 So, good afternoon everyone. I call the meeting of this advisory medical meeting to order. I'm Tom Alaska. I'll just take a quick roll call of our subcommittee members. Um, you can open up, you can take your present. Present. Uh, Meg. Present. And then, we also have, uh, Chairman Pepper in attendance as well, and that's it from the board. That's right. Okay. And then, we do not have Dr. Clifton up to call yet. Uh, she calls all, all note of fire for Bill Paul. So, since this is our first subcommittee committee meeting, I wanted just to do brief, very brief, uh, introductions because we've got a lot to do and discuss. And I'll be speaking really quickly. Uh, again, I'm Tom Alaska. I'm General Counsel for the National Association of Cannabis Businesses of the NACB National Trade Organization that specializes in creating standards and best practices for the cannabis industry. Our goal is to legitimize and elevate the growing cannabis marketplace. And part of our function is to consult with various state legislators and regulators as we are doing in this engagement. Uh, my background is a 20 year attorney, uh, in commercial business litigation. I've been in the cannabis phase for about seven or eight years, starting with partnership disputes between cannabis lights and holders. And like any other, um, business, they have the compliance of the state. I served on this, they were based on panels for cannabis and then throughout the country on issues like licensing, social equity, 280E. So it's my privilege to be able to coordinate, uh, these subcommittee meetings and create some good policy for the state of Vermont. So, um, Jim Romanoff serving on this subcommittee, did you just want to give a brief introduction Jim? Uh, yeah, thank you Tom. I'm Jim Romanoff and I'm currently the chair of the Cannabis for Symptom Elite Oversight Committee. And I've been on the committee for several years, four years. Um, and because of that position, serving on the advisory panel as well. And my background is, uh, in private business and publishing as well as, uh, other media communication related businesses, mostly around food and, uh, gardening and agriculture. Thank you Jim. And Meg Delia. Hi, I'm Meg Delia. I'm, I represent the Vermont Cannabis Trades Association. Um, I have worked now with them for about four years. My background is in public health as well as in the medical field. Great. Thank you Meg. And thank you both, uh, Tom and service on the subcommittee. I know we have some members of the public, uh, attending the subcommittee meeting as well. I wanted to make sure that everyone knows that written public comments can be submitted electronically via the web form on the CCB website. And that has been available since May 2021. And I wanted to ensure everyone that your comments have been received reviewed and considered by each and every subcommittee member. And we certainly appreciate your input. There will be a time for public comments and questions toward the end of the hour as there will be with every meeting going forward. And in addition, the CCB will be hosting dedicated meetings for public comments both at their Friday board meeting via public link or the CCB's public comment evenings that will also be posted on their website. So your voice will be heard and considered. Uh, but we do have pressing deadlines on us and it's critical that we have some constructive communications between the board members to meet those deadlines. So I don't want the hour to be dominated by public comments. Uh, but certainly you will have an opportunity at the end of each meeting and also you can address your concerns through those avenues that I've discussed. So I just want to make sure we still don't have Dr. Clifton will also be on the subcommittee and I disseminated some of the, uh, reference materials for this meeting and going forward as you're aware. Uh, the enabling legislation for the subcommittee are acts 62 and 164 that I included the pertinent portions of those acts. Um, and unlike some of the other subcommittees that I've been on all day today, we do have the benefit of some existing regulations as well as the 2019 report authored by our very own, uh, Mr. Jim Romanoff. But with the advent of this legalization, we've got a golden opportunity to identify areas to enhance and improve the medical cannabis program for patients in the state of Vermont. So let's begin with some of the issues that I wanted to identify that we can get agreement on to tackle with this group. And I'd like to hear obviously from the subcommittee members and we can modify and prioritize as you see fit. But one of the things that's happening, it's not exclusive to Vermont, but when adult use comes online, it's ensuring that the medical cannabis community and those patients have the continued care and service and they're not marginalized in any way. So I'd like to hear just both of your thoughts on some of the supply issues the last few years and ideas on how to protect medical patient access to the product that they need. Do you want to go first Meg or? Sure. Um, so in terms of really keeping the medical program viable, I think our first and foremost priority is really access. Without a large enough program, I think it will be difficult to maintain the current medical program. So access, expanding that, making it known that this program is available to Vermonters and making it a program that isn't more restrictive than adult use. So, you know, just like for adult use, you could walk into any dispensary and purchase cannabis. Right now in medical, for example, you can't do that. You have to designate a dispensary and there are a number of items like that that I think will kind of push people into the adult use market rather than medical just because of all those groups they have to jump through. So addressing access is definitely my priority. Thank you. Have any comments? Yeah, I would agree completely about access. We've had a lot of, at our oversight committee hearings, a lot of concern expressed by board members and members of the public that in the rush to the adult use market and the money that can be made there that the medical program will suffer. But, you know, that if both access is, I think, a really important point and I have some things that I can address on that. But besides, I think having access to the program, adults can go to adult use products if they're cheaper, so there are things like cost as well. I think that, you know, ensuring that the program itself is comparable to what is available in other states in terms of product, variety, testing, all those types of things. And, you know, we have a good program but there's a long way to go in terms of the kinds of products that are available. So definitely access, definitely, you know, the program improving itself in terms of products availability and testing. You know, I think another issue for access, which Vermont patients are interested in is reciprocity. We can go to another state and use their medical dispensaries, use them up in Maine. Other medical patients can't do that here. I'm assuming that that would support the business side of our dispensaries if other patients were able to come in and purchase from the dispensaries. But, you know, I think that the people are looking for some designs of protection of the patients and the medical program. And I think we need to consider the patient who's the lowest common denominator, who isn't speaking up and isn't showing up at these meetings, can maybe barely afford medical cannabis and has difficulty maybe even physically getting it. So, you know, for those people I think being able to let people know that we're going to watch out and not let the program slip during this period. Thank you both. And I've got some follow-up questions for that, but I think Dr. Clifton just joined us. Dr. Clifton, can you hear me? Yes, I can. Thank you. Hi, Tom. Hi. We got underway, but if you could just say a quick hello and give a quick introduction. Oh, thank you, everybody. I had some unexpected misdirected travel and a terrible night last night. So, sorry to be joining you a bit late. Dr. Clifton, I'm internal medicine, 25 years. The founder of CBD and cannabisinfo.com, my 203 video website and education product, just basically medical and scientific consultation in the cannabis space. So, looking forward to contributing here with you. Great. Thank you, Dr. Clifton. And I had just posed the question. The first issues I wanted to address was the protection of the existing medical patients as adult use comes online. And what Meg and Jim had talked about was ensuring access, cost, product availability, variety, testing and reciprocity. And those are some of the issues that we take through. Can you just give me a sense of, because for example, like I know in Illinois, even when the program was still just medical, there were, and obviously, you know, there's population difference. But they couldn't keep up with the demand. In Vermont, there's, I'm aware of the issues just of kind of geographical difficulties or strains for certain people. But I mean, Meg and Jim, do you have a sense of what the supply and demand metrics look like for the medical patients? Were there vast shortages like in some other states? Or was there some equilibrium and how that might be affected going forward as we open up to adult use? Jim, do you want to go first with that? Sure. You know, I am chairman of the Oversight Committee and I'm a patient as well. You know, there has been always a supply, and I would say that it's limited. I couldn't say whether it's limited because of the difficulty growing it or the economics of it. It is certainly limited in terms of variety, strains, number of strains. Part of that is difficult to legally import them and get them going in Vermont. But I'm sure also a matter of business. And using a broad spectrum of strains, varieties, chemotypes is a very effective approach according to many people. It has been for me. So the supply has never been what it is elsewhere. It's always been limited here to number one. And I do want to say one quick thing that I do want to point people to the 2019 report that you mentioned because I think that it does outline points really specifically that speak to what Meg was saying about access as well as all these other issues of access related to costs and geographical considerations, all those kinds of things. So I did want to just mention that again. But to answer your question, I think the supply has been limited already. And so, you know, I would hope it doesn't get more limited. Again, other states do better. Yeah. Thank you, Jim. I did reference your report and the existing regulations in the reference material. And I didn't send that to you because he says to me, I assume Meg has that. I sent it to Dr. Clifton as well. I have the benefit of that. And that's obviously a good resource enforcement, a good starting point. Meg, did you have anything to add? Any color to add on the supply? So I think in terms of supply, as Jim said, it's absolutely limited. And I think where we as the dispensaries run into an issue with providing, you know, not only a large supply, but also a diverse offering of products is that right now the program is so small that economically, it is really difficult for us to be able to, you know, grow all of these strands, produce all of these products and allocate all of those resources when our patient base, you know, over the past few years has decreased. And so with fewer consumers, just economically, it doesn't always make sense to really just increase all of the resources to provide a variety. So I think there is that. And as Jim said, without interstate commerce, there are definitely the complications of how are you, you know, getting seeds for a new strain, etc. That absolutely poses some difficulties. And then, of course, now with COVID, I think we're seeing quite a delay in supply chain of other material that maybe impacts our final products that are going to the dispensaries. Right. Thank you. Thank you. So one of the considerations is with the expansion, the coming expansion of the market from the adult use patients or customers, will that spurn the supply side because of the greater number of cultivators or growers? And to what extent? Will that just service then the adult use community or will the medical community benefit from that as well? Or will we have the opposite effect where maybe there'll be some stagnation on the supply side or cultivator side and then you have greater demand from the adult use market that will marginalize the access to the medical community? Right. Those are some of the concerns that I have at least going forward. Yeah. I mean, I think our hope is that with adult use, whether it is the revenue game from that or as you alluded to the growers that we're working with, hopefully we will be able to commit more resources to a more diverse product of how the funding to do so. And then really depending on the rules that we will learn more about hopefully in coming months, whether or not the product from craft growers could also be sold to medical dispensaries or is that only adult use. So getting clarity there, I think will help determine that answer. I would add into that that I would hope that the adult use market benefits medical, but I don't see any reason to assume that it definitely will because usually money speaks unless there's a regulation in place. So I think there's a baseline of products that are available to medical patients and I think one of the pieces that we have to talk about is not just really the raw flour and raw product, but the processing and the process product. That would assume I don't have these numbers, but then the majority of patients are using a tincture, a concentrating product that's been transformed into something they can digest, sub-legal, all these different things. So ensuring that there's a baseline of products that medical patients are getting now and it's not a huge variety. So being able to ensure that those stay and are continually made at the same level, I would think would be important. Now there hopefully with the broadening of the market there will be similar varieties and products that do similar things. These are going to exist at strengths that are not going to be the same as the adult use market. So they are different, the concentrates might be the same, but the products are going to end up being different. So hopefully the variety will expand eventually and we'll be able to educate patients if this works for you. Now there's five things that are like that available and hopefully we can do that and it will benefit the patients. But in the short term, I don't think we have a guarantee and to be able to look for some sort of a sense of security for the patients and feeling that they can at least count on for a certain while the product that they're using now to be available as the market transitions I think would be important. Yeah, thank you for that. So I have two follow-up points. One, in a separate subcommittee, the market structure, licensing and fees subcommittee, we just received or we'll walk through the market analysis and I will send both of you because that kind of helps dictate every other subcommittee. The second thing is, as to your, it's funny, so I've been in every subcommittee all six months today and there's usually different perspectives. In the sustainability committee of all committees, we talked about the product landscape and what might be coming in the future. The comment was, well, this is Ramon, people like flour. And then the counter to that was, well, you know, nationally at least as far as what sales look like for your average dispensary, at least half of them are probably on the edible side now. That's probably going to be growing and the comments made especially typically kind of the older and the medical community moving away from flour. So, and there was some agreement about that, but I mean, I think it's going to keep, continue to trend that way. One new problem. And one thing I would say also is that, you know, I don't think the medical patient is the typical cannabis consumer and that is what we have to look out for. I mean, there are people who are sent in desperation with a terminal illness and they might have never tried cannabis ever before. And yet it's what's going to get them through it. So they, you know, comments about what Vermonters like and what, you know, I'm not sure it all pertains to what the medical patient needs. Right. And I think we also have to, you know, continue to carve a space out for concentrates for the medical patient, for the seizure patient who's developed a high tolerance for THC. He needs to use a concentrated THC formulation or for somebody with panic disorder or migraine headache who needs a rapid administration for rapid resolution of the symptoms. The dabs are BSO or hashish. Those are products that are, that do have a, weirdly, have a position in the medical space. I don't think that people see them as immediately medical products. Does the subcommittee feel like positioning homegrown prominently in the discussion will really help the medical cannabis patient in Vermont to, to have to, you know, overcome the issues of availability of product? I think they have dealt with it and they can talk about that. Go ahead, guys. It is safe for my own experience and it's not for the faint of heart. And if you need, we live in Vermont. Okay, so being an indoor car grower is very complicated. Things, you know, it's a whole different environment that you're creating. Outdoor growing, we live in Vermont. It's a short season. It's an odd weather. And if you're counting on this for medicine, you can lose it all to worms or a frost or a blight. And I think that we're not, we don't have a marketplace yet where consumers have confidence in growing cannabis. I think they will. I don't think it's a lot different. We're avid gardeners in Vermont, but we're not there yet. Because mostly people who grow cannabis or have in the past in closets are telling people how to do it. And it sounds scary and not doable. So we'll get there, but not yet. Well, you know, I have to say I feel similarly that I'm not a gardener. But it does seem like for a lot of people with limited incomes and limited mobility, and a green thumb, that the home grow may offer a nice opportunity for a lot of people. In one of these closet situations where you can buy these freestanding spaces where you can grow, I think that should be something you should not use as an excuse to not really shore up the supplies and the dispensaries for medical, but also in this committee make sure that we keep that available for people. You know, I would agree with Jim, you know, on the initial kind of reaction in that, yes, we certainly have a significant part of our medical population that do grow. But I think what a lot of medical patients are coming into the dispensaries for is not necessarily just the flower that they could grow at home. They're products that really are lab tested, safe, consistently dosed, reliable, consistent. And even though it may, you know, at first glance appear to be the more financially viable option for somebody who, you know, maybe is interested in saving some money and growing at home, I think as Jim alluded to, you could lose it all at once. So all of that money that you put in could be resulting in nothing in the end. And I think that's a significant risk for a lot of patients to potentially lose their medicine. And if they are concerned with contaminants or anything like that, they will end up with those costs of lab testing, which the dispensaries are already doing. So as much as I think home grow is an important part of the medical program, I don't know that I would say that that's something I would want to put at the forefront of this committee's priorities. So just getting back to, and this is still on the first issue of how do we protect the existing medical patients as we transition on their adult use. Jim, for your 2019 report, did you get a sense were there any studies done? And this is to your suggestion of we've got to ensure that baseline of products for the medical community or have that safety net. I mean, how do we go about finding what that is or those numbers? Is that part of the report or any studies done for that? No, I'm not aware of specific studies that were done at that granular level of how cannabis was being used as a product. What was, you know, concentrates, flowers, that type of thing. I would say that given we have a limited number of dispensaries in Vermont and we have a limited number of patients right now, it wouldn't be that difficult to determine, you know, I've looked at my dispensaries menu. It's pretty, and I don't mean that this is in a negative way, it's limited. It's limited so I could, you know, to ensure what's on there I don't think would take much of a, you know, discovery process to see what's there. I think the dispensaries, you know, have information I'm sure about products that are, you know, more important to their patients in terms of what they're getting versus not. And I assume given it's been a difficult business for them in these years. When I blog that they've made it through it, you know, things have weeded out that it's there because either a patient absolutely begs to have it, even if it's not cost-effective to make, or it's there because it meets the standard of, you know, it's good business and the patients are using it. So, you know, from my point of view right now, I just want more variety. There's always more you can get. But you could look at the menus right now and say, you know, in these categories, we want to make sure that there's this type of concentrated product, this type of flower, you know, that they're available for X number of months during, you know, the changeover. You know, again, I'm not in the dispensary business, but besides the, you know, demand for processing and whatnot, the strains are there and they're growing. The dispensaries, I'm sure, are eager to grow new genetics and all that type of stuff. But, you know, I'm growing those strains. They can't be cut except above. So it's there. It can be done. I don't think it's the biggest thing. And, you know, I think ensuring it, I don't know if there is just a commitment. I don't know that that will satisfy a lot of the, you know, concerns I've heard from both our board and the public. Yeah. And again, I will send you that market analysis. And there's got to be a way to extrapolate, like, what's existing now because they're just medical sales until now and using that to form our baseline. I would suggest having as a, you know, testimony from, you know, or written testimony from the dispensaries just of what they're, you know, where they are with the product would be a good idea. And we can gauge their, you know, both, I wouldn't call it appetite, but their ability to, you know, in good conscience, keep the medical products going and expand in this new marketplace. It's not so big it shouldn't be possible. Right. I mean, if you've got those contacts you want to reach out and they can develop that for us, that'd be extremely helpful. I don't know. There'd be better for me or you may. That's your, your peeps. So, yeah, I, I just think we should work with the dispensaries and we'll see what what they're prepared for. None of this is a surprise to them. Their patients are talking to them every day. They don't have any recreational patients yet. But all you so they're only here and worried patients. I'm sure. Right. So we'll do that. Okay. I mean, I've got as other items to consider as far as does not continue to review the medical program. And where, you know, some of its shortcomings were and how we can better serve the community. And I know you both have testified. I mean, one of them, one of those issues, I think, Meg, you were talking, talking about this was just addressing, addressing qualifying conditions. Do you just want to speak on that and what we can do to improve the program? Absolutely. So as you all know, there's a list of qualifying conditions currently. Those conditions were determined not necessarily by individual positions, but by the state. So I feel strongly that we should allow healthcare providers to determine what is or isn't a qualifying condition for their patient. I think, you know, especially in the last couple of years, there's been an increase in sleep disorders, anxiety and panic disorders. Those are not on the list, but we've heard from physicians who have said they would like to recommend medical candidates for that. And I, I just think that the doctors are the ones who have been trained. And they should be the one determining what is or is not qualifying. I think we could also expand the list and really kind of fill down and just be listing. But at that point, I think we're faced with kind of an ever growing list, there will always be something to add. So why not put it in the hands of the healthcare professionals now? Dr. Klipsch and I'm sure you have some feedback or some comments on that? Oh, I love the idea of making, of giving doctors plenty of room to just make decisions. I mean, the vast, vast majority of people coming in for medical cannabis, I think in my experience, between years of national registries is going to be chronic pain, insomnia and of course anxiety. So having PTSD and anxiety as a, as a diagnosis that can, that can fall under the treatment of medical cannabis would be helpful. And I agree with all that. Yeah, Jim, I'll let you comment as well. I'm just thinking about this from a, from a legislator's perspective. I don't know if just giving CART launch to a healthcare professional would be the most palatable recommendation. But certainly, Dr., you're referencing the national registry. If we could support at least an expanse, more expansive list that's not currently included. I don't know, I don't think, is anxiety. Anxiety is usually kind of a touchstone one. Is that included, Megan, in the current 12 time conditions we ever want? Most of the time it's not included. Sorry to interrupt you, Meg, but then PTSD is included in a more progressive state. And then when a doctor is doing the card, if a person has anxiety as their primary diagnosis, we use that anxiety diagnosis as the patient's pain. And so we'll, we'll put the card in as a pain card with anxiety being the pain diagnosis. So it, we, it, that's the workaround, sort of the general workaround for somebody. Or a lot of times you can find an anxiety patient who has some that are in back pain or arthritis pain somewhere. And so we can work it in as a pain card. Right. But yeah, so if you understand my suggestion, maybe, maybe if we could develop that, that list at least, this is an alternative. I mean, I hear you and, and Meg's saying, let, let the healthcare provider decide. But as a fallback, I'd like to have at least a list that's more expansive than the one now to expand the program for the qualifying conditions that we can support with what's going on in other states as well. And would it be helpful to have language from other states who have adopted allowing healthcare providers to determine health conditions? Okay. I can certainly find that. You know, I think it is important to remember that in the way it works in Vermont, the, and I don't want to just say doctor. I would want to say, you know, a healthcare provider because nurse practitioners, psychologists, there's many practitioners, you know, a nature of tasks. I think that should be also, I think, able to recommend people to the program. And that's really what we have here. It is not, you know, a doctor or healthcare provider is just saying, I work with this patient and for this long and they have this condition. It says nothing. They're, they're not recommending cannabis. They're just saying they have this condition. They are inadvertently recommending it by letting them be in the, in the program. So, you know, that's one thing that down the road might need to be addressed here in Vermont is how healthcare professionals are referring people to the program. It's very backwards now and it's meant to, I believe, protect them from having to say, I'm asking you to do something that was currently at that time illegal. Now, as adult use opens up, it seems to me that, you know, a medical program needs to be less restrictive obviously than an adult use program. It's, it's regulated in a certain way and you would not say to a doctor, you know, you can't, most prescriptions can be prescribed off-label if a doctor decides, I'm going to, you know, prescribe, you know, a anti-spasmodic for sleep. They'll do it. So, you know, moving in that direction is probably a good idea. I don't know, you know, a logic for legislature to give up the control. I think you're right. Right now it's certain conditions but they're going to be, you know, every adult's going to be able to get cannabis in some form legally. So, you know, I think when we're talking about medical products, the quantity will change over the next few years. I do hope our conditions list can be as inclusive as possible. First of all, and just because of times, I'm going to dive. Some of what I want to cover also is potency issues, care for delivery concerns, and then whatever else you see as improvements that we can make to the medical program. But on the potency, I mean, it's, it's within the act kind of a caps and then there's discussions about medical not having some of those. What are your perspectives on caps? You know, as a patient, I would say you just, it's counterproductive. You know, some things take an incredibly concentrated approach to effect. And I think, you know, we're still talking about a medicine that in many ways is in its infancy here that in terms of power formulating it. So it's a little bit of a hunt. You learn what works and what doesn't work. And putting caps on it will make it less effective. And I don't believe, you know, there's been a substantial, you know, amount of product going from a medical market into an adult use market. I don't think that's ever turned out to be a major concern in Vermont. So I don't see why we would limit them. It would not be good for patients at all. If Vermont is, as a state is trying to limit their concentrated THC products, similar to the way Iowa is, a THC waiver can be created. In Iowa, when I do cards, I have to do a THC waiver. The patient is supposed to try the existing medical cannabis products for a month. And then if they don't get the relief that they were looking for, they can circle back. And then, you know, the problem with that waiver is that I don't charge for it when I do my cards, but a lot of people will charge for that. And they probably should because it has its level of time consumption to make another appointment and have another conversation with the patient. And it's another hoop for a patient who requires high THC. So it could be something, but sometimes people don't really know what they need when they first come either. But sometimes they do. And then that one-month wait using lower concentrations products is, you know, I mean, it's just another hoop. Yeah, I would agree with that. I think limiting the concentration is just creating more barriers to access for patients. It's impossible to predict, especially for dispensary staff, how one person, you know, their biology is going to react to THC. So, you know, we can't say, oh, well, you'll never need more than X concentration. Everybody is different. Everybody's conditions and symptoms are different. And so I think it would be incredibly detrimental for the patients. I worry so much about these medical cannabis patients, you know, because the product just gets treated. I worry about my patients' access to all kinds of products and services, you know. But cannabis, physical therapy, you know, there are so many things that patients just can't access because they don't have the money. And the big question for me is, you know, if you don't have a green thumb and you can't grow your own, I mean, how can we assure that patients have affordable cannabis through dispensaries? Because every medical patients always say, I mean, always say in so many states that the medical cannabis is a joke, that it's, you know, it's too expensive, the options aren't available, and patients are always scoffing at the medical cannabis program. I mean, I feel like there's going to have to be some mechanism to subsidize this if we're going to rely on dispensaries because I don't see how we can rely on dispensaries as, you know, income generating, you know, businesses to take a hit for medical cannabis just in some sort of good Samaritan rule or, you know, I really do worry about the cost of dispensary based cannabis and oftentimes it seems like the medical communities maintain the black market purchasing because of the limitations. Yeah, and we'll get to costs, but I just want to stick with this idea first of potency and limits. When you're getting that waiver in Iowa doctor, so you get the waiver to what? Is it to a certain limit again? It's generally to 29 or 35 grams, you know, the Iowa products that are available, we are lower in THC, and then you're allowed a gram amount of THC per month. Go ahead. We'd be going back. Absolutely. It would be creating that people just drop out of the program to have to do that. Number one, our medical community is not prepared to do that. They don't know about what the products are at all. As far as I can tell, I'm sure there are a few that do, but my experience has been even when they're positive about it, they don't know about it. And having to go back to get a cap, I mean, we've looked at the weight limits of flour and, you know, can a doctor say somebody needs more? It doesn't fit within how our system has doctors speaking to the registry. They're not, you know, giving that kind of advice. And we would just send patients backwards to do that. We're really talking about, you know, and a weight limit would just raise the price for them. They'd have to pay for more to get the same concentration. So, you know, the concentrates are being made now. There's no question we're going to be making concentrates at a certain level in order to make many of the products that are going to be part of the adult youth market. So it is really an issue of legislative ethics, whether they understand medicine and medication. And, you know, as much as we have concerns about pharmaceuticals out there, you know, we have to let the doctor, the patient, and who's providing the medication, in this case, the dispensary, figure out what works. And we've been doing that, and we would be going backwards. And I think in the legislation, legislators understand that we can't go backwards for these patients. That's going to make a big difference. And so there's no limit? Well, there's weight limits in terms of, well, you know, but here's a little crazy loophole. Concentrates weigh very little. Even though they have lots of THC in them. So that's really the question is the amount of THC you're getting. And, you know, if somebody could need 10, and that works, milligrams THC, and somebody could need 150, and I'm not kidding. And not have any, you wouldn't know. The one that they're on 150 milligrams. It's like a narcotic. If you're in a horrible pain, you're not high for it. It just works. So anyway, the limits are really would be a step backwards. And I think we need to communicate that. That it's absolutely appropriate to look at it in the Adobe Sparket, but not appropriate to look at limiting it for an existing medical program. That thousands of patients count. So the existing limits now are what leave those alone? They do, because if your limit is two ounces a month of weight of medical marijuana, you can get concentrated usually within that weight that I believe that you need. Because it's a lower medical cannabis weight, but the THC concentration is higher. So you should get what you need. There are definitely testimony I've heard that there are patients who don't get what they need. Excuse me, sorry. Here in Vermont, and they go to Berkeley, and they go, you know, where you can get different concentrations, I guess. I'm not sure, but that's anecdotal. Okay. And we're coming up on the period where we can use some time for public comment. But Dr. Clifton, if you could, because I know you've spoken with some of the caregivers as well and just identify some of those concerns, which I think might be alleviated with just the, as adult use become more available and the increased availability of some retail outlets. But go ahead, Dr. Sorry, you're just muted. Sorry about that. I didn't realize I knew myself. The increased availability of retail outlets is going to be important. I think just the mobility of patients and the ability to get there, to do their shopping. But also the availability of well-priced products for patients is going to be an issue for those patients who can't or don't want to do their own home grows. And I think home grow is not a perfect option for everybody, but the patients tell me that once you get the initial cost in place, the monthly cost of the electricity and other issues can be as low as $40 a month, which is just going to be really hard to beat from a dispensary standpoint. So for people who can do that and want to do that, that option is an important option for us to attain for them. And then having more availability through the dispensaries and figuring out a mechanism for keeping the cost low. And we certainly hear from patients everywhere that it's hard to get to the dispensary and then the products are prohibitively expensive in a medical market. And it seems difficult for us, you know, even in a traditional Western medical model with, you know, insurance and all of the systems that we have been developing and having in place for so long. It's really hard for patients to get their prescription medication, you know, and treating this like a medication. I don't know. It's hard, I think, to get patients great access. I mean, through dispensary-based products. Thanks, doctor. And then just quickly, Jim, are there other issues with the medical program that I didn't include in this that you do want to address as we go forward that I include on this? I think kind of in alignment with Dr. Clinton's point here with access, you know, it isn't always easy for patients to get to the dispensaries frequently if they may wish to. And so I would advocate for either increasing patient limits or doing away with them, whatever really is in alignment with adult use. You know, if there are not going to be any possession limits or purchase limits for 30 days on adult use, I don't see why we would implement that in the medical market. That's absolutely prohibitive to patients. And then I know Jim had mentioned it, but I think he mentioned it kind of in the opposite sense of patients from Vermont going to other states, but I think in order to support the program, we really need reciprocity. Right. You know, Vermont sees, yeah. Intestine. Okay. Yeah. Yeah. And if Meg, and both of you wanted to reach out to your dispensary clients or contacts to get work on getting some of that data on how to formulate that baseline for protection from medical patients. And then with that, we have some time. I want to make sure any public participants that had any questions or comments had the opportunity to do so now. Great. So yeah, we have, I think, a few people in the room. Would anyone like to make a public comment at this point? Either of you. Jeffrey, come on in. Hello, everybody. Again, Jeffrey Pizzatello from the Vermont Brewer's Association and the Vermont Kind of a Second Coalition. Really here, I guess, as a caregiver, just briefly, I've been a registered caregiver in our program since its inception. I've been growing cannabis, and by the way, it's about 13 or 14 years. So my patient and I have been on since day one. I've been growing cannabis for a couple of decades as well, myself, so it's quite some time. I've been growing professionally for about a decade now. I just want to speak to the ability and capacity to for Vermonters to sort of sustain themselves and homegrow some context. Think of Vermont as almost northern California and it's per capita for producers. We have more producers in the state than many other states per capita. One reason why is because we're an agrarian state. We've got excellent farmers. We've got excellent growers. We have a very robust, illicit marketplace right now. In fact, that is one reason why one of the very few states with a medical program where the numbers are actually going down. They're diminishing. And that is because it's being replaced by cleaner medicine that has grown with confidence and comfort in someone's home. I urge you to look at the main medical program, which has a decentralized market structure and that allows mom and pops to get in through accessible licensing. As a result, their average cost per ounce is $200 to $250. In Vermont, it's $350 to $400. That's just the price of flour per ounce. Concentrates, anything else is exponentially more expensive and cost prohibitive for patients. So please keep that in mind. I would like to end with an anecdote. When my patient first purchased concentrates from a dispenser, I'm not going to name it, she went to Medicaid and the concentrate reacted in a way that reflects a contaminant. So she purchased a very expensive oil from a local dispenser and it was contaminated. I sent it to a lab. It had mold in it. So this is one reason why Vermonters are choosing to grow their own and not serve as dispensaries is because of the lack of quality. Right now, our medical program, there is no burden of testing necessarily on these dispensaries. They test themselves. It's really more of a marketing item than an issue of quality and cleanliness. So I've been working with, I've been back from that in those anecdotes. I've been working with Jesselin Dolan of the Vermont Cannabis Nurses Association and several other advocates across the state for a couple of years. We have a 14 point proposal for recommendations which we will submit to you guys that comes from the patient and caregiver community. In those proposals, we ask for things that main has. So for instance, a patient to caregiver allowance. So for every one patient, they can supply for up to five different, for one caregiver, they can supply for up to five different patients. Apologies. So just things to keep in mind and I look forward to continuing the conversation in the coming weeks. Thanks everybody. Thank you. Thank you. I'm looking forward to receiving that information. That reminds me, one of the, I think one recommendations you had in another testimony was regarding health care providers being able to or these patients being able to get the recommendations from more than one health care provider or something of that effect. Am I confusing that with another state now? It doesn't sound familiar. So you've got those liberties then in Vermont where you're not restricted by by the health care providers as far as... Tom, I think we have to have a certain minimum relationship. I think it's three months with the health care provider. And a physical. And it's an annual renewal. So if you're part-time in Florida, part-time in Vermont, you can't rely on your Florida doctor, I don't think, to get you a referral, right? Yeah, so there's absolutely those complicating factors, the three-month relationship and oftentimes the appointments thereafter, if it's specifically to get this verification, can be of greater cost to the patient. And then there is the renewal. Each year, the doctor needs to verify that this patient still has this condition. And so I think, for some patients that we're seeing who are terminally ill or chronically ill, we have asked that there be a re-evaluation of that process because if somebody has a chronic illness, disease, et cetera, we know that's not going anywhere. And so I think putting them through this additional hoop, it's just one more barrier to access. There is a whole separate industry in medical cannabis card production and Vermont really, to some degree, protects their patients from that industry with all of these. Because you can't do them telemedically, they have to be, the cards have to be done brick and mortar with somebody that you've established a relationship with. But at the same time, the renewal of these cards for chronic conditions annually, it might be interesting to create a waiver system where those renewals are less frequent. The problem is that you are using a powerful medicine that the patient should check in with somebody who understands using a medication like that. And checking in annually is really not that frequent and not that onerous. But the problem is that the checking can't be done telemedically. And it has to be done in this established relationship situation, which in some cases, if your doctor isn't understanding of cannabis, and the studies reveal that 70% of doctors believe that cannabis may have value, particularly in terminal conditions, but only 30% of doctors really feel comfortable making the recommendation, because their medical malpractice may not even cover them to allow them to do it. It's a special waiver in your medical malpractice. And then you're limiting the number of doctors that the patient can go see in order to get their card. And that escalates the cost and the impactful factor substantially. Well, again, if there's something we want to recommend and re-evaluate with respect to, even if it's just for chronic or terminal patients, now is the time to do that and for us to dig into that as well. Great. In the 2019 report recommendations. Right. Okay. Okay. We are at time. So I'm going to choose a journey and we will talk to you again on Monday. Thank you, everyone, for your time and service tonight. If I get a second to adjourn, we'll be all in our way. I'll take a second. All right. Thank you, everyone. And thank you for everyone in Vermont. That's another one for attending. Appreciate it. Thank you. Thank you.