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HIGH HOPES FOR PAIN RELIEF

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STORY BY Anne Haddad      PHOTOGRAPHY BY Mary C. Gardella

Shannon Hoffman was a chemical analyst in the cosmetics industry for nearly two decades, most recently at Covergirl in Hunt Valley. Last June, when her job was moved out of state, she chose not to follow it. A more exciting opportunity was sprouting right here in Columbia.

“I saw that medical cannabis was an emerging industry that was coming to life in the next six months,” Hoffman says. “I knew it was something I could be excited about and contribute to, because of my experience.”Hoffman is the regional director of operations and certifying chemist for Steep Hill Maryland in Columbia, one of four independent laboratories that Maryland has certified to test the quality and safety of medical cannabis products sold to consumers under the new state law. Steep Hill, a cannabis science company headquartered in Berkeley, California, operates labs in several of the 29 states that have legalized medical cannabis.

Just as when she worked at Covergirl, when Hoffman mentions to people what she does for a living, they ask if she can get them free samples.

“The answer, in both cases, is ‘No,’ ” Hoffman says.

But while a new acquaintance back then might have mentioned a favorite foundation or mascara, the talk is more earnest now. Hoffman says people now open up to her about how a relative suffering from chemotherapy-induced nausea was helped by cannabis, or how another has been waiting for it to become legal.

“Everyone has a story, and everyone has a family member or friend who has suffered,” Hoffman says. Some of these confessors have gone out of state or tapped into the illegal marketplace to alleviate their loved ones’ suffering. But things are changing, she points out. “People can access it now without fear of (criminal) charges. It’s really inspiring and it gives a sense of purpose.”

LEGAL, BUT REGULATED

Medical cannabis is currently being sold legally in Maryland to long-suffering patients who have been unable to find other relief for certain conditions, including anorexia, wasting syndrome (often associated with AIDS or cancer), severe pain, severe nausea, seizures, severe or persistent muscle spasms, glaucoma, post-traumatic stress disorder and chronic pain.

The products include unprocessed dried flowers from the plant, topical balms and creams, and liquids that can be inhaled through a smokeless vaporizer. For now, the law in Maryland does not allow for “edibles,” such as gummy candies that contain cannabis. All of the cannabis products sold by dispensaries must come from state-certified growers and processors in Maryland.

“We focus on the smokeless products,” says Dr. Leslie Apgar, a Howard County obstetrician-gynecologist who co-founded Greenhouse Wellness with her entrepreneur neighbor, Gina Dubbé, and also serves as its medical director. The two women, backdoor neighbors, are successful in their respective professions and wanted to create a safe and welcoming dispensary for the Howard County community.

The business partners are clear about their mission, says Dubbé. “We feel very strongly about having a medical staff on site. We’re trying to elevate this and talk about disease prevention and treatment.” Much of their work, she says, is educational.

Patients, especially in the first wave of legal access, are not likely to know about the various products available and which ones would be best for them, point out the Greenhouse Wellness founders. So patients will first sit down with a nurse to discuss their conditions and preferences, before selecting and purchasing products.

“We’re medically directed,” Apgar says. “This is a clean and comfortable environment that is welcoming, safe and secure.” To further ensure product safety the company has formed partnerships with growers and processors.

Dubbé co-founded TheraPearl, the company that produces the now-ubiquitous hot or cold compresses filled with gel beads, after realizing that she could go at least one better than the bag of frozen peas everyone was using. She wanted a reusable, mess-free, drug-free way of relieving pain and inflammation, one that could be cooled in the freezer—or warmed in the microwave.

The innovation got her designated by Forbes Magazine in 2014 as a Women Who Built Outstanding Companies, and Thera- Pearl made the Inc. 500 list of the Fastest Growing Private Companies in the U.S. for two consecutive years. After selling the company in 2014, Dubbé started looking for a new project—just as Maryland passed a law allowing medical use of cannabis.

Apgar has practiced medicine for 17 years as an OB-GYN, and in 2008 opened PuraVida Medspa and Cosmetic Center in Fulton. Born and raised in the Pacific Northwest, she graduated from Penn State University College of Medicine in 2000 and completed her residency at the Penn State Health Milton S. Hershey Medical Center. Her familiar last name is associated with the Apgar score, a 0-to-10 scale for measuring the health of a newborn. The test was developed by the pioneering physician Dr. Virginia Apgar, a distant relative of Leslie Apgar’s first husband.

As a physician, Apgar says, she follows research on medical cannabis and looks forward to future studies that will explore the role of cannabinoids on pain, inflammation, gut health, cancer and other diseases. Evidence indicates that in states where medical cannabis is available, opioid overdoses have declined, she says.

While cannabis can be addictive, even an overdose is not fatal, although it could cause feelings of paranoia and other physical and psychological symptoms. Apgar says Greenhouse Wellness and the physicians who certify patients will be vigilant for signs that a patient might be addicted or intoxicated when they arrive, although between the state registration process and certification by a physician, these patients should be flagged earlier.

AN ARRAY OF PRODUCTS

Dispensary sounds like a stark office where a nurse hands out doses through a glass window. But the soothing green and white décor at Greenhouse Wellness on Dorsey Hall Drive in Ellicott City makes this state-certified dispensary look more like a private medical office, albeit with a high level of security. The building also houses several other medical offices, including a large diagnostic radiology and imaging practice.

Visitors and patients must first be buzzed in—the front door and the subsequent door are locked. Only patients registered with the state and their designated caregivers are permitted into this inner sanctum.

THE COMMUNITY DOCTORS

Under federal law, there is no such thing as medical marijuana; there is only marijuana, and it’s illegal. The gray area is whether physicians and health care organizations with federal contracts are vulnerable to sanctions even if they follow state laws in approving cannabis for patients. MedChi, the Maryland state medical society, has chosen not to take a position on medical cannabis, leaving it to individual members to decide whether to register with the state.

Dr. Warren Ross, a physician with Lifebridge Health in Ellicott City, has been practicing medicine for more than 40 years. An internal medicine specialist, he registered with the Maryland Medical Cannabis Commission when it began accepting applications. But he had to withdraw his name later.

“My employer is a large health system that has to be fully compliant with federal regulations,” Ross says. He can discuss cannabis with his patients, but they will ultimately have to decide on their own whether to seek a prescription from a state-certified doctor.

“There are patients in my practice who will definitely benefit,” he says, as well as those for whom medical cannabis would probably carry more risk than benefit.

“It’s not right to think of it in a simplistic way,” Ross says, adding that researchers are still working to understand the endo-cannabinoid system.

THE CHEMICAL ANALYST

In some ways, Hoffman’s job is the same as it was at Covergirl—making sure the products are safe and effective by running tests for specific active ingredients, potential contaminants and harmful substances.

While she can’t give her friends free samples, she can offer the assurance that legal medical cannabis undergoes rigorous testing that the illicit marijuana sold on the street does not.

In the case of cannabis products, chemists test for the amount of active ingredients, such as cannabidiol (CBD) and tetrahydrocannabinol (THC), the primary molecules in the cannabis plant that have been shown to have medical use. The 100-plus different cannabinoids identified have different effects; THC, for example, is psychoactive, but CBD is not and is in fact already a legal pharmaceutical. State-regulated dispensaries are able to recommend some products over others, based on such qualities as the ratio of CBD to THC.

Chemists also test for molecules that should not be there. These include heavy metals, pesticides, mold, yeast, foreign matter and other contaminants.

Natural plants can be affected by the soil, fertilizer and water they are exposed to—which can be contaminated with heavy metals, Hoffman says. “The cannabis plant is very happy to absorb heavy metals from whatever it’s growing in.”

It’s a sobering fact to consider, since marijuana sold illegally undergoes no such testing.

ADDICTION AND OVERDOSE CONCERNS

Cannabis itself has no lethal dose, and medical evidence supports some benefit for certain conditions (See resources, below, to find a summary of the research.), although the number of studies and participants is small because the drug’s federal status as illegal with no medical use. However, one study in 2014 in the Journal of the American Medical Association, indicated that medical marijuana legalization might be associated with decreased use of prescription opioids and fewer deaths from opioid overdose.

Cannabis can still be psychologically addictive, but it does not lead to physical dependence, experts say. Physical dependence is not the same thing as addiction. A person being treated for pain with opioids over the long term is bound to develop a physical tolerance and need a slightly higher dose to achieve the same pain relief after, say, two weeks. As the dose is increased, the body’s tolerance increases. Higher doses are needed for the same pain relief, leading to dependence. A physician would need to supervise tapering the dose back down, or prescribe a drug such as buprenorphine, to ease withdrawal, which otherwise involves intense pain, vomiting and other physical and psychological distress.

Much of the current opioid crisis stems from the 1990s and early 2000s, when pharmaceutical companies and some physicians began asserting that opioids could be used more widely to alleviate chronic pain.

“With opioids, we were burned very badly,” Ross, the internal medicine physician, points out, and as with any drug, cannabis could become over-prescribed, diverted or otherwise abused. “Everyone is looking for the pill that will make their pain go away.”

Ross says he hopes people will understand that the product is not a cure-all but a tool for moving toward better health. “The worst thing that could happen is it becomes too casual, so that someone who doesn’t have a medical need can just access it.”

SCIENTIFIC RESOURCES

National Academies Press

To learn about the most recent scientific studies of the effects of cannabis, one trustworthy source is the National Academies Press, part of the National Academies of Science, Engineering and Medicine.

Go to www.nap.edu and search “cannabis” to find all reports on medical cannabis. Ignore the prices given, and go to the Download Free PDF or Read Online buttons. The latest report is a comprehensive one called The Health Effects of Cannabis and Cannabinoids (December 2017). Note that this is a comprehensive report, not a pamphlet, so don’t click on “print” before looking at the page count.

National Institutes of Health, ClinicalTrials.gov

To see what’s going on in cannabis research—including some local clinical trials involving cannabis and pain, or in case you want to volunteer—go to clinicaltrials.gov and type “cannabis, Baltimore” in the “other terms” search field. As of late December, there were at least two trials in Baltimore at Johns Hopkins University recruiting participants to study cannabis as an analgesic. There are far more studies listed that address cannabis in the context of substance abuse.

HOW TO GET IT

Patient Registration and Access

The rules are many, and patients must start by registering online with the Maryland Medical Cannabis Commission at http://mmcc.maryland.gov, where they will also find information on the process and the providers.

Patients should at least discuss cannabis with their own primary care provider, but most will need to see another doctor from a list of about 20 physicians registered with the state commission. These state-certified doctors determine whether cannabis is appropriate for the patient.

Patients need one more thing: cash. Prescription plans don’t cover cannabis (To start with, it is not FDA-approved.). Banks and credit card companies have to comply with federal laws. However, an app called CanPay works as a legal bridge for patients to pay participating dispensaries in states with legal cannabis, using a debit card.

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