 Here, our thing have been, for those of you that have been with us since the beginning, you know that we are learning all about cannabis, where it came from, why it came from, and cannabis and medicine, cannabis, and religion, cannabis, and food, and cannabis, and dear old Uncle Sam. But one today, we are going to talk with Dr. Cliff Otto. And again, for those of you that have been with us the whole time, Dr. Otto was one of our first guests, because he is not only a medical doctor, but he is an expert in cannabis. And he was one of those people that began this whole move for cannabis in Hawaii. And so today, we are going to talk to Cliff about Hawaii Medical Cannabis Day, June 14, 2019. It's the 19th anniversary of the day that Hawaii accepted the medical use of cannabis. So, Cliff, thank you for being with us. Hi, Marcia. Thanks very much for having me. Cliff is a medical doctor, an eye specialist, and so he has to go to different islands to take care of patients, and we're so happy to have people like that. So, Cliff, tell us all about Hawaii Medical Cannabis Day. Well, how did you get, you were first, let's go back. You were here from the beginning. When was that? Well, so I started becoming involved with the program back in 2012 when I started to become a bit of an advocate after seeing how the substance was helpful for a family friend who was going through cancer surgery and chemotherapy, and I was able to see the benefits firsthand myself, and then started doing a little research on some of the literature that's out there and learning about it from a medical point of view, and then started studying about the law itself. And that's when I really became a bit of an advocate because I saw some of the changes that needed to be made in order to protect our patients. So that's how I got into it. Wow. So, now, but you are a specialist, of course, with the eyes. Now, how does that help with the eyes at all? Well, so that's a very good question. You know, Hawaii and a lot of states have glaucoma as a qualifying condition for our medical use of cannabis program. And actually, the American Academy of Ophthalmology does not recognize smoking cannabis for the treatment of glaucoma, but I can tell you I have several patients who swear by using cannabis, both by inhalation and topical use in the form of eye drops that they're sometimes able to acquire. Certainly something that needs to be studied further because there is, there was a recent study that indicated that the topical use of cannabidiol or CBD, which everybody's heard about, might actually raise eye pressure a little bit. But there's some very good evidence that THC use topically could provide effective eye pressure control without the intoxicating side effects. So I think there's a lot of potential there, but like a lot of areas with the medical use of cannabis, we just need to do a lot more research. So when you talked about the pressure and adding the pressure, what does that mean? Well, glaucoma typically is diagnosed when there is an elevation of pressure in the eye, and that's something that we measure in the clinic, along with characteristic changes to the optic nerve itself, which we examine doing a dilated exam. And then also evidence of loss of peripheral vision. Those three things together make up a diagnosis of glaucoma. And our main treatment is lowering the pressure enough so that we don't see any further loss of vision of peripheral vision, because that's usually what goes first. And that's what's most dangerous, because a lot of times patients don't notice that they're losing peripheral vision. And so the THC raises the pressure, is that what you said? No, actually THC has been shown to lower the pressure, lower pressure. So it could actually be a potential treatment. Most of the eye drops that we have now lower the pressure by different mechanisms, either decreasing the production of fluid inside of the eye or increasing the rate at which the fluid is able to escape the eye. So in either case, our primary treatment right now is addressing the pressure, which is probably more a secondary finding of glaucoma, because we know that inflammation is a big part of a lot of different diseases. And so that's another area where some of the other chemicals in cannabis could be potentially helpful. Well, now, but you wouldn't have to, I mean, are there other ways other than with eye drops, like what is that you put under the tongue? Well, right, so there are different preparations that are available, like, well, exactly. So when people think of cannabis, they often associate that with smoking, and of course, we don't recommend smoking as a medical route of administration, but the inhalation of cannabinoids can be very effective, because they act very quickly and they're very easy to regulate. But of course, we don't recommend smoking, but vaporizing using a high quality vaporizer that allows dried flowers to be ground up and heated to a temperature that allows the cannabinoids to be released into a vapor, not a smoke. And so this has been shown to be a much safer way of inhaling cannabinoids for various medical purposes. Yeah. And then what about the edibles? Would they help? Well, so there hasn't been a lot of good research done on the ingestion of THC and the effect on intraocular pressure. That's something that needs to be studied. More, of course, ingesting does carry with it some of the potential side effects of intoxication, because when you're ingesting, the absorption and the metabolism is very different and can often create more side effects than you really want, because as you've probably heard in the news, it's very easy to take too much of a cannabis edible, especially if it's a homemade product and we don't know how strong it is. Now, I am not a baker. I don't bake, so this might sound like a dumb question. However, if you were baking an edible, cookie or whatever, and you put the THC in it, then you put it in the oven, doesn't the heat change the molecules? Well, so I think what you're referring to is something called decarboxylation, which is a process whereby, I know, fancy name, but it's a process whereby the naturally occurring cannabinoids, which occur in what's called the acid form, the form of the cannabinoid that the plant naturally produces, which has an extra molecule of carbon dioxide attached to it. Now, cannabinoids in their natural form do have their own physiologic properties, but in most cases, when the THC, the THC acid is heated either through smoking or vaporizing or cooking, then the carbon dioxide is released and that significantly changes the physiologic properties, especially of THC. Well, like I said, I was guessing I'm not a baker, so, but I know that different temperatures do different things, so. Yes. Sure. And there are certain temperatures that work well for the various cannabinoid decarboxylations, depending on how it's being prepared. Again, back to this, if I go into the dispensary and I do have a card, I go into the dispensary and I say, well, I want this and this and this, but I don't know how to use it and I don't know if eating it with something makes a difference, all of these, I have no idea about all these products, no. And yeah. Right. Well, so this brings up the important point of the doctor-patient relationship, which is required under state law in order to be a medical use of cannabis patients. So all patients, in order to get into the dispensary, need to be certified by either a physician or an APRN. And during that evaluation, it's critical that the certifying provider go over things like state law so that patients can stay out of trouble, go over potential drug interactions because THC and CBD interact with a whole host of prescription medications. And then the last part should include a discussion of how to use cannabis safely and effectively for the patient's qualifying condition. So my opinion is when a patient walks into a dispensary, the first thing that the staff should ask is, what is your certifying provider suggesting? Now we're not giving prescriptions and we're not really recommending the medical use of cannabis because of its current scheduling status, but we can give suggestions and the medical advice within the doctor-patient relationship. Now speaking of the scheduling, my first conversation with you was about de-scheduling. Where are we in that, the de-scheduling? Well, right. So there's this whole discussion about re-scheduling or de-scheduling and our understanding of this whole interaction between state and federal law has been evolving. The thing that we're trying to point out right now is that states have the authority to accept the medical use of controlled substances. That's what's allowed our state and nearly all the states in the union the ability to create medical use of cannabis programs. So once a state has given cannabis medical use, that means that that medical use no longer meets the criteria of a schedule one controlled substance. So this is a very important interaction that Congress established when they created the Uniform Control Substance Act and the Federal Control Substance Act to allow a process whereby changes in the medical use of controlled substances can impact federal scheduling. But we haven't changed it in Hawaii. Well, you know, I would say that no, we have not. There's been no scheduling changes in Hawaii or at the federal level. And I would say that scheduling is not really necessary because we have several examples where federal schedule one is not being applied to certain activities. For example, the religious and sacramental use of peote is exempt from federal schedule one. The inter-island, the transportation of cannabis aboard aircraft is exempt from federal schedule one regulation if it is authorized under state law. So we have several examples of activities that can be exempt from federal regulation. And my argument is that that's the situation we have in Hawaii. We have an accepted medical use of cannabis, which means that our program is exempt from federal schedule one regulation, which is the biggest roadblock right now to patients being able to engage in our program and dispensaries being able to operate without this misconception that everybody is violating federal law. Yeah. Well, I'm glad you said that because that was one of my questions I've asked repeatedly if the major dispensaries are here on Oahu, well, what about the other islands, people on other islands? You know, that seems so discriminatory that we can't fly, they can't go back and forth and see to the dispensary if they live on one of the islands. Well, they can fly back and forth and visit other dispensaries on other island. It's just if they were coming back and they were to be found carrying cannabis for medical use, they might be allowed to board their flight or they might not be able to. Unfortunately, the perceived federal situation is being applied by our local law enforcement officers at the airport. And our state law actually specifically allows dispensaries to transport between islands for testing purposes because we can't have labs on every single island. Yeah. And some would say that our current law allows patients to transport to other islands as long as they're not transferring with the purpose to transfer to other patients. But still the ability of patients to transport to other islands for their own personal use needs some further clarification. So there is actually a bill on the governor's desk right now that would specifically protect the right of patients to travel to other islands with their medicine and would require the Department of Public Safety and the Department of Transportation to come up with administrative rules to allow that to happen. And I should point out that LAX, Oakland airport, Portland airport and Logan all have protocols in place that allow customers to board planes with cannabis as long as they're abiding by state law. Well, yeah. So I guess the difference then is that we're not crossing the ocean. Is that? Well, so the argument is that maybe the islands only go out 50 miles. And so that space in between is regulated by the federal government. But even then, we have a federal aviation regulation on the books since 1970 specifically exempts the carriage of marijuana aboard aircraft if it's authorized by either federal or state law or federal or state agencies. So this is a situation again where state law can directly impact upon the federal regulation of cannabis. And yet, well, there's no one, there's no other than anybody know that. Really? Oh, sure. They do. You know, this information has been given to our state lawmakers for the past two years. This year, my focus was on submitting as much testimony as possible, because I just didn't have the time to go sit through all these public hearings. Right. And so some of, I think some of that information is being looked at and is being incorporated. I did submit testimony for the interisland transportation piece that was incorporated into this bill that's now on the governor's desk. So. Oh, good. But this is an issue that's so, has been so controversial over the years. And because of this misconception that everybody's violating federal law means that people just don't want to deal with it. They would rather not be associated. And I'm afraid that that is really just perpetuating the current dilemma and actually causing a lot of patients who could benefit from this to shy away completely because of this fear of violating federal law. Well, now you mentioned that, you know, your relationship with the medical school. What about the law school? Because I saw an attorney, a young attorney who knew nothing of what you're saying. And he was saying it's all illegal and it was clear that he did not know. So what have we reached out to the law school? Oh, sure. I've reached out to professors at the law school asking if they had any students who would like to be involved in this project. And I think the problem is that it takes a level of understanding that really isn't happening because people have this preconceived notion of how federal supremacy works and don't completely understand how federalism comes into this and how there has to be an interaction between state and federal law in order for things to run smoothly. And it's because we are not recognizing that interaction that we're in the situation that we're in right now. Well, now, speaking of interaction, you sent me this beautiful proclamation about Hawaii Medical Cannabis Day, which is again June 14th. So I'm going to read the proclamation. Whereas the authority to accept medical use of controlled substance is retained by the states under our system of government known as federalism. And whereas the state of Hawaii determined that cannabis has medical use in Hawaii on June 14, 2000, when Governor Cayetano signed Hawaii's Medical Use of Cannabis Act. And whereas Hawaii's Medical Use of Cannabis Act is codified as Act 228, under Section 9 of Hawaii's Uniform Control Substance Act. And whereas Hawaii has upgraded a state-regulated medical use of cannabis program for the past 19 years without any opposition from the U.S. Department of Justice. And whereas Hawaii's Medical Use of Cannabis Program has enabled tens of thousands of patients with debilitating medical conditions to benefit from the personal medical use of cannabis in Hawaii under medical supervision. And whereas the medical use of cannabis in Hawaii is currently accepted medical use and treatment in the United States, which means that the federal regulation that lists cannabis as a Schedule 1 control substance does not apply, does not apply to the medical use of cannabis in Hawaii. Therefore, I, David White, E. Gaye, Governor, and I, Joshua B. Green, Lieutenant Governor of the state of Hawaii, do hereby proclaim June 14 as Medical Cannabis Day in Hawaii. And ask the people of the Aloha State to join us in recognizing that medical use of cannabis in Hawaii is lawful activity under both state and federal law. Done at the state capitol, executive chambers on a loop this 14th day of June, 2019. Excellent, excellent, excellent. Thank you. So now what should we do? Well, let the proclamation, what do you want us to do? Well, I should point out that this is a proclamation request and this is the form that it was submitted to the governor's office. So this is, it has not been approved yet. Some people I've shown this to say, wow, this is great and we have a proclamation, but we're still waiting for approval from the governor's office. And this came out of the fact that back in April, right around April 20th, I was receiving some emails from some of our dispensaries that were advertising 420 as a special day with special sales offers to patients. And you probably know 420 is a recreational term that was adopted by that culture. And so my feeling was, why do our dispensaries that are providing cannabis for medical use to our patients having to associate with a recreational youth holiday? And so I was trying to figure out, well, couldn't there be a better day that we could use to educate patients and to support the medical use of cannabis in Hawaii? And I did a little research and realized that, well, actually June 14th is that day. And as you mentioned, I'm coming up on it. Oh, awesome. June 14th is Flag Day. Well, and maybe there'll be a flag flying above the Capitol on that day, because I did put in a flag request to a congresswoman, a woman gathered as well. So that would be quite a nice coincidence. But the idea was to recognize what our state really did. And unfortunately, when you read about this in the paper, they say, oh, Hawaii legalized medical cannabis. Well, the reason that that term is being used by the media is because they go off of whatever the Associated Press has in their style book. And the Associated Press does not have the term accepted the medical use of cannabis, which means none of the media can use that term. And I've asked Associated Press to consider adding that term to their book. And they said, well, they're in discussions about it. But anyway, I think it's very important that we use the correct terminology and that we recognize that actually what Hawaii did was accept the medical use of cannabis. Congress never defined accepted medical use in the Federal Control Substance Act, which under federalism also leads it up to the states to decide whether they want to give medical use to controlled substances. So that term accepted medical use is critical because then that impacts upon the Federal Control Substance Act, which says that a substance cannot be in federal schedule one if it has accepted medical use. And we already have very good court history, case history of the various pieces that support state accepted medical use being currently accepted medical use in treatment in the United States. And we've learned that FDA approval is only one way that you can have accepted medical use, not the only way. Well, wow, it's a lot to hold on. It's a mouthful. It is and we are out of time. But thank you for taking the time away from your patients to spend with us. And the closer we get to June 14, we'll talk again and see if we can have some people show up for the event. That would be that would be awesome. Always a pleasure to talk with you, Marsha. Thank you so much. Aloha. Have a good day.