. Available from: https://www.medicalmarijuana.ohio.gov/.Medical conditions in Ohio
• AIDS • Multiple sclerosis
• Amyotrophic lateral sclerosis • Pain that is either chronic and
• Alzheimer’s disease severe or intractable
• Cancer • Parkinson’s disease, positive
• Chronic traumatic status for HIV
encephalopathy • Post-traumatic stress disorder
• Crohn’s disease • Sickle cell anemia
• Epilepsy or another seizure • Spinal cord disease or injury
disorder • Tourette’s syndrome
• Fibromyalgia • Traumatic brain injury
• Glaucoma • Ulcerative colitis
• Hepatitis C
• Inflammatory bowel disease
• Ohio Medical Marijuana Control Program [Internet]. [Cited 2019 Feb 8]. Available from: https://www.medicalmarijuana.ohio.gov/. 21Approved cannabinoid-related medications in U.S.
Generic Brand Indications UH Formulary
Status
Nabilone Cesamet (C-II) Antiemetic Not on formulary
(THC-like)
Dronabinol Marinol (C-III) Antiemetic; Anorexia Available on the
(THC-like) Syndros (C-II) associated with weight loss Adult & Pediatric
in patients with AIDS formulary
(U.S. only)
Cannabidiol Epidiolex (C-V) Seizures associated with Available on the
Lennox-Gaustaut and Adult & Pediatric
Dravet’s Syndrome formulary;
restricted
• Nabilone [Package Insert]. Valeant Pharmaceuticals. Costa Mesa, CA: May 2006. (https://www.accessdata.fda.gov/drugsatfda_docs/label/2006/018677s011lbl.pdf)
• Marijuana-based medications in 2018-Here’s what you should know [Internet]. GoodRx,Inc. 2018. Available from: https://www.goodrx.com/blog/medical-marijuana-fda-approved-cannabinoids/
• Marinol [Package Insert]. AbbVie Inc. Chicago, IL: Aug 2017. (https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/018651s029lbl.pdf) 22
• Syndros [Package Insert]. Insys Therapeutics, Inc. Chandler, AZ: Sept 2018.
• Controlled Substances [Internet]. DEA Diversion. [Updated 2018 Oct 1; Cited 2018 Oct 18]. Available from: https://www.deadiversion.usdoj.gov/schedules/orangebook/c_cs_alpha.pdf.Review question 1:
• According to federal law, hemp may be grown and shipped across
state lines if:
A. THC content > 0.3% on a dry weight basis
B. Is specifically indicated for medical use
C. Only the seeds are shipped
D. THC content < 0.3% on a dry weight basis
23Review question 1:
• According to federal law, hemp may be grown and shipped across
state lines if:
A. THC content > 0.3% on a dry weight basis
B. Is specifically indicated for medical use
C. Only the seeds are shipped
D. THC content < 0.3% on a dry weight basis
24Objective 2
Explain considerations important for health systems
25Discussion of common terms
INAPPROPRIATE APPROPRIATE
Prescription for medical marijuana Recommendation for medical marijuana
from a prescriber with a Certificate to
Recommend (CTR)
Medical Marijuana Prescriber Provider with CTR
General conversation
CTR Recommendation for medical
marijuana Prescription for FDA and DEA-approved
THC/CBD product
Recommendation for FDA and DEA- Prescription for FDA and DEA-approved
approved THC/CBD product THC/CBD product
Pharmacy for medical marijuana Dispensary for medical marijuana
Marijuana or CBD/low THC product Medical marijuana
(in Ohio)
Physician Insurance coverage (WRA vs marijuana-specific insurance from state)
26Common questions to consider
• How will your institution manage the following?
– CBD oil bought online?
– What a physician can discuss with a patient?
– Electronic medical record documentation?
– If a physician can make a referral to a physician with a CTR?
– How will institution’s police be involved?
– Will confiscated medical marijuana be returned to patients?
27Review question 2:
• An important consideration for a health system includes
understanding how a hospital will document patient’s medical
marijuana use in an electronic medical record:
A. True
B. False
28Review question 2:
• An important consideration for a health system includes
understanding how a hospital will document patient’s medical
marijuana use in an electronic medical record:
A. True
B. False
29Objective 3
Construct a policy for your institution
30Implementation of a policy
Workgroup to
vet content
Education and
Draft policy (Legal, Approvals
Dissemination
Pharmacy,
CMOs, etc)
31University Hospitals medical marijuana policy
• Medical marijuana (UH definition) – marijuana and non-FDA-approved
associated components and/or ingredients, including but not limited to,
cannabidiol (CBD) and tetrahydrocannabinol (THC)
• Medical marijuana is not continued as an active medication during
admission/visit
• UH Pharmacy will not store, dispense, or supply
• Physicians with professional liability insurance provided through UH
may NOT become recommenders (i.e. certificate of recommendation
(CTR)) of medical marijuana as they will risk termination of their
medical malpractice coverage
• UH Policy. CP-143 Medical Marijuana Possession and Use 32University Hospitals medical marijuana policy
• In order to maintain Medicare status, NIH funding, DEA licensure to
distribute controlled substances, etc, UH must comply with all laws
– Until use of marijuana is legal under BOTH State and Federal
Law, UH will not administer, store, dispense, or supply medical
marijuana at any UH Facility
• UH Policy. CP-143 Medical Marijuana Possession and Use 33Drug screens and CBD products
• Urine drug screens test for THC or its metabolites
• Most CBD products do not contain enough THC to reflect a positive
result on a urine toxicology screen
– However if a high dose or an impure form of CBD is used it could
lead to a positive result
• Not all CBD products are TCH free, even if labeled as such
• HR Policy provides additional information
https://www.cannabisprogrower.com/californias-cannabis-testing-troubles/
• Medical Marijuana. Pharmacist’s Letter. 2017. 231; 1-17. 34Review question 3:
• Use of a CBD product cannot lead to a positive urine drug screen.
A. True
B. False
35Review question 3:
• Use of a CBD product cannot lead to a positive urine drug screen.
A. True
B. False
36Think-Pair-Share
• What topics are important to your institution related to managing
medical marijuana?
• Who is involved in developing your institution’s stance/policy?
• Who will be involved in educating staff and how?
37Summary
Federal Ohio Policy
Marijuana CSA Schedule I CSA Schedule I Hospital definitions
Illegal except
medical marijuana
Hemp Legal ifConclusion
Hemp
FDA-approved
CBD
CBD
containing
medications
Hospital
State Law
Considerations
Medical
Federal law
marijuana Policy
management construction
at a hospital
39Slide references
• National Academies of Sciences, Engineering, and Medicine. The health effects of cannabis and cannabinoids:
The current state of evidence and recommendations for research. National Academies Press; 2017 Mar 31.
• Nature. Scientific Reports. 2018;8:4519. DOI:10.1038/s41598-018-22755-2. Available:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5852027/pdf/41598_2018_Article_22755.pdf
• Medical Marijuana. Pharmacist’s Letter. 2017. 231; 1-17.
• Your guide to CBD [Internet]. Mother Nature. [Cited 2019 Mar 29]. Available from:
https://mothernature.com/2019/01/the-benefits-of-cbd-cannabis-oil-for-pain-mental-illness-anxiety/.
• Hemp vs marijuana: the difference explained [Internet]. Accessed 2019 Mar 29]. Available from:
https://medium.com/cbd-origin/hemp-vs-marijuana-the-difference-explained-a837c51aa8f7.
• Epilepsy & Behavior. 2017;70:288-291.
• Industrial Hemp [Internet]. United States Department of Agriculture. National Institute of Food and Agriculture.
[Cited 2018 Oct 18]. Available from: https://nifa.usda.gov/industrial-hemp
• State Industrial Hemp Statutes [Internet]. National Conference of State Legislators. Washington, DC. [Updated
2018 Aug 8; Cited 2018 Oct 18]. Available from: http://www.ncsl.org/research/agriculture-and-rural-
development/state-industrial-hemp-statutes.aspx.
• Hemp 101: what is hemp, what’s it used for, and why is it illegal? [Internet]. Malawi Hemp Association. [Updated
2018 Aug 8; Cited 2019 Mar 29]. Available from: https://malawihemp.org/article/hemp-101.
40Slide references
• Controlled Substances [Internet]. DEA Diversion. [Updated 2018 Oct 1; Cited 2018 Oct 18]. Available from:
https://www.deadiversion.usdoj.gov/schedules/orangebook/c_cs_alpha.pdf.
• Memorandum for all United States Attorneys. Marijuana Enforcement [Internet]. Office of the Attorney General.
Washington, DC. [Posted 2018 Jan 4; Cited 2019 Mar 29]. Available from: https://www.justice.gov/opa/press-
release/file/1022196/download.
• Memorandum for United States Attorneys. Guidance Regarding the Ogden Memo in Jurisdictions Seeking to authorize
marijuana for medical use [Internet]. Office of the Attorney General. Washington, DC. [Posted 2011 Jun 29; Cited 2018 Oct
19]. Available from: https://www.drugpolicy.org/sites/default/files/DOJ_Guidance_on_Medicinal_Marijuana_1.pdf
• DEA internal directive regarding the presence of cannabinoids in products and materials made from the cannabis plant
[Internet]. U.S. Department of Justice. Drug Enforcement Administration. [Updated 2018 May 22; Accessed 2019 Mar 29].
Available from:
https://www.deadiversion.usdoj.gov/schedules/marijuana/dea_internal_directive_cannabinoids_05222018.html.
• 112th United States Senate, 2018. Agriculture Improvement Act of 2018 - Conference Report. United States Senate
Committee on Agriculture, Nutrition, & Forestry. [Accessed February 11, 2019; Cited 2019 Mar 29]. Available from:
https://www.agriculture.senate.gov/imo/media/doc/CRPT-115hrpt1072.pdf.
• Map of marijuana legality by state [Internet]. DISA Global Solutions. [Updated 2019 Mar; Accessed 2019 Mar 29]. Available
from: https://disa.com/map-of-marijuana-legality-by-state
• States Where Marijuana is Legal [Internet]. Business Insider. [Posted 2019 Jan 4; Cited 2019 Feb 12]. Available from:
https://www.businessinsider.com/legal-marijuana-states-2018-1.
• State medical marijuana laws [Internet]. National Conference of State Legislatures. [2019 Mar 5; Cited 2019 Mar 22].
Available from: http://www.ncsl.org/research/health/state-medical-marijuana-laws.aspx.
41Slide references
• Ohio Revised Code - Controlled Substances Definitions. 2015 (Qid) s 3719.01. http://codes.ohio.gov/orc/3719.01v2
• Essman E. The 2018 Farm bill, industrial hemp, and what it means for Ohio [Internet]. Ohio’s Country Journal. [Updated 2019
Jan 3; Accessed 2019 Mar 29]. Available from: https://www.ocj.com/2019/01/the-2018-farm-bill-industrial-hemp-and-what-it-
means-for-ohio/
• Decriminalize hemp and license hemp cultivation Senate Bill 57 [Internet]. The Ohio Legislature 133rd General Assembly.
[Accessed 2019 Mar 29]. Available from: https://www.legislature.ohio.gov/legislation/legislation-summary?id=GA133-SB-57.
• Clarification on cannabidiol (CBD) oil [Internet]. State of Ohio Board of Pharmacy. Columbus, OH. [Posted 2018 Aug 27; Cited
2019 Feb 8]. Available from:
https://www.medicalmarijuana.ohio.gov/Documents/formsmethods/FINAL%20FORMS%20AND%20METHODS%20RULES/Clar
ification%20on%20CBD%20Oil.pdf
• Ohio Medical Marijuana Control Program [Internet]. [Cited 2019 Feb 8]. Available from: https://www.medicalmarijuana.ohio.gov/.
• Nabilone [Package Insert]. Valeant Pharmaceuticals. Costa Mesa, CA: May 2006.
(https://www.accessdata.fda.gov/drugsatfda_docs/label/2006/018677s011lbl.pdf)
• Marijuana-based medications in 2018-Here’s what you should know [Internet]. GoodRx,Inc. 2018. Available from:
https://www.goodrx.com/blog/medical-marijuana-fda-approved-cannabinoids/
• Marinol [Package Insert]. AbbVie Inc. Chicago, IL: Aug 2017.
(https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/018651s029lbl.pdf)
• Syndros [Package Insert]. Insys Therapeutics, Inc. Chandler, AZ: Sept 2018.
• Controlled Substances [Internet]. DEA Diversion. [Updated 2018 Oct 1; Cited 2018 Oct 18]. Available from:
https://www.deadiversion.usdoj.gov/schedules/orangebook/c_cs_alpha.pdf.
• UH Policy. CP-143 Medical Marijuana Possession and Use. Available internally.
42Additional resources
• https://www.projectcbd.org/guidance/cannabis-oil-vs-hemp-oil
• S.3042. Congress.gov. [Accessed 2019 Mar 25] Available from:
https://www.congress.gov/bill/115th-congress/senate-
bill/3042/text?q=%7B%22search%22%3A%5B%22agricultural+improvement+act+of+2018%22
%5D%7D&r=2.
• Cannabis and Cannabinoids (PDQ) – Patient Version [Internet]. NIH. National Cancer Institute.
Bethesda, MD. [Updated 2017 Dec 20; Cited 2018 Oct 18]. Available from:
https://www.cancer.gov/about-cancer/treatment/cam/patient/cannabis-pdq
• Ther Adv Psychopharmacol. 2012;2:241-256.
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3736954/)
• Nature. Scientific Reports. 2018;8:4519. DOI:10.1038/s41598-018-22755-2.
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5852027/pdf/41598_2018_Article_22755.pdf)
• Controlled Substances [Internet]. DEA Diversion. [Updated 2018 Oct 1; Cited 2018 Oct 18].
Available from: https://www.deadiversion.usdoj.gov/schedules/orangebook/c_cs_alpha.pdf.
• Epilepsy & Behavior. 2017;70:288-291.
• Industrial Hemp [Internet]. United States Department of Agriculture. National Institute of Food
and Agriculture. [Cited 2018 Oct 18]. Available from: https://nifa.usda.gov/industrial-hemp
43Additional resources
• State Industrial Hemp Statutes [Internet]. National Conference of State Legislators. Washington, DC. [Updated 2018 Aug 8; Cited 2018
Oct 18]. Available from: http://www.ncsl.org/research/agriculture-and-rural-development/state-industrial-hemp-statutes.aspx.
• Controlled Substances [Internet]. DEA Diversion. [Updated 2018 Oct 1; Cited 2018 Oct 18]. Available from:
https://www.deadiversion.usdoj.gov/schedules/orangebook/c_cs_alpha.pdf.
• Memorandum for all United States Attorneys. Marijuana Enforcement [Internet]. Office of the Attorney General. Washington, DC.
[Posted 2018 Jan 4; Cited 2018 Oct 18]. Available from: https://www.justice.gov/opa/press-release/file/1022196/download.
• Memorandum for United States Attorneys. Guidance Regarding the Ogden Memo in Jurisdictions Seeking to authorize marijuana for
medical use [Internet]. Office of the Attorney General. Washington, DC. [Posted 2011 Jun 29; Cited 2018 Oct 19]. Available from:
https://www.drugpolicy.org/sites/default/files/DOJ_Guidance_on_Medicinal_Marijuana_1.pdf
• Watkins E. Medical Cannabis: Is it right for you? [Internet]. The Marijuana Herald. [2018 Oct 12; Cited 2018 Oct 18]. Available from:
https://themarijuanaherald.com/misc/medical-cannabis-is-it-right-for-you/
• State Marijuana Laws in 2018 Map [Internet]. Governing the States and Localities. [Cited 2018 Oct 19]. Available from:
http://www.governing.com/gov-data/safety-justice/state-marijuana-laws-map-medical-recreational.html.
• Ohio Medical Marijuana Control Program [Internet]. [Cited 2018 Oct 18]. Available from: https://www.medicalmarijuana.ohio.gov/.
• Medical Marijuana Is Coming to Ohio: What is UH’s Policy? [Internet]. University Hospitals. Cleveland, OH. [Posted 2018 Aug 30; Cited
2018 Oct 18]. Available from: http://uhdoctor.org/news/medical-marijuana-is-coming-to-ohio-what-is-uh-s-policy.
• Clarification on cannabidiol (CBD) oil [Internet]. State of Ohio Board of Pharmacy. Columbus, OH. [Posted 2018 Aug 27; Cited 2018 Oct
18]. Available from:
https://www.pharmacy.ohio.gov/Documents/Pubs/Special/MedicalMarijuanaControlProgram/Clarification%20on%20CBD%20Oil.pdf.
• Nature [Internet]. Scientific Reports. 2018;8:4519. DOI:10.1038/s41598-018-22755-2. Available:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5852027/pdf/41598_2018_Article_22755.pdf
44Additional resources
• Lexicomp [Internet]. Hudson (OH): Wolters Kluwer. 2019. Epidiolex; [updated 2019 Feb 9; cited
2019 Feb 9]. Available from: online.lexi.com
• Devinsky O, Cross JH, Laux L, Marsh E, Miller I, Nabbout R, Scheffer IE, Thiele EA, Wright S.
Trial of cannabidiol for drug-resistant seizures in the Dravet syndrome. New England Journal of
Medicine. 2017 May 25;376(21):2011-20.
• Devinsky O, Patel AD, Cross JH, Villanueva V, Wirrell EC, Privitera M, Greenwood SM, Roberts
C, Checketts D, VanLandingham KE, Zuberi SM. Effect of Cannabidiol on Drop Seizures in the
Lennox–Gastaut Syndrome. New England Journal of Medicine. 2018 May 17;378(20):1888-97.
• Thiele EA, Marsh ED, French JA, Mazurkiewicz-Beldzinska M, Benbadis SR, Joshi C, Lyons PD,
Taylor A, Roberts C, Sommerville K, Gunning B. Cannabidiol in patients with seizures associated
with Lennox-Gastaut syndrome (GWPCARE4): a randomised, double-blind, placebo-controlled
phase 3 trial. The Lancet. 2018 Mar 17;391(10125):1085-96.
• Clarification on cannabidiol (CBD) oil [Internet]. State of Ohio Board of Pharmacy. Columbus,
OH. [Posted 2018 Aug 27; Cited 2019 Feb 8]. Available from:
https://www.medicalmarijuana.ohio.gov/Documents/formsmethods/FINAL%20FORMS%20AND
%20METHODS%20RULES/Clarification%20on%20CBD%20Oil.pdf
• WHO Peres FF, Lima AC, Hallak JE, Crippa JA, Silva RH, Abílio VC. Cannabidiol as a Promising
Strategy to Treat and Prevent Movement Disorders?. Frontiers in pharmacology. 2018;9.
• Medical Marijuana. Pharmacist’s Letter. 2017. 231; 1-17.
45Additional resources
• Bergamaschi, MM, Queiroz, RH, Chagas, MH, et al. Cannabidiol Reduces the Anxiety Induced
by Public Speaking in Treatment Naïve Social Phobia Patients. Neuropsychopharmacology.
(2011). 36; 1219-1226.
• Notcutt, William; Price, Mario; Miller, Roy. Initial Experiences with Medicinal Extracts of Cannabis
for Chronic Pain: Results from 34 ‘N of 1’ Studies. Anaesthesia. 2004; 59(4); 440-452.
• Crippa, JA, Derenusson, GN, Ferrari, TB. “Neural Basis of Anxiolytic Effects of Cannabidiol
(CBD) in generalized social anxiety disorder: a preliminary report.” Journal of
Psychopharmacology. 2011; 255: 121-130.
• The National Academies of Sciences, Engineering and Medicine. The health effects of cannabis
and cannabinoids: current state of evidence and recommendations for research (2017).
• “Demystify Cannabidiol Oil”. Pharmacist’s Letter. September 2018
• 112th United States Senate, 2018. Agriculture Improvement Act of 2018 - Conference Report.
United States Senate Committee on Agriculture, Nutrition, & Forestry. Available at:
https://www.agriculture.senate.gov/imo/media/doc/CRPT-115hrpt1072.pdf [Accessed February
11, 2019].
• Ohio Medical Marijuana Control Program [Internet]. [Cited 2019 Feb 8]. Available from:
https://www.medicalmarijuana.ohio.gov/
46OSHP Annual Meeting 2019 Stirring the pot – medical marijuana policy considerations for health systems in Ohio Indrani Kar, PharmD Drug Policy/Formulary Pharmacist University Hospitals, Cleveland, Ohio Indrani.Kar@UHhospitals.org Acknowledgement: Kacie Cassell, PharmD and Hannah Buehrle, PharmD (UH St. John PGY1 residents) May 6, 2019
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