Good morning, everyone. I'm John Samet, the Dean of the Colorado School of Public Health. Welcome to Colorado. When you think about Colorado, I think about mountains, the beauty of the state, what we have done here in public health, the growth of medicine and public health in the state, our good record on population health, but our challenges. Many people, when they think about Colorado, perhaps cannabis comes to mind. We were pioneers in the legalization of cannabis. And for those of you who have wandered the streets of downtown Denver and perhaps gone to the 16th Street Mall, you may have noticed the rather ubiquitous odor of marijuana smoke in the air and perhaps also the widespread presence of dispensaries. This was a convenient meeting for me. I have a condo about 10 blocks that way right by Union Station with dispensaries to the left and right. This is an important issue for the state and for all of us, which is why this is an important session. There's a great deal going on and we're going to plunge into some of these issues. We're missing one speaker today, Tom Marcotte, who couldn't make it, so we'll have ample time for a dialogue about these issues. After our presentations, we hope that you'll bring your questions forward. We're not a large group now and we'll have an opportunity, I think, to really talk. With that, let me introduce our panelists. First, Gillian Shower. Dr. Shower is the Executive Director of the Cannabis Regulators Association, a nonpartisan nonprofit that convenes government officials involved in ... Aha, a hint. Did I take my mask off? Do I sound better? Has anybody ever given a lecture with a mask on? It's really tough. In any case, Gillian is involved with the Cannabis Regulators Association, which convenes government officials involved in cannabis regulation from more than 40 US states and territories to share best practices and lessons learned to protect public health and consumer safety. She's worked in public health and drug policy for nearly two decades and has a decade of experience working with federal and state agencies on cannabis policy, data monitoring, and research translation. Dr. Shower worked on tobacco prevention and control, where we first met, around the Surgeon General's report. She's also an affiliate research scientist with the Addictions Drug and Alcohol Institute at the University of Washington. She has a PhD in behavioral sciences from Emory University. Pleased to introduce my colleague, Lisa Barrow, from the University of Colorado School of Medicine and the Colorado School of Public Health. Lisa and I also first met through tobacco control long ago in the days of the secondhand smoke wars, if you will. She's a leader in evidence synthesis, better research, studying commercial determinants of health, particularly interested in conflict of interest. She's chief scientist at the Center for Bioethics and Humanities at the CU Anschutz Medical Center. She's senior editor for research integrity for the Cochran Collaboration and Cochran Public Health and Health Systems Network. She's worked on bias in design, conduct, and dissemination of research and has pioneered the utilization of internal industry documents and transparency databases. I will say that Lisa and I are now partners, colleagues, in carrying out a project that she'll talk about. At the moment, a large scoping review of the evidence on the health consequences of cannabis, a project that we hope will be of broad public health benefit. Finally, we have the participation of Dr. Kalen Klee, a duly boarded certified physician in family medicine and addiction medicine with special clinical and research expertise in perinatal addiction medicine and the integration of addiction care in the primary care setting. As part of medical school, she trained as a marriage and family therapist. She's a graduate of Rush Medical College, did her post-medical school training here at the University of Colorado. She's the founder of the Denver Health and University of Colorado Perinatal Addiction and Recovery Clinics, program director for the addiction medicine fellowship with the university, and a steering member for the State of Colorado Substance Exposed Newborn Task Force, and more. Thank you all for joining us. Jillian, I think you are our lead off. Thank you, Dr. Samet. Hopefully, you guys can hear me okay. Is there an echo? The mic isn't on? They're both on. Is that okay? Okay. I'm really pleased to be with you today. I wanted to start by just showing a slide about my organization, the Cannabis Regulators Association. I think since we have cannabis in our name, people often think, oh my gosh, that must be the industry, and we are not. We are an organization of just government officials. We have no non-governmental members. You can see from the map whether or not your state is a member. We basically have all of the adult use states and all but three of the medical states in our membership. We have a couple territories, and we have some states that don't have any policies legalizing cannabis yet, Kansas and North Carolina, in our membership as well, so they can learn about the regulatory process. Our goal is not to advocate for or against legalization. It's really to help facilitate learning and best practices. This is an issue that the federal government is not particularly engaged in because of the scheduling, and that's how I first came to this. States were trying to figure out everything on their own and really needed a collaborative to come together and do that. Our goals are to identify and share best practices to safeguard public health and consumer safety, to promote equity, which I'll talk more about, and to promote regulatory certainty for industry participants across states. We work through special committees. Our board are all volunteer regulators, and our special committees are staff from state agencies that work on those issues. Please come to me if you have questions about that. Hopefully, you're excited about the Cannabis Regulators Association. Now's the part where I tell you that what I'm going to present is my own opinion and not theirs. I don't have any industry or other funding to disclose. I'm going to try to cover a good lay of the land for you all to set the stage for our discussion, really kind of an A to Z. I'm going to briefly touch on health effects, national epidemiology. I'm going to go deep into the current policy landscape and compare what we see across states. I would be remiss if I didn't mention hemp, which is a really big regulatory issue right now. I will be talking about that as well. I want to start with the health benefits of cannabis. I always start here, especially when I present to public health and prevention, because I think there's a tendency to want to say cannabis is just like tobacco, commercial tobacco. It's not for a lot of reasons, but one of those reasons is that there are really no health benefits to commercial tobacco use. There is science supporting health benefits to use of cannabis or cannabinoids. I want to remind everybody, cannabis is not one thing. There are more than 100 different compounds and cannabinoids. There are many different kinds of products. I want to be careful not to paint with too broad brush strokes here, but for the purpose of having 30 minutes to cover a lot of ground, I have to generalize a little bit. What we see in terms of the science around health benefits is evidence of benefit for chronic pain relief. Not all types of pain. We're learning a lot more here. Relief of nausea, appetite stimulation, patient-reported symptoms of multiple sclerosis, rare seizure disorders like dravets, and some evidence for sleep. There are FDA-approved cannabinoid drugs. Most of those are synthetic cannabinoid drugs. There's one CBD-based drug that is derived from the plant. You may be thinking to yourself that your state is authorizing much broader usage of medical cannabis, and that's true. Basically, all states authorize use that goes well beyond what the science supports now. That's not to say the science won't be there. We're very behind the science compared to where we are in policy. With the benefits in mind, now I want to talk about the potential health risks. I think we're living in an era where you can find a study to support whatever you want to say about the health effects of cannabis. That can be dangerous. It's very important, I think, as a steward of public health and consumer safety to look at reviews. That's where we've consolidated evidence, and that's where I tend to go. I don't have the benefit of having heard from Dr. Samet's group about their forthcoming review. What I'm going to synthesize here are from three reviews that I highly recommend. One is the National Academy of Sciences report. It's now a bit dated. It came out in 2017, but it is a really rich review of the science of benefits and risks of cannabis and cannabinoids. Right here in the state of Colorado, the Colorado Department of Public Health and Environment has, every two years, been statutorily mandated to put out a review of the health effects. Those are excellent reviews. Their latest report, I believe, is from last year, and you can find those on the CDPHE website. The World Health Organization has also put out a review that's now quite dated. It's from 2016, but it's a good narrative review of the science. What do we know about the potential risks of cannabis? Surprisingly little, and most of what I'm going to cover with you is by association. It's not causal. I liken our knowledge in cannabis to prior to the 1964 Surgeon General's report on smoking and lung cancer. We had causal associations in 1964 for tobacco. There are not many things where we have a real clear causal association for cannabis. With that in mind, there are some acute risks. Cannabis use can impair motor coordination and reaction time, which has been associated with an increased risk of motor vehicle crash. This is compounded when cannabis is combined with alcohol. That's quite a dangerous combination on the road. Cannabis in high doses can lead to acute psychosis and paranoia. States have enacted policies that I'll talk about to try to curtail overconsumption, but this tends to be what we see for the overconsumption reaction to cannabis. It's not a respiratory depressant. It doesn't function like an opioid in that way, but it causes this paranoia, especially in naive users that overconsume. It can change the development of the brain in individuals for whom the brain is still developing and lead to cognitive development and related outcomes. There are studies that show that has led to associations with lower completion of education, lower workforce engagement, etc. There are pregnancy outcomes. The one with the most research here is really lower birth weight in pregnant individuals who use cannabis. We're learning increasingly more about prenatal and postnatal outcomes as well, but not enough for me to feel like I can share something that there's consensus around. There's quite a bit of research around the mental health outcomes. Cannabis is associated with an increased diagnosis of schizophrenia, especially in individuals who use cannabis at an earlier age and have a higher rate of consumption and who have a family history of schizophrenia as well. Again, lots more to learn about that, whether it's bidirectional, the causal linkage, etc. Cannabis is also associated with increases in depression and social anxiety. It's also associated with a range of other mental health outcome effects and symptoms. There are respiratory and cardiovascular effects as well. The one that we have the most science around is bronchitis, and that especially is seen when people are smoking cannabis. Increasingly, and I'll talk a little bit about cannabis secondhand smoke, we're seeing a tie between cannabis use and heart attack. Cannabis use can cause cannabis use disorder as well. That seems like a no-brainer, but it's only fairly recently that we've been able to document what cannabis use disorder looks like and truly focus on that. Then I'm often asked about the gateway effect, whether or not using cannabis leads people to use a range of other drugs or substances. As of the 2017 NAS report, there was not sufficient evidence to suggest that. However, there was sufficient evidence to suggest that using cannabis would make it more likely that you were dependent on other substances and harder to stop using some of those other substances. Again, an area where we need a lot more research. You will note there are a range of things where I didn't put any outcomes or I didn't list cancer being one of them. There's a lot of confusion in the literature. It does seem that cannabis use may be associated with some cancers. On the other hand, certain cannabinoids are being studied as possible treatments for some cancers. The research there is very nascent. There are a lot of health effect areas that I am not speaking to because we simply don't have the evidence. Why don't we have the evidence? As all of you probably know, being a Schedule I substance, cannabis is extremely hard to study. It is often entangled with a number of other substances. It's hard to disentangle that in research. Traditionally in research, we have not done a very good job of measuring exposure for cannabis. Cannabis is not one thing. It's many things. We need to improve our surveillance systems and make it easier to do research so we have some better answers here to guide policy. Many of these health effects are more concentrated in individuals who use at a younger age and who have a higher pattern of use or frequency of use. What does the national epidemiologic data show us about use patterns? These are data that on purpose are pre-COVID because I think there's a lot more work to understand what's happening with substance use in a COVID era. These are from the National Survey on Drug Use and Health. These are national data on past 30-day cannabis use by age. You can see the orange line are young adults. That line has traditionally had the highest prevalence of use, and that use has been increasing over time as we've seen policies change, which is concerning because the brain is still developing for many of those individuals. The gray line at the bottom, these are other adults 26 and older. They have had traditionally the lowest prevalence of use but just eclipsed in the past couple years adolescence. Then you can see the blue line are adolescents 12 to 17. That's been a pretty flat line trend. That trend has been mirrored in almost all states whose epi data I've looked at. That may not be the whole story. This is just past month use. A lot of people's next question would be, well, are kids using more? Are they using more frequently? Let's look at daily and near daily cannabis use among past month marijuana users, also data from the National Survey on Drug Use and Health. Here again, we see this high prevalence and increasing prevalence among young adults. We see other adults have also increased in terms of prevalence and are now the highest in terms of prevalence of daily or near daily use. Then again, we see this flat line trend among youth, which is arguably good news, but is that the entire story? A thesis that I consistently present on because I think it's an important one. First, the sky has not fallen with regard to youth use, which I think is important, but that's not the whole story. This is the healthiest generation of youth in terms of substance use that we've seen in a long time. We see alcohol use declining, binge drinking declining, despite increases in opioid overdose, we also see illicit drug use declining. There are only two areas for which we do not see declines among youth looking at monitoring the future data, and that's with regard to vaping, which I would strongly argue is not a substance. It is a device that you can use for many substances, and cannabis. We see cannabis as a flat line. It may be, if not for policies being enacted, that that would also be declining. It's hard to tell. This also isn't the whole story. I don't have the luxury of an entire epi presentation to divide and stratify data to show you what's happening in subpopulations, but there are certainly subpopulations where we are seeing increases in use. We're also seeing a shift in the type of products that youth are using. I want to shift briefly to talk about cannabis policy now. This is a map that is already outdated because if you follow the news, Rhode Island legalized adult use a few weeks ago, but this generally shows the number of legal adult use, which I'm going to use the term adult use instead of recreational use. I think it's a better descriptor. States with legal adult use and legal medical use are the dark green. States with legal medical use are the light green, and states with low THC or CBD programs are in yellow. You can see how much this map has changed in recent years, and there's indeed been an exponential increase in adult use legalization with the 2020-2021 year bringing a lot of new states on board in terms of legalization. This slide shows a timeline of adult use cannabis legalization by state. The year that legalization passed, whether or not it was a ballot measure or legislative passage, and we have definitely seen a shift there. Early on, everything that we were seeing in terms of legalization was coming out of a ballot measure, and now we're seeing legislation be the primary way that that happens. Then you can see the lag between when legalization happened and when the retail marketplace opened. This lag is important for a lot of reasons, and it may seem that it's a long time. It may seem that 18 months or two years is a long time, but to set up an entire new industry, it is not a long time, and often public health outcomes, especially early on, were short-changed because that window was so narrow. On the other hand, that window is an important window to look at in terms of prevention in public health because you've legalized and decriminalized cannabis, but there's nowhere in a regulated marketplace for people to get it. Anyone who's here from New York is probably aware of the trucks that are pulling up in downtown New York City and opening up the back and selling illicit cannabis because it's now legal in the state, but there's no marketplace. That can be a very risky time for states in terms of illicit market activity. They've legalized, but they have no market. What's happened in terms of the legalization process? I think we're in cannabis legalization 2.0, maybe 3.0 now. Early on, there was really a focus on the Cole Memo, which was the memo that came out of the DOJ and basically said to states, you're allowed to proceed with this experiment of legalization provided you adhere to these eight things, of which illicit market activity, public health, and safety were part of that, but the illicit market activity had a lot more focus in the Cole Report. That's where states started, but there has been a shift in where states are in terms of legalization now because of what's happened. There's been a shift where states are focused much more on legalizing with social equity and restorative justice in mind. Part of that is because studies out of Washington and Colorado early on showed that legalization's not enough. Legalization alone does not repair the harms of criminalization of cannabis and does not necessarily increase equity either. Arrests overall may go down, but they are still disproportionately focused on black and brown communities. That, I think, was important information for states to get to think more about how they legalize. Public health and consumer safety has also become more of a focus in part because of the vaping lung injury outbreak, which I think really caused states to take a careful look at their regulations and consumer safety and the products that they were allowing. Then increasingly, as I'll talk about hemp at the end of my presentation, I'm seeing states try to get more parity across cannabis as a plant in terms of regulation, bringing medical, bringing adult use, and bringing hemp under the same umbrella. It can be very difficult to have different state entities regulating those through different processes and can result in gaps in regulation where there's a gray area and products are not being regulated. I'm going to talk about a sampling of policy variables that I think have regulatory importance to public health and prevention. Each of these could be their own presentation. I'm going to paint with some broad brush strokes to get through the content. The first one is what regulatory scheme is chosen. This is from a paper by Bo Kilmer that I really like. It shows that there are many different ways that we could regulate cannabis. We have traditionally in the U.S. been at the far left hand of the spectrum with prohibition and increased sanctions. We have pretty much overnight moved to the far right hand, a standard commercial model. We know from other industries that a standard commercial model can make it much harder to protect consumer safety and public health. There are other regulatory options, government operated supply chain, which we see in some states for alcohol, public authority, nonprofit for benefit companies. We've not chosen these in any U.S. states to date. I think now that we have so many states that have legalized and an established industry, it will become increasingly hard to choose those. I think that's important for everyone to acknowledge that does create more challenge in terms of protecting public health and consumer safety. Who regulates cannabis I think matters a lot. It colors the approach that they might bring to the regulatory framework. Traditionally, we saw in early states, Alaska, Oregon, Washington, we saw liquor, alcohol, and beverage control boards being given regulatory authority for cannabis. Colorado has Department of Revenue. We've seen a trend over time towards having separate cannabis regulatory agencies or commissions that are standalone state agencies. Part of the reason for that is that cannabis regulation touches virtually everything. It touches virtually all agencies in a state from revenue to environment to transportation to health to commerce. States have decided that one approach may be to have a separate agency that can pull from all the other state agencies. What's interesting is in medical programs, so I'm talking about adult use now, for medical programs, public health agencies are still the dominant regulator for medical programs, but we see a shift when adult use comes. The only state that has kept public health as the regulator is Arizona. Then we see in Connecticut, who legalized just last year, they're the first state to use their Department of Consumer Protection, which I think is already yielding some changes in the type of regulations we're seeing. What are the taxes and where do they go? We all know that tax can be a behavioral tool in terms of policy, and if cannabis follows on to something like tobacco, higher prices might discourage youth from accessing certain products. We haven't seen a lot of taxing based on different kinds of products. What we've generally seen states enact is a point of sales tax, a tax at the register as you're purchasing the product. Those taxes range widely, from just 6% in New Jersey to 37% in my home state of Washington. Illinois, New York, and Connecticut are the first states to try a tax that is attached to the amount of THC in a product. In theory, that should make higher THC products more expensive. That will be very important to study to understand what the impacts are on youth consumption. Taxes fund a range of things. I won't read them all. You can see, probably of interest to everyone in this room, public health and prevention does get some funding out of taxes. I should mention it's not much, and it often, in most states, supplants other sources of public health funding. Mental health and substance abuse is also being funded. States are funding a range of things that don't relate at all to the effects of cannabis or outputs of cannabis as well. There's a trend in funding, especially in the new states on the Eastern Corridor, that I think is worth focusing on. That's funding communities, reinvestment in communities. I want to take a short detour and talk about equity. Most of what the mainstream media covers in terms of equity in cannabis is about equity in the industry, which I would argue is important. There's no reason that, to be blunt, white men should be making billions of dollars on cannabis when communities that were disproportionately harmed by the criminalization of cannabis are not sharing in those profits. I would also argue that communities that have been disproportionately impacted, most of the people in those communities probably don't want to work in the cannabis industry. How can you create equity? I think it needs to be a broader discussion, and it's starting to be. Part of that is expungement and resentencing. Expungement needs to be automatic. States have struggled with that. It should not be a petition process. Again, decriminalizing substance for everybody and still having people that are bearing the brunt of incarceration is not okay. I think that's an important focus for public health and prevention in my mind. The other one is community reinvestment. This gets me very excited. To put it bluntly, this is reparations. This is taking cannabis tax dollars and giving them to the communities that have been disproportionately harmed for whatever helps those communities. It's been very broad. There are only a handful of states that have this in practice now. California and Illinois were the first two, but we see a range of states on the Eastern Corridor that are planning to do this. New York is planning to give upwards of 40% of all of their cannabis tax dollars to community reinvestment. Virginia is slated to do that. Connecticut is slated to do that. New Jersey is slated to do that. These are things that will help public health and prevention at a foundational level where we often can't work. Job placement, mental health or substance use treatment, system navigation services, legal services, reentry services, linkages to medical care, housing, violence prevention, youth development. This is something where if you are able to advocate in your communities, in my opinion, this is where tax revenues really need to be going to bring everybody up and to not continue to have communities that are suffering because of the disproportionate criminalization of cannabis. Moving on, how is the market structured? All states have licenses for cultivators. That means you can grow the product. Processors, that means you can turn the product into something, and retailers, that means you can sell the product. Increasingly we see licenses for delivery where I think I have a lot of outstanding research questions. It's unclear whether delivery will curtail some potential impaired driving, whether that will create more access for youth who are at home and there to receive products. I think there's a lot more study to be done there. Then increasingly we see licenses for social consumption establishments, which I'll talk about in one second because I have a lot to say about that. Vertical integration, that means you're allowed to grow, process, and sell the product. That is allowed but not required in most states. There's some feeling that that might create a less equitable market to allow people to vertically integrate. They can also then get economies of scale and make products cost less, et cetera. It's not allowed in Washington and New York. In New York it was a distinct decision by the legislature to try to have a more equitable market not to have vertical integration. Adult use home grow, this is another one where I think we need a lot more research. Unclear whether home grow is a big source of diversion or not. Home grow products are typically not tested, may expose consumers to additional contaminants. Home grow for adult use purposes is allowed in all states except for Washington, Illinois, and Connecticut. All three of those states allow home grow for medical patients, which is often the argument made. I have a particular plant or strain that I've been growing. I need to keep growing that. They allow that for medical patients, but they've said for adults that want to consume cannabis, we have a marketplace with regulated products, that's where you go. In Nevada they have some exemptions around whether or not you're close to a retailer. Let me talk a little bit about social consumption since this is a new license type that we see. Briefly, what we know about the secondhand effects of cannabis smoke is very little, but we know that secondhand cannabis smoke has many of the same constituents as secondhand tobacco smoke, some in greater proportion. We also know from animal studies that it has similar effects in the body, especially with the cardiovascular system. In fact, a great study out of the University of California, San Francisco showed that the rebound time for some of these cardiovascular effects was longer with cannabis than it was with tobacco smoke. We have reason enough to be concerned. This issue might seem black and white, cut and dry from that description, but it's not because of some complications. As a reminder, cannabis has medicinal use. Effectively, if you don't create a public space where people can consume cannabis, you may only be legalizing cannabis for certain people. You may not legalize it for people who are in public housing or rented housing, who don't own their home. It may still be criminal for them to use cannabis there, which is not the goal that most legislatures or voters have in mind. It's a challenging issue for that. It's also a challenging issue in terms of the tourism that happens. I think all of us would say we probably do not want our cities to become a place where tourists are wandering around, ambling around smoking cannabis. That's not something that we probably want in terms of social norms or exposure. If you're not allowing public use of cannabis, where are tourists supposed to use cannabis? This is the crux of the issue for lawmakers and legislators. That has created an advent where we have social consumption happening. I think there are probably smarter ways to approach this policy, but just to be frank, public health is generally not at the table for this. Public health has decided, we don't want any of this. We don't want any social consumption. We're not going to weigh in. What's happened is indoor consumption of cannabis, which could roll back decades of gains in terms of clean indoor air and tobacco. I think a take it outside approach, obscured from view, is probably better. We do still see some states that are prohibiting any public consumption, Maine, Oregon, and Washington. Massachusetts has a place to allow it in statute and policy, but it conflicts with other state statutes so they don't have it in place. California and Illinois have kicked the issue to locals and have basically said, we will create exemptions in clean indoor air if your locality approves it. We now have five states that have a statewide license for social consumption. In Alaska, it has to be attached to a retail outlet, which I think is a limited way to allow for that. That, I think, has some benefits if you're going to do it. Colorado is more broad scale. It's a separate license. You can also have a mobile vehicle license so that you could have people consuming inside of a vehicle as part of a tour or something. Michigan has broader licensing as well. You don't have to be a retailer. Then Nevada just enacted a policy. I think this is an important space to watch and to understand the nuance that it's not black or white. It's not as easy as just saying, this shouldn't be allowed. There are other issues at play. Product types and forms, we basically have not seen many restrictions here in states until recently. There are three states, Michigan, Washington, and California, that only allow shelf-stable edibles. You can't make ice cream or lasagna. That more has to do with food inspection because this is a Schedule I substance. Food inspectors have challenges getting engaged in it because of that. The other area that we've started to see policy is around concentrates. Vermont and Connecticut are the first states to have a cap on concentrates. Their cap, however, exempts vaping cartridges, which I would argue from a public health standpoint might actually be a good thing. What a cap on THC in a vape cartridge would mean, it's 60% in both Connecticut and Vermont. If they were to apply that to a vape cart, that would mean that 40% of that vape cartridge would have to be something else, and it would probably be additives. We are just on the heels of the vaping lung injury outbreak, where vitamin E acetate was one constituent that was found to be implicated, and the CDC could not rule out others. We do not have a safety profile on all of these other additives that are being used. I've talked to really smart laboratorians who have said the safest vape product is probably one that is 100% cannabinoid. You want to limit serving size and have other approaches, but as soon as you start adding in all those additives, we don't know what they do when they're aerosolized. I think that may be part of the reason that we've seen some states exempt vape cartridges. The 60% concentrate ban in Vermont and Connecticut effectively means that concentrates, which are like shatter, wax, BHO, those will not be able to be sold in those markets. Again, an opportunity for research to see what do consumers do. Do they try to make it at home, which is very dangerous and a huge fire hazard? It's a felony in Oregon to do that. Do they utilize other East Coast states, or do they change their behavior and not consume those products? I think there are a lot of interesting research opportunities on the Eastern Corridor. Product ingredients, I've talked a little bit already about diluents and excipients have become an increased focus for regulators since EVALI, as well as terpenes, which are the flavoring agent that's naturally found in the cannabis plant, but can be extracted and added back in. What we tend to see is vape cartridges that have a lot more terpene being added back in than we would naturally see in the plant. Terpenes are usually 6% to 8% of the plant, and we see some vape manufacturers adding in 30% terpene, 40% terpene. States have started to have some policies to curtail that. In the wake of EVALI, states have also started to require full ingredient disclosure, which had some trademark privacy issues around it before that they've worked out. They've started to require some standards to try to increase the standards for additives that are being included. Product testing, I probably don't have enough time to get in here. It's generally a third-party lab structure in states. It's possible to shop labs, because these labs have as their customers the industry. The reason we see this third-party lab approach is because of the Schedule I designation, again. State labs generally cannot get involved in testing cannabis, because they take federal funds. Colorado is one of the first states that figured out a way to have a state reference lab, which is extremely important. States vary in terms of what they're testing for, how they're testing, when they're testing, how they're collecting samples. This is an area that definitely warrants standardization, and has been hard to standardize without federal engagement. Packaging and labeling. There are some challenges in terms of protecting kids here. All states, all adult-use states have provisions that packages cannot appeal to youth, but they generally have a hard time operationalizing those, because what appeals to youth is very subjective. There's a lot of packaging out there that still appeals to youth. However, what's shown on the top here, these are generally the types of packages covered in the media. These are illicit market products, or hemp market products. These are not the types of packages you would see in adult-use or medical-use retailers. The packages you'd see in adult-use or medical-use retailers, though, still do, in my opinion, appeal to kids. That's this bottom tranche of pictures. There's a lot of room for improvement there. There's also a lot of room in terms of more effectively reaching consumers with information about what they're consuming. Data from the International Cannabis Policy Study, which is just a wealth of research that's being conducted by University of Waterloo in Canada, they've found, by asking consumers questions, that most consumers don't know how much THC or CBD was in the flour they last consumed. Even in the American flag with the pot leaf, those are adult-use states, fewer than 30% of consumers could tell you how much THC was in the product they last used, and then most of them reported an average amount of THC that is just not found in products. There's a big gap in terms of consumer knowledge here that we need to make up. Increasingly for packaging and labeling, there's a focus on plain, uniform, and opaque packages. Those provisions are often challenged by the industry, but Connecticut is slated to be the first adult-use state to really try to put that in place. Most medical states do have plain or uniform packaging. There's a focus on more prominent or clear warning labels. Generally warning labels on packages read like a legal disclaimer. It's not effectively communicating to consumers about what they should be aware of. We have gains to make there, and our neighbors to the north in Canada are doing rotating warning labels that are in a big yellow box that are half of the package. Some medical states have started to adopt that in the U.S. as well. Universal symbol, that's a symbol that denotes, hey, this product contains cannabis. That is required in most adult-use states and is really important for populations that can't read, that can't read or speak English. I don't know if you all saw the article of the Connecticut bus driver that came out a couple days ago. He purchased a hemp product, but he stopped at a rest stop while driving a bus of 39 people across states and bought a pack of gummies and was just chomping on the gummies down the road. They were not marked with a universal symbol, not clearly marked as containing THC, but in fact did. Fortunately, he pulled the bus over before he passed out and was found completely unconscious. The universal symbol is really important as a way of saying, hey, pay attention. This is not the product that you might think it is. Increasingly we're seeing inclusion of a poison center phone number on packaging and better labeling for total THC, not just Delta 9. Advertising, lots of challenges here in terms of youth exposure. The early states were adopting the alcohol industry's provisions for policing themselves for advertising. State statutes would say that at least 71.6% or more of the audience had to be reasonably expected to be age 21 or over for you to advertise in that outlet or medium. When stated differently, almost 30% of the audience could be underage. I think state regulators understand that that's a problem. We've seen recent regulation get much more strict. Connecticut, again to be an example of a recent state, they're slated to have 90% or more of the audience has to be adult only. There's still extreme challenges with social media advertising where it's much harder to monitor and enforce. Most of the pictures on this slide are from social media. There's no age restriction required for people to access the sites that are showing these. States are aware of that. They're trying to come up with creative options. More research and federal engagement would help. What's public health doing in terms of public education? Many adult youth states have had public education campaigns. They're obviously not funded to the same tune as what we see the industry advertising being funded at, but some of them have been very effective, especially right here in Colorado. Those campaigns generally start with educating people about the law because there are a lot of misperceptions when cannabis is legalized. They then generally move to drive high, get a DUI campaigns, campaigns for kids and parents, campaigns to reach pregnant and breastfeeding individuals, and then finally, responsible adult use, which is really a harm reduction campaign, safe storage, don't drive high, start low, go slow, all of those sorts of messages. I would be remiss if I didn't end cap my presentation by talking about hemp-derived novel cannabinoids. Hemp was legalized federally in 2018. The federal definition legalizing hemp was extremely broad. It basically drew a line in the sand around 0.3% THC in a dried plant. You can extract a lot of legal THC out of a dried plant. We already see legal products on the market that have just as much delta-9 THC as products on the adult use market, but are far less regulated, are sold in grocery stores, are sold in gas stations. I'm not talking about the retail environment as part of this presentation, but one of the effective policies for adult use and medical use cannabis, I think, is that it's sold in adult-only, age-verified stores that can only sell cannabis. It's not like tobacco where you can buy it at the gas station. Hemp, a lot more like tobacco, and increasingly, we're seeing impairing hemp products. Lots of concerns there. They're not subjected to the same packaging and labeling requirements. They're not subjected to the same testing requirements. They're widely available to youth. They're widely available online. You can all go online right now and probably buy yourself a product with 200 milligrams of delta-8 or delta-9 THC online, delivered to your home, without having to do much more than check a box that you're 21. They may undermine adult use markets, which regardless of what you think about the legalization of cannabis, adult use cannabis is being highly regulated. There is a focus on consumer safety. There is a focus on trying to prevent youth access. If hemp just skirts around that by being an industry that's much more accessible for people to operate in with no consumer safety standards, that will be a problem for the regulated market as well. I've talked about a ton in a very short amount of time. Some quick conclusions to wrap it up. Science does support medical uses for cannabis, which is important to keep in mind when we think about this substance, but there can also be risks to cannabis use. Policies can help mitigate against those risks, and your regulators in your states want to hear from you. That's a really important constituency in terms of engaging with them, testifying on certain issues. Youth use has generally not increased nationally or across states as legalization policies have changed, but subpopulation analyses can vary, including the types of products that youth are using. Policies with importance to consumer safety and prevention of youth include those related to how it's regulated, the regulatory approach, product ingredients, testing, packaging, labeling, and advertising. This ramp is really the biggest regulatory challenge right now, in my opinion, in terms of consumer safety. I think that's it for me. Thank you for your time. Thanks. Thank you so much, Jillian, for setting such a broad foundation for this session. That was spectacular. I'm going to turn now to Lisa Barrow, who will lead on with the project underway at the Colorado School of Public Health. Lisa. Thank you, John, and thank you, Jillian, for that great lead-in. Now I really want to just focus down on one specific topic. As John said, this is a topic that the Colorado School of Public Health is taking a lead on. I'm very excited to talk about it because it's actually research that is driven by a state policy need. Here's my disclosure. This work is funded by the state of Colorado, and I have no conflicts of interest related to this presentation. This project I'm going to talk about was written into a state bill in Colorado, and I'll talk a little bit more about that, but I just want to emphasize it's been a very public process, so it's not like how research typically goes. We have a website on our project called the Cannabis Research and Policy Project. You can go to that. You can find all of our documents, information on all of the people participating in the project. We have updates, and we have links to other resources. That is our website. There's a lot of people involved in this project, so we have a research team. The members of this research team you'll see here, and we have methodologists because the primary research output is a scoping review, which I'll be talking about. We also have recruited over 15 public health students from the School of Public Health to work on this project, and it's just been a great experience. You'll see it's a very, very large project, and so we've been really happy to be able to have the students involved. One of the requirements of our project is that we have a science review committee that reviews every step of our work, so here's the members of our science review committee. They're led by Chris Urbina, and you can see that we have people with various clinical expertise on this committee, expertise related to cannabis in different ways, and interestingly, the bill that I'll get to stipulated the types of people we should have on the science review council. We've had a great council, and the job of the council is to review our research work and then make recommendations to the legislature. What is our charge specifically to the Colorado School of Public Health? Our task, which is in HB 21.13.17, which I'll finally refer to as 13.17 after this, is to conduct a systematic review of high-potency THC marijuana, and interestingly, Gillian mentioned that there's just a couple of states regulating potency, and so this is such a great example of a policy-driven research question, because Colorado is considering regulating potency, and so they actually wanted to commission research to know about the health effects of potency. So one area I actually work in is the translation of research into policy, and you don't see this too often, such a targeted request from a policymaker to have evidence that would inform their policy. Other parts of the bill stipulate the establishment of the scientific review council that I mentioned, something I won't talk about today, but this will also culminate in a public education campaign that will be informed by our research. So let's get to the details of the bill on what we are actually supposed to do in this systematic review. It's to systematically curate and synthesize evidence regarding all the possible physical and mental health effects of high-potency products, to identify needed research, to report on these gaps by January 2022 and what's needed to address the gaps, potentially outline needs for future funding and new studies, provide our initial report by July 1st, which we're on track for. These slides were actually due before July 1st, so I don't have the latest data for you, so it's a work-in-progress. Conduct additional research, and I want to note that the bill stipulated that the research must be conducted independently without any predetermined outcomes or influence of industry, and so all of the members of our research team, all of the members of our scientific review council have no... So, we are tasked with doing a systematic review. And as many of you probably know, a systematic review is usually around a focused research question in a certain population, looking at specific outcomes, specific exposures and comparators. But we were tasked with looking at all adverse or beneficial effects potentially, so this makes it pretty tricky to do a systematic review. So, we're actually doing a systematic scoping review. And as it turns out, it was a great idea that we went in this direction, because there's a lot of material that we need to go through. So, again, the bill stipulates the systematic review cover all possible physical and mental effects. We clarified, as we were working on this, that this included adverse and beneficial effects. But when you think about that, that really depends on context, right? Because sleep inducement might be an adverse effect for someone with Parkinson's, but it might be, I mean a beneficial effect, sorry, for someone with Parkinson's, but it might be an adverse effect if someone's driving, right? So, it depends on the context. And we're looking at all of those possibilities. And as I said, we need to look at high potency products, but also high potency levels. And I'll get to this in more detail. This is the really tricky and difficult part of this review. And there was no definition given to us for what high potency should be. And there's not a good definition, at least that I have found, in the literature for this. And the other issue that the bill used the term potency, but as Jillian said, and as we refer to in most of our documentation, we say concentration. So, by potency, what we really mean is the concentration of THC in a product. But I might say potency because that's what the bill said. So, our specific research questions are to identify and describe studies that explore the relationship of high potency cannabis products with beneficial and adverse health outcomes, and to identify and describe studies that report the adverse effects of exposure to high potency products, even if they have no comparison group. So, what that really means is that we're including things like case reports, or case series, or systematic reviews of case series. So, why are we doing the scoping review? And this is actually a well-documented method that's often used, actually really during COVID, a lot of this was used, but to inform policy making. And so, basically, it gives an idea of all the research, what's the type of... that actually and the exposures and the outcomes we're looking at. It helps us look at how research is conducted on a particular topic, whether it's strengths, whether it's weaknesses, and to identify key characteristics related to a concept. So, for example, key products or key exposure routes that may be relevant. It's to help us prepare for further systems. review. And it's also great for identifying knowledge gaps. Because the scoping review is meant to be very, very sensitive, not specific. So the idea is we don't want to miss anything. So this is what we get in a nutshell. The overview of the literature, future systematic review ideas, and research gaps. So as I mentioned, this is a very public process, but we would have done this anyway. We have published a protocol for our scoping review in OSF, Open Science Library. And this scoping review protocol was published after we revised it. So, a scoping review have steps that are very similar to a systematic review. So, we define the question, which I've already told you. We have criteria for study inclusion. So, in this case, we're including really any types of study designs. We search for the studies. potency. Then we extract the data. That blocked out area is a risk of bias assessment. Because we include different types of study designs, we're not doing a risk of bias assessment of all of those, but we are doing So right now, we're in these two steps. We're still doing data extraction and we're still doing synthesis as we do the data extraction. So here is our flowchart. As I said, we had an information specialist work with us. We aimed for a very sensitive search. We didn't want to miss anything. So I want to draw your attention just to a couple numbers here. One is the number at the top which is in the thousands. So those are the tens of thousands. We're relying on humans because you really needed to look more in depth at the study. And what we wound up there with at the bottom box is we have 489 observational or randomized control trials that appear to meet our inclusion criteria. studies. So I can show you the preliminary data, just roughly characterizing So these are just the characteristics of our 489 studies. We looked at the author affiliation. Most of these are academic authors, actually, but a fair number in government, not too many affiliated with industry. We looked at the conflicts of interest and the study funding for these studies. And again, most of them are government funded and most of them don't declare conflicts of interest related to industry, although they are some. And again, these are variables that we can analyze by if we do systematic reviews or meta-research in the future. Study design, not surprisingly, we have the highest number, the first bar there of observational studies, particularly if we're looking at harm outcomes. So we recorded whether a study was looking at harm outcomes, efficacy outcomes, or both. So the trials were slightly more likely to look at the efficacy outcomes and the observational studies, the harm outcomes. Where are these studies coming from? Well, not surprisingly, most of them are coming from California and Colorado, but they're scattered around the U.S. And actually, there's participants from every state and territory in the U.S. in these studies. We also had studies from other countries. And the age range of these included studies is really all over the gamut. As you might imagine, it's difficult getting these age ranges into certain categories. This is something our Science Review Council advised on a lot, how we should divide this up, and I think we're using the standards that are commonly used in Colorado. But we have a very good spread of age range here, although a surprising number of studies still don't give you information on age range, or you just can't figure it out, which is really unfortunate. Okay, so that's kind of all the straightforward stuff. So if we look at the characteristics of our included studies, we feel pretty good, because we've got a nice range of studies over populations. The one area we don't feel good at, that I'm not showing here, is the ethnic diversity in the studies. There is very, very poor reporting. That's not why I'm not even showing it here. Less than 20% even reported anything, and we looked at studies conducted in the U.S., because we were hoping the reporting there might be better on race and ethnicity, and it was not. And the other thing we wanted to do, if we do a systematic review, is apply what's called an equity lens. It's a certain type of analysis you can do with a systematic review, and so for that, you need to have any data in the study that might So, the other thing that's been really difficult is the classification of exposures and outcomes. And I see a lot of heads nodding. I'm sure you all are not going to be overly surprised by this. And this is actually a challenge. the potency of the product, or it focused on a high potency product, and it focused on any of these outcomes, right? So that's what we think these 489 studies have. So what we were extracting in our data extraction form, and we used automated forms and double coding to confirm all the data extraction and checking, is we record in the paper the highest THC potency they're reporting in the study, and the also the lowest, and we report it in the units that the study is using. So it might be percent THC, it might be milligrams, it might be a blood level of nanograms per milligrams, whatever it is, we report that. And we also report whether different doses were compared, a dose response. So I think you can click through the next couple of clicks. Oh, I'm clicking, sorry. I'm clicking. Gosh, this really is too early in the morning for me. Okay, yeah, so we get the potency by number, we record whether there's any dose response there, because even if we don't have data on potency, we could potentially do future modeling studies if we have dose response. One of the things we have in our protocol is actually a theoretical model. What we're really concerned about is the dose in the person's body, but a lot of factors will influence that dose in addition to just the potency of the product, right? Frequency of use, whether there's tolerance, dependence, how often. So we have that in our model, but interestingly what the state is interested in is potency. They're not interested in the dose in the body, because they're going to regulate potency, not what's inside the body. But we're collecting this other data because it might help us figure out something about potency. And then we look at whether these doses are therapeutic, being used therapeutically, and whether there's a high potency product. So, these are some of the problems that we're running into. So we get a specific type of product and route reported. So here you see gummies mentioned, we see products that would be considered a high potency product, we see edibles mentioned, so that's why this study's in. Or we see specific routes, but no type. So a lot of studies will just generally say cannabis, and they don't, you have no idea what type of cannabis that is, and as Jillian pointed out, that's a problem. So they'll give us, the cannabis was taken by these different routes. If it's vaping, we can kind of think, well that's probably going to be a higher potency, but it doesn't actually say that, right, in the paper. So what we're extracting then is anything that's reported in the paper. So you'll see that this paper here, this example shows, it was looking at cannabis concentrates, and it gives us a range of potencies. So very high is up there, 80% THC or over. You were showing potencies much higher than that, which I thought was interesting. And then we've got the, again, this paper shows those ranges. So we try to extract the exact amount, but all we may get is ranges. And this is our data extraction form, which is just showing you it has a long list of products here. I think we're incredibly comprehensive, and if we come across a product that's not in our list, we can add it, but we extract information on the exact type of product. So other issues that we're running into is, sorry, I already showed you that name. So we'll get categorical values or thresholds. So a study will say it looked at low potency or high potency, but it doesn't tell you anywhere in the methods how that was defined. So again, we would include that, but it's going to be hard to know how to synthesize that data. And then we actually might get data on THC that is consumed, or THC dose of something that is to be consumed, or, and I'll show you an example in a second. We might get data on THC in the product, but that's not really telling us what's getting into somebody's body. So again, this is what we're trying to extract, shown here, data on potency, and we're running into all of these issues. Remember, we got 489 studies, so we have a lot more variations than this. So we're trying to come up with ways to normalize the potency, particularly in areas where we think we can clump the studies. But we think that's going to be challenging. Then we get information on frequency, or how the product is taken. So we might get something very general, like this. We might get even more general, like daily, less than daily. This is just an example from an actual paper showing you that some of the ways this is reported. of what we're finding. But again, we have categories in our data extraction. If it doesn't fit that category, then we write down exactly what is done. But remember, with 489 studies, we're doing a lot of automation, so it's difficult with all of this verbatim data to synthesize that. So then we run into these problems where we have data showing percent THC in a product. So we know in this study that some of the participants used greater than 10% THC as measured in the product. But then the actual intake is reported by mouth, and it's reported by, like, maybe milligrams, and it's not correlated at all with the potency. So the problem is here is we have an association that might be investigated in this study with an outcome, but we can only associate it with the intake that's reported in the person, not at all with the product, which was just kind of reported separately. So then we also have issues with our outcomes. We have a long, long list of outcome domains, they're called. So there's, like, mental health, neurological, psychosocial domains. And these are based on some of the reports that Gillian mentioned, as well as other reports we've done. Basically, any outcomes that people have looked at in authoritative reports are in our list. And so what we might find is a study that is looking at outcomes within one domain, like this study is showing us. Or we may have a study that's looking at multiple outcome domains, and so this is looking at, you know, mental health and other outcomes. And then we also might have multiple symptoms reported for a single outcome domain. So again, this is very challenging for our data extractors, because they have to get whatever's being reported as an outcome here into these broad categories. So that's why we have the double coding, so at least people agree on what is being reported. So again, this is just an example of multiple outcomes per domain that is shown in this figure here. And then that's our list on the right of the different outcomes that we have in our data extraction form. So again, we're trying to group things into categories, but there's still many categories. But the idea here is that we can look for clusters of use by categories. Then the last challenge we run into, and this has been very interesting to me, is that we may actually find data on potency reported in a paper, but then when the analysis is done to link the outcome to some exposure, it's not linked to potency, for example. It might just be linked to the product in general, or the frequency of exposure. So basically, even though they might have had data on potency, they lumped all of the products together and just said THC exposure. Or they reported by frequency of intake for all the different products, and not by the potency of the product. So these are studies where potentially we would have the data if we do a systematic review, but we'll actually have to go back to the authors and ask for the primary data to get that. So this is why a scoping review is valuable, because we don't want to go to all that trouble and resource until we actually have a focused systematic review question where we know we can go to the primary data. This is basically what we're trying to collect in our data extraction form. If there have been associations that have been studied, we just report that. We actually have studies where they don't do any analysis at all. So this tells us if they've done an analysis and what they've tried to link. So what are the preliminary results? Well, these are very, very preliminary. As I said, this is a moving target. We've got over 100, almost a quarter of these studies extracted now, but when these slides were due, we actually had only 14 studies extracted. So by extracted, what do I mean? So we have a data collection tool. It's in something called Distiller. And then we export it into a database, which is really producing an evidence map. And I'll show you an example of that at the very end, but the evidence map is actually one of the main products of the scoping review. And it's going to be a publicly available resource where people can go to the evidence map and they can search it on any of these variables that we have been extracting to see if they identify a cluster of studies that they may be interested in. So these are some of the questions that we and our science review council are asking of this evidence map. And so we wanted to know of the different types of cannabis products being studied, how many have reported potency, frequency, or duration, and so by product. And so you'll see here under the generic cannabis category is where we're getting most of that data reported on potency, frequency, and outcome. But, for example, if I want to look at concentrates, I know that I've got five studies that reported on potency of concentrates. And so I could hone down on those five studies. And again, the pattern we're seeing is the same now when we're up over 100 and something studies, basically. So another question we can interrogate this evidence map with is to ask what types of outcomes have been examined for the studies that reported potency. And you'll see we're getting a lot of studies on mental health, and that is still our top area now that a fourth have been extracted. But we have a pretty good spread on many of the other outcome domains we're looking at. And just keep in mind that these are outcome domains, and so there may be And then here we can break it down a bit and just ask what types of outcomes have been studied for different types of cannabis products. And so if I'm particularly interested in resins for example, I could look at that. And I know the bars are kind of small here, but the different colors show you the different types of products, and then there's the different outcomes on the bottom. And again, most of these have been studied for generic cannabis, so not as informative as we like, but we are getting substantial numbers of studies that could be synthesized on some of the known high concentration products there, like resins or things like that. And then the other question is potency. So what potencies are actually being reported? So this shows you the medium potency. Again, this is for these 14 studies that have been reported in that red box. And disappointingly, these potencies are pretty low compared to what the potencies are in products nowadays. And so again, we think we're going to have to do some modeling to extrapolate potentially from these lower potency products. But what you'll see in that slide on the left is we've so far in these studies gotten up to about 80% THC in some of the studies we're looking at, which is again much lower than Jillian was showing in the products. But again, that's an actual exposure level, not a product level. And then on the right, we have fewer studies at this point looking at milligrams of THC, but for the edible products, they're typically reported in milligrams. And then we can look at what potencies have been studied by outcomes. And that's interesting because it goes a little bit along with what outcomes have been studied overall, but not necessarily. So again, this could help us narrow down studies where we have a group of outcomes that have really focused on high potency products. So the last thing I want to show you is just the evidence map, which is the kind of outcome of this scoping review. And the evidence map is an interactive database. We're actually using Tableau, but you can use different databases for that. These are used very often now in environmental health where people are looking at broad arrays of chemicals and want to know like every type of study that's been done with that chemical. So again, this will be posted publicly. It'll be interactive, and people can use it. And so this is just showing you outcome domain by study design. So again, you could look at any variables you wanted to, but if you wanted to just focus down on say randomized control trials that looked at, you know, cardiometabolic outcomes, you could find those doing this. And what the evidence map does is if you click on the box where you have found those studies, you actually get links and a summary of the original study. So that's what's shown at the bottom there is the studies that have wound up in your particular search, and you get the abstract, and you get the actual study. And you can also get all the other data extraction on that study. So that was the included studies for that search, and those are the links. So again, we can do this for any of the variables. So we can focus that down more. So if I wanted to look just by age group, for example, I could focus on adolescence where there's been cardiovascular outcomes studied. And again, it gives me... Alright, so that is the evidence map. We've got 100 and some odd studies imported into that now with only, what, 300 and something more to go. So we're getting there. We actually are on target, so we plan to complete our data extraction by August 2022. So I'm very sorry I don't have the complete data now and the full data, but we are on track to do that. And we're currently preparing our report, which is due July 1st, and I'm not going to tell you what's in that. If John wants to do that, he can. But we are going to have a lot of recommendations, as you might imagine, about evidence and kind of the nature of evidence that would be used. And as I said, as somebody studies translation research into policy, this happens all the time. There's a really targeted policy question. Getting the evidence to address it is much, much more difficult. So our findings go to the Science Review Council, who can make their own recommendations. Great. Thank you, Lisa. So what we're going to do is we have time for discussion. We're going to lead off that discussion with comments from Kaelin Klee and then we'll go on to have an open discussion of all that we have heard. Kaelin. We can just talk. Thank you so much for having me. I'm honored and humbled to be able to represent the American Society of Addiction Medicine. Preventive Medicine and Addiction Medicine, for many of you who may actually have a foot in both worlds, tends to have a large overlap. And for myself, who spends the majority of my time with folks for whom exciting and thrilling to be able to see all the work that's happening so that hopefully you can put me out of business that down the road there would not be And separated out, I think what I would give back to ASAM, is changing terminology to adult use. So they separated. related to cannabis products. I was scribbling notes because I got to say, you know, when I'm talking with patients, love to have this data, increasing amounts of this type of data, to give back. One of my questions that I had was with so many different opportunities... So why don't we do two things. Thanks so much, Cailin, for your comments. And I think you left us with a question. And please, for those of you sitting with us, come to the mics, I guess, and ask your questions. Identify who you are. And perhaps, Jillian, do you want to respond to Cailin's? Yeah, I was ready to jump in with where we should activate. I mean, I think there are a lot of areas. Just broadly, I would say that, and I testify on behalf of states on several cannabis issues, I am often the most public health voice testifying. So there's a void there, just in terms of general engagement on these policy issues. And because this is a generally new topic area, I think there's been a reliance on the industry, the legacy industry, to say how things should be. So I want to encourage all of you, again, to get involved in cannabis policy issues in your communities. You are clinicians. You have a really valuable perspective. And it is typically missing. With that general caveat, I think the most pressing issue I see is with hemp. Again, there are lots of areas where we can continue to make public health gains with regard to medical and adult use cannabis. But hemp is basically, in most of your states, probably totally unregulated. You probably have a regulator who is regulating the growing in the field. And nobody who is regulating the processing or sale of hemp products. Your patients may be accessing CBD products that they think just have CBD. But because of the Farm Bill definition, those products may also contain THC, which can result in positive drug tests, adverse effects, consumers that are not safely storing or locking their products. And those products are consumed by children. So I think the hemp issue is really a huge one. State by state, we're seeing legislative activity to try to come up with solutions for that. But there has not been a lot of activity federally. I didn't have time to cover it, but FDA, if they wanted to, could get engaged and stop a lot of what we're seeing on the hemp marketplace. And what they've opted to do is send a couple of letters to companies that are marketing their products with medical benefits and shouldn't be. And they've opted to start sort of a data collection process. And they've held some hearings. But there's no federal regulation. And states are struggling to fill the void. And you are probably all having patients come to you who are consuming these readily available products without full knowledge of what they might mean in terms of their condition, other drugs they're using, their home environment, et cetera. Yeah, and I think we have a pressing need also for a research agenda that's coordinated. Because a lot of the research, and we're finding this in our review, but Gillian pointed out, it's done around the therapeutic uses and maybe those aren't the relevant policy questions all the time. And so we have policy being made in the absence of research. And there's things we could do that have been done in other areas of public health, like think of core outcome sets that all studies would include, have standards for the way exposures and outcomes are reported. And so that gives us a lot more evidence that could then be prospectively synthesized and much more useful. And also incorporating policymakers and consumers and patients into the design of the research questions, then we could get on the front foot about answering some of these pressing needs. So I think there's just a critical need to get the research up to speed with all the pressing policy and clinical questions we have. Yeah, great question. So interstate commerce is not legal for adult use or medical use cannabis. Some states do have internet ordering of those products for pickup or delivery, but there's not interstate internet ordering of adult use or medical use products. Very different for hemp, though. For hemp, we do have interstate commerce without federal regulation. And so what you find online are all the things that you've mentioned and I've talked about. Delta A, we're seeing HHC, hexahydrocannabinol, which is not found in nature. Derivative, CBD is being chemically converted to that. It's never been used in humans, and you can widely find it online. THCO acetate is another one. There are new cannabinoids every day. And the online marketplace, even as states try to regulate hemp in their state, is one that they have not been able to do much about. So Oregon, Michigan, those are two states that had really broad-reaching bills to try to bring hemp products under the adult use cannabis regulatory framework. So they have to be tested, labeled. They have to have a safe process. They did not include a provision for online because it's really hard to enforce that without federal engagement. So even in states that closed the loophole in the state, they still have not closed it online. And I think that's probably where many youth are accessing these products. So again, opportunity to provide some insight to federal agencies about why it's important for them to get engaged and close down some of those. Yeah, I think that's a really difficult question because we don't have the comparative research across modes of use. Again, not like tobacco where we know combusted is bad and there may be less harmful approaches. For cannabis, every mode of use has its set of public health risks. So with edibles, it's a delay onset. It's hard for people to dose. They often can overconsume. Those products can be accidentally consumed by kids. With vape cartridges and concentrates, it's higher levels of THC. People might quickly have dependency issues because they're consuming so much. With smoked, it's the combusted. So I think it's really still at the clinician patient level of trying to decide why is your patient consuming cannabis? What conditions might they have? Is there a particular mode of use that you would recommend over another? But we just don't have the science to say that one is better than the other. In terms of other harm reduction messages, certainly you wanna be screening for cannabis use disorder. You wanna have treatment options available. But there's some basic harm reduction messages that I think every clinician should be giving out. That's about safe storage. Just like a gun, it should be locked, out of reach, out of sight. Start low, go slow to figure out your dosing. I think the more engaged clinicians can be in helping patients think about the type of cannabis product they should be consuming, the better. And there's a whole gap in clinician education here that we haven't had time to talk about. But all cannabis is not equal and patients often hear from a clinician, yeah, okay, maybe cannabis is okay for this condition. And then it's left to the dispensary or retail outlet to help them figure out what are they using? And that's not how we do medicine usually. So yeah, I'll stop because I could go on about the need for more. But I definitely talked to people. Similar to what we've already talked about, there have been a range of studies about cannabis and opioids, most of them trying to suggest that cannabis is going to be the cure-all to the opioid crisis. And there's just not evidence for that. And many of those studies were done here in Colorado and were done at a time when public health in Colorado also had a myriad of other efforts to try to curtail the opioid epidemic. And those are not always accounted for in studies. So that's a big caveat. In terms of being able to help patients reduce their opioid use or dose, there are some small studies suggesting that. And there are ongoing natural experiments in some states that have medical cannabis programs to look at that. It's not reached a level of evidence where I would say, yes, that's the case. I think we still have a lot more to learn. Anecdotally, you may certainly have patients that report that that's the case. But you may have patients for whom using cannabis also makes it more difficult for them to get off of opioids. So I think we don't quite understand what in cannabis is effective for that. Is it a particular cannabinoid? Is it a particular type of product? And we have a lot more to learn. I would say for the patient, so my population is a skewed sample, right? Because it's people mostly who have not only potentially cannabis use disorder, but opioid use disorder. And may also have co-occurring chronic pain. So take my comments with a grain of salt, right? The people I'm thinking of are not always necessarily. Yeah, I think you can definitely do retail and point of sale surveillance. In terms of surveys with individual consumers, that gets much more difficult. It's maybe easier in a state like Nebraska where you don't have other policies in place, but you have other illicit cannabis products that are coming into the state as well. And what we know from surveys like the International Cannabis Policy Study is consumers do not know what they're consuming. And they have a very hard time probably even telling you all as clinicians, oh, I'm consuming a product that's from the medical market, or I'm consuming a product that's made from hemp, or I'm consuming a product with CBD and nothing else, or with THC. They just don't know that, which makes it very difficult. So I think where I've seen states be effective on the hemp issue is helping their public health prevention community to get up to speed on it, putting together some fact sheets of why is this happening, what is this, what is in the community, doing some community-based surveillance of what's out there and how are people marketing that and bringing that to bear. And I think you can activate public health and prevention coalitions to then be doing education with their communities about what these products are so that we start to get more educated consumers. But I suspect that it's probably worse in Nebraska than other states. The CDC Han that they put out found that poison center calls were slightly more likely to be occurring from states that had no policies legalizing cannabis for Delta-8 because there are no other cannabis products legally sold. And so consumers who want it are creating a market for this gray area of hemp. So I think it's tough, but I think public health and prevention stakeholders can really be helpful. Can you direct me to that CDC site? Yes. I don't know who to follow up with, but it's a Han that CDC put out. Okay, yes, I'll follow up and make sure that they have that. The education need for patients and people and providers is clear. to highly recommend and incentivize education. You know, but I think it goes back further than that, right? And so I think the more that all of us who have the opportunity to engage with students, residents, right, earlier learners, we can continue to advocate for more cannabis education in general. And I'll just add, a number of medical states require some CE or CME for recommending clinicians. And I did a crosswalk of that. It's been maybe five years, so the landscape could have changed. But in very few instances, the state was offering the CME. In most instances, it was, you need a credit of CME to be a recommending clinician. Go get that credit. And that void was filled by industry, pharma, a bunch of other entities that were making CMEs. It wasn't necessarily a program being made by epidemiologists and scientists. And I think a fair CME is one that both ends of the spectrum would be upset about something. The science is generally right now in the middle. And it's not reefer madness. It's also not a cure-all for everything. And I think CMEs tend to be on one end of that spectrum, which doesn't. That's a hard question. I think there are a number of third party groups that work with the industry that are trying to reach consumers with that information. So I don't know if you've all been to Leafly, but the mission of Leafly is to educate consumers about the plant and the product. And they have an association with the industry. So I do think that it would be valuable to have a non-biased place where consumers and clinicians could go. The challenge is the science. We don't have good science on dosing. We don't have good science on individual cannabinoid composition. There are some medical states like Florida that have really empowered recommending clinicians to try to be the voice for that. And in Florida, if you recommend cannabis to a patient, you have to recommend the dose. You have to recommend the mode of use. You have to recommend the type of dominant cannabinoid in the product. But I think there is a gap in terms of clinicians as far as knowing what to even recommend. So it's tricky given the lack of research. Our policy is far ahead of where we are with research. So I think that creates a gap. I do think we could do more to translate science for consumers. And it would be great to have nonpartisan, neutral entities do that. Cannabis looks very different than tobacco. We don't have a lot of the voluntaries involved in this space. We don't have American Lung Association. We don't have American Cancer Society. They have not stepped into this issue in a big way. And so I do think there's a void for consumer education. Wish I had better answers for how to solve that. Lisa? Yeah, I just want to say that part of that bill, HB 1317, is to do a public education campaign. So that's something the state has been anticipating, using the findings around potency. We don't know the form that's going to take yet, but it is a public-focused campaign. I mean, there have been public health education efforts in cannabis. But I still think they've not been what you're describing. They haven't helped people that might want to use cannabis medically to understand how and what, and exactly how to reduce harm. They haven't been helpful for clinicians in terms of understanding, what do I tell a patient? And we've all seen the studies that many clinicians don't know what to tell a patient. And the absence of saying it. I would say follow the policies. Yeah, so a couple of resources for you to start off. NIOSH has done a fair bit of work on cannabis in the workplace and has toolkits. And you can Google NIOSH and cannabis and get some resources. The National Safety Council has also done some work and has, I believe, a white paper on workplace policies in cannabis. But I think the questions you get at are really difficult. I mean, I'm sure everybody's followed the media coverage that delivery operators and truck drivers, they can't find enough of them when they drug test because they're testing positive. The challenge with cannabis is because it's fat soluble, it stays in the body for a long time. And we don't have a good understanding of how it's metabolized differently across people, how that metabolization, as Lisa said, relates to impairment. Whether you're a naive consumer or a regular consumer. And then there's the whole complication of medical patients who are consuming as a medicine. So I think those are the challenging questions for the workplace. Again, I'm sad to say we don't have answers to them, but there are some groups that are helping workplaces think through their workplace policy. So NIOSH and National. It's not like, you know, we have cotinine levels that every researcher is using. And most of the studies we're looking at, you can't actually tell what concentration of THC is at the receptor level. I mean, they're not doing that, and all the measures are very heterogeneous. So I think we actually need the basic research on that first before we could even recommend some sort of testing. And then again, just to emphasize, hemp products can also result in a positive drug test. So there's Delta-8, Delta-10, Delta-9 THC in them, and a lot of people don't know that and are using it. I think that's, we need more research there. And again, that's because it's fat-soluble and stays in the body a long time. We need more research to understand the levels at which impairment happens, and for whom, and how it's metabolized differently across populations. It's not as clean as that. I'll leave the clinician question to you, but on the data question, it's been probably a decade since I first worked with CDC to get cannabis questions on the BRFSS survey and to update the YRBS survey. National Survey on Drug Use and Health has not updated their questions on cannabis in a long time. I think they still say marijuana or hashish, which is really outdated language as well. So this is a huge gap in terms of our federal surveillance and it's not moving fast enough to respond to the market. That said, there has been some cognitive testing done by federal agencies and by other groups that has generally found that consumers can't answer questions about the type of product they're using, even if at the outset of the survey, you say we're asking about cannabis. By cannabis, we do not mean hemp, all of these caveats. They still, in cognitive testing, up to 50% of them are responding to marijuana questions when they used hemp or hemp questions when they used marijuana. So there's a huge consumer confusion here and I think we need to look more at proxy questions that can help us as researchers disentangle those data. So questions like where did you access your product? Very informative because we know adult use and medical use cannabis is not available in the grocery store or gas station, harder with illicit market products, but I think there's a lot of discussion at the federal level about how those types of questions can be integrated and then we see these other survey mechanisms coming up that can be much more responsive like the International Cannabis Policy Study. I spoke with them last winter and said, gosh, we really need good data on Delta-8 and they were able to just add a question about Delta-8 into their panel so we could understand. Interestingly, that Delta-8 question, we had to add a bunch of sort of fake Delta-8 options because consumers didn't necessarily know what Delta-8 was, so we had to ask about Delta-5 and Delta-4 and Deltas that don't exist to understand do consumers really know or are they just sort of checking the box? So I think we have tools to do a better job but surveillance has been challenging for this area and is definitely needed. So I'm gonna make a quick comment here. It actually reminds me of the changing tobacco marketplace. We are behind, the marketplace puts us behind and the ability, particularly in large federal surveys, to move in a nimble fashion, it's just not there. And I mean, I think this is a real problem and given, in fact, look back at cigarettes, we used to be able to say do you smoke, came in units of 20 and it was pretty easy to get a history and now in the tobacco world or in the cannabis world, it's complicated and moving fast. And I think you put. mentor who talked about, you know, how do we bridge some of these. towards cannabis or would consider becoming a cannabis We're actually fairly like minded or wavelength, but I haven't. Yes, they are moving in. It's been happening for a number of years now, and there's a great article that Stan Glantz and Rachel Berry put out about how the industry tobacco documents, back in the 70s, stated that this was something that they were interested in getting into. I think initially in the US, their engagement was limited because we don't have interstate commerce. Where I really saw it pick up was as soon as Canada legalized, and now we've since seen a number of other countries legalize. So they are definitely following this issue, interested in this issue, investing in companies, investing in coalitions. And it's becoming harder and harder to disentangle big tobacco from big cannabis. That said, there's an interesting dynamic happening in the cannabis industry, and that's related to social justice and equity. And there is a very vocal group against big tobacco's engagement in cannabis because they see that as taking away opportunities for equity engagement in the industry, to have big multistate operators, big international companies. So within the industry itself, there's a pushback right now on having big tobacco be engaged. And some of the companies and coalitions that have big tobacco investment get bad press in industry publications about that. Now, regardless of whether or not big tobacco is ultimately going to be a big player in this space, and big alcohol is in there as well. I didn't have a chance to point it out, but on one of my slides, some of the alcohol companies are now making cannabis beverages with their logos on it. So Pabst, PBR, you can get a PBR cannabis seltzer, which I have all sorts of questions about consumer awareness there. But whether or not big tobacco is a big player in this space or not, there are large cannabis companies that will be multinational, that are multinational, that are appearing, that may behave very similarly to big tobacco. So I think some of the lessons we've learned on that space can translate. The one thing we have, unfortunately, is very effective aerosolization devices that can put whatever it is into the lung. And remember, the size of a tennis court, the surface. So whatever it is gets to the brain very quickly. So we have time for two, I'll say now, quick questions. Please. I would say on the hemp side, again, those products are not regulated by anybody, so there might be concerns about other things that could be in them. On the medical use or adult use side, I don't think topicals have been a big problem. There are issues with items that have direct contact with mucosa, so that might be oral or vaginal or rectal, and those are very quickly taken up into the body. So I know clinicians try to warn patients about those. They may see those as also being topical, but they have a much quicker effect in the body. But I've not heard a lot of discussion about concerns in the regulated market with topicals. And they're a very small proportion of the product landscape, I should say. So I would say stay tuned for the results of the review. We have some included in our site. We'll see if anything comes out. I can't speak from the clinical perspective, but you're absolutely right. And that's what I mentioned in my talk. Overall arrests have gone down, but are still disparate. And if anything, maybe more disparate in terms of who's being targeted. And there are issues with disparities in terms of access to medical care as well. So I think your point is really well taken. I think I covered the main approaches that are happening broadly in terms of regulation and equity. And again, I think the community reinvestment. And that can have dollars that go towards system navigation, medical services, engagement, to try to bridge equity gaps there. I think that can be really valuable if it's operationalized well. Which is another area for you all to be involved. If your state or community is allocating tax dollars towards disproportionately impacted communities, you should be there to talk about what the needs are for your community or communities that you serve as a clinician. I think that's a valuable contribution. Great. Well, I think we are done. And I really want to thank the panelists and thank the audits. I mean, this has been a terrific exchange. I thought we might have extra time, given that we lost a speaker. I guess we're lucky we lost a speaker, because we had so much to say to each other. So thank you all. And let's turn it over to Donna. Thank you. Thank you. Thank you all so very much. What an incredible panel and so much great content. We certainly have come a long way from Reefer Madness, as was said. Wow. Well, here we are. We're right at the closing. This is it. This is it. And it's kind of sad, but it's bittersweet. Just the same. As you all probably know by now, I'm Donna Grande. I'm the CEO of ACPM. And I couldn't be happier for the last four days that we've had together. It's been so special and so rewarding and just so wonderful to see each of you in person and to reconnect with many of you who we haven't been in person with for quite a while. Altitude, I can't wait to get home. I don't know how you live here. But on behalf of the Board of Regents, on behalf of Dr. Carlsa Wood, on behalf of all the committees and the staff, I certainly hope you've enjoyed your time here together in Denver and that you're really feeling good about the time that you've had, the information you've gleaned, the people you've met, the new friends that you've made, the colleagues that you've been now aligned with. And I really hope that you've met so many new mentors for your career journey. How about that ballgame last night? Was that fun? It was so cool to see the ACPM logo up on that big jumbotron. That was a real treat. And then, of course, to be with my colleagues waving and being on there, that was a real treat. But it truly has been an incredible few days together. We kicked off with the State of the College and all that we've been doing for the past year and made a few requests and a few calls to action. I don't know if I have control, John, or not. OK, we're going to stay right there. In a moment, just in that moment in the opening remarks when the QR code came up, we went from 54 to 105. That was really cool. So thank you for your comments. Thank you for your contributions to that survey. We really are excited about the insights that we're going to get from the data that we'll be able to tabulate and see. I also want to thank you. There were about 15 of you that were interviewed. So thank you for carving out the time, going into the media room, and offering your member insights. That was very exciting. But the most exciting was the ambassadors. We started off with about 19 ambassadors that have been with us on this vaccine journey. And we actually signed up 50 more ambassadors. So we are going to have 70 ambassadors. And that's just what we captured here. So I'm certain when you get home, you look at your calendar and you start thinking about things, you'll probably want to get involved. So please don't hesitate to let us know if you still want to become an ambassador. But that map that I had with all of the little, the magnifying expanded, we're going to be there. When we meet together in March, we're going to definitely have a full map. So we kicked off day one with the KBS lecture. And that riveting presentation by Dr. Janine Clayton, was that amazing? I mean, just all the information on the data and the disparities and the research inequities related to sex and gender, it was really compelling, to say the least. We heard about the COVID impacts on clinical preventive medicine, and news about a potential CDC funding opportunity with adult vaccines, and really instilling a new adult vaccine program. And the thing that was pretty cool is that Dr. Kopaka really made the case for our Vaccine Confident campaign, when you think about it. Everything he said about getting back on schedule. And I was inspired at our opening reception, because two residents, Sophie and April, you know who you are from Stanford. Dr. Lane, thank you. We also heard from Dr. Bradley on the need for improved screening rates and the opportunities to focus on health disparities and health resilience to be better prepared for the next pandemic. The session on gun violence focused on new or different approach to reducing the death toll related to guns and really focus on the harm reduction angle, which I thought was pretty interesting and I'm certain many of you did as well. But we really need to, and she highlighted the need to be mindful of the words we use and how we choose our words when we do get engaged in discussions around gun violence because everyone has a different fear tolerance or risk tolerance and I thought that was really important message to walk away with. We then focused on the infodemic in social media and the communications challenges we've all been experiencing through this pandemic and we learned of the new field of infodemiology, which I thought was pretty cool and the fact that computer scientists are also now engaged in public health, who knew? We closed out our plenary yesterday with the interesting word clouds, that was a pretty cool, Dr. Carr, you continue to amaze with your inspirational technology advances and engaging us in new ways, but really the opportunity to bring industry and business together and really look at ways where we can intersect to advance and improve health outcomes, but also recognizing that values matter and our own personal values. on the cake. I mean, all of the evidence, all the research, and all the great contributions to this conference, it's been really quite remarkable. But I really truly hope that you've all really learned much. And I only highlighted the plenary sessions. Just think of all of the additional topics and content in each and every one of those concurrent sessions. It's just truly been remarkable. And it takes a village to do all of this for certain. I said in the opening that we need to continue to be bold, to be proud, to really stand up and express your voice in what preventive medicine is and what it means. One of the comments that came up was, you know, I'm not a doctor. You are incredible physicians, and don't ever forget it to those residents in the room in particular. You are leading the way for how to transform our country through population health strategies and tactics. And you tell anyone of any other specialty that tells you otherwise, I hope you, I hope you went. Hope you will embrace all that you are. So, putting on a conference like this takes an incredible amount of work, an incredible amount of dedication, tenacity, resilience, all of the above. And I wanna thank, and start by thanking our leadership council and the PM22 Planning Committee. Dr. Linda Hill and Dr. Lisa Miller. What a dynamic duo. Stand up and take the applause that you're so deserving of. And Dr. Croupane, I know I saw you earlier if you're still in the room. Thank you so much for serving as our board liaison and bringing your insights from PM2019 with Dr. Celeste Phillips. And I saw her earlier, I don't know if she's still in the room. Thank you for your leadership as well from the past. And it's really cool to be able to see how the planning committee members continue this momentum and the friendships and the bonds that form through this. It's just really amazing. And Dr. Croupane served and will continue to serve as the board liaison into the next planning session. I also wanna thank each of our track chairs because you also have done such incredible work to ensure the content, all of the concurrent sessions, all of those sessions and speakers are really amazing. So Dr. Jadot, thank you for your time. I wanna thank Dr. Karen Studer. Are you in the room as well? For all of your leadership with your sessions. And she is the one that brought us the Rockies game. It was her idea. So we're doubly appreciative of all of her efforts and in kickstarting those conversations. And then Dr. Wilnice Jasmine, are you in the room? It's hard to get flights from here home at any particular time, but Wilnice has also just done an amazing job. Unfortunately, Dr. Margaret Hasek was not able to join us for the conference. And I feel so terrible that she missed out on all the great work that she did building up and bringing forward the great concurrent sessions as well. So in her absence, we'll still applaud her. And then all of the posters, correct me on that, Angela, 150 posters submitted and 75 approved. 150 posters submitted and 75 approved. Lorraine led an incredible team of reviewers to go through each and every one of those abstracts to select those 75 that actually were in the presentation room. So again, just tremendous work. So Lorraine, you can hear us applauding from afar. And then, as I said at the start, and I'll say it again, it takes a village. And I am so incredibly blessed to have such a remarkable, talented set of colleagues to work with. And I want to personally thank Angela Michelide for her leadership with the team, with all of the work here. So when you want to stand up and be acknowledged, please. I want to thank Ayesha Beadle. Ayesha, where are you? Stand up and be recognized. Ayesha's our meeting planner that we would never have been able to do all of this without your grace and your composure through all of it. And of course, the amazing team at ACPM. Would you please stand up and be recognized as well. Your tenacity, your dedication, your talent. We have so much fun. We're back in the office. We come in three days a week and we have everyone in on Wednesdays. And we've been that way since June of last year. And this is a really resilient team, I have to tell you. And we have a lot of fun together. And I think before I move into the installation of new officers, I think we had an unannounced ribbon contest. And I think it was pretty much a tie. There's no gift. You don't need to come forward. But I think it's a tie between Linda Hill and Uri Jadot. So just note that for next year, there might be a spoken contest about the ribbons, but I'm afraid they might be too long if that was the case. So I want to move now to a little bit more seriousness. And I want to acknowledge and now also install officially and recognize officially our new board members that have stepped into their official seats. And to thank those that are leaving our board as well. Dr. Kathy Whitcup was a tremendous leader on our board as well as Dr. Joni Shen. And so you, I'm sure have met our new board members throughout the week or throughout the last few days. So again, I look forward to working with you as we impart on this journey forward. And now I am so thrilled to announce our chair and vice chair for the PM 23 conference. This is the fun part. Linda Hill agreed to do it again as chair. So her leadership enthusiasm and her ideas on all of and her ability to find in addition to the panel, really great speakers. And then Hunter Smith is going to be joining us this year as the vice chair. He is about four or five years out of his residency program. He's currently in Kenya, finishing up his international work in Africa and he'll be returning to the DC area in June. And I'm really excited and I really, and he went to the Tulane PMR program. So he's excited. He did his medical school and his residency in Tulane in New Orleans. And so we are looking forward to seeing you all in March in New Orleans. And you can always remember the dates. So look at this. It's really cool. So it's March 20th to the 23rd, 2023 in 2023. So that's gonna be really cool. And I think we have a video to get us all excited. So safe travels, we'll see you in New Orleans and get your beads on.

scoping review

health effects

high-potency THC marijuana

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research gaps

recommendations

observational trials

randomized control trials

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government affiliations

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public education

cannabis use

vibrant culture