 Hello, welcome to the judge Ben show. My name is Ben Joseph and I'm a retired Vermont trial judge. This is a program in which I interviewed people and talk about current issues that involve the law in the courts. Last year, Vermont's legislature passed a law permitting retail sales of marijuana, which will start, I think in October of this year. The law also set up something called the cannabis control board, which is to make rules, for example on the amount of THC, which is a tetra hydro cannabinoid I think is the word it stands for. It's a chemical that's in in the cannabis causes. It gets you high, you know, for one of a better description. I'm going to read from a press release that the Vermont Medical Society put out. It's not too long. Then I'm going to go to speaking with my guest who's sharing leave you who is a doctor and who works at Boston Children's Hospital. I didn't mention this to her earlier but I just saw an article it suggested that. So as cannabis is legal in Massachusetts that last year they had $2 billion of sales. And as a consequence they collected, I think it's $200 million. I think it kind of goes to the heart of what this is all about that. As they used to say where I came from money talks. I'm hoping that people will understand there should be more controls on the way this stuff is done. And the cannabis control board will limit the amount of hallucinogen THC that's in these products that are going to be sold. So without further ado, I will read from the press release that was put out. Oh, a little less than two months ago by the Vermont Medical Society. They headline their press release Vermont Medical Society calls for commercial cannabis potency limits. No advertising and for warning labels to include mental health risks. Montpelier November 30 2021 the Vermont Medical Society which represents 2400 physicians and physician assistants across Vermont. They adopted a policy resolution urging the Vermont cannabis control board and the Vermont legislature to require that all cannabis grown produced or sold in the state, contain less than 15% THC. That's the, that's the thing that makes people high tetrahydro cannabinoid only took me a week to learn how to say that, but I got it done. The Vermont Medical Society policy opposes all cannabis advertising and advocates for cannabis products and advertising to list evidence based health risks associated with cannabis use, including psychosis and suicide attempts and persons with no prior mental health history. Uncontrollable vomiting dangerous driving addiction and harm to fetuses and nursing babies. I get here that I keep pretty close track and the number of people killed each year by persons driving under the influence of marijuana. Last year that number was 18. There are another 16 people killed in accidents where the driver was under both the influence of both alcohol and marijuana. So there's a, there's a, there's a steep price to pay for the use of this drug. Health and mental health risks are of immediate concern because Vermont currently has the nation's highest past month cannabis use, including use of high potency that is greater than 15% THC products. Evidence shows cannabis use especially with potency greater than 15% THC is associated with increased urgent and emergency department psychiatric visits and increase mental health disorders, including psychosis. It is also associated with increased urgent non psychiatric visits for respiratory distress. Cannabis hyper metastasis syndrome. I won't try to pronounce that one again. That that means uncontrollable vomiting and poisonings. However, in Vermont there is a significantly inappropriate low perception of harm of cannabis use. Most of our mantras associate legalized cannabis sales with marijuana from the 1990s, when the THC levels were less than 2%. Yet in states like Colorado and Washington where commercial cannabis sales have already been legalized, THC potency has dramatically increased with averages for marijuana flower ranging from 17 to 28%. And for concentrate such as dabs and waxes as high as 90% THC. Wow. The cannabis control board is currently drafting proposed regulations in order to implement Vermont's commercialized market for cannabis sales, which is slated to begin in the fall 2022. Last week, the CCB, that is the cannabis control board released proposed rules, which include drafting label, label language that leaves out all mention of serious mental health. Effects associated with cannabis use, including the increased risk of addiction, anxiety, psychosis, suicide attempt or self injurious behavior. Vermont Medical Society President and Psycho was a psychiatrist. I think this is see me Robin stated quote at a time when Vermonters are facing filled hospital beds crowded emergency departments and prolonged wait times for inpatient mental health treatment. These medical professionals believe Vermonters deserve accurate information about the risk of cannabis use, and they should not have commercial access to high risk high potency products. That's the end of the quote. The medical society policy also urges the Vermont CCB and state leaders to dedicate adequate resources to statewide prevention and education efforts that include cannabis use prevention and education at schools and in underserved communities. Evidence based after school activities to decrease high risk behaviors among adolescents treatment of cannabis use disorder. The state leaders, the media and the public of the increased cost and burden to our health care system caused by cannabis use, especially greater than 15% THC cannabis use, including emergency room crowding and overburdening cannabis addiction, psychosis, suicide suicide attempt or self injurious behavior, mental illness, cannabis vomiting syndrome, child poisonings and driving injuries. Let's see. Let's just a little blurb here at the end promoting a medical society which I think I ought to read. The Vermont Medical Society is the leading voice of physicians in the state, and is dedicated to optimizing the health of all Vermonters on health care environment in which Vermont physicians and physician assistants practice medicine. The society serves its 2400 members through public policy advocacy on the state and federal levels, as well as by providing legal administrative and educational support, producing a rich flow of news and information, and offering member benefits that increase medical practice effectiveness and efficiency. So that that caught my attention when it came out for obvious reasons. And my time in the bench I saw a lot of sad things that have happened, because people were using this drug. I'm very, very happy to say today that I have a guest from Massachusetts, whom I hope you can see on your screen. That that guest is Dr Sharon Levy, your doctor of medicine, is that right. Yes, I am a pediatrician, and I have specialty boards in developmental behavioral pediatrics and also addiction medicine. Oh, wow. And you work at Boston Children's Hospital is that right. I direct the adolescent substance use and addiction program. We opened back in 2000, and we were the first substance use disorders specialty program situated at a Children's Hospital in the country so we have a pretty long history of taking care of of kids with substance use problems and disorders. Those are the credentials I like to hear when I have a guest on talking about these subjects. I have a connection with the Harvard Medical School. Well, I do I'm on the faculty at Harvard Medical School I'm an associate professor there. Wow. Wow wow wow. Do you supervise other doctors and therapists as part of your job at the Children's Hospital. So, one of the activities that we do it in in ASAP is that we run a fellowship training program so for guests who may not know doctors go through a lot of training right you know there's medical school. After you finish medical school you do internship and residency training I think a lot of people probably are familiar with that. And that is in your primary specialty so for example for somebody like me that was in pediatrics we spent three or four years doing that training. After completing that doctors can go on and subspecialize. So I'm subspecialized as an addiction medicine specialist. And we run a program that takes physicians after they complete their residency training to do one year of clinical training in pediatric addiction medicine so they learn how to take care of kids with substance use disorders by working with us. Well how many patients do you deal with in a typical year do you know. Last year we completed 5000 visits on it that was with you know somewhere between 500 and 1000 unique patients at any given time. We have four to 500 patients enrolled in our outpatient program so those are patients who we're keeping in touch with who are actively engaged in outpatient therapy with us. What are the typical problems you see when dealing with adolescents that are caused by marijuana by cannabis same thing. And so you mentioned in the statement mentioned the most common problems. You know, I would actually say that the biggest problem that we see is addiction. So one thing that we know about the adolescent brain is it's still developing and it is particularly vulnerable to being interested in trying psychoactive substances like cannabis. You know kids are risk takers. They also do things they like to look for activities that will be very very exciting so we know that right we know that in general that's the kind of behaviors that we see that we expect in high school kids and young adults. We also know that their brain is developing and that the kind of the brakes on behaviors of things that help adults to control impulses and to self monitor and to make good decisions. Those skills are still developing during adolescence, and it turns out that during that period right where kids are so drawn to high risk activities and at the same time, don't have the neurological hardware yet in place that's going to help them reliably make good decisions. During that time period, kids are susceptible to developing the neurologic changes in the brain that that cause addiction. And when I say addiction I'm really talking about loss of control over substance use. Right, and so I think people in their minds I have a good picture of this. For example with cigarettes right there. Probably everybody knows somebody who smokes cigarettes or uses nicotine who would like to stop finds that they can't write that that smoking has become kind of a reflex for them. And they, as much as they would really like to give it up. They find they can quit but they can't really maintain it right. Same thing happens with other substances as well. Right. I mean we know that it happens with alcohol, there are people who really just can't stop drinking even though they want to it certainly happens with opioids. And it happens with cannabis or marijuana as well that people become addicted to it, and they can't control their use and so even when they want to stop. They really struggle with that and people develop addictions, typically during their adolescence, some of the, some of the problems may not present until a little bit later, but something like 90 to 95% of, of adults who have an addiction are not using substances before their 18th birthday. And so, you know, I would put that as number one on the list, because we know that people with addictions people who use cannabis chronically actually have worse outcomes across a number of domains and adulthood so they do. They attain lesser education and job performance. They're less likely to, you know, establish fulfilling relationships and have their own families. And that's all been very very well documented. So, you know, I think that a lot of these are long term consequences, but the addiction really does start in adolescence and really, I think it's incumbent upon all of us to really try and protect our kids during this vulnerable phase of development and really make sure that they go down that path. So, so very long answer, I would say addiction is, is, you know, for me the number one concern with adolescent substance use. So the other things you mentioned. People who use cannabis, particularly those who use during their adolescence are much more likely developmental health disorders, including psychotic disorders you talked a little bit about psychosis and acute psychotic episodes that bring people into hospitals. So, you know, cannabis hyperemesis syndrome. That's syndrome of uncontrolling bomb, uncontrolled vomiting we often, many of us probably think of cannabis as something that reduces nausea and stimulates appetite and that's true in low dose but as we've seen these products become more and more concentrated actually cannabis can do the opposite and so this used to be a very rare condition in my experience. And now probably not a week goes by without me getting a consult for a patient either in an emergency room or in a or a consult from a pediatrician colleague asking how to manage this problem so clearly it's becoming much more common. Wow. Well, by addiction is someone becomes addicted to this stuff does it mean they have to use it all the time. Yeah, so when somebody becomes addicted to a substance what it really means is that they've kind of lost control. I think maybe Mark Twain put it fast he said, quitting smoking is easy I've done it a million times. Right. And so really what that points to is when when addiction develops substance use almost becomes a reflex or sort of the default behavior right. And so they can stop using right but but typically they have to muster a lot of energy to stop using. Okay, because using is almost become a reflex. Think of it like breathing right breathing is a reflex we don't have to think about it we just do it. Now you can actually suppress the reflex can hold your breath. But eventually the reflexes can take over and you're going to start reading again right now in obviously with breathing that's a good thing with with substance use. When that reflex develops, people can actually control they can choose not to use and for any given episode right. And, you know, typically what people find is when they decide to quit they can go a couple of weeks, you know, maybe a month or two. What they're what's really happening is that they're using a lot of mental energy to suppress the reflex and eventually what often happens is people find themselves using again kind of when they let their guard down a little. Now I do want to say for people out there that treatment works. You know, I'm an addiction medicine specialist so I fully believe that I wouldn't have gone into the field if I didn't think there was anything that we can do about it, and we can certainly help people rewire their own brains and sort of undo that reflex that's developed. So, you know, I not it's not that all hope is lost but it is a condition if left untreated. I, you know, people end up often, you know with with with consequences right with you know health consequences with mental health consequences with with all kinds of untoward problems so we want to do everything that we can to prevent this from developing in adolescence. And then when people do develop addictions we want to make sure that there are resources available for them that they can access so that can help them recover. When I read this thing from medical society. I inferred from what what they were saying that the cannabis with a higher THC content is more likely to cause addiction and health problems. Did I get that right. Absolutely right. And so that's a problem across the board with addictive substances. So, we need, we need different kinds of regulation when we're talking about addictive substances, as compared to non addictive substances. What we do with state based regulation is that states don't really have the infrastructure to do that kind of regulation right. Typically, we expect the food and drug administration to, to put those regulations in place. And we have, we've learned a lot of lessons some of them very hard come right you know we know people who are watching may know that for a long time, the FDA did not have jurisdiction over tobacco, right. That changed under the Obama administration, and now the FDA actually does have jurisdiction and so they can regulate tobacco it's obviously tobacco is a product with a lot of potential firms for public health. So, what we've seen over the past 20 years is actually quite significant decreases in smoking among adults and kids, but even more dramatic amongst the kids. And so, you're talking about teenagers. I'm talking about teenagers and I'm talking specifically about tobacco use. So, these regulations can work. And, and, and they're really critically important. Now you take the case of vaping. I'm talking a lot about nicotine because I think it's illustrative here. When, when these new e-cigarette products came out, they were initially not regulated by the FDA. And that was actually kind of a loophole. It was subsequently been closed, but it took a long time to close the loophole and so we had this period of time where manufacturers didn't have to follow the FDA rules for tobacco with nicotine. You know, now we're in a process where they're going to have to but we saw what happened we had these huge increases in youth vaping. And if we had just applied the rules that we already know are effective that we insist on for tobacco to vaping, we may have not, we may have avoided that situation entirely. So, you know, I think that that's something that we need to think about when we're talking about regulating cannabis. We already have a lot of rules that, that are applied to the tobacco industry, you know, that I think have important impact. We need to, that should be a baseline of rules that we apply for cannabis. Now there are different psychoactive substances. So some of the, there may be some, you know, different challenges. But, you know, these are the kinds of regulatory schema that we should be thinking about. What's really challenging here is that because cannabis is in this gray area where it's illegal, of course, by federal law. And that being legalized state by state is that we don't have a federal authority to keep an eye on that. And that really imposes some burden, I think, on each state to figure that all out, and actually implement those rules. But, you know, I think that some of some of the rules that you talked about are exactly on target. So things like limiting concentration in the product. 15% is actually, you know, that's the cutoff that that Vermont is using I think some other states are doing something higher. It's actually very concentrated as you said, back in the 90s back in the 1970s, you know, certainly cannabis plants were in the range of about three, two to 3% THC so 15% is actually quite a bit higher. And then, if we're going to apply the term cannabis or marijuana to other substances and also legalize them under the same rules, then they also have to be highly regulated so, for example, that, you know, when we're talking about vaping liquids that contain cannabis. You know, in some ways when we say okay, we have we've legalized cannabis or marijuana. What does that really mean so that really you know cannabis refers to a plan. Are we going to call absolutely any product that has THC and it cannabis and thereby call it legal, or should we have, or should we have a more thoughtful approach to it. Well, what I wanted to ask you is, what, what limit do you think should be the cannabis control board in our state will have the power to limit the amount of THC. 15% 30% whatever, what do you think is responsible on that record. So I think that limitations on the, on the concentration of THC is important, it's not the only factors that determines how much of an active ingredient, a user might be exposed to. So formulation, or how we deliver the product how people get use the product is also really important that's particularly true with, with people who are using vaping devices or other sorts of mechanisms to consume cannabis right so even so there's no doubt, you know, one of the is probably the number one aspect of how high of how much THC somebody will get, but there are also other things like the power of a device how you know how strong the voltages of the of a vaping device that you're using, what other, what other components are going into the illiquids or even we know this also from tobacco, what other chemicals are going into any sorts of cigarettes that are cannabis cigarettes that people will consume, all of these things actually will influence how much THC people can get that this is why it's an incredibly complex topic, and it's, and I appreciate that it's hard for states, you know that don't really have the machinery to really put these regulations in an effective way, it's just it's very burdensome to states but it's really important that we do it. It's also the case that for tobacco and nicotine products that manufacturer not allowed to sell flavored products because they're too attractive to teams. And, you know, like the taste of apple sauce or what kind of flavors you don't. Yeah, so for so tobacco products there was a time when tobacco products were flavored with all kinds of flavors vaping products are flavored with candy flavors fruit flavors dessert flavors. For tobacco products flavors aren't allowed for vaping products there's still some flavored products on the market but I think you're going to see them disappear, we should be asking ourselves, should we be allowing cannabis products to come in in flavors in candies in baked goods that are so attractive and so easy to use for younger people. The cannabis control board here in Vermont would have the power to prohibit products being sold with THC content. Should you be in favor of that. You know, I personally would be in favor of, of taking off the market products that are made as desserts candy flavored soft drinks all of these really attractive and accessible products to youth. I don't think they should be on the market personally, you know, of course, they tend to be very good sellers. The industry would surely, you know, have a different opinion on that. But I think, you know, again using nicotine as the example if we look what happens when we make these products. Not only are they attractive to kids, but they also sort of give the message when you package THC into candy bars and into other, you know, products that really look like they're designed for children. And it's actually giving a message that, hey, this is safe. You know, that's how Pete that's how the public tends to interpret these kinds of, you know, this subtle message. So it makes a product looked look safe. It makes it easy to consume, right. You know, if a kid gets into it, a younger kid it makes it easier for adolescents may to consume these things. And it also gives the message that this is a product for kids. I mean, I think that there's no other way to interpret, you know, a gummy bear product right I mean, you know, how can you look at that and, and, and it's a very confusing message to say, you know, here's a lollipop with THC in it, but it's not meant for children. I mean lollipops are by definition for children. So it's a very confusing message. And I personally think that those products really should go right that doesn't. That could happen, and you could still have adult access to certain forms of legal cannabis right. What's always a tension is that, you know, some of the, some of these products would be very, very good sellers. And so the question is, how much do you let market forces decide what the, what's going to be allowed and how much is this really driven by public health, rather than trying to maximize revenues. It's, well, what could it should a parent do with they have a child who's getting involved with addiction to this stuff. Well, I would say that if you think that your child may have developed a substance use problem. I would actually talk to a health care provider and I would start with your child's primary care provider and get advice. I think the conditions are treatable. It's really important that we treat and not ignore. Well, I'm just hoping that the cannabis control board will adopt rules which will contain and prevent some of these problems from proliferating. When I heard that there were $2 billion worth of sales in Massachusetts. I was just, it's just mind boggling. You must be a very busy place. Well, Sharon, I'm sorry, you know, I'm up against my time limit. I'm so terrific. I, and I so admire what you're doing. I hope you continue on and have, have success. Okay. Thank you very much. Thank you very much. And ladies and gentlemen, I'm up against my time limit. I want to thank you for looking in and please contact the station here if you have any suggestions for other things you'd like to hear about. One of the things that's difficult about doing this job is I don't often get much feedback. Although once in a while, the very nice things that are said, but I want to encourage the public to let me know what you want to hear and what you think about these interviews are doing for you. Thank you. And thanks for looking in so long. So long Sharon. Thanks. Thank you.