 Thank you so much, Dr. Lev. My name is Catherine Antley and I am delighted to be here. I am a dermatopathologist and medical laboratory director and I serve as treasure and member of the board of Isaac. So the promise of a regulated market is primarily what we'll focus on in this portion. Is the legislative or cannabis control board system which most states use to regulate cannabis able to protect public health. Is the public accurately warned of possible health harms of choosing to use cannabis and is the product itself pure consistent and reliable. Are the promises to protect public health and improve racial and criminal justice goals realized. We have come to expect safe and reliable products both prescribed and over the counter. They expect accurate warnings, safe concentrations and an adulterated products. We know that cannabis unfortunately is contaminated with bacteria heavy metals and mold. Here are a few references on this slide but a number of articles have come up out describing mold on cannabis. One survey by the department sorry the Denver Department of Public Health found that 80% of the shops that they surveyed had mold on their cannabis. There are instances where employees are threatened with violation of nondisclosure agreements when they reveal that to the press that mold is on the cannabis that they're selling. In other words, they're threatened with lawsuits. And we've seen this happen in Vermont. Cannabis contaminated by fungus heavy metals and pesticides is sold in regulated state sanction shops where the public has again come to assume pure product. Warnings and are well publicized for adulterated Tylenol and E coli contaminated lettuce but the public only seems infrequently to become effectively aware of cannabis product containing lead fecal bacteria or mold. In Colorado, the E coli contaminated cannabis is not discarded, but it's remediated and then consumed. We've seen that cannabis users can be sensitized to cannabis allergen and also other allergens unrelated to cannabis such as mold, mites and catnander. In addition, cannabis users and workers like bud tenders have documented higher blood levels of heavy metals, lead and cadmium. Cannabis accumulates lead and other heavy metals including nickel from the soil. California and Massachusetts do not test for nickel and some employees report allergic type responses consistently each time they dab. Oregon has had legal regulated marijuana for seven years the Secretary of State's office did an audit in 2019, which revealed that only 3% of the shop labeled product was tested, and only 33% of the growers were monitored. Unfortunately, the state concluded that Oregon's marijuana testing program cannot ensure that the products are safe. Furthermore, at one point state officials in Oregon announced that all 20 individuals in the state with cases of a valley, including one patient who died, reported using THC products bought from legal sources. Another issue which is cropping up is cannabis testing laboratory fraud. New laws that were passed in California require product testing but shops selling the product complain that they can't compete the illegal market, which undercuts their price and doesn't have to test. The temptation is to use less than perfect testing labs and this has contributed to impure products sold to the unaware public even in regulated cannabis states. Crematologic and skin products such as cannabis derived cosmetics sometimes circumvent regulation. Cannabis manufacturers appear to be exploring marketing strategies that navigate the less stringent cosmetic regulations of the FDA, especially as they market CBD and other similar cannabinoid containing products. Studies have shown that the concentrations of CBD are inaccurately labeled and more than 20% of the product labeled just CBD actually contains psychoactive THC. We do know that transdermal absorption of lotion and oils occurs in the industry is using nanotechnology to increase absorption. We have someone in recovery from canvas use disorder who then buys something they think is just CBD but ends up having THC delivered through nanotechnology into their bloodstream will this lead to an unintended relapse of their cannabis THC use disorder. We have reports of folks testing positive through your analysis for THC after rubbing just CBD on their skin and subsequently losing job opportunities and this is something that we've seen in Vermont. We've heard about this relationship between THC especially high potency THC and psychiatric disorders and addiction addiction to mental health risks of high concentration THC which is by the way again just defined as around 10 to 15% THC greater than 15% THC. So these risks are clear and there's a team of the Dutch government health experts that have concluded actually that THC with concentrations greater than 15% should be considered a hard drug, just like cocaine. Here we see that as the average THC concentration increases in red, then subsequently admissions for THC cannabis dependence or addiction increases afterwards. So THC cannabis use is getting in the way of these folks keeping their job functioning and requiring treatment for their cannabis use disorder. This is a representation of a study done by Dr. Deforti and Sir Robin Murray and others from King's College London and Oxford University was created by Dr. Bertha Madras from Harvard, and it demonstrates how concentrated THC again defined as just about 15% THC acts as an environmental risk factor for increasing mental illness like psychosis in a community in cities with higher concentrations of THC like Amsterdam or London and where there's more use there is more cannabis induced psychosis. So for example specifically in Amsterdam the authors found that 50% of the total number of people who suffered first episode psychosis which is a medical emergency would be well. But for their cannabis use I think I will just repeat that in Amsterdam they found that half of the people who are presenting with a medical emergency of first episode psychosis would actually be well, but for their cannabis use. So this really constitutes an enormous public health risk and public health cost burden for us and for insurance carriers, which is directly attributable to the availability and use of high THC cannabis in a location. With low THC and low population use rates the incidence of cannabis use disorder and cannabis induced psychosis were lower. Thus having low THC concentration cannabis in your community is a protective factor regarding mental health said another way, just by living in a state or an environment with high THC concentration available. With a lower perception of harm of cannabis, you increase the risk that you or your children will be diagnosed with a severe mental illness like cannabis induced psychosis or use disorder. Cannabis hyperemesis syndrome is Dr. that pointed out is a disorder which almost didn't exist prior to the invention of high THC cannabis, or prior to cannabis commercialization. So uncontrolled vomiting dude THC was so rare was a case report. Now, as she mentioned nearly every ER and cannabis legal states are seeing these patients daily presenting with cannabis hyperemesis syndrome, of course this also is an enormous cost burden for hospitals and insurance carriers. And yet the public is generally not informed or aware of this risk. So nearly all patients who present with pain dehydration uncontrolled vomiting from cannabis do not believe that cannabis is the cause, how would it be. They're taught to believe that cannabis is harmless, even medicinal. So this is a slide taken from a grassroots organization of patients suffering from cannabis hyperemesis syndrome, and they're upset because they were not warned. They created a film this film pitch to try to get something like Netflix to do a series, which could be used as a vehicle to inform potential cannabis users the risks of cannabis hyperemesis syndrome. So far they've been unsuccessful, however, the condition is a real concern and patients have extreme pain, some of them end up being prescribed opiates and some actually have unnecessary surgeries like colostectomies or appendectomies. And they can result in extreme dehydration seizures or kidney failure. Often they can't stop using. And as you see on this slide, some of the moms here are talking about their kids who have succumbed to the disorder. So Vermont has one of the highest past month use rates of illicit drugs, and one of the highest past month cannabis use rates in the United States. Vermont now also has high ER utilization rates, cannabis hyperemesis syndrome, cannabis induced psychosis and severe mental illness. Nevertheless, paradoxically, the state has documented a decreasing perception of harm of cannabis. So why would this be, why is it that the Vermont public is not made aware of the risks. In the lay press in Vermont, we are seeing a number of articles you'll see one at the bottom talking about adolescents, especially confronting mental health crisis. He's waiting for days in emergency rooms for treatment in Vermont. They have a term for this, the kids are being warehoused as they wait for treatment. They're putting closets, ER exam stalls, sometimes for weeks. The newspapers were reporting on this, however, generally do not make the connection to cannabis as a possible root cause of some of the increase in the adolescent psychiatric disorders. In this instance, we talked to the reporter and let them know about cannabis hyperemesis syndrome and psychosis. One of our psychiatrists from the health department discussed also with the reporter, let them know that the health department was well aware of the link between cannabis and psychosis and suicidality. Unfortunately, this reporter in newspaper did not publish a follow up article talking about this link. On this slide, you'll also see that in Vermont, we're seeing that as kids use more cannabis, the rate at which they attempt suicide or plan suicide also goes up. This is an association that we're describing. I think this is a very important slide and we're getting at why is it that the lay public is not being informed. They're not being informed by reporters on this issue, but the lay public is voting on public health issues like whether to put a marijuana shop in their town in Vermont. They're not getting science based information. Instead, the public ends up getting their information from lobbyists and this comes from one of the publications that was put up by one of the lobbyists. The public health content experts in Vermont, for example, the state's administration or directors of 501C3 non-profits like prevention groups. Both of these categories of experts on public health and drug policy are not weighing in in Vermont. Why? Because an administration is generally low to the scale in a public vote, and employees of 501C3s are fearful that they'll risk their nonprofit status if they weigh in on something which is a ballot issue or up for a vote. So to summarize, we're not having reporters interviewed physicians and report on the harms of cannabis, cannabis, hyperemesis syndrome, cannabis and psychosis. In addition, our public health content experts associated with state government and in nonprofits are not speaking up. The result is that the Vermonters have an inappropriately low perception of harm of cannabis in addition to actively being misinformed by lobbyists. What do we mean by this? So I'll just read what's in blue on this slide, which was produced by one of the lobbyists in a very well educated, well-meaning town in Vermont. This slide shows on the right-hand side of a public website and what it says is, quote, every study ever conducted in any state on underage cannabis use following legalization has concluded that legalization does not lead to an increase in underage cannabis use. On the left, we fact check this statement in the form of a number of well done robust studies published in peer review journals which demonstrate that quote, legalization greater retail availability of recreational marijuana are positively associated with marijuana use among adolescents or quote, that recreational marijuana legalization correlated with increased cannabis use disorder in the US from 2008 to 2016. And that in California, commercialization of cannabis was associated with an increase in adolescent marijuana use comparing 2017-18 to 2018-19. It's long known that the closer a child lives to a liquor or tobacco store, the more likely they are to use. And so it's logical that we're seeing the same trends with cannabis use use and use disorder and now that data is barely beginning to come in. In Vermont, we had five years where this was debated and many of the risks and pitfalls of commercialized marijuana were explored. So the legislature was fairly well informed and they put in some guard whales when they passed their cannabis commercialization law. First in the nation, Vermont put a cap on the concentration of THC. They paid attention to the studies from Keynes College, London and Oxford University. They paid attention to the studies that were informing the Dutch government and feeling that 15% THC or greater should be considered a hard drug. And the cap was placed at 30% for plant and 60% for concentrates. Delta 8 which is now often synthetic and quite likely potentially very dangerous was outlawed. The cannabis control board by law is tasked with creating science-based warning labels for our marijuana so that the public would be informed decision makers and Vermont Cannabis Control Board was tasked with looking directly at the issue of THC and psychosis. The Medical Society did a deep dive and reviewed hundreds of articles and came up with this warning label to help the cannabis control board it lists psychosis impaired driving addiction suicide attempt uncontrolled farming and harm to fetus and nursing baby. Unfortunately, the cannabis control board which is composed of again two lawyers and a non-medical human resource professional instead came up with the warning on the left, which includes almost 130 words. It's very small print, and as one person said, no one's going to read that. But the biggest problem with this warning is that it's inaccurate by omission does not list psychosis addiction per se suicide self harm or cannabis hypereomasis syndrome. We know that caps work because in Quebec they put a 30% cap on their THC concentration and indeed if you look at the red that's Quebec they're using much less high potency and illicit cannabis than the other provinces are both edibles and concentrates. This is a slide which demonstrates that the legalization of marijuana in Vermont at least has impacted people with less than a high school education and earning less than $25,000 or more disproportionately would just take a few minutes and look at criminal justice goals are they realized by legalization in Washington DC after marijuana was legalized we saw that arrests for public marijuana use increase and arrest for marijuana distribution also increased. The promise of social and criminal justice. We have a University of Vermont study run right here in the state of Vermont looking at legalization of cannabis and it did not show that the increased rate at which BIPOC drivers are stopped compared to white drivers did not decrease after we legalized and commercialized marijuana and actually the ACLU also has studies which show similar findings. We know that the industry targets vulnerable populations and these studies on this slide show increased distribution of dispensaries and underprivileged minority neighborhoods findings in this study in Oregon. Support the hypothesis that cannabis retailers are more likely to be located in relatively deprived neighborhoods, suggesting the need to consider spatial equity in cannabis policies to mitigate disproportionate exposure to retailers. In another study out of Washington state we found that quote most deprived areas had increased likelihood of increased cannabis outlet density when compared to least deprived areas. So we have to ask the question, can these states actually regulate cannabis in Vermont we have a situation which the medical society composed of 2000 states doctors recommended 10 to 15% THC concentration camp. They passed by legislators recommending a cap of 60% concentration and 30% for flower Colorado after eight years has no cap. And after the Vermont law was passed the cannabis control board was tasked with protecting public health. They did this by lobbying to eliminate the statutory THC concentration cap. The cannabis control board again is a board composed of two lawyers and a non medical non science human resource professional, and they advocated for 100% or THC to be produced advertised and sold to Vermonters, even though as we've been mentioning the science is really now settled that these products with high THC are highly addictive dangerous in terms of mental health harms such as psychosis and cannabis control board in Vermont also lobbied the legislature to obtain the right to regulate delta eight instead of having it outlawed outright. The cannabis control board also researched psychosis and THC and came to the inaccurate conclusion, citing a 2006 15 year old article by Hall et al that there's not enough evidence to suggest that cannabis can lead to psychosis. Psychosis is an inaccurate conclusion by the ponderance of experts in the field of schizophrenia and psychosis and the evidence which is now available for review and hundreds of peer review articles. The cannabis control board created package labels for cannabis which are inaccurate by omission. They did not mention psychosis self harm cannabis cyber room assist syndrome or addiction per se. In terms of zoning and protecting vulnerable and minority communities that cannabis control board created rules, which allow a cannabis shop to be located right next door to a daycare for nursery and just 500 feet from a school. Can cannabis commercialization laws be written which protect the public are our state cannabis control boards acting as regulators protective of public health. The term of health is a relatively new term introduced in 2013 defined as quote strategies and approaches used by the private sector to promote products and choices that are detrimental to health. 80% of an addictive product is generally consumed by less than 20% of users creating a more addictive product by targeting youth and vulnerable sectors of our society are cornerstones of their profit model, and are embraced by the industry of addiction historically. It remains an open question if the corporate determines of ill health will prevail or science based cannabis regulation is indeed possible in the United States to challenge is the existence of a system in the US, which relies on regulating an addictive drug through popular vote. Elected lay legislators and non medical cannabis control board professionals. Thank you. I think Vermont Medical Society's considered other approaches to high THC products because I agree that they're a challenge. And the University of Washington actually just had a one day symposium on on addressing high THC products and as part of that symposium they're doing some legislatively mandated work to look at lots of different policy approaches. Like serving size limits package or purchase size limits. They've come up with 30 or 40 different policy approaches. I'm curious if that's something the medical societies assessed at all, you know there can be some potential unintended consequences from different policies and I think it's valuable to look at wide variety of policies and talk about them as, you know, a wide array of stakeholder groups to assess what's feasible and has the best outcome for public health. Yeah, we felt like we didn't want to dilute the message. It's very difficult to get that message out that high potency THC is dangerous. That it exists. I think delay public chance tends to think cannabis is all in their mind 1960s pot. And so I think it's pretty hard for them to wrap their mind around the idea that it's a completely different drug. You know that crystalline 99% THC could be sold legally to an advertise to folks 21 years and older. The idea that there are severe mental health harms out there. This is a very important issue to the medical society. We have a conference which is going on the eighth and ninth of October, where Dr. Libby Stout is going to be talking and it's dedicated to a woman who had a son with cannabis use disorder ended up with psychosis and schizophrenia. And she was an incredibly healthy person physically. She was very intelligent psychologically she had a large social group of support intact family and resources. For the last 15 or 15 years of taking care of her son, she developed a unmanageable anxiety, which deepened suddenly into unrelenting depression and she is, you know, jumped in the bottom of the Winooski River in December five years ago. The impact is not just the few people who end up in the ER or psychiatric hospitals but also the entire family. And if you talk to her widow or he says, you know, when my son came down with schizophrenia my whole family came down with schizophrenia. So I think, you know, the medical society is very focused on really staying with this idea that this is dangerous and trying to communicate that as effectively as we possibly can. Thank you so much, Dr. Love and Dr. Antley.