The John A. Burns School of Medicine’s first CME on medical cannabis kicked off with a cautious start. (click here to download the PDF)

 By Pam Lichty

Pamela Lichty is president and co-founder of the 25-year-old Drug Policy Forum of Hawai`i (DPFH). She serves on the board of the New York-based Drug Policy Alliance. She’s a long-time member of the Board of the American Civil Liberties Union of Hawai‘i and she chairs Hawaii’s Sterile Syringe Exchange Oversight Committee.

On Saturday, November 4, 2017, the John A. Burns School of Medicine (JABSOM) in Honolulu, held its first- ever Continuing Medical Education (CME) session on medical cannabis. The lecture drew a sold-out crowd of 150 attendees, including at least 50 physicians, Advanced Practice Registered Nurses (APRNs, who are also allowed to certify patients in Hawai‘i), pharmacists, students, and members of the public. There was a reasonable fee of $30 for physicians and $10 for the general public. This low price was an indication that JABSOM and Amy Brown Ph.D., the organizer of the event from the Department of Complementary and Integrative Medicine, were aiming for accessibility. Continuing education credits were available for doctors, pharmacists, and psychologists.

The low price certainly was one reason for the packed house, but more important was the pent-up demand for a CME session on medical cannabis. The state-run Medical Cannabis Program has been in place for 17 years—since 2000. Despite this passage of time, the title of the class, “Medical Cannabis: What’s the Evidence?” demonstrates the cautious nature of the event.

In keeping with this focus, Dr. Brown presented first and touched on some research on the efficacy of cannabis for various conditions or diseases; however, the only source she cited was “The Health Effects of Cannabis and Cannabinoids,” a chapter from a January 2017 National Academy of Sciences report. A summary of this chapter was distributed.

Many other more positive findings from renowned cannabis researchers, such as Dr. Donald Abrams and Dr. Ethan Russo, were not mentioned. These and other “pro-cannabis” studies, which find cannabis to be uniquely efficacious for numerous conditions without the side effects of conventional medications, were ignored. The attendees were left with the mistaken impression that there is little existing research on cannabis, and that the research that does exist does not meet the “gold standard” of double-blind studies with control groups. The fact that the National Academy of Sciences report surveyed over 10,000 peer-reviewed cannabis studies was not discussed.

Aside from Dr. Brown, who has a doctorate in human nutrition and foods, the remaining speakers were physicians and attorneys. Some of the physicians certify patients, while others do not. The four-hour long agenda encompassed a basic, but fairly comprehensive discussion of medical cannabis in Hawai‘i. The program included an overview of medical cannabis, and discussions of the endocannabinoid system, research and best practices, medical consulting, and ended with a non-CME portion on “Obtaining Cannabis Legally.” Each section ended with a question and answer session.

Due to repeated requests for copies of the slides presented, Dr. Brown assured those in attendance that the material would be made available at a later date after addressing copyright and intellectual property issues. In fact, she promised to send the slides to every attendee. (The slides are not yet available to attendees, but will be made public once they are sent out). One highly unusual aspect of the program was that all of the slides, with the exceptions of the presentations by Doctors Clifton Otto and Thomas Cook, were prepared by Dr. Brown. This led to some awkwardness when the presenters struggled to present their own ideas within the context of the pre-prepared slides.

Medical cannabis professionals and experts at the event felt that the session perpetuated myths and prejudices surrounding cannabis use. These attendees were especially offended by some sensational imagery in the slides, such as a “stoned” dog stumbling around and a half-naked pregnant woman using a hookah. Dr. Brown’s comments even referenced the long-discredited myth of the “gateway effect” of cannabis leading to the use of harder drugs.

In her introduction, Dr. Brown noted that the session was “for information purposes only.” The political context of medical cannabis was intentionally not addressed. For example, she asserted, incorrectly, that there is a shortage of research. She explained how the Schedule I placement of cannabis creates an obstacle to research, but she included no discussion of why this is so. She implied that the scheduling was inappropriate by showing charts illustrating the other substances in Schedule I and lower schedules, but she did not explicitly criticize cannabis’ placement. Similarly, she noted that cannabis was removed from the U.S. pharmacopeia in 1937 (this caused a buzz of surprise since many attendees did not know that cannabis was ever included), but she declined to mention the reason for this. She did say that the cannabis provided to researchers by the University of Mississippi, the only legal supplier approved by the federal government, was of very low potency and quality, and noted correctly that this added to the difficulty of conducting research. Dr. Brown did not mention that the U.S. federal government has been funding cannabis research in Israel for the last 50 years.

Dr. Brown reviewed the centuries-long history of cannabis use, and brought it up to the present day with a NORML map illustrating the current status of cannabis in the various states. She spoke about THC concentration and said that it differed, in part, due to the time of harvest. She noted that inconsistent and vague popular names for cannabis cultivars create confusion and present another barrier to research. She also said that topical applications were increasingly popular, and she reviewed some of the synthetic medicines, such as Marinol and Sativex, including their legal status and exorbitant cost. Brown said there are 10 approved drugs made from cannabis—most unavailable in the U.S.

Some observers thought she seemed more positive about the use of synthetic cannabinoids than products made from the whole plant, but I thought she presented this information fairly neutrally.

Psychiatrist Dr. Thomas Cook presented an interesting discussion about terpinoids and their importance. He noted that some of the terpenes are useful to treat depression and that some reduce craving for other substances, demonstrating many potential uses. He noted that one terpene, akin to hops, promotes good sleep.

Dr. Thomas Murtaugh reviewed the endocannabiniod system in the most clinical of the presentations. He summarized the discoveries of the various cannabinoids, and noted that in the Flockhart Chart, a basic resource for physicians and others to track drug interactions, cannabis is missing.

Dr. Zain Valley, a specialist in occupational medicine and internal medicine, discussed some research, noting that there was more in the psychological realm (417) than the physical (313). He again referenced the National Academies of Sciences, Engineering and Medicine publication, “The Health Effects of Cannabis and Cannabinoids,” which presents nearly 100 conclusions and makes recommendations to improve research and public health decisions. He noted in passing that researchers often find mold in the Ole Miss-grown cannabis which complicates research results.

He was followed by Dr. Tricia Wright, an obstetrician-gynecologist and addiction medicine specialist, who spoke about some side effects of cannabis on the reproductive system in men. She said it can reduce testosterone and sperm counts and has been argued to increase the incidence of testicular cancer. In pregnant women, she noted that there is little convincing evidence of harm, but effects on the fetus are unknown. Although a Canadian study reported that 92 percent of women found it helped with nausea and vomiting, she believes that there is definitely potential for harm to the developing brain. For the same reason, in a very brief aside about the adolescent brain, she said, “It’s best [for teens] not to use.” She offered no support for these statements.

Dr. David Roth, a physician triple-certified in developmental pediatrics, child, adolescent, and adult psychiatry and neurology, concluded the section on research and best practices. He spoke of experiences with his own patients, and discussed the relationship between serious mental illnesses, such as paranoid schizophrenia and bi-polar disorder, and the use of cannabis. In short, he found it to be a chicken and egg situation with some people who are predisposed developing psychological problems especially with early, frequent, and/or high potency use. On the other hand, he noted, there are those who use it successfully to self-medicate for bi-polar disorder and paranoid schizophrenia.

The final medical presentation was by Dr. Clifton Otto, an ophthalmologist with a specialty in retina issues. He spoke from his direct experiences consulting with and certifying patients. He provided useful and concrete advice, such as substituting grapefruit for CBD and Marinol for THC in the Drug Interaction Checker. These, he suggested, are the types of work-arounds health professionals must use in the absence of precise information about cannabis in conventional sources of medical information. He noted that Health Canada has good advice on appropriate dosing—an issue that makes many medical professionals uncomfortable. Dr. Otto noted that there is a dosing capsule commercially available, and this may prove useful in assuaging concerns.

Finally, attorneys Amanda Jones and David Banks (both with Cades Schutte) reviewed the procedures for medical professionals to qualify patients and the current status and availability of dispensaries in the state.

Despite its overly cautious and conservative tone, this session offered a good beginning to what should be an ongoing process of continuing medical education for communities across Hawai‘i. The strong interest, evinced by the sold-out attendance, should encourage JABSOM and other professional entities (like the Hawaii Medical Association) to continue these important educational efforts.

Now that dispensaries are opening and demand for the program is rising steadily, there are not nearly enough knowledgeable medical professionals to work with the growing numbers of patients. In many cases, medical professionals either do not understand what is required of them, or believe that they do not have enough information on this long-stigmatized medicine. As the use of medical cannabis gains ever more credibility and accrues more evidence worldwide, it is vital that JABSOM continues to offer and improve a program to educate their constituencies with the latest information and research on this cutting-edge medicine. We applaud this vital first step in their educational efforts.


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Continuing Medical Education In Hawai‘i