Is Recreational Cannabis Hurting the Medicinal Market?

Medicinal cannabis is at a crossroads in America right now. After the passage of California’s Compassionate Use Act in 1996, medical marijuana slowly became a viable and thriving market throughout the U.S., and the patient was king. But as states like Colorado and Washington opened the door for recreational cannabis, some felt that medicinal patients were getting left behind.

As the recreational industry continues to evolve at breakneck speed, we wanted to gain a better understanding of where the medical market stands. For instance, is adult-use legalization ultimately a good or bad thing for patients? Is it still a good idea to get a medical marijuana card? What does the future hold for medical marijuana?

To shed some light on the situation, we spoke with Pamela Hadfield, co-founder of HelloMD, a leading digital health platform for medical marijuana patients and prospective patients. HelloMD works with Shoppers Drug Mart to certify medical marijuana patients in Canada, and the company also supports patients in Illinois, New York, and Pennsylvania. HelloMD has helped over 150,000 patients so far.

For Hadfield, the mission is personal. She struggled for years with migraines and other health issues, and she was able to stop using all conventional pain medications when she discovered cannabis. Now, through the work of HelloMD, she helps others to manage their own conditions with the help of medical marijuana.

During our conversation, Pamela shed some light on the ways in which medical marijuana services are improving and also the ways in which they’re losing ground in the changing market.

Recreational and Medicinal Labels Do More Harm Than Good

The characterization of recreational vs medicinal is largely a product of the regulatory agencies, and this misleading distinction has led to a lot of confusion over the years. This confusion is compounded by the fact that many cannabis manufacturers use terms like “medical-grade” to market their products. As Hadfield notes, “Anyone who has consumed cannabis knows that there’s no real black and white labeling like that. It’s a spectrum. So I think it’s unfortunate that we are pushed into these categories.”

But those labels—arbitrary as they may be—can have serious ramifications for patients. When a state market turns recreational, much of the government and regulatory attention shifts to adult use, which is much more profitable. The medical patients get left behind.

Hadfield references California as a prime example of where things can go wrong. “In 1996, we had the Compassionate Care Act. And there were a lot of benefits for medicinal patients, including tax benefits, and including the fact that when you went into a medical dispensary, the dispensary was able to get cannabis to the medical patient, including those who were at a serious financial disadvantage. All of that went away when recreational came in.”

The problem, Hadfield notes, is that recreational cannabis tends to overshadow the state’s medicinal program and eliminate the advantage for medicinal patients. For example, if you’re a patient with a specific condition like epilepsy, chronic pain, or peripheral neuropathy, what type of cannabis do you take? What about the dosage? Your average budtender isn’t in a position to offer personalized medical recommendations based on clinical data and a patient’s medical history.

It’s Easier Than Ever to Get a Medical Marijuana Card via Telemedicine

The medical market hasn’t just been impacted by adult-use legalization in recent years. Since 2020, it has also been impacted by COVID-19, and mostly for the better. The reason all boils down to telemedicine, the ability to get certified via a virtual (computer or telephone video conference) appointment.

Prior to the COVID-19 pandemic, only seven states allowed telemedicine evaluations for new medical marijuana patients: California, Connecticut, Maine, Nevada, New York, Pennsylvania, and Rhode Island. But as of May 2020, that number jumped to more than two dozen states, largely in response to the need for social distancing.

Unfortunately, many of these new directives are temporary. For example, Arkansas started allowing telemedicine evaluations in March of 2020 as part of its Medical Marijuana Emergency Rule. That directive expired on March 31, 2021. It’s yet to be seen how many states will revert to their pre-COVID requirements.

In spite of this, Hadfield believes that the COVID-era emergency declarations will have a lasting impact on the industry. “Nobody can see into the future, but we believe that the regulations that were extremely restrictive before, for cannabis and telehealth in general, will continue to be looser as people expect to be able to see their doctor online now.”

Patients Should Still Get a Medical Marijuana Card—Even if They Don’t Have To

Despite the setbacks, it’s still in the best interest of patients to maintain a current medical marijuana card. One benefit is access to more dispensaries and more products. Another benefit is fewer restrictions. For example, in Colorado, adults are allowed to purchase and possess up to 1 ounce of marijuana at a time. But medical marijuana patients are allowed to purchase twice that amount.

The most notable advantage of a medical marijuana card, though, might be the savings. In states like California, medical patients are exempt from paying sales tax, which can exceed 10% in some cities.

And other states have especially noteworthy tax benefits for medicinal patients. Hadfield notes that recreational buyers in Illinois pay about 30% more than medicinal patients, the result of an inflated taxation model.

In Chicago, the tax rate can veer close to 50% when you factor in the Cook County excise tax and the 7% state wholesale tax (which most consumers don’t even notice since it’s imposed further up the supply chain). Washington is another state where recreational users pay close to 50% in state and local taxes.

Research shows that high taxes bolster the illicit market. One study found that, in California, a 5% decrease in the tax rate could drive 23% of illicit market supporters into legal dispensaries.

Europe Might Have the Solution to America’s Struggling Medical Market

There are still a lot of unanswered questions. When and how will the FDA regulate cannabis for medicinal use? What will that mean for the current prohibition on interstate commerce? Will state markets ever develop a more uniform system for addressing patient needs?

Hadfield believes that states will likely continue to manage their own individual markets for the foreseeable future. But if we want to move the industry in a more consumer-friendly direction, we might want to take a lesson from the European market.

“I think Europe is taking it much, much more slowly,” Hadfield notes. “And I think at the end of the day, you’re going to have a much better system. I mean, you’re already seeing that with the CBD hemp market. You have to have a specific certification in order to sell CBD hemp there, which gives the consumer confidence, and it’s the largest CBD market in the world. Even though they’ll have countries with different regulations, I think they’re setting up the entire market to work for the consumer, not the other way around.”

The U.S. might also look north to Canada as an example of how to better cater to the needs of patients. As Hadfield notes, Canada uses a pharmacy-based model whereby card-carrying patients receive guidance and obtain products from licensed healthcare professionals. Patients can visit a neighborhood retail pharmacy like Shoppers Drug Mart and receive the same care and expertise that would be expected in a clinically run medicinal dispensary. This type of service is lacking in the U.S.

Now More Than Ever, Medical Patients Need to Do Their Homework

Medical-only dispensaries were once an invaluable asset to patients. You could walk in, speak with a licensed physician, and obtain personalized recommendations for strain, dosage, and delivery system—all tailored to your condition.

But in states where recreational cannabis is legal, these patient-friendly establishments are disappearing. When Oregon legalized adult-use marijuana in 2014, the state went from 400 medical-only dispensaries to just two. Similar trends have occurred in states like California, Nevada, and Washington.

But as Hadfield notes, medicinal patients still have the same questions they had before the recreational market took over, and they still need the same type of expert clinical insight that a budtender is ill-equipped to provide. What’s worse, budtenders are often inclined to promote high-THC products.

Hadfield recalls a personal example of this dangerous trend. “In Florida, which has a history of being a medical state, my 84-year-old aunt was given a hundred milligrams dose of resin” [used to make highly potent cannabis concentrates, often exceeding 60% THC].

The problem with budtenders is that there’s no standardization of care. Some give excellent recommendations while others are far less reliable, and there’s no specialized education or certification required.

Many patients are turning to the internet and using apps like Leafly and the ReLeaf app to research products, but much of the information is user-submitted and not curated by medical professionals. Hadfield acknowledges that there’s an unmet need for dependable online resources, and that’s why organizations like hers are in the process of developing specialized content to help patients make informed buying decisions.

For now, the most important thing a patient can do is to learn their product and dosage requirements before stepping into a recreational dispensary or shopping online with digital cannabis coupons—and the advice should always come from a medical professional, such as their recommending physician. A person’s needs can vary significantly depending on their age, condition, medical history, and concurrent medications.

“We service a lot of people over the age of 65, and an average patient is often on six to eight or more medications at the same time. So you get into really dicey territory there. On one hand, cannabis can actually help you reduce the amount of medication that you’re on, but you have to ride this very fine line of how to ramp somebody onto this without putting them into a situation.”

Psychedelics May Be Legal Before Medical Cannabis

Though Hadfield acknowledges the uphill battle that cannabis advocates are fighting, she believes there’s more than a reasonable likelihood of federal legalization in the next few years. At the very least, she predicts that all 50 states will have a legal medicinal market in the next five years.

But regardless of whether or not these milestones come to fruition, the expanding cannabis market is already having a snowball effect, and ironically, some of the snowballs are moving even faster than the cannabis itself.

“It’s interesting,” Hadfield notes. “Cannabis, on some level, has opened the door for the acceptance of psychedelics. The reality is that psychedelics are ahead of cannabis in terms of FDA approval and clinical trials, and the evidence has been out there for the last five or six years. We’re seeing the decriminalization movement with psilocybin mushrooms going across the states in a very patchwork way.”

Oregon approved the legalization of psilocybin mushroom therapy in November, and now similar bills have been introduced in both Florida and Connecticut. The FDA has also approved Phase 3 clinical trials for the use of MDMA on chronic PTSD sufferers.

“What we’re going to see in the next three to five years are a lot of other psychedelic analogs and derivatives going through the clinical trials pathway. But I don’t see that for cannabis.”

Psychedelics are several years ahead of cannabis in terms of federal regulation because, as Hadfield notes, “the starting point is everything.” Cannabis was first brought to the public via voter referendum, and not via FDA approval. As such, the federal government still has a difficult time recognizing its clinical value. Psychedelics, on the other hand, were introduced through a federally legal framework for the purposes of clinical research, and that has made an enormous difference.

Psychedelics are showing tremendous promise for issues like PTSD and addiction, and we may see them more widely used for clinical therapy in the near future.

The Cannabis Black Market Is Still Thriving

Even with the widespread availability of legal cannabis, the black market is still thriving. By some estimates, as much as 87% of cannabis revenue in the United States is from illicit marijuana. The reason, as Hadfield notes, boils down to taxation and regulation.

“If you can buy your black-market cannabis at 50% less, and you have been working with somebody who’s selling that to you for the last 10 years, and it’s a trusted source, why would you possibly go to the legal market other than to access a brand? You can go to New York and you can go into apartments where they basically have a whole dispensary set up that mimics California products.”

Legitimate canna-brands are at an immediate disadvantage because their ventures cost millions of dollars per year. In California, the licensing fee alone can cost up to $120,000. Then you have to account for the costly testing requirements, high taxes at every level of the supply chain, and other basic costs associated with running a business. It costs between $80,000 and $250,000 to open a dispensary in California, and monthly costs can be as high as $70,000. Illicit operators can sell for pennies on the dollar because their costs are limited to the seeds and grow equipment.

And while older medicinal patients are less likely to seek out the illicit market than younger patients, they’re the ones who suffer most as a result of high prices. Many older patients are on fixed incomes, and no health insurance provider covers medicinal cannabis.

Cannabis Testing Is Far From Perfect

One of the biggest reasons to choose legal over illicit cannabis is the testing. When your cannabis is required to undergo third-party analysis, you don’t have to worry so much about unknown chemicals, toxins, and contaminants.

But while Hadfield believes that testing is important, she acknowledges that it’s far from a perfect system. For starters, testing standards vary significantly from one state to the next. In addition, there have been major reports of falsified test results in the cannabis industry. For example, one Washington lab was just suspended in December for labeling cannabis samples with falsely high THC levels, presumably to appeal to customers seeking a more potent high. In 2018, a Sacramento lab lost its license for falsifying pesticide results. So if the laboratories are designed to hold businesses accountable, who holds the laboratories accountable?

Another issue is that labs only test for specific pesticides, fungicides, and compounds. As Hadfield notes, “You can test for certain pesticides, you can test for mold, and you can test for fungus. But if you decide, ‘I want to increase my yield on my crop, and I’ve found this new chemical that’s going to help me do that,’ testing labs don’t necessarily test for that. They can’t test every single kind of chemical out there. So the consumer is still at risk. I think testing just mitigates the risk.”

CBD Is Not Going to Replace Whole-Plant Cannabis

Cannabidiol (CBD) has been getting a lot of attention, particularly for its therapeutic and medicinal potential. But Hadfield believes that, while CBD does offer some key benefits, it also has some important limitations that shouldn’t be overlooked.

“I’ve heard many times that CBD is the medicinal part of the plan, which is simply not true. Cannabis, in and of itself, is a medicinal plant. The cannabinoids and terpenes work in conjunction. So CBD is an appropriate medicinal element for some people, but you can’t divorce it from THC.”

If you’ve tried using CBD oil, and you haven’t noticed a significant health impact, you might find whole-plant cannabis to be more therapeutic.

COVID-19 Is Helping to Normalize Cannabis

Interest in cannabis has been surging over the past year, and COVID-19 has a lot to do with it.

Legal cannabis is more accessible than ever thanks to the increased availability of telehealth, delivery services, and curbside pickup, and a growing number of people are using cannabis to manage lockdown-related depression and anxiety as well as the symptoms of COVID itself.

But there’s a larger benefit here than just increased sales and availability. To Hadfield, the biggest positive effect is the increased normalization of cannabis. “Cannabis has gone into hyperdrive. So I think for me, being from the inside the industry, we can look forward to a lot more normalization in the coming years, and that’s thanks to COVID.”

We Must Ensure That Medical Patients Don’t Get Left Behind

There’s a lot of good news on the horizon for cannabis advocates. Cultural attitudes are shifting dramatically, and we can expect to see far more states—and possibly even the federal government—get on board with legalization in the coming years. We must ensure, though, that patients don’t get left behind.

If you depend on cannabis for medicinal purposes, there are steps you can take to be an informed patient while also ensuring that the medical market remains viable and successful.

  • Renew your medical marijuana certification every year; this will help you to save money while also affording you more privileges and signaling the continued demand for medical marijuana services.
  • Shop at clinics and medical-only dispensaries when possible.
  • Seek the advice of knowledgeable medical professionals to determine your optimal strains, dosage, and other crucial information.
  • Always do your homework ahead of time when shopping at a recreational dispensary. Don’t place your fate in the hands of a budtender who may or may not understand your needs.

There has never been a better time to explore the possibilities of cannabis. The genetics are getting better, the products are becoming more diverse and sophisticated, and the laws are becoming more favorable toward consumers and patients. And thanks to tireless advocates and educators like Pamela Hadfield, medicinal patients still have an invaluable support system and access to essential resources.

We’re encouraged to see more recreational markets open up nationwide, but let’s not forget about the needs of those users who rely on cannabis the most.

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