COLUMBUS, Ohio – Patients who suffer from irritable bowel syndrome may soon be able to legally obtain medical marijuana, after a committee recommended the condition be added to a list of illnesses for which the drug is permitted.
The State Medical Board of Ohio also is expected to look at marijuana for autism spectrum disorder and obsessive-compulsive disorder, although the committee of medical board members voted in May to advise the full board to keep them off the list – based on information provided by experts.
At the same time, though, the board also is facing questions about how it chooses experts to provide testimony, with members of the public challenging the state over whether those offering expertise have the background and credentials to have a say in influencing decisions about the conditions for medical marijuana should be prescribed.
The full board next meets July 12. It’s not yet known whether it will discuss medical marijuana conditions, as a meeting agenda hasn’t been published yet.
The committee, which is made up of five members from the 12-member full board, considered expert testimony on May 10 for autism, OCD and IBS. The experts, all physicians and one who works for an addiction treatment facility, generally opposed marijuana for autism and OCD.
But a retired surgeon and medical school professor who testified about the ways marijuana could benefit IBS patients apparently helped persuade the committee to take the rare step of recommending the full boad to add a condition to the state’s list.
Each year, the medical board – made up of appointees of Gov. Mike DeWine, who is not a fan of cannabis – solicits petitions from the public of conditions to add. The board is generally conservative and does not add most of the petitioned conditions, insisting on having double-blind, randomized controlled trials proving marijuana’s efficacy for each condition. The trials are the gold standard in medical research, but are sparse in the U.S. because marijuana is a Schedule I controlled substance under the Drug Enforcement Administration, considered more addictive than methamphetamine and cocaine, and difficult for researchers to legally obtain for study.
Patients have expressed frustration with the medical board’s hesitancy to add conditions, a potentially persuasive factor for voters if backers are successful in getting an initiated statute proposal to legalize recreational marijuana for adult use on the November ballot.
The campaign of medical marijuana businesses behind the recreational campaign, called the Coalition to Regulate Marijuana like Alcohol, must turn in around 125,000 signatures of Ohio registered voters by Wednesday to get on the Nov. 7 ballot.
Tom Haren, an attorney representing the group, said it has the sufficient number of names, which first must be checked by county boards of elections to ensure there are no duplicates or errors in voter registration, which can disqualify people’s signatures.
“The unfortunate reality is even under the medical program, too many people don’t have access because of the failure of the medical board to expand qualifying conditions,” Haren said. “An adult use program will provide access to allow those patients to buy marijuana from a licensed dispensary, instead of going to Michigan or going to the illicit market.”
Theresa Daniello, a patient advocate and cannabis educator from Geauga County, said she’s disappointed that OCD and autism likely won’t be approved by the full board. Around two dozens states allow autism in their medical programs, and she notes that people with autism who experience discrimination can complain to the Ohio Civil Rights Commission, which investigates claims and enforces discrimination laws. If they’re protected under civil rights law, the state should also expand their medicine options, she said.
“These children (with autism) are banging their heads against the wall,” she said. “They’re on medication after medication after medication, and a lot of time it’s not working.”
She said state regulators need to have “compassion for not only the children who are suffering with autism but also their families.”
People who have any of the following 25 conditions can potentially legally obtain medical marijuana to help with symptoms:
– AIDS
– Amyotrophic lateral sclerosis
– Alzheimer’s disease
– Cachexia
– Cancer
– Chronic traumatic encephalopathy
– Crohn’s disease
– Epilepsy or another seizure disorder
– Fibromyalgia
– Glaucoma
– Hepatitis C
– Huntington’s disease
– Inflammatory bowel disease
– Multiple sclerosis
– Pain that is either chronic and severe or intractable (including arthritis, chronic migraines and complex regional pain syndrome)
– Parkinson’s disease
– Positive status for HIV
– Post-traumatic stress disorder
– Sickle cell anemia
– Spasticity
– Spinal cord disease or injury
– Terminal illness
– Tourette syndrome
– Traumatic brain injury
– Ulcerative colitis
Most of the conditions were established in the 2016 law the legislature passed legalizing medical marijuana. The medical board added cachexia to the list of conditions in 2020. The board added Huntington’s disease, spasticity and terminal illness in 2021.
Read more: State board adds cachexia to the list of conditions for Ohio medical marijuana
Also in 2021, the medical board determined arthritis, chronic migraines and complex regional pain syndrome were conditions covered by pain that’s either chronic or intractable.
IBS is related but not the same as inflammatory bowel disease – a qualifying condition in Ohio – and many patients confuse the two. While IBD is a disease of the bowels and intestines, IBS occurs in the gastrointestinal tract.
During testimony last month, Dr. Frederick A. Slezak told the board about the endocannabinoid system, the network of neurotransmitters that carries chemicals throughout the body, as he made the case that IBS patients could benefit from marijuana.
The medical board should either add irritable bowel syndrome to the list of qualifying conditions, or include it under the existing symptom of pain that is either chronic and severe or intractable, Slezak said.
Slezak is a retired colon and rectal surgeon and a retired Northeast Ohio Medical University clinical surgery professor who now teaches part-time at the Cleveland School of Cannabis about the the endocannabinoid system for people interested in getting into the marijuana business or just learning more about the drug.
In North America, about 12% of the population has IBS, he said.
“Numerous causes have been proposed, none of which have been proven to be the sole cause of symptoms,” he said.
Some of the causes could be early life abuse and other stressors, food sensitivity, intestine infections, altered brain-gut interaction, microflora in the gut, small intestinal bacterial overgrowth, bile acids, genetic predisposition, among other potential causes.
Treatment for IBS is focused on the symptoms – abdominal pain and discomfort, diarrhea and constipation, depression and anxiety that are treated with diet manipulation, exercise, peppermint oil, modification of the gut with prebiotics and other treatments.
“No single effective therapeutic option exists for all varieties of IBS,” he said. “More often treatment is a combined approach including dietary and pharmacological interventions…. Overall, no ideal treatment has been identified for IBS symptoms in part because the root pathophysiologic cause has not been confirmed.”
For centuries, cannabis has been used to treat a variety of ailments, including intestinal symptoms such as diarrhea, dysentery and constipation. Marijuana fell from favor in Western medicine but in recent years researchers have begun to understand the endocannabinoid system, which is a network of neurotransmitters that carry chemical signals to cellular receptors in our brains, nervous systems and other parts of the body, Slezak said.
Scientists have even identified the endocannabinoid system receptors in the gut. A researcher in 2004 suggested a concept of clinical endocannabinoid deficiency to explain a number of ailments, such as migraines, fibromyalgia and irritable bowel syndrome, he said.
“Overall, the ECS (endocannabinoid system) provides gut homeostasis by affecting immune tolerance, gastrointestinal motility (the movement of food through the body), and visceral pain,” Slezak said.
Slezak said there have been dozens of studies on cannabis and IBS, but only three human, double-blind studies, having taken place in the U.S. and Italy. One involved using dronabinol, which goes by the brand names of Marinol and Syndros, a pharmaceutical that is given to cancer and AIDs patients to treat nausea, vomiting and loss of appetite and weight loss. Dronabinol contains synthetic tetrahydrocannabinol or THC and the study found at low doses of THC, there was a decrease in colonic contractions, he said.
Another study looked at cannabis in hospitalized patients and found decreased healthcare utilization and costs, which researchers attributed to the effects of THC, Slezak said.
Slezak told the medical board that medical marijuana should be allowed for IBS, especially since “many of the pharmaceuticals developed for IBS have been associated with significant adverse events and even death.”
The medical board chose Dr. Timothy Kantz, the medical director at CDC Addiction Services in Summit County, who oversees a medication-assisted treatment program that serves hundreds of patients a day in recovery from opiate use disorder, to provide expert testimony on OCD.
Kantz said the medical board should keep OCD off the list of conditions for medical marijuana, pointing to the only double-blind, randomized controlled study, from 2020, which found anxiety decreased in patients in all groups – including those who received a placebo.
Typically, patients with OCD can receive other medications, such as Prozac, Zoloft and Lexapro, and undergo a cognitive therapy that involves gradually exposing them to a feared stimuli while refraining from compensatory compulsive responses.
For instance, if someone washes their hands excessively, treatment may start with just thinking about touching a doorknob, then actually touching a doorknob and refraining from washing hands for four hours, Kantz said.
But 25% of patients don’t respond to the pharmaceutical drugs or exposure therapy, he said, and many others suffer due to an inadequate treatment response.
“Evidence of the potential benefits of using medical marijuana to treat OCD is too weak at this time to overcome the evidence that suggests significant potential harms involved from recommending medical marijuana for the treatment of OCD,” he said.
Minnesota recently joined Michigan in becoming the second state to allow medical marijuana for OCD, and Kantz said he hopes that “will help propel more and higher-quality studies on the relationship between cannabis and OCD.”
The board this year sought expert testimony from two doctors on autism – both of whom cautioned against it.
Dr. LaRae Copley, a child, adolescent, adult psychiatrist in the Columbus area who is also a registered pharmacist and has a doctorate in molecular biology, urged the medical board to exercise caution. She noted a recent study showed promising results, but the level of THC used was estimated to be well below 3%.
“This is simply not what medical marijuana is in the State of Ohio,” she said, noting the law allows products to contain up to 35% THC in flower and 70% in products containing marijuana extract.
Trials are underway looking at whether a synthetic THC pharmaceutical that normally treats seizures can help with autism, Copley said.
Dr. Craig A. Erickson, an associate professor of psychiatry and behavioral neuroscience at the University of Cincinnati, opposed marijuana for autism.
Erickson said there are no pharmaceuticals approved by the Food and Drug Administration to treat the core social, communication and repetitive behaviors of autism.
“The only FDA drug approvals in ASD are for use of aripiprazole or risperidone in youth with autism targeting, specifically irritability defined as physical aggression, self-injurious behavior, and severe tantrums,” he said.
However, Erickson said he found problems with all the autism studies involving marijuana.
“This lack of rigorous evidence supporting marijuana use in ASD occurs in the context of known risks of marijuana use, including exacerbation of psychiatric disorders including psychosis and mood disorders, negative impact on cognitive function, and gradual decline in pro-social behavior,” he said. “These risks are of particular concern in an at-risk population of persons with ASD, a developmental disability. The communication deficits that are characteristic of ASD render side-effect management more difficult as the affected people with ASD may be unable to clearly articulate ill feeling or other potential adverse effects associated with medical marijuana use.”
Though not deployed by the medical board as an expert, each board member received a letter written by Dr. Uma Dhanabalan, a physician in Cambridge, Massachusetts, who has recommended cannabis since 2014 for her autism patients.
“I have found Cannabis to be a much safer option and can be used as an adjunct therapy that can help reduce and eliminate other medications and improved quality of life,” she said. “This impact is not only for the patient, but also for their families, caregivers and society.”
Members of the medical board received public comments, which ranged from people asking for the option to use marijuana to treat their illnesses, to those who are opposed to every aspect of the medical program.
Kevin Finisterre, a patient and caretaker in Dublin, said he wants more transparency from the medical board for how they choose the conditions.
“Without a documented methodology the results of this particular qualifying condition review period can in essence be considered as (biased) as previous review periods, which in turn continues to subject patients to discrimination, and discriminatory practices at the hand of the board. This behavior is unethical, and negligent. The board should at ALL times be able to recall, share, and cite (its) methodologies for reviewing potential qualifying conditions.”
Dr. Douglas Woo, a neurologist in Athens, said the experts used by the medical board should have experience and actual expertise jn treating patients with marijuana. He said some of the experts used didn’t even complete the minimum two hours of continuing medical education required by the state to be certified to recommend marijuana to patients.
“I ask that the board consider hearing from physician experts who have expertise both in autism and in medical marijuana, so as to fill this void of knowledge,” he said. “Not doing so will leave the state medical board open to well-justified criticisms of bias.”
Woo wasn’t the only one who questioned the experts who provided information on the conditions.
Parents who want medical marijuana for their children with autism questioned expertise from doctors at Nationwide Children’s Hospital in Columbus, who ran the clinical trials for Epidiolex, a cannabis-based medication for seizures manufactured by the pharmaceutical company GW Research. Federal records show the hospital received $263,000 for the trials.
In 2019, the marijuana committee was prepared to recommend the full medical board OK autism, but weeks later, the full board decided to delay the decision, after physicians from Nationwide said they opposed children’s use of medical marijuana. This year, Nationwide physicians submitted comments against marijuana for autism during the public comment period.
Jerica Stewart, the communications officer for the State Medical Board of Ohio, said that the medical board staff finds experts by looking for doctors with relative expertise and receives recommendations of potential experts from stakeholders. When a candidate is identified, the board staff asks them to complete a questionnaire about their practice, board certifications, licenses and experience.
The board staff reviews and confirms the information, as well as ensuring the doctor has no prior or pending disciplinary actions against their license. Once the candidate has been vetted, the board’s Medical Marijuana Expert Review Committee must vote to approve the expert reviewer, Stewart said.
Dr. Brian S. Dean, a North Carolina emergency room physician and president of Living the Life Medical Solutions, was absolutely against marijuana for all medicinal uses.
“There’s no medical role for ‘medical’ marijuana. It’s a joke,” he said. “It’s simply a liberal way of making the harmful drug legalized. Although it’s still federally illegal. I see countless problems with THC/ cannabis in the emergency department. It causes more harm than good and there really is NO true medical purpose for this drug. In my professional opinion specifically not for irritable bowel syndrome ….one of the stupidest (things) I’ve ever heard of being contemplated.”
Laura Hancock covers state government and politics for The Plain Dealer and cleveland.com.
