 Good afternoon everyone. I'll call the meeting for the medical advisory subcommittee to order. Just a quick roll. Dr. Clifton. Here. Meg Delia. Jim Romanoff. Here. Great. Thank you for attending. Welcome back. I'm going to turn it over to Dr. Clifton. I think she's got just a quick PowerPoint to bring us up to speed on what we discussed last time. And Meg I know you, we talked and you circulated that list that we can discuss as well. And Jim also recirculated the 2019 report that he did that I'd like to give it to. So Dr. Thank you. I'm happy to share my PowerPoint. It was my impression that I needed to share it with the group ahead of the meeting rather than just sort of, you know, drop it on your here. But it's all the stuff that we've already talked about. And if you're comfortable, I can go ahead. Or if you'd like, I can present it on Thursday. That's fine. That's fine as well. Is it okay to just go ahead then? I don't know how to, I don't know how to share my screen here with this particular system. I'm better, I have a little bit more. Let me, let me get an alien here. There should be a, like right by the leave button, there should be a little like box with an up arrow in it. If you don't see that. Oh, there you go. I think, I think I have it. Okay, perfect. How's this looked to you guys? Okay. We can see it. Just now. Okay, I'll just leave it in this format just so that we don't, we don't, there's not too many slides here. It's just a quick 13 slide deck. But, oh, did we call to order? Did we have to call to order? Okay. We took roll. Oh, I apologize. Did everyone get the minutes? Yes. Yeah. Any issues or edits with that? Otherwise I'll make a motion to approve the minutes. I'll take a motion. I guess I'll make a motion. Okay. Okay. I think Meg just moved to approve it. Can I just get a second and then we'll move on to the slide? Second. Okay. Thank you. Good. All right. Thank you. So just as a quick agenda, you know, we did also have the summarized public comments. Does anybody have any particular comments that they want to share about the public comments? Let me see if I can make mine available here at the bottom. But if anybody doesn't have any particular, we can just make a note that we reviewed the public comments. Okay. So I'll just ask that whoever's keeping notes that they just make a note that the public comments have been sent to each of the individuals within the committee and that everybody's had opportunity for review. And as far as the agenda for today's meeting, I wanted to discuss these recommendations for medical cannabis for symptom relief, specifically breaking it down into laboratory testing. A potential for increasing possession limits and continuing to support home grow as an alternative for the disabled or limited mobility. Allowing patients to visit dispensaries without additional fees, allowing medical cancer patients to move from dispensary to dispensary. And then thinking about streamlining the cannabis card consultations so that they can occur potentially telemedically, removing that need for an additional in person exam or the three month relationship requirement that currently exists in Vermont. And then expanding acceptable medical conditions to include the commonly prescribed medical conditions of anxiety and insomnia, advertising, reciprocity, and finally the use of excess funding. So just starting at the top, we've reviewed the public comments. In terms of laboratory testing, I think the suggestion for the subcommittee and that would be consistent with standards around the country is performing a third party laboratory testing through an additional laboratory testing company that is not the company that has manufactured the product. Just to allow that additional level of oversight to assure that the product is safe, free of contaminants, and to confirm the potency. We could also consider the addition of random sampling by regulators that could be additionally added to assure compliance, but that's not a mandatory thing. These test results should of course be made available to the public and I think that that in a lot of cases is already the standard practice where people expect to see third party testing on the products that they're buying. So these batch tests are probably very reasonable and aren't going to represent anything probably much different than what's already being done. Excuse me about this, I didn't take this out. I was working on this increased possession limits over the weekend because I didn't really understand possession or I won't say I don't understand possession, but I didn't really understand exactly how or what other states are doing. There's a two ounce per 30 day limit and I'm wondering if maybe I can just open the file that I created on possession and just made a list and if you guys want me to share this with you, I'm happy to share it with anybody or everybody in the subcommittee. This is just a list of all the states where cannabis is legal and then what their possession limits are. And in California I thought was a mature state and probably has thought about it maybe and come up with a good idea that maybe the rest of the country could consider. And in California you're allowed to possess and transport up to eight ounces and have also six mature and 12 immature plants. This number of plants in the amount that's possessed varies from state to state. It seems to be related to what people think is either a 30 day or a 70 day or a 60 day amount of medication. And then the plants are a question about how much a person can do with their home grows. And particularly somebody had mentioned Maine last week so I marked this as something that I wanted to look at a little bit closer. The possession is two and a half ounces, six mature plants, 12 immature plants, unlimited seed leaves and up to eight pounds of dried cannabis. Which I assume is for the same reasons that Vermont was talking about potentially having to increase the number of mature and immature plants available for a Vermont home grow. Because there's potential that a person has a short growing season and that they're going to need to grow enough and store enough that they have it for future use potentially for months and months. Also when I think about cannabis as medicine my patients routinely go to the pharmacy and get a 90 day supply of their medicine. And that's a very commonplace thing. So if we're thinking about possession in terms of a 90 day supply we should probably look at how much people are using over a 90 day and allow possession to be a 90 day supply would be my first thought. And then expand on what people are doing with their home grows so that their home grows can function properly in a state that has sort of a limited growing season. Go ahead Tom, I'm sorry. No, thanks doctor. Meg sent around a document earlier today as well. And I, Meg I think your suggestion was three plants and three ounces. Did you just want to read on it for doctor? Sure. We specifically asked to increase to three ounces per month. This is just based kind of on anecdotal evidence that we have from the patients. I think two ounces at the current is not enough. But overall we had recommended that the patient possession limit aligned with that of the adult use. So right now patients are limited to two ounces per month. If that is not going to be the case with adult use we ask that we reconsider that limit. Okay, okay. I mean three ounces is probably within the range of what most places in the country are doing in terms of the amount that's available at home. I'm not sure how I feel about that because I mean if we're just in terms of people using different products you know if we're, I mean I feel like a lot of this possession language is sort of deriving from the prohibition language. And if we truly don't have a prohibition on cannabis then I think you know I'm able to go down to the wine store and buy a case of wine and add it to the multiple cases of wine. I already have stored in my wine cellar if I'm a wine aficionado then the same would be true of any other hard liquor. So, so I don't know that I don't really understand why we are continuing to impose a limit on the amount that a person can possess before they, before they run into trouble. Dr. Clifton, this is James Pepper. Do you mind if I just weigh in quickly to see, to just prompt folks and just... Yeah, we'll have to have this discussion and flesh this out a little bit. So the current what you're, what's being referred to as a possession limit, the 30 days two ounces is a purchase cap. And I think that that just needs to go away totally. I think that the two ounces is under our criminal laws is the amount that triggers a criminal penalty. I think it's actually just a civil violation if you have above two ounces. So what I would think is that, yes, the one time purchase limit should either track what is, what's happening in the adult use, or it could be up to two ounces, or it could be more than that if we make an exception for people in the medical registry on their personal possession limits. But as far as possession limits in your home in a secured locked place, you're actually allowed to possess unlimited amounts of cannabis in your home, even if you're not on the medical registry because we have home grow. And we don't have a mechanism to determine whether what you have at your house was part of your home grow. So, you know, when we talk about possession limits, I think the question should be, get rid of the cap in a single transaction or take it to what the current criminal law allows you to possess on your person in a single, you know. So either limited at two ounces or we should discuss creating kind of a 90 day or whatever you thought, you know, if a person, if a patient wants to go and purchase a 90 day supply that they would have an exemption to the criminal penalties. I think that's where the discussion should go. And then of course, if we want to, we could also discuss the kind of comparables like what is, you know, what amounts is converted to, you know, high THC oil or a shatter or something along those lines. If we want to go down that route, because it sounds like that's kind of a gray area in the current regulations for the medical program. Well, there's, okay, this does divide up a number of different ways. Purchase cap, different from possession, different from the limit on the number of plants for home grow. I'm sorry, I think I interrupted somebody. I was just going to, this is Jim, I'm just going to have, you know, my understanding, I think you're right, the limit is in part because of what you can transport and, you know, from a dispensary to your home. And medical patient, it is going to be a problem of access. You know, we're saying you need to make multiple trips. I think for many people it's both, you know, not possible for physical reasons, but also probably not economically possible. The plant amount really should just not be, is a separate issue because, you know, of what you would purchase at the dispensary. And the oversight board is recommended that we definitely increase the limit to at least half parity with the bill use. You know, we've also discussed there's no reason to have the limit because of the home possession being unlimited. So. Okay. Oh, I see. So really having a plant doesn't make sense when your home possession is unlimited. Well, I think that, that isn't what I was saying, but I would agree that, you know, I think the plant limits, the reasons for having them or not having them are multiple. I think they weren't just part of the prohibition and the move away from prohibition. There are plenty of ways that a mature plant, you know, you could have all of them die in a week, especially if it's outdoors. You know, so I think that's part of it is being able to hedge your bets or they don't get big enough and don't produce that much. You know, one plant will produce one amount at one time and not the next time. So I think that's really separate from the limits in the dispensaries. And pepper's correct. Right now it's a gray area on the concentrates. It is the way that, you know, a patient is not using flower that usually they are able to obtain the product they need because the concentrates are not one for one looked at as the same weight of medical product. So in some states it's a 90 days supply as deemed appropriate by the, by the pharmacist or by the doctor. So it's a, you know, it's a limit of three ounces or a 90 days supply as deemed by the pharmacist or doctor. So that could be something that would help us to manage the concentrates maybe for people who are who are using the concentrates and we have that gray area there. Okay. I think we could, but you know, the other thing is that the concentrates in looking at these weights when you're not talking about being prescribed in the same way as a pharmaceutical would be. It's hard to really compare it because, again, one strain could have one amount of THC, a homegrown amount could have a totally different amount. And the effectiveness of it as with a pharmaceutical can change over time. So, you know, there's a lot of question as to whether the health care provider, you know, as with a pharmaceutical would have a way to say, you know, if it's working for this patient they might need more. But the sort of cut and drive numbers are, they're difficult to tie directly to the, you know, one for one. Yeah, I agree with you. I really did find this very murky and difficult to come to a conclusion that sort of met the needs of the medical patient as much as possible. And follow the guidelines of what other states have in place. It does seem, you know, I mean, I'm sorry, homegrown possession kind of blur for me. And so I, so, you know, thinking about homegrown, I agree that when you're dealing with plant limits, those do seem somewhat arbitrary too, because with crop failure or with a short growing season, somebody they end up needing 12 plants rather than, you know, three plants in order to provide themselves the product they're going to need for the entire year. So, okay, good. I'm really, really glad that we had that conversation because that helps me, you know, think about how we might prepare, you know, some additional recommendations. Does anybody else have any comments on possession and purchase caps and plant limits? Meg, I'd be curious to hear your thoughts on this question, because to me there's kind of three options, which are one, peg this to whatever adult use purchase limits are, which we don't know yet. Peg this to what the criminal penalties are so that no patient who's driving away from a dispensary might get pulled over and have an interaction with a police officer where they have to show their medical card or do something along those lines, or have a greater than two ounce purchase limit and require a tweak to the criminal statutes and then potentially have this area where you might have some police enforcement that might lead to kind of, you know, it might lead to just someone being detained or something like that. It's a medical patient. Yeah. You know, I think that's something we of course want to avoid at the end of the day. I think if we introduce this idea of patients potentially being detained or dealing with law enforcement, it's only a bigger barrier to access to the program. So I think I would probably lean towards aligning this with adult use purely for the simplification of it and really making sure that the medical patients are not more restricted than adult use. I know that's hard to say without knowing what the adult use limits will be, but I would tend to lean towards aligning with adult use limits. The other thing I saw in a couple of states, Megan, was that patients were required to carry their medical card with them. And that seems reasonable because we're used to care identification or driver's license that doesn't seem particularly onerous on the patient, and that would provide that level of protection if they have, you know, an excess, what would be considered an excessive amount, you know, from a recreational or legal standpoint. Yep. And that's, I think, completely reasonable at the dispensaries that patients are required to show their medical cards every time. So that's definitely not overly burdensome. Okay. All right. Wonderful. Does anybody else have any comments? I really appreciated that input Megan. Thank you. And Jim. Okay. The other modification, the other concept we were thinking about was allowing patients to visit any dispensary because right now the rule in Vermont is that patients have to choose a dispensary, and if they go to a different dispensary, they have to pay an additional fee to get access to that dispensary. My thought would be that different dispensaries have different products, and if a patient wants to go to a different dispensary or their access to their current dispensary is limited due to, you know, travel to visit somebody else in the state or due to a storm or something, it might be helpful for them to be able to visit dispensary to dispensary. I wonder if maybe part of the reason why a single dispensary is allotted to a single patient is because we don't have adequate patient monitoring systems in place. But I think that those are pretty easy to put in place now or they're already in place for opioids and controlled substances. And we could kind of, you know, work on that footprint to make sure that somebody isn't taking their prescription to more than one location or getting multiple prescriptions from multiple, you know, doctors and filling them in other places, you know, any types of abuse like that. Does anybody have an opinion on that? I would agree that I would agree that we need to allow patients to visit any medical dispensary. We know that when adult use comes, not only can medical patients go to their medical dispensary, but they can absolutely go to adult use dispensaries as well. So it just, it seems honestly quite silly to have some limitation where they could turn around and then just go to a handful of other dispensaries and yet be limited from another medical specific dispensary. Yeah, I think we're probably all in agreement on this unless Jim or either Jim had something to say, but I think this one's pretty sweet. No, this one's good. Yeah. Let's say we just move on. This one's pretty obvious. Okay, marvelous. I agree. The one thing I would say is that, you know, if we are going to be asking the dispensaries to preserve a baseline of products, medical products, you know, I think that would be the question is whether every dispensary everywhere is making the products that are, meet the regulations for medical that are most likely going to be at higher THC caps. So, you know, in theory, as a patient, I would definitely want to be able to go to any dispensary, but I would imagine it's more complicated just in terms of the products themselves. Not every patient's going to want to go and buy the adult use product will be adequate. So it's really not an opposition. It's just a caveat about it. All right. Thank you, Jim. And then this next slide is on exempting cannabis cards from an in-person exam. This is sort of a consolidation of a number of slides where there was a question of exempting PTSD from an additional physical exam or exempting patients from annual exams for their cannabis cards. And my suggestion would be that we continue an annual evaluation because really in virtually every circumstance, even in terminal medical conditions, doctors see their patients and follow up because new conditions or new medications can be put in place that can be impacted by the current medications. Drug interactions have to be explored. And we're continuing to learn about all of the drug interactions associated with cannabis. Once a year is really quite a liberal policy already. You know, a lot of things we see patients for every three months like depression and high blood pressure. But what I thought might be valuable to the patient would be to cap the annual revenue for a doctor to do cards to $250, which appears to be if you're running a card company and you're paying the additional med mail. I just paid my med mail to be able to talk about cannabis and to work in cannabis. That cost me $6,000 in addition to the other med mail that I'm paying. And mine's probably low because I don't have any judgments against me for any med mail judgments against me. And so for most doctors at 25 years of practice, that's probably not the case. But probably the most innovative and patient-focused thing that we can do with examination for cannabis cards is to create a telemedicine system to provide a patient-centered, safe approach where the provider can talk to the patient about their conditions. They can request old records or communicate with other providers as needed and provide follow-up for the year after that card is completed. And the telemedicine examinations are available for cards in the state of New York and in the state of Iowa. And I'm sure in other states, but I haven't looked it up. And there's really been no significant risks identified. The patients get to do it on their time from their own home. And the doctors are, of course, licensed in Vermont and have been trained similarly around the country and have the same licensing procedures around the country. And of course have their license updated in Vermont so they could provide the cards. Telemedicine is certainly not the controversy that it was two years ago before the pandemic. So I wonder how people feel about this. If you could just clarify, this telemedicine system, is this a system employed by the state? Or I guess I'm a little confused how this... Are you allowing their existing physicians to connect via telemedicine or is this an entirely new program? Well, I don't think this would be managed by the state. It would just be managed, Megan, I think, by different physician groups. There's MarijuanaDoctors.com, Larry Hill, PrestoDoc. There's a lot of telemedicine doctor organizations that bring doctors into various states to provide cannabis cards really easily and quickly for patients. But then doctors right in the state could also do a cannabis card from their office telemedically. It seems like when patients come to cannabis, they're often not coming to cannabis as their first treatment for their diagnosis. Seizure patients, for example, it is on average the 13th medicine that they're trying for their seizures. So they have a well-established diagnosis of the seizure. They've gone through multiple physical examinations. So this would be the idea that the patient doesn't probably need an additional physical examination to clear them for using medical cannabis. And you can actually do a pretty good physical examination over the phone. Like, I can see that all of you are breathing normally. You're not coughing or sneezing. You're sweating. You don't have a tremor. You know, you're well-nourished and well-capped. So you can get quite a bit of examination done without having to put your stethoscope on someone's chest. Sure. So this would be in addition to the option of also seeing your healthcare provider that you've been seeing or whatever condition it is? Yeah. I mean, yes. Yes, that's true. The problem is that a lot of people don't want to get into cannabis cards again because, you know, the MetVal, if you start even bringing cannabis up in a conversation, is that additional $6,000 a year. So unless you're really doing cards, it's very hard to, like, one-up a card or do a card for half a dozen people in your practice. It just doesn't make financial sense. And I'm not affiliated with any of these companies. I don't have. I mean, just to be perfectly transparent, I don't have any relationship. I'm just, I just think that as far as patients and patient satisfaction and ease for patients, you know, you could just do telemedicine from your living room and that's the right card covered. This is not how our program works in Vermont. Right. It's changing it completely at this point. The way it works here is that your doctor is not giving you a card. Your doctor is not even recommending cannabis for you. The doctor is just verifying that you are their patient for X period of time and the requirement has been six months and that they are treating you for this condition. And they don't have to say the condition they recommend to be treated with cannabis. They're just saying you have a condition and then when you send your form in it qualifies you from the registry. So we have asked at the oversight committee that the $50 fee be waived because that's the direct fee that you're paying to get your cannabis card and once there's an adult use market and taxation, the assumption is that it will be funded in another way. And the question of the length of time that you need to know your doctor, we wanted those decreased from six months down to three months and the question of PTSD patients was really not related. If that is a question that mostly is relating to the veterans and the VA, there are other people with PTSD that are not veterans that have other backgrounds but in this case the VA is not allowed to recommend or sign these papers so it's considered an extra burden to get that patient to go to a different doctor for a relationship for that amount of time. But we would be adding more restriction to the patient than there is now and we'd be asking the doctors in Vermont to do something that they're not currently doing so I didn't imagine at this point we were overhauling the system. I guess I didn't have much time to do it. I would agree with you Jim. I think we already have so many doctors who are hesitant to even be a verifier and this would present an additional intimidating factor potentially. And I do want to just go back a little bit because I know you had mentioned it's not necessarily a hardship for patients to see their health care providers for a chronic illness annually but I do believe that in 2019 there was support by the Senate. We had asked that that requirement be removed for people with chronic illness illness that was not going to be going anywhere anytime soon. And terminal illness. Yes. So it's not that they're not checking in with their physicians. I'm sure if you have chronic illness or terminal illness that you are absolutely seeing a physician on a regular basis but we just ask that they don't need to have an appointment specifically for the verification annually. So I've got two questions for Megan Jim because I read your list and I read 2019 report. First, did you guys delve any deeper and did you come up with a definition of what chronic is or might be because that seems like it might, that could be maybe overly vague with respect to some conditions. And then second, on the consultation time Jim, I saw we're, and then you just said I think you were recommending the three month from six to three and then I think Meg you just wanted to eliminate it all altogether, right? Yes, that's correct. Jim, are you in line with that or? Well eliminating it all together would absolutely be a good idea. I mean you know three months in part was to reflect the concern for some people who were not in state the full year but were, was complicated to you know have necessarily a three month relationship and be able to address medical concern with cannabis in a timely fashion. So three months are less, absolutely. And you know I think your other question, chronic illness, well I'm not a lawyer. You guys would do better. I would but I believe it's referring back to the list of approved you know conditions that are in the law and of those you know what are considered chronic. So I'm not sure that there was a lot of room for much you know mistake because you couldn't comment and say I have you know chronic sleeplessness because that was not an approved condition. We'd like that to be approved but it wasn't. And I just want to, I'm sorry Jim, go ahead. I just want to be clear I believe it is not six months it is a three month relationship with health care providers at this point. You know I love, I love, I have to say I love this. This is wonderful that you guys have a system in place where a patient can just simply go to see a physician who's comfortable with verifying the physician can charge the patient for a visit that will probably be covered on their insurance and then they can have the documentation they need to take to the state and it only costs $50. That is as inexpensive as it gets I think and as streamlined as it gets. I just want to add that chronic illness or maybe we could say incurable illness might be better that you have a pain that's not going away or that if you get for example diagnosed with multiple sclerosis it's a chronic illness that's not going away. So that would also be a, you know we could call them terminal incurable or chronic illnesses. In medicine when we consider something chronic it's generally 12 weeks or more. If we've been working on a pain syndrome for example that you've been dealing with for 12 weeks you're on two medications that we've titrated up and you're not better. That's where we consider it a chronic diagnosis. Excuse me, so we could make chronic illness like a diagnosis that's been in place for three months. And I like the idea of discontinuing the three month relationship because if you have a physician who's comfortable qualifying people then other physicians in the community can say, you know I don't want to do this but Dr. Smith does this and you can go and see her and then the patient can make that transition without having that three month delay. I have a question. So this is James Pepper here. I mean I feel like the direction that we need to go in a little bit is giving physicians more autonomy over their patients and not being too heavy-handed. And I'm wondering if it could be no more than once a year but at the discretion of the doctor. And if the doctor is saying this is an incurable, in my opinion this is an incurable or a chronic illness I don't ever need to verify this condition again. I know that you're going to live with this for the rest of your life. And you could just waive this annual verification altogether. And that way we avoid having to define what chronic means. But I'm fine with either honestly but I do think that Tom's right that we'll have the, in our rules define what chronic means because I feel like physicians especially in this realm want more directive than less. I'm happy to send the language from S117 that was sent in 2019 as well because that specifically addressed that and obviously the language is there. Yeah, that's exactly what Jim and Meg were recommending and also increased health care provider autonomy, which you also mentioned. Meg's correct, I just spoke. We are down to three and we were supporting just eliminating it all together. We went from six to three to four. And then, you know, I think that absolutely, you know, giving the doctors more autonomy is good, but I'll say it again, I think the reason chronic is in there is the conditions are so limited right now. I think the autonomy would really be in broadening the conditions and allowing doctors to say what conditions they felt were appropriate for medical cannabis because right now they just have to say I know you and the list of the conditions came from the doctors at the legislature. So, that's where we're at now. Yeah, I think we're getting to the qualifying conditions. I would imagine that's on this list. Yeah, yeah, I actually was, when you said qualifying conditions, I said I dug on it. I forgot to put my list of my massive list of qualifying conditions in here that we could go over. But let me see. I'll go ahead. I just want to interject and say that along with the language in S117 about doing away with the animal visit for chronic conditions, there is also language supporting, allowing healthcare providers to determine what is or is not a qualifying condition. And your last time there was some question about the legislature's appetite for that, but that was passed by the Senate in 2019. Good, good. And Dr. just saying we've got about four or five minutes before we have to open up for public comment. The only thing I have left is advertising and I don't really know what to talk about with that other than maybe that should just mirror the alcohol and tobacco regulations. But that's what the Jim's 2019 report recommended. And then Meg also suggested in what she circulated that it sounded like you were promoting more of, it's not counter to that, but you wanted more freedom to do more educational awareness. Yeah, I think the focus of that is really making people aware that we have the program, but specifically educating healthcare providers on the program and having that come from the state I think would be critical because, you know, as much as dispensaries may be able to speak with a doctor who is interested in learning about the program, we would like to see some more outreach from the state or at least more educational resources available to them. You know, back to these barriers to access, there are plenty of healthcare providers in the state of Vermont who are not comfortable with being verifiers. So we think that could be critical to at least getting with you more comfortable. Thanks, that makes a lot of sense. And there isn't a separate subcommittee public health that is focusing on developing the rights for advertising in a more comprehensive format as well. And then moving quickly here through these last few slides, the reciprocity. We were thinking about allowing anybody who has a valid medical cannabis card from any other state to allow to be purchased in Vermont's medical dispensaries to support relocation, tourism, or people who have second homes or vacation homes that want to have, you know, both Florida and Vermont. Some states have reciprocity with neighboring states. A lot of space states don't have reciprocity. But doctors, health providers are certified and licensed and trained very similarly across our country. So reciprocity, excuse me, seems like it might make sense from my point of view and make it as easy as possible for patients. Yeah, I would agree. I think reciprocity is critical. Yeah. Okay. And then I think the only the three month relationship we had already talked about it. I'm not really sure what to do with the excess funding. So I think that's probably a broader discussion that we probably don't have time to do in less than one minute. So Dr. Clifton. You have a long way to do it. I appreciate this. Dr. Clifton, we don't have any public comment in the room. I just did a quick poll. I did have a question about reciprocity because of course, you know, other states mean their qualifying conditions list is essentially whatever a doctor thinks should be a qualifying condition. And I'm wondering if this puts for monitors at a disadvantage when they can't access a dispensary when have they lived somewhere else and got their card somewhere else they would be able to. It puts us at a disadvantage because we're able to use our card already in other states. Right. The disadvantage is here that a lot of the, you know, for monitors that yeah, I guess I'm agreeing with you. I mean, the current patients aren't affected as much as the potential for new patients. And I think part of the reason for reciprocity is, you know, to support the business of the medical program that, you know, the products themselves and creation of them and stocking of them will have more economic stability and strength. There's a greater customer base, you know, allowed to come and purchase. I think to me the question is that the disadvantage is kind of if you have a condition that you qualify for from out of state, somebody might not qualify here, you're correct to come and use the dispensary. But I'm not sure that that is so much of a disadvantage that I take it away. Yeah, it doesn't worry me. I was just flagging it. Are we going to limit the people that have the qualifying conditions in Vermont? You know, if you're from New Hampshire and you have, you know, terminal cancer, then sure, you can come and use ours. If you have anxiety or acute pain, the two that kind of have been historically the political footballers on qualifying conditions, can you come to Vermont and use your medical card here? It's just a question. It seemed like we went pretty quickly on reciprocity and I just wanted to dig into that aspect of it. I wanted to also share with you guys from my, I do this, stopping the top killers with cannabis is the talk that I do when I'm running around. I spoke at Mecan in Boston last weekend and I'll be in, I get to speak also in New Jersey in a couple of weeks and then in Chicago at the end of October. But I just created this list quickly thinking about all of the different things that cannabis can treat. And there's, you know, there's such a, such a broad number. I'll go ahead and enlarge that a little bit for the purposes of our call. But there's a whole bunch of things on here that really respond beautifully to cannabis. A lot of them that fall under chronic pain, but you know, ADHD, autism is getting looked at closely. And a lot of skin conditions that could be considered a good reason to allow somebody to use cannabis. So there's room for expansion on these diagnoses, but I don't, I'm not sure how we would proceed with that. You know, with such an inclusive list of potential qualifying conditions, I am still, I'm still in support of allowing physicians to determine what is a qualifying condition. You know, looking at this list, it sounds like you could really, you know, if a patient comes to you and says, okay, this is, I'm having XYZ problems. It sounds like it will likely fit within this list in some sense. And so why not then rather than having this expansive list? Does that, does that, again, fundamentally change the nature of the program? Believe me, like, I think it's time for a refresh. But does that go beyond a doctor verifying that you have one of these conditions to a doctor recommending that you use cannabis to treat it? In that sense, I would say it will change, Jim, you look. No, I'm agreeing. I mean, it's one of these things where it's an unspoken right now. You know, we, we've gone so far in Vermont to allow the doctor to not have to say they recommend cannabis that, you know, we forget that my health care provider in a discussion with me agreed that it would be a good idea. You know, and then signed all the papers that we had this relationship and what the conditions that I had were. And, you know, I think that the idea, I think, Chairman Pepper's correct, we're due for a major refresh because our law, you know, does, with all due respect to the legislature, has our legislature acting as doctors at this point and deciding what conditions are appropriate. And I, I am not a lobbyist or political strategist, but I would imagine going to the legislature one at a time to try to approve conditions that are acceptable is going to be like pulling teeth and though legislative session after session after session and not serve anybody, especially the patient very well, whereas once there's an adult use market, you know, I think a different argument can be made that, you know, the conditions can be wrong. But we also do have to have a medical community that is on board with it, or at least laws that are flexible enough to, you know, let the medical practitioner, the health care practitioner, you know, know that they are considering. Again, to consider what to recommend for their patient. I mean, I think at this point we will have to engage the medical community and not just keep saying, if you're not comfortable with it, you know, science will be done now as the laws change. So that's the only reason I'm sort of, you know, smiling and showing you my shoulders. I agree, we need a big change, but we've been at a hard time getting the legislature to change much of anything very quickly. So, you know, I would think just trying to get them to broaden it to the point where having a doctor to decide right now seems like a very minimal thing to do and no harm to anybody because the doctor doesn't want to do it. They're not going to do it still. The law will work the way it used to do. But if they can do it, it would make a huge difference. Yeah. And to your point, I mean, I think we saw that, you know, we've seen how difficult it is to add qualifying conditions and yet there was support two years ago in the Senate to allow HCPPs to determine qualifying conditions. So I do think it changes slightly the nature of the program. But at the end of the day, the physician is still verifying that the patient has a condition that could benefit from cannabis. Okay, so great discussion. I'm just not sure what direction we're going on the list of qualifying conditions. I think it would be a good idea to propose that they add the ability of a doctor, strengthen what the Senate already approved, and let's hope that the House and in conference it would get passed at this point. Okay. You know, I think that would benefit everybody and be certainly a stop gap to, you know, considering more of an overhaul as the medical community grows with the changes in the laws and the availability of double-wide peer-reviewed studies. I like the idea of having a physician override that the physician can say this patient, you know, for whatever reason is deemed the reason that the patient can go ahead then. Okay. Well, everyone, I think that that maybe is that, oh, no wait, reciprocity. We already talked about removing that three months relationship hurdle and then funding. But oh boy, I don't know how it's possible. You know, and I've got, I just have three more things on my list, Meg, based on what you had circulated to are kind of, I think we've got to deal with health and safety issues. But it's the fingerprinting for caregivers offers and the buffer zones are the two health and safety issues. And then there's a question on the limits for how many can be served in dispensary at a time. I think it's three. Right now that will be, I imagine that's going to increase anyway with adult use. But yeah, maybe for next time we could put that at the top of the list to discuss fingerprinting for caregivers, doctor and buffer zones. Okay. And that was, that was from Meg's suggestion list that she circulated. There had also been from the oversight committee, lots of question and debate about the number of patients a caregiver can work with. Right. And, you know, having that number increased just to reflect the fact that every patient is different. There seemed to be a lot of confusion about the question of a caregiver as a grower, which I think really should be a separate issue, but I'm really speaking about, you know, a caregiver right now we do have pretty substantial limitations and not a lot of good reason to not allow a caregiver to have more patients based on the type of patient. Yeah, I would have to say that I feel like the caregiver limits are pretty punitive. And I don't really understand them. I mean, doctors of course have limits to the number of people they can see. But, you know, I think our limit might be 30 a day or 32 a day before you start to, you know, draw attention to yourself from regulators who monitor things like this. 15 patients for one caregiver seems really low. Well, is that, yeah, and the doctor, yeah. It's lower than that. Yes, I believe. I don't know what Vermont's rules are, but the caregivers seem to vary from state to state also. One. One. Oh, one. Oh, one. Yeah. Well. It makes it. And the bottom is again, it's about possession and questions under the period of governed by the whole, you know, or advised by the whole amount of what a caregiver was going to be able to go and pick up medical cannabis and have it in possession. And I think the intention of guessing by the legislature was to limit the number of hands that a product has to build. But it seems irrelevant. It seems counterproductive in any medical setting and unrealistic if people would have multiple caregivers in many situations. And it just seems an adult use market. Yeah. I got to jump to the next subcommittee meeting. But there was also, I don't know if this is a suggestion, but an option. I mean, think about whether or not. We're okay meeting. We haven't done it yet, but two times a week. And we're scheduled for Mondays and Thursdays. Or if you'd like to do that once a week with, you know, continue phone calls, individual phone calls throughout the week. What works better for your schedule? Assuming, you know, we can keep the productivity arc going the way we have. But it seems like we're making some good progress. So you can think about that as well. Okay. We'll circle back the next time. I mean, I think it would might be a good idea to work this Thursday together. And then maybe go to weekly. We'll work on fingerprinting buffer zones. And then this possession purchase cap concept a little bit more. And we should have this pretty well fleshed out, I think. Thanks so much. I really appreciate everybody's hard work and attention. All right. Good to see everyone. Thank you. Thanks, everyone.