aldrin. later in the month, the southern festival of books will be held in nashville, tennessee, from october 9th-11th. let us know about book fairs and festivals in your area, and we'll be happy to add them to our list. e-mail us at booktv@c-span.org. >> now, dr. david casarett on his investigations into medical marijuana around the world. >> welcome again, i'm george, and welcome to the college of physicians at philadelphia. we are delighted tonight to bring one of the hand grenades of current thought and issues medical marijuana, not recreational use of marijuana, but should marijuana and its derivatives the cannabinoids be used for health purposes, a very

controversial issue and one in which frequently there's forward more heat than light and where we frequently see people who seem to be immune to data. but we have experts tonight to talk about this, and it will be moderated by dr. david casarett who is chief of college of care at university of pennsylvania. i'm a psychiatrist, and i often think most people -- including many physicians -- don't really understand what psychiatry is. nobody understands what palliative care is, and it's a wonderful branch of medicine and needs to be better understood. dr. casarett launched a book here a year ago that was wonderful. this is his second book he's launching here. no, we do not have royalties on it, but i own two copies of it. so dr. david casarett will come up in a minute. we believe all of you are literate, we print biographies in the program. this is not grand rounds, i'm not going to sit up here for ten

minutes and read every paper that everybody wrote. but dr. casarett will come up, talk for a while, and then he will introduce our three panelists, and then he will moderate a discussion amongst them. if you have questions during the evening, there are notecards, i believe, that you can write on and pass them, and they will be collected. we'll also put a microphone up later for questions. please don't interrupt the speakers, though, in the middle of the thing. dr. david casarett, please. [applause] >> thanks, everyone. it's delightful to be here again, a year later, different topic as divisive, as problematic, i think. i'm rearranging the script a little bit. i was supposed to ask this question in another half an hour, but i'd like to ask it now. i'd like to know what people in the audience think about legalizing medical marijuana in

pennsylvania. i'll give you three options. you can either be for or against, or you can be undecided. and we'll is that question later. so all of those of you who are for? okay. all of those of you who are against? some. those of you who are undecided? which often means you have an opinion, you just don't want to state it for the record. it's okay, i've been there. so my goal in the next half an hour or so is not to change your minds. i'm not going to try to take all of those of you or even one of those of you who are pro-legalization and shift you. i'm certainly not going to take those of you who are negative and shift you the other direction, and i'm certainly not going to take anybody in the middle and try to nudge you one way or the other. and, honestly, i shouldn't be able to do that. if you can be nudged that easily in the space of a half an hour for an issue that's this important, you probably haven't thought through it carefully enough. so that's not my goal, and that shouldn't be your goal here either.

what i'd like to do in the next half an hour and what i've asked our panelists to work on in the sessions that they have follow toking this is not to try to change your minds, but to try to give you enough data, enough evidence so you can have a thoughtful discussion to support whatever your opinion is, and to do that knowing what the other person on the other side of the debate thinks too. so what we're after here is not a consensus that medical marijuana either should or shouldn't be legal, but a thoughtful discussion wherever that discussion ends up for any of you, okay? fair enough? so sponsors, thank you to all of these folks. and a special round of applause, if you could, for jill staal who's standing in the back there in the bright dress -- [applause] who's responsible for doing all of the last minute things including getting me a glass of wine for free about 15 minutes ago which really, really helped. so thanks for that. [laughter] these are my conflicts of

interest. i've asked the panelists, also, to describe their conflicts of interest. is she for or against? [laughter] i'll take that as a undecided. >> [inaudible] >> we'll work on that. i don't have any conflicts of interest. the views i'm about to describe are those of myself, not those of the university of pennsylvania. i couldn't resist putting this picture, this appeared with a book review for "stoned." i showed this to some of our social workers on the palliative care service at the hospital of university of pennsylvania, asked them if this guy looked like me, and they said, no, which was good until they said, no, that guy is much more cute than you are. [laughter] so thanks to all of you. this, ultimately, is the question i think we need to wrestle with whether you're thinking about whether medical marijuana could help you or a loved one or on a policy level whether medical marijuana should be legal. is it a medication, is it a weed, is it something that could

be helpful, is it an illegal drug that should be banned. or maybe is there some middle ground that we could find a consensus about. i wrote the book "stoned" for a patient i took care of about a year and a half ago. this was a hospice patient who came to us. i had a conversation with her about some of her symptoms. she had advanced pancreatic cancer, she described to me symptoms of weight loss, nausea, pain that sounded like it had a neuropatrick component meaning pain due to nerve damage. and in the course of that conversation, she asked me whether i thought medical marijuana might be helpful for her, and i told her what i had learned in medical school which is that medical marijuana doesn't exist, marijuana is an illegal drug, there's no randomized, controlled, trial-date to support its use. but she is a retired english professor, and she spent the

last 50 years of her life giving students a tough time and cross-examining them. so when i said there's no day day to that to support medical marijuana use, she said, really? because i went on the internet, and i found a couple of studies, and here they are, and she pulled them out of her bag. it was at that moment that i had to admit to her that maybe this retired english professor knew more about marijuana than i did. so i promised her that i would look at those papers, i'd look for other studies that had been published, and i would ask some of my colleagues and experts in the field, and i would get back to her with an answer about whether and how medical marijuana might help her. and my advice to her was that, yeah, based on the evidence out there, it could certainly be helpful to her. but that realization that one of my patients with no medical training, a retired english professor, actually knew more about the evidence for medical marijuana than i did made me realize that there are probably other people out there,

policymakers in our legislature, patients, families, other physicians who had the same perception that i did, that there's no evidence to support its use. so that's really what led me not just to research medical marijuana for judith, but to also embark on this process of writing a book. and as i did, i came up with three big surprises, probably more than this, but in the next half hour or so i'd like to walk you through these three big surprises. and just parenthetically, a couple of people in the press interviews i've been doing for "stoned" had asked me which science writers i find most influential for me, who i've looked to to be role models in how to be a medical science writer. and there's certainly some, people like mary roach i'm compared with a lot, sometimes favorably, al very saks. -- oliver saks. but honestly, the most influential examples for me have been travel narratives. the really, really good travel

narratives by people like jonathan raven, jan morris, these are people who write travel narratives really, really well. and what makes a really good travel narrative is mistakes and surprises and misconceptions that get rearranged along the way. good travel narratives aren't really about getting from point a to point b, it's about trying to get from point a to point b and winding up somewhere else entirely, or maybe getting to point b in the end and realizing it's not at all what you thought it was going to be. and so when i think of what a good science nonfiction in the medical vein looks like, it's kind of like travel writing in a way. so that's what i'll try to share with you. it's the ways that researching this book, talking to a lot of patients, researchers, reviewing a lot of studies, talking to a lot of physicians, visiting clinics, trying medical marijuana for myself, what that's taught me not only in terms of the science, but really in terms of surprises and ways in which i've been surprised

and, frankly, the ways in which i've been wrong. so the first that i'll tell you about is that there seems to be a science of the way that medical marijuana works. the second is that, as my english professor told me, medical marijuana does have benefits. and, third, that it has risks. although not necessarily the risks that i expected. and i'll walk you through each of these. so there's a science of medical marijuana. i really thought that medical marijuana or the appeal of it was just about getting stoned. it was the feeling of being high. it was the chance to forget whatever else was going on with you whether that was a terminal diagnosis or pain or nausea. it was something that was disassociative. i mean, it kept us from focusing on whatever else was going on, but it wasn't really therapeutically valuable. that's what i thought. a little bit of background is useful. two main species of marijuana, some people argue that a third

species is a true species, some people would mix it in with that these two, but generally when we're talking about medical marijuana or recreational marijuana, we're talking about two species. when we're talking about the active ingredients of marijuana, which i'll show you in a second, the big ones, the main ones that we know the most about are thc, cbd, those are present in these little tricomb that look sort of like nailheads that appear in the buds and, to a lesser degree, on the leaves and stems. so when you're talking about the cannabinoids in medical marijuana, you're really not talking about the entire plant. you talking about what's -- you're talking about what's highly concentrated. you'll really talking about these two molecules. there are a bunch more. there are dozens out there. it's really thc and cbd that are present in the largest amounts, they've gotten the most attention in terms of what's been studied, but keep in mind although what i'll talk about in terms of benefits and a lot of

what you'll hear from the possiblists will be benefits -- panelists will be benefits for thc and cbd, there are a lot, many of which we have no idea what they do, but there's certainly reason to believe they could be therapeutic as well or pose risks that we don't yet understand. another surprise for me in this overarching category was that marijuana, thc, cbd, other cannabinoids, act through receptors. it's not just a global feeling of being high, but there are very, very specific effects. cbd seems to bind to other receptors mostly in the immune system, potentially elsewhere in the body as well. and also, interestingly, in cells in the brain which has led several scientists i talked to including donald abrams at ucsf to begin to think the cbd may be very, very useful in treating of

pain, pain due to nerve damage and due to muscle spasm and multiple sclerosis. other receptors as well, this is just one angle of one snapshot of what we know. what really convinced me, though, that there was a science to medical marijuana that i really hadn't appreciated is that the man pictured here is, arguably, the grandfather of medical marijuana. i made a trip, a pilgrimage would probably be a better term, to meet the doctor in his laboratory at hebrew university or in jerusalem to hear about -- thank you -- to hear about some of his would work. and he was, in addition to other things that he's done, he was the one who discovered with til devain so-called the bliss molecule. from the sanskrit. and it's interesting for us because it gives us a sense of

how marijuana, thc and cbd in particular, do what they do. we don't have -- and this was a surprise to me -- we don't have or we're not born with receptors that are designed to bind to thc. we're not born with thc receptors. we are, however, born with an demand mid receptors. so when you take thc into your body in the form of marijuana that's inhaled or vaporized or eaten in the form of an edible, you're tricking the body into thinking that it's suddenly experiencing an in-rush. i'm oversimplifying a little bit, but just a little bit. so you're basically hacking into the natural endo ca nab nowed system, and you're convincing the body that it's seeing it, and the reason it's important is the system is really very complicated. it's present in the immune system, this the brain -- in the brain, certainly, this most

organs. it's also, by the way, present in pretty much every species except for insects for reasons which i don't really understand. so when you're using medical marijuana or recreational marijuana, when you're taking thc, for instance, into your system, you're really hacking into a very complicated system that we don't quite understand. so not only is the science of medical marijuana much more complicated than just getting stoned, it's even more complicated than just one molecule binding to one or two receptors this the brain. you're really tapping into a really complex in ways that are kind of hard to understand right now, and i don't think we have a full idea of, but you're tapping into a very complicated system in the body. so that was one surprise, that there was really some science, there's microbiology, there are receptors, there are also natural variations in receptors, your ca nab nowed receptors are not the same as mine, so how you respond is different potentially from the way i would respond to a gummy bear or brownie.

that was one surprise. the other surprise is medical marijuana really does have benefits. i really, as i said before, thought medical marijuana was a joke starting out, but i had to admit based on some of the studies that judith showed me and some of the studies and researchers that i saw and talked with, there really is some good data out there. of increasingly, there's a picture of a vaporizer here because increasingly some of the best data on marijuana for a variety of indications including pain come from these vaporizers. the science behind vaporizers is that you heat a marijuana bud usually to a temperature that's hot enough to make the cannabinoids, thc and cbd for the most part, evaporate, turn into vapor, but not hot enough to get the stuff this marijuana to burn. ..

i wouldn't go this far but one thing we discovered and looking to the world of medical marijuana, particularly dispensary owners, particularly the people who have a vested interest in pushing medical marijuana is there's a lot of overstated claims. i would say their medical benefits to marijuana. i would not say that it's been the best thing. not a wonder drug, doesn't cure all ills. it doesn't cure cancer. we will save that for the record to take a look at state laws

including some indications include in some of the legislation that's moving through pennsylvania, you see very long list of things that are listed as qualifying conditions. that's one interesting fact. the other interesting fact is there's a huge amount of agreement from state to state. what is the qualifying condition and one state may not be in another state which is fascinating because they there's enough evidence to support use of medical marijuana for ptsd or chemotherapy induced nausea, or there isn't but it's not like that evidence would be greater in california that would be in colorado. there doesn't seem to be huge out of agreement from state to state. there's ideas out there about how medical marijuana can help. so how much is there really of medical benefit from medical marijuana? i could spend a couple hours walking through the evidence it would be a very, very efficiently putting you all to sleep, which i will not do. there's an article published in

the journal of the american medical association just about a month ago now that was a very carefully done and somewhat stringent review of the evidence of both smoked marijuana and cannabinoids, natural and synthetic. they summarize the evidence more thoroughly than i could reasonably get in a short period of time so i will just say what they found. and is more is less passionate and this is more or less what they found. there is some evidence but are not as much as a lot of people would like. certainly not as much evidence as many patients who are looking to medical marijuana for relief would hope would be unavailable. these are their designations, not mine. modern evidence for neuropathic spain, weak evidence for some of these other indications i've listed. i'm thinking that's although the odd because that's not entirely diametrically opposed to what i

said in "stoned" or the impression i got but it seems like it was tougher, more harsh than what i thought. i decide to unpack this little bit. remember if they said there was only modern evidence for the benefits of medical marijuana for neuropathic pain, so i just picked one study more less a brand, done at uc davis which i mentioned, a really well done study published in a decent journal, and it was a study that i cite as evidence that there does seem to be a decent reasonable amount of fairly impressive evidence that medical marijuana is useful in achieving the neuropathic pain. to unpack the a little bit based on the journal articles criteria, there's notable strength, randomized controlled trial. you can get placebo marijuana. that's a surprise to me in writing this book or even

actually in pretty much the same way they remove caffeine from coffee beans. chemically the same process. both processes seem kind of a stupid waste of time to me. am not sure why you'd want to do either one of those unless of course you're a researcher. many use placebo marijuana. also use low and high dose groups to detect those effects. but in that jama article they pointed out to weaknesses only 30 of subjects and imperfect lining meaning some of the people in the placebo group, some people in active group knew how they were outside, knew what they're getting which makes you think about it. if you can't tell whether you're getting real honest to god marijuana are the equivalent of oregano, you're probably not paying attention. said yes, some people managed to figure out. those two weaknesses were enough

to downgrade the study i just showed you despite the fact it was a placebo-controlled, randomized controlled trial to a poor quality study. i don't mean to argue with those criteria. they could use whatever criteria they feel are important but keep in mind those criteria really are pretty tough. those criteria are also to because right now there is no federal funding for medical marijuana research. those of you who are researchers know it's really hard to do large randomized controlled trials, this grading article that the jama article i mentioned used if there was a small study, less than 250 people. so it's really hard to do studies that would hold up to that level of evidence that that jama article would call strong. looking at the wrong criterion, but when your discussions of evidence being weak or moderate or strong, it's important to note as educated consumers, policymakers, physicians,

patients, it's important to know what that means. rather than summarizing the evidence and talking about nuances, i thought it would be most useful to post this question. this gets to the heart of a lot of the debate about medical marijuana and how we should think about it. and that's how much evidence do we really need? i think the answer depends on who you are. if you're a policymaker, if you're a hard-core researcher, the amount of evidence you would want to make sure that any treatment, whether it's a new implantable cardiac device or a form of medical marijuana, to be sure that it works you would want multiple, large meaning some other people randomized controlled trials. if you're a patient as with many of the patients i spoke with, one young man in his 20s had a bad but treatable form of lymphoma, without the awful, horrendous after every round of chemotherapy.

so bad he couldn't even leave the house for about a week. nokia that was so bad, this is a 24 year-old who's thinking about stopping his chemotherapy for lymphoma and enrolling in hospice because he couldn't stand. he had been through four or five different types of anti-nazi medications when his doctor finally recommended that he tried medical marijuana. he said sure, he would give it a try. i tell you that story because his level, threshold for evidence is probably going to be different and a little lower than that of an administrator at the fda only hard-core researcher. i'm guessing one of those two is right, the administrator at fda, his or her job is to protect the public so the job is going to be to ask for the highest possible level of evidence. if you're that kid trying to struggle through chemotherapy, or if you're a hairdresser naked

cdc oil for your kid with intractable seizures, or a guy who is suffering through ptsd like somebody i met when it's researching "stoned," been through a dozen different medications, a couple suicide attempts, needed some form of relief, your level of evidence, the threshold for what constitutes enough evidence will be different. not trying to privilege one of those positions but when i hear people arguing about whether there's enough evidence, often was going on his people know exactly much evidence there is but they just have a different tug boat for what constitutes enough evidence. made me think about that going forward as we enter the debate phase of this evening and it used to parse out some of your thoughts in some of the discussion. of the things other just about the potential benefits of medical marijuana, is an op-ed i i wrote for "the new york times" which were brief period of time with printing as one of the most e-mailed articles in "the new york times," ahead of paul

krugman, which i thought was pretty cool, behind the unfortunate an article about sending copies to prison to be therapy dogs. i beat paul krugman but i lost to the puppies. the point of the article though has made you think a lot about what medical marijuana means, especially in light of the discussion we just had about -- if it seems, probably through, it seems like the utilization of medical or what is getting ahead of the evidence, many more people using it for more indications that are really supported by randomized control trials, i think that is fair, part of reason for that is health system for the most part doesn't do a great job of taking care of patients who need extra attention, x. is for, asked education, certainly good symptom management. i feel comfortable saying that. many people from palliative care team who i work with were able to do a pretty good job but i think in general that's their job, but i think in general the

health system doesn't. i have begun to see interest in medical marijuana not so much based on a belief in the evidence, partly that but also based on dissatisfaction with having to go to a physician not having time to address concerns been in and out in 10 minutes without really having the support and advice you need. evil are getting it as i discovered from medical marijuana clinics and from dispensaries. it's a chance for many patients to begin to take control over their own. i promised you three surprises. the third one, briefly, medical marijuana does have risks. a few of them were pretty sure about the whole bunch other speculative and others are things that i didn't expect that i'll walk you through this quickly. this is something else i from dispensaries owners, something else that is just frankly not true. those of you with medical train window there's a logical flaw in this argument.

marijuana doesn't have any risk. it's a flower, not like morphine. morphing isn't all prelude to the morphine is an opioid. this was a dispensaries owner convinced that marijuana is natural, it has to be safe which is not true. a few known risks, driving impairment could believe it or not i did not think addiction was a significant risk of marijuana. it's probably not as significant as addiction to cocaine as herr went to be there but is probably on par for something like alcohol, both in terms of risk addiction, risk depended. maybe not in terms of health consequences. there's lots of downstream health consequences including liver damage to a call addiction that don't occur with marijuana.

it to be treated with a hot shower for reasons that i just don't understand. known risks, a lot of unknown risks. these are listed in no particular order and if it were, i would walk you through as i do in "stoned" may think the evidence lies for each of these. some of these are probably more likely than other like myocardial infarction, stroke, i think probably not. not cancer, not one disease but i just want to call those out quickly. those are the areas of which there've been a lot of very large, very, very well done studies. i spent time talking with a pulmonary function test physician, at ucla in los angeles and houston some of the biggest death studies of lung function over time and the sound there really isn't any decrease

in lung function can increase risk of emphysema from chronic marijuana smoking which makes no sense, right? dislike the stuff that you inhale when you smoke a joint is exactly more or less the stuff that you inhale when you smoke cigarettes. so why doesn't that cause emphysema was this a couple of explanations. some theoretical, but the simplest one is the most obvious and those logical to me that's a matter of those. i used to work in the va. men at the veterans i took care of wood smoke to our three packs of cigarettes a day for 30 or 40 years. that's often for many people what it takes, but those the people, the dose to cause lung damage. imagine, would you be like if you smoke 40 or 60 joints a day for 30 or 40 years. your results would be the least of your problems. it may be that if he really managed to smoke that much, which would take real guts,

determination, anybody wants to try it, go for it, if you were able to smoke that much, you might wind up with emphysema but in the way most people smoke is not a concern. obviously, edible, vaporizing, it's not a concern at all. another surprise to me. it's worth pointing out there some flaws in the data. lots and lots and lots of case reports. somebody used marijuana were racially often invent something that happened to them. and in that resulted in a case reporting alleged. that doesn't marijuana use caused that, whatever it is. it's possible to find case reports if you wanted to a summer eating strawberry ice cream and then having a migraine. iis a cause and effect or coincidence? it takes a lot to try to sort through the. the second part is probably the most important thing is we really don't have any good safety studies of medical marijuana. lots and lots and lots of studies of recreation marijuana

use but there's important differences. it's really hard and probably kind of risky to generalize from studies of recreational marijuana use for medical use. so it may be just hypothetically that a 24 year old who uses marijuana recreationally for five times a week along with other drugs like meth, mullahs, other things is at increased risk of it psychotic episode the next two or three years maybe but that means, the initiative process in a positive vision who uses marijuana once a week to get to sleep, they should also at risk in the same way? i don't think so but we don't know. that's the bottom line because all the studies that have been done really happened in recreational marijuana use with often whole lot of other drugs if every different settings. any of the studies can't control for all the other things that go on. so here's a challenge for you,

something we need to think about as we begin to wrap up here as i've tried to describe to you, medical marijuana use is common. that are probably, broadcast, at least a million people are registered medical marijuana gives around the country, and for every person as a registered user in a state program, the are probably several, maybe a dozen more, who are not registered or who are using illegally. so that figure is probably a vast underestimate. it would be nice if we had trial of control data, because using it for ptsd, the woman using it for, the guys using it for multiple sclerosis, to be great if we had those clinical trials but we don't. we will punish have an adequate bank of clinical trials really in the next five or 10 years, probably more. again no funding for research but it's going to be hard to build that bank of clinical evidence up.

what i ask you think about is how we can do better at crowd sourcing research. how we can get better at learning from the experiences that people have think about that. a million registered users around the country. there's really no organized way to collect data about their expenses, no organs which collected data about the long-term effects, side effects and risks. so there's lot of experience out there just going to waste. i don't know what to do about that. egc five reports of somebody using marijuana for the nine, that's interesting.

but egc 50 or 100 or 200 or 500, then some researchers probably are going to start paying attention and thinking we should really do a randomized controlled trial. the advantage is we use crowd sourcing results in the right direction a somewhat reports are. so it took these three surprises, there is a science out of what was a surprise to me. to our medical benefits. probably not as many as some dispensary owners claim but probably more than some of the people who oppose medical marijuana would admit. it also has risks which i think everybody needs to admit although as i told you in the smoking example, not position of the risks you think about. medication, we did, i'll leave that to you to think about and the panelists help you think through significant benefits, real risks, artistic medication because one plant is one plant.

is not a medication is in the same way and amoxicillin bill is medication but to our molecules in marijuana in a cannabis plant that do the real physiologic effects and some other beneficial. so think about what terminology you want to use but hope that i've given you enough facts related to science, related to benefits and risks to think as ralph waldo emerson did, although i don't think he was in the about medical marijuana. i have a couple of think she is too many people who interviewed along the way. including sasha the wonder dog with his german shepherd who stands guard over this wonderful dispensary in california outside of san diego. it's like the perfect clinical environment. i think of all of the outpatient glance at a german shepherd, our patient satisfaction scores would be through the roof. all of our patients with heavy. odds are physicians and nurses

be a whole lot happier, too. so let me stop there. let me thank you for being very attentive as i walked to probably more signs than you really wanted to hear, especially to some of you but you've been very patient, so thanks for that. next, i'm going to introduce our panel briefly on looking digital for advice. a, going to increase our panel briefly? i'm going to introduce our panel briefly and i'll ask them all to come up. you have in your handouts their bios. come up. i will not walk through their bios to of also invite didn't say a few words about themselves, the elements of their bios that underrepresented them. to my far right end we decided we'd make executive decisions we will use first names. during the question and answer session as you begin to pass questions forward please refer

to me as dave. to my far right will jones who joins us from washington, d.c. steven auerbach and also joe sebok will ask them to do 10 minute presentations. as they do if people have questions, ask them to be passed forward to me passed forward to meet her, probably if it's okay say those questions until we actually get through the presentations because i really want them to have a chance to give you a sense of their perspective. especially since although i can't give you an unbiased view am also aware that what i told you could certainly be perceived as having one direction or another i want to give them a chance to set the stage a giveaway if they feel that's appropriate. a couple of quests -- request.

this is a topic a lot of people very strongly about. either because you have political or intellectual leanings any particular direction, some of you have your own personal health insurance is, in short people to talk about climate encourage you to be extra careful, courteous in your comments and your questions. last but not least it's probably not going to surprise you to learn after having looked at people's biases that there's both a spectrum of views about medical marijuana represent before you among the panelists that myself and that will jones is probably on the more conservative and. and given how many hands went up in favor of medical marijuana when asked 3 30 minutes ago, i would ask us all to be taken respectful of will jones, reminding us all that he is a guest here in philadelphia. i promised him that people in

philadelphia are much nicer and more polite than the politicians he just did it was in washington. please don't make me a liar. i have no doubt mr. jones can take care of himself, but he is a guest cannot ask us all to be respectful. >> gentlemen, do we have an order i'm glad because i don't have an order. mr. joseph, take it away. [applause] >> joe and i will be very, very tough timekeepers, so beware. david is hard act to follow some going to call for help from the past president of the college of physicians, doctor hobart who wrote in 1887 and published in

the therapeutic gazette, clinical and physiological notes on the action of canada's indica. quote, cannabis has been before the profession for many years as a remedy to be used in combating almost all forms of pain. yet all the variations that exist as with activity, it has not received the confidence which i think it now deserves. i agree, he wrote these words in 1887. you as president of this college, 1925-1920 when he wrote this. he was a professor of -- medical mentors or therapeutics at jefferson a few blocks away. so let's fast sort a little bit

to a more recent source of material, this wonderful book called canada's pharmacy, published last year. it goes over many different medical conditions, more on davis was as well as a discussion of dosing streams and methods of administration. you see, back when cannabis was a medicine, it was a generally only available as -- this is a photograph of turn 13 and a picture form prior to it being banned for political and racial reasons in 1937. there were other forms of this comes from australia, cannadonna, a combination of cannabis which was used for

excess mucus conditions and hayfever. the pharmacology is excellent to this very day, although we have drugs for these conditions with fewer side effects. cannabis was part of american medicine even beyond the presidency, the portrait of the president is in the middle of the road who i begin to talk with. the textbook i have is the principal and practices of medicine by sir william hosler, in 1914 addition, who's also a professor at the university of pennsylvania. a co-author was a professor at at jefferson medical college a few blocks away.

this college sits in between them. so just want to quote one thing from this book, one of many things about cannabis, and this is under cannabis indica, that under migraine, that cannabis indica is probably the best remedy, the most satisfactory remedy. we recommend a prolonged course of the drug. so cannabis was part of american history and if nothing is new under the sun, it's being rediscovered. there's more to cannabis plant in cbd and thc picture of many other cannabinoids which are known which are present in small quantity, and which influenced the effect of the other

cannabinoids. this is called the entourage effect, or the whole is greater than the individual parts. as an analogy, one could have a diet of totally processed foods and take vitamins and live, or one could eat very healthy foods, fresh fruits and vegetables, nuts, oil, extra virgin olive oil, et cetera, and live envelope. the difference is that sum of the whole is greater than the individual parts. ..

and this is the reason why one stream and another strain of the plant may have identical qualities or quantities of thc and cbd, but the other cannabinoids are going to make a difference in the therapeutic effect. for example, classical strings are continued stimulating iraq debating and addictive strains are sedating. for somebody with severe pain who can't get out of bed might be called more useful for them for somebody with inflammation, arthritis, crohn's disease who

wants to go to sleep, the indicative strain may be a better choice for them. i want to talk about a little-known federal program that has been supplying medical cannabis for a very long time for a very small group of patients. this can represent 300 cannabis cigarettes schedule one that the federal government has been getting to bring roosevelt for about 33 years. irving wrote a book about it called my medicine, how i convinced the u.s. government to provide marijuana and helped launch a national movement. medical marijuana in large part is due to his efforts. irving has a very rare bone disease and he discovered a serendipity that smoking

cannabis worked and he tested this on and off and sure enough, it provided more relief for him than any other medication, including fda approved thc which is also culture now but no. so i want to basically stress that there is a lot of ingredients in cannabis we don't know about all of them, that there are effects from the plant that are not present in the isolated ingredients, did each strain has slightly different qualities. they may even be referred to as a scientific treasure trove. also, our bodies and no cannabinoids system is very important for the implementation of the earliest part of pregnant the two-way stimulates a newborn baby to drink.

it is the presence of the window cannot be made in the mothers rest milk that gives the newborn baby, if you will, the munchies a result they're getting nutrition at the end of cannabinoids system is the master system that works to retrograde signaling that helps restore and balanced tone, helps modulate the other narrow transmitters. in fact, people who use cannabis medically can reduce opioid use by 50% because of the interactions. also, opioid addicts who have access to medical cannabis are more successful in a recovery from opie is. i'm sure you're going to have a lot of questions. we've only begun to scratch the surface. thank you very much.

[applause] >> everyone, i would like to thank david, joseph and will come of my co-panelists and also the college for inviting me up to speak and also a personal note in the advertising of not having my picture next to a big refer leaf. that is all i need is to be a lawyer with a big pot leaf. i represent a couple business people who are interested in opium dispensers in pennsylvania. i also represent amish in growing hemp. it's an interesting dynamic. do i want to be the pot lawyer or a business attorney who happens to represent cannabis interests. so again commit thank you for not having my picture next to a big pot leaf. i was asked to give a bit of a

synopsis of where we are legislatively intense of a gnat. i will talk about some of the political movements, what a medical marijuana infrastructure would look like here in the state and as a transition to well, some of my personal reservations here. so last year we had senate bill 1182 and it passed 437 in the senate. this was the band medical cannabis act and got renamed one of us reintroduce and this shows we take it to 1182 that we reserve the title and this is something that will help our sick veterans, people suffering from als, multiple sclerosis,

very seriously debilitating medical conditions that we quite frankly can't wait for federal government to step up to the plate. it has change precipitously in pennsylvania is attributable to manufacturers. when i first start talking about it, a couple significant polls of what people thought about medical cannabis and then it was university clinic paid. right now 88, 89%. people in pennsylvania don't just check a box are you undecided. that figure translated for the ballot box. reelections on their primaries so i'm talking williams, wozniak

and fullmer. 100% of the people who put their name on medical cannabis won reelection and that was not just bowing graciously to the people in normal t-shirts. it is people taken a great interest into medical opinions. 20 minutes a day by peru's the internet and the spill and medical marijuana legalization specifically for medical purposes. i will spend 20 seconds name in a couple. american college of physicians, alaskan medical association, california medical association, california nurses association,

colorado nurses association, connecticut, epilepsy foundation, federation, florida medical association, hawaii medical association, white nurses association, the? them up only a, mississippi nurses association, new jersey, new mexico -- advisory council and new york nurses association, rhode island, state nurse association. largely to medical association, wisconsin public health association. try to do it all in one breath, but couldn't do it. the then senate bill 1182 was then reintroduced by senator

fulmer and leach by senate bill three. this passive subcommittee and 47 in the full senate and added a percent is late to help in pennsylvania. those suffering from her pocket pain and other to help diabetes. it was brought over to the house. it is currently being redrafted and fit into another bill. under house bill 1432. we are hopeful about will have a committee by early fall still having fingers crossed. this will be the framework of limited numbers of who can actually open a dispensary's.

limited licenses for people who are going to process the plan and they will be 65 licenses for growers, 65 and 134 dispensaries. we are expecting the number will be cut down because there's over 12 million people and how many liquor stores with the arbitrary low number. one of my fears is someone in pennsylvania is going to be in an area where he can't get access to his medicine because someone who wants to open up a dispensaries not going to want to be in a low patient area understandably. if we are already limiting the number of veterans who live in the countryside.

a couple benefits of what we see in house bill 142 is it's not a constitutional amendment. one of the things we saw and the reason we don't have medical cannabis is because they tried to push it through as a constitutional amendment and the reason is we wanted to ensure patient protection that we couldn't have another tom corbett comment and reserve our right to patient protection. we are going to read straight through. the next is senate though three or h.b. 1432 with pennsylvanians to california. my impression is that the fact or legalization. in pennsylvania a patient needs to have a preexisting relationship not predicated on the dispensation of cannabis. i've been told if you had been

told and perhaps dave can confirm this you can walk up to a doctor with a good story and get a recommendation. he's going to have to have a medicine similar to everything else. this is not going to be cbt only. cbd has a lot of attention lately. there are hundreds of components and cannabis. cbd does not get you high. cbd hasn't shown to help tremendously with kids who suffer with debilitating epilepsy. in pennsylvania, children who suffer from epilepsy cannot hundreds of episodes a day.

we get these kids up to seven narcotics, some which are xanax. can you imagine given a 7-year-old xanax? and colorado states where we have access you cannot get high in the 200, 300 up to 700 episodes a week. the problems we now see his kids addicted to xanax from birth is what we've been giving them are now seven, eight, nine years old and their parents are trying to get them in rehab to kick the xanax. these are the problems we are now having. unfortunately, we are going to be more inclusive, helping our veterans because thc activates conditions. the next thing we are going to see, i just got the one minute mark so i would give a

transition to well. one of my concerns when i started the association of pennsylvania and the pennsylvania medical cannabis society. it's edible. i have friends in colorado and when i visit them, quite candidly about give a segue to well. one of my my fears have seen the coming bears in the coming worms and things attractive to children. quite candidly and three in new hampshire right now. i think it is frightening that we have medicine that could be attractive and is tracked and children. one of the things in pennsylvania we will make sure -- i don't think medicine should be attract up to children. [applause]

>> hello, everyone. as i can see from the raise of hands, i'm definitely in the minority here in more ways than one. but that is not a problem for me. i appreciate the invitation to be here and to share my perspective on this end anyways controversial issue today. i am here with the organization cm or smarter purchases to marijuana which was founded by an advisor for three administration, clinton, bush in a bomb and the only senior adviser to the bush an obama administration. congressman patrick kennedy. i'm going to start out here. my thoughts on marijuana just in general have developed immensely over the last few years.

to be honest and 25 right now, but a few years ago i did not have a conclusive view of the marijuana issue. i knew it wasn't something that i wanted to do personally as a personal choice, but on the legality of it all the things i had no concrete position. i began to do some research for myself on the issue and that has led me to be staunchly against legalization in general for recreational use. we are not talking about that tonight. i'm going to explain my reasons for why i think we shouldn't rush into medical marijuana that it seems that the tide today, the momentum is to the local medical marijuana. i will bring up a few reasons why we might want to put on the brakes and slow down before we

welcomed us with open arms. i would say that every person in this room once anyone that can be treated by a medicinal component of the marijuana plant to have access to the treatment in a safe form. i don't think any person here would stand up and say i don't want someone treated by something in marijuana to be treated like that because marijuana is bad. i don't have any moral issues. i don't think it's a doubles it's a double suite or anything like that. i am looking at this list from a medical good and more from a societal perspective. what is the impact of medical marijuana on society? what is the impact on youth in our society then it's not so much the fact can people be treated by medicinal components in the marijuana plant.

i think we would all say yes, probably so and we need more research to see what can be treated by this. we definitely support research into this house has and i've met people, especially kids suffering epilepsy, seeing how they are able to access cannot annoyed oriole and how that treats epilepsy, it's a great thing we should accelerate research for that in order they can have access and a better quality of life. what i am concerned about and i think we should all be concerned about the influence of corporations and businesses and our society, particularly on this marijuana issue whether recreational or medical. i will bring up a reminder for all of us. it was not too long ago that

there is another plant repeated to have many medical benefits. there were doctors endorsements as for as long of a list as you could wish testifying to the medical benefit of this plant. we as a society welcomed it with open arms and now we are reaping the consequences of that. i'm referring to tobacco. on our site that has videos of panels and panels of doctors and congressmen testified to the medicinal properties of tobacco and how it should be this great day. we have a great place in our society and we are now paying the cost of close to 500,000 lives per year. my concern is not necessarily that there's going to be deaths from marijuana although that's another issue. but the impact of an industry,

an industry that profits off of addiction and that profits off of young users, unfortunately. keith stroud, the founder of normal, one of the organizations that lobbies for marijuana and medical marijuana at emory university said we are trying to get marijuana reclassified medically. if we do that -- this is a quote. he says we are trying to get marijuana reclassified medically. if we can do that we will use the issue is a red herring to get marijuana a good name. that is what i'm afraid we see today. i'm not afraid pete will be treated as medicinal component in the marijuana plant but i'm afraid of the industry emerging, particularly the recreational one but i thought the medical marijuana industry which as was pointed out in places like california is ridiculous.

npr wrote an article showing how in los angeles before example, the number of marijuana dispensers outnumber the starbucks. this article was in 2009. about a thousand in los angeles versus six to 700 starbucks. this is a profitable industry. a former microsoft executive wants to create and emit more millionaires than microsoft. you have to be careful when there's big financial interests and any other thing we are talking about meta-sin this evening that we have not seen few fair jury and we are not being wanted unduly by the push of billions of dollars estimated that marijuana could bring if it's legalized across the nation. we are not unduly influenced in the past.

i would like to ask people a question. for example, let's look at meta-since we do have. would you grade how we handle medicines and opioid abuse across the nation? would we give it a comedy, c., d., f. a lot of people say we're not getting a bit into the medicines we have and it's becoming in certain states and academic. this is one i'm concerned to see that marijuana, we are already seeing epidemics with drugs that have gone through the research data or fda approved in clinical trials with the many restrictions required in the abuse of those things prescribed. what are we going to see when we

welcome an industry that has very little restrictions in terms of a medicine that's not fda approved. how will people know if they are receiving medical marijuana. they recently did a study on things that have command annoyed oil in them and 50% had what they said on the label. a lot of people argue this is a case for let's legalize it so we can better regulated. let's first look at how we are doing with what we are regulating and ask every ready to introduce a new drug that has huge financial incentives into the discussion. we should do everything we can for people that need immediate use. for example, kids with epilepsy. they should have access to

experimental research and treatment as we discover this. but there's no reason to give marijuana an exception that no other medicine has had. no other medicine kidney self prescribe, kidney self dose, which is often most of the time the case of marijuana. we like to point out as well, i'll put it this way. the way medical marijuana is most often used is smoked when we refer to that. but you don't have to smoke marijuana or any other medicine to receive the medicinal properties. for example, we don't smoke opium to get the medicinal benefits of that. likewise we shouldn't have to do that with marijuana. in conclusion, everyone in this room are you in agreement that we need to do everything we can to see that the marijuana plant

like any other plant is responsibly researched and available for people treated by you. we have to be very careful that corporations are not unduly influencing our quick acceptance of the drug that has the loosest restrictions for any medicine majority have a problem with opioid abuse across the nation. are we going to add to that problem on a massive nationwide level and i don't have time to go into the potential down side, but some of those were touched on as well. are we ready to welcome mat on a national level or are there more responsible ways and other legislators say we are going to determine what can be treated by something not approved as anything else and let people decide for themselves. let's put on the brakes and take

a responsible route forward with this plan. [applause] >> thanks very much. there were so much better than i thought it might. not sure why i thought back, but i think that dovetails perfectly. thank you for taking the time to prepare statements. those of you who have questions on note cards if you could pass them wherever you see the beautiful and talented jill stoll. she will collect, store, shuffle and hand them to me. while we are waiting, a couple questions we are to have that have been used to stack the deck, which requires me to

choose. let me ask this question of everybody and give everybody a chance to weigh in briefly. if medical marijuana becomes legal in pennsylvania or potentially in other states, should physicians who have a moral, ethical, medical objection be allowed to opt-out and not provide those recommendations? i'll ask each of you would never order you choose to weigh in. or you can pass if you want. joseph, do you want to go first? >> of course physicians can opt-out. most gynecologists won't perform therapeutic abortions. most international prescribed cancer chemotherapy. so of course yes, physicians can opt-out. >> i don't have any problem with it either. as david had alluded to in his

introduction, medical schools don't teach it outside of california. they don't teach this. if a physician doesn't feel comfortable or knowledgeable in this area, we shouldn't force them to do it. >> if a physician does not feel is good for a patient, there's no reason he should have to prescribe back to the patient. >> another question before well and i will try to work as a round of cards command will try to choose them so we don't put any one person on the hot seat. certainly there are other substances out there, alcohol, tobacco which he mentioned which also have health benefits. i don't think it was meant that way and i certainly don't mean it that way. are there ways in which

marijuana is different that makes him that makes you more concerned about it and about alcohol or tobacco or some of your resistance to legalizing medical marijuana and recreational marijuana essentially expressing the same concerns you have about alcohol and tobacco. is marijuana different or as a part of the same? >> love the question. one thing different is i'm alive now have the opportunity to speak up and say something about the issue in a time of alcohol or tobacco i did not have the opportunity to speak up or research and say we shouldn't do this so quickly. in terms of timing, that's one way like to see it, that it is very different. alcohol and tobacco in the past are embedded in our culture. there's all these other reasons why we try prohibition and you cannot -- it didn't work.

in terms of medically speaking, there is a difference. and neither medical journalists. the debate raises back and forth so not going to say the studies i say are the only studies out there. every study -- also studies with public research that leads to an eight-point i.q. law. but it can lead to schizophrenia many personal stories about how marijuana has personally helped. i can also share an anecdotal story about a close relative of mine, my age that started using marijuana and now has mental issues. we have to realize there's a

difference. tobacco does not impair your driving. there's no study showing up will impair your driving which will endanger other people. they are definitely different and marijuana versus the others. not so much again that it has to be treated differently. i would say let's take them all out of mainstream. let's take liquor stores off the corner and all but tobacco advertising so i would be consistent but my consistency wouldn't be to make it be easily available to everyone. >> great, thanks. i'll do my best to sort these on-the-fly. will it not for clarity sake get to all of these. if you can see the podium it looks like professor judith i explained to you a few minutes ago had a really bad trading

afternoon. we will be a litigator to all of these. can i get to all of you depending how strong you feel to weigh in on this question which again i will paraphrase a little bit. there is a movement towards legalization of medical marijuana. there's also increasing interest in recreational marijuana. certainly now legal in colorado, oregon, alaska and other states are they considering it. is that a potential problem for discussions we've been having a very careful use about marijuana as a drug. is it a problem and this is not in the question, but how should we do without. >> this is a question i thought about a lot. if the state has specific criteria for medical cannabis

use and the patient does not have one of those conditions, but the state also has a recreational cannabis provision, they can purchase cannabis on the recreational side, pay the tax in colorado if 25% and have the same quality tested quantified free of pesticide, molds and toxins. the answer is recreational can certainly help the medical patient. >> i think the two issues are frequently deflated unfortunately. the only thing medical marijuana marijuana -- regulated marijuana have in common is the word marijuana.

my interest tonight and hopefully the scope is getting safe medical access to those who need it most. there are those who are strongly foreign again expanding that and they would cite a multitude of reasons for that. some which they cite statistic of what's going on in colorado right now. they see a precipitous germanic decrease in burglaries in downtown denver as the epicenter of the legalized marijuana movement in the country if not the world. they are seeing increased tax revenues and decrease traffic. again, go back to the fact that i need to avoid conflating the issues. there are some things brought up and the concern was the impact

on children. i would encourage everyone to take a look at an article put out in force last month, june 15th citing a study from columbia university. this study was a 24 year study. 48 states, 1 million kids 13 to 18 have shown conclusively legalizing cannabis for medical purposes does not increase teen usage. quite the contrary. teen usage is going never accept the state to legalize it for medical purposes. perhaps it is how this is being shown. we are showing kids this is medicine. a difference between use and abuse and when we showed mrs. madison, people with aids, cancer, hiv, et cetera is no

longer viewed as a party drug and kids don't use it. there are many reasons to legalize it for beyond medical purposes by tonight my focus on the folks that discussion is for medical purposes. >> we are talking about recreational use. i could go on all night about why that is a terrible idea. not based on some moral evil but the impact it's going to have just on society based on different studies but not going to get into that. it is interesting in a lot of states that have recreational marijuana, the market for medical marijuana is sharply dropping. one could say there's no need to get the medicine dispensary at

the closer shop or what have you. i find it interesting that some team is truly a medicine, do we become comfortable just buying it from a nonmedical place. that points to the fact we don't really know what we are getting. this is not a prescription type thing. for a few people they tried very hard to do it that way. it is unregulated. there is no standard on these things. the reality is medical marijuana for many people it's just like recreational marijuana. if your number of people across the country. and there's people with terminal illnesses, kids with epilepsy not using recreationally. most people right now say they

have it for medical purposes has been a guide. in studies i'd be happy to share the articles if anyone afterward. the average user of medical marijuana is a white male with self-reported pain. i think it is very interesting. our perspective is medical marijuana is to create a broader social acceptance of marijuana so we can then get to the real moneymaking scheme which is a recreational vehicle marijuana. the >> rate, things are switch gears a little bit and ask questions for one panelist or the other can also give time to point out different views. to see them. question for you as we've discussed in all the presentations, state laws

identify qualified conditions. state laws often vary. so when a qualifying condition may not be in california or washington or vice versa. this question relates both to not end broadly to whether you think it's a good idea if state legislators should be determining qualifying conditions. the second part is whether then having state laws or risks to having a state medical word or can have more real-time decisions rather than requiring a change of law. it's a translation of what is a fairly simple question. does that make sense? >> a two-part question is you take a look at different medical

marijuana bills across the united states. some of them specifically memory conditions. if you have one of these, you can get access to cannabis assuming you have this condition to write a recommendation. first of the other more liberal laws perhaps that we been up to a doctor to decide if she did not get access. i hope everyone in the room would agree with me that i view this as a medical issue, not a political issue. if i'm in hospice i don't want a politician harrisburg making medical decisions of what i can put in my body. [applause] i would hope that people who are make in these decisions are physicians.

if we read dr. david spoke, i'm sure we are seeing many physicians are not trained at this yet. people we trust who are allowed to make decisions don't understand the drug, how could mix the politicians to understand these drugs. so one can make an argument we should leave that up to that yours to make this issue given that it's a medical issue not a political issue. that having been said i'm a realist and i live in the real world as we all do and often times we have to make political concessions as the rights of pennsylvania. if we were to take a look at dan senate bill 1182, there was three pages of qualifying conditions. everything under the sun that has been used in other jurisdictions.

i was privy to some revisions and people actually took a red line to hiv and aids, meaning someone in harrisburg decided you want my vote on 1182, pick out aids and hiv. this is a type of political posturing but unfortunately it's right in the midst of. it's not that tobacco. if people with ulcerative agendas and pharmaceutical companies had the head of the house health department, it's no secret, mr. matt baker has accepted campaign finance donations to the likes of merck, ostertag, big pharmaceutical companies and he is responsible for not being on of the house health committee. i am hesitant to allow or agree to allowing a list of minimally

qualifying conditions but unfortunately that has to happen. fortunately, our legislature recognize they are not positioned and this body of evidence is kind of the expanding. we need to have an oversight that acts as great transparency to review the nonmedical avenues involving medical evidence to expand its criteria. i am sure joseph can speak it can speak a better link so that would make a good fit to that. >> my very simple answer is having patients with chronic diseases on the medical board would really appeal to me for the obvious reason. they are suffering. they may have been remission from other other people with similar disorders and that's all

i want to say i'm not. thanks. >> i would agree it seems bizarre politicians would be deciding who gets medicine. especially with the white areas across state of what qualifies against medical marijuana. i'm kind of scratching my head wondering why medical marijuana is getting this passed. my solution is its part of recreational. but i don't think it should be left in the hands of politicians to decide who gets access to certain medical treatment. what i do think would be better and there's many other options for moving forward with marijuana research that we are to be honest not exploring because another unfortunate reality for those that differ with the marijuana agenda as we

see a lack of a name for those that disagree with the stance. i will bring up another medicine that received an exception. marinol had 20,000 patients. it had 3000 doctors that participated, used yet she come in schedule one substance. compassionate treatment was for those 20,000 patients able to use it by selling something under schedule one. after the proper medical trial to show that with the fact that i'm removed from the category of people cannot access that. that's how we should be moving forward with medical marijuana i prefer to say medicinal properties of the marijuana plant should be done in a medical way, not a political way at all. >> we have about 10 minutes left. we have about 18 questions.

do the math. i will direct questions for each of you and ask you for brief responses and then we'll try to move on get through three of these if we are lucky. dr. joseph. should medical marijuana be covered by health insurance? you don't have to do yesterday now. you can explain your are a little bit. >> i will lead up between the individual patient health insurance company. >> to think health insurance should be obligated to pay for medical marijuana the same way they pay for beta blockers? >> i think that is more of a political question, and i think -- the answer is i don't know. it's not really a medical question. >> i think it is. let me weigh in. this is my question but i loved it. i think you could make an

argument they should. for a couple reasons. it has medical benefits and number two we know lots of patients out there who are stopping their medication than switching to marijuana instead. people like to use medical marijuana because it gets you up with opioids. they are not paying for the medical marijuana you buy at the corner store, the health insurance make money off of the switch to medical marijuana. i've been a little bit doubles at the kitty here. but i think the argument could be made. [laughter] [applause] >> mr. jones, we talked around it a little bit, but i'd know something we are operated back to some degree how much diversion we know is going on right now for a medical to

people using it recreationally and states in which it's now legal. >> the ones they're very, very blurred because it depends on what the qualifying conditions are in a specifics date and whether it is something someone can pretend they have are verifiable they have a certain illness. places like california you mentioned is pretty much legalization. states with area restricted medical marijuana laws. i would say the use of medical marijuana is a lot harder. the respective states as to how much is being done. on a pure numbers overall across the nation for the studies that have been done, there are so

studies showing that the vast majority of people that say these medical marijuana is used for medical purposes. >> stephen, one question from the audience. we talked about the number of dispensaries recommended in the current though in pennsylvania, maybe not as large as it should be. what is an optimal number? maybe the question underneath is how we begin to figure out what the appropriate number of dispensaries with you to provide access. is there a formula that doesn't involve the state liquor board near you? >> it depends how many dispense areas there should be. because like a population density, or more specifically patient accounts of where these people are. there's actually -- philadelphia

has the fourth-largest concentration of hiv-positive people in the united state. i don't know if that's true. perhaps more dispensaries located in this area. certainly one in every county. people shouldn't have to be expected to drive an hour and a half to get medication. >> one last question for joe seven nonetheless each of you to say 30 seconds to one minute tops of rapid statements. and joe said he couldn't go last i'm not able to give you time to think. the question focused for you if medical marijuana because legal in pennsylvania as other states, but carriers do you see it will face an encouraging, cajoling, nudging physicians to embrace the medical marijuana therapy. >> at the next-line question.

medical education is really important and medical education comes formally through continuing medical education credit. it also comes another waste listening to your patients and reading some of the nonspecific medical literature. i want to address the medical education as part of the board exam for the american academy of cannot avoid medicine is really excellent. as far as listening to your patients, i wrote a recommendation for a medical history out of this day, out of this country and i watched and medicaid for multiple sclerosis. he had two types of pain. one went away immediately with the first inhalation, the second changed in character. that is learning from your patient. the third is her mother's

versus. well pointed out that medical cannabis is really just an excuse to get on the recreational side. i think it is the exact other way around that many of the so-called illegal users because we don't have that are self-medicating. let's go down with the industry of the drug pushers, the drug importers, those who poisoned cannabis with pesticides just to sell it and have claimed cannabis patients can use without fear of arrest that are certified as to cannot invite content, chirping content and being free of pesticides. [applause] it's been a good, excellent clapping. that will suffice as your closing comment. you're not going to be able to top that. i would just run with it.

[applause] closing comments >> again, especially taking care of our guests over here, we have a jail in a court in our state and we are taking care of our guests here. thanks again for having us. just in brief summation, take a look at what's happening in other states and what's being done efficiently and effectively. we are not seeing zombies walk the earth that kids are having a fax as to non-psychotropic can have annoyed and we are seeking 24% reduction in opiate use. we are not seeing big cannabis, what's the alternative. let's take a look honestly at

colorado. we see decreased crime both filings in burglaries because the cartels are wholesaling leaving colorado had going elsewhere. everyone in mr. cheney and get mexican ditch weed in colorado if you wanted to. instead, patient are getting safe access to medication that has been tested with mold and chirping and give safe access to alternatives that are here. thank you. [applause] >> surely the last preferred. >> i think that myself and everyone here wants people that can be triggered by any medicinal component to be able to have access to that. we all wanted to be in a medical

way. i think too often the discussion on marijuana by this legalization of medical marijuana goes into dichotomies in museums there is. and the experience and it shows that this is not really medical how were going about it. is ample evidence with other drugs that were restricted with preliminary studies that we can follow with marijuana as well so that those that media can have that. the medical marijuana was as they stand necessary medical marijuana move forward across the country, i don't see very much that's very medical about it. it is basically allowing people to use medical marijuana. if they feel will help treat something they have.

it's either cooperate to legalize marijuana and deal with making a medicine later. both colin and what we have right now medical marijuana is not properly in the category. i think it would be less have legalized marijuana or not versus medical marijuana as we see it across the country right now. >> great, thanks. [applause] thanks to all of you and our panelists. george has a few last words. i want to thank you personally for being a great audience and sticking around to the almost bitter end, for being thoughtful, for being curious, for asking great questions, most of which i regret we did have a chance to get to but you can ask the panelists later. thank you for taking the time to think about this. it's easy to have an opinion about medical marijuana. it's a lot harder to think

thinking process and listened and asked the right question on i applaud you for doing that and i applaud her pale for helping us all do that tonight. [applause] >> i can think of no better place in the college of physicians of philadelphia, the oldest professional society in the united states have had this discussion this evening. i also want to say i hope i never need this professional services, but dr. casarett's manner and style is just wonderful. [applause] i am going to put in a prepublication order for his novel, which i suspect is going to be just amazing. i want to take the chair's prerogative here, full disclosure amongst other things i'm an addiction psychiatrist. some of the worst things i've seen in emergency rooms have

been people who thought they were smoking marijuana and were actually smoking really other bad things. secondly, one of the things i is a physician i'm concerned about is there a many physicians perhaps capable of treating addiction and capable of treating very severe chronic pain but don't want to because they don't want guys with gold badges showing up in their offices. it's a very significant discouragement to people in the medical field. do i think we should be regulated? yes. do i think self-regulation is deficient? i won't give me my opinion. i also think it's important and will jones referred to it very gracefully and didn't go there, but in a city with such significant health care does parodies on both sides of the

examining table, where the patients endure the treating people? the socioeconomic and ethnic differences about drug use and access to medications are very significant. ..