Rapid rise in Iowa medical marijuana waivers fuels fears of abuse

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The website for Iowa’s only medical cannabis manufacturer is bold and splashy, with a trendily dressed couple casually loitering next to a big black-and-white message on a startling red background:

“Get full THC in Iowa. Legally,” Bud & Mary’s message proclaims. “There’s no THC cap on Iowa medical cannabis, and getting a card is fast and easy. Get your med card today!”

After Iowa removed its 3% cap on THC levels in cannabis products, instead allowing registered patients to purchase up to 4.5 grams of THC every 90 days, Bud & Mary’s is painting a new picture of Iowa’s medical marijuana program — one with no cap.

And Iowa’s oversight board isn’t happy about it.

The language is not only incorrect, the Iowa Medical Cannabidiol Board says, but “in violation of both spirit and letter of current Iowa Code Rules.”

Board members worry that Bud & Mary’s promotion of its products, along with the ease in accessibility to telehealth providers, may be connected to a tripling in the number of patients who have received a waiver to Iowa’s THC purchasing limit.

With little evidence in hand that high THC dosage results in better medical benefits, board members have asked the state to step in to stem what they see as potential abuse of the program. THC is the main psychoactive component in marijuana and gives users a “high.”

Bud and Mary’s disputes the board’s claims, stating they have not violated any state law and the board failed to put forth any evidence that their marketing efforts are directly tied to skyrocketing THC waivers.

More importantly, company officials say they are working to make Iowa’s medical marijuana program viable and more accessible to Iowans who could benefit from their products.

“I sensed from the conversation (in early February) that there was some feeling that this might be a source of abuse, and I’m not sure on what evidence,” said Lucas Nelson, group president of Bud & Mary’s, which also owns dispensaries in Windsor Heights and Sioux City.

Medical marijuana program saw continued growth last year

Since it was established in 2018, Iowa’s medical marijuana program continues to see annual growth.

Active cardholders certified to purchase products under the state program reached nearly 15,000 individuals by late last year, up from about 7,800 patients in December 2021, a report from the Iowa Cannabidiol Board shows.

In November alone, more than 3,000 cards were issued.

Sales have risen as well, climbing from about $2 million in sales in 2019, its first calendar year, to $10.2 million last year, according to state data.

Last August, the program surpassed $1 million in sales in one month for the first time in the program’s history, according to state data.

But with those rising sales has come an even sharper increase in waivers — and with it, concerns about abuse.

Percentage of THC waivers in Iowa’s program doubled in past year

Once a provider certifies them to participate in Iowa’s medical marijuana program, patients are limited by state law to no more than 4.5 grams of THC every three months.

However, Nelson says Iowa has removed the THC limit on individual products such as edibles, tinctures, creams, capsules and vapes.

“What we’re trying to make sure people know is that on any individual product, there is no cap on THC,” Nelson said. “There is a limit on what you can purchase, but that’s even changeable by the waiver too.”

Iowa’s medical marijuana program allows patients to purchase more than the 4.5-gram limit if they obtain a waiver from a health care provider certifying it isn’t enough to treat their qualifying health condition.

Providers can also grant terminally ill patients a waiver.

Since the waiver was implemented in July 2020, hundreds of health care providers have certified patients to receive THC levels beyond that cap. In the past year alone, the percentage of certified patients receiving waivers has nearly doubled, state data shows.

Of the nearly 15,000 active cardholders in the state’s medical marijuna program by November 2022, about 2,300 — or 15.6% — had received a THC waiver. That’s compared with about 650 patients, or 8.4% of the 7,800 individuals enrolled in December 2021.

This increase in waivers is a “good indicator that Iowa’s program is being abused,” said Peter Komendowski, executive director of the Partnership for a Healthy Iowa and an opponent of expanding the state’s medical marijuana program.

The combination of marketing that says there’s “no cap on THC” in Iowa and the promotion of telehealth providers willing to certify patients remotely for the medical marijuana program raises fears that loopholes in the law are being exploited to sell more products, Komendowski said.

“By giving people an easy way to get these high percentage THC applications, it really benefits the abuser more than the user,” he said.

The medical marijuana board has stopped short of denouncing Bud & Mary’s directly. But it issued recommendations to address its larger concerns and asked the state to engage in “good-faith” discussions with the company.

The board also maintained no evidence exists to support THC doses exceeding 4.5 grams within 90 days.

Why Bud & Mary’s says there’s no cap in Iowa

Nelson said the dispute boils down to semantics, saying they’re just making sure customers know that Iowa’s old limit of no more than 3% THC on individual products is no longer in effect.

Gov. Kim Reynolds signed a law in 2020 replacing that rule with the 4.5-gram limit over 90 days.

“We’re trying to help people give the program two seconds of thought by saying ‘there is no cap on THC,’ which is true, because again, it was capped at 3%,” Nelson said. “That is no longer the case.”

Among its cannabis products for sale in Iowa, Bud and Mary’s offers high-THC formulations that include a 1-gram vape cartridge that has about 800 milligrams of THC — meaning a patient could legally purchase no more than five cartridges in 90 days without a waiver.

Still, Nelson said company staff would often hear from patients who believe they couldn’t obtain enough THC to alleviate their symptoms, or don’t have the means to travel to a dispensary every 90 days to buy products.

Those patients would instead seek out products from states that allow recreational marijuana or pursue illicit sources, he said, which is less safe.

Telehealth becomes potential concern for Iowa’s medical marijuana program

Even as the telehealth boom has created an ease of access to health care providers for Iowans, the state’s medical cannabidiol board watches those services with growing apprehension.

In the meeting earlier this month, the board echoed concerns expressed last fall that telehealth providers could be driving up the number of THC waivers the program saw in the past year.

They say that could harm patients if providers are prescribing medical marijuana and a THC waiver without appropriate oversight of the patient’s care.

“You can’t let a person doing a medicine judge for themselves if it’s really working,” Komendowski said. “If you’re getting high, you might feel better, but it might not be doing anything for the symptoms.”

Three health care providers are responsible for certifying more than 200 waivers each in Iowa’s medical marijuana program, according to state data provided to the Des Moines Register. Two have certified 101 to 200 waivers.

The majority of certifying providers have issued less than 10 waivers, data shows.

The data does not identify which providers gave out the waivers.

Board members say Bud & Mary’s website includes links to six organizations with providers that certify patients for a medical marijuana card, including some that offer that service virtually.

However, the board did not provide evidence that those medical organizations are directly linked to the increase in THC waivers.

Nelson said he strongly disagrees with any characterization of a link between the Bud and Mary’s website and the increase in THC waivers. His company provides recommendations on providers who are knowledgeable about medical marijuana, he said, no different than seeking out other medical specialists suited to treat specific conditions.

He also said the links are provided as an educational resource — not a formal referral process. Iowa law prohibits manufacturers from referring patients to specific providers or from having any financial relationship with a provider.

“We want to provide people resources for where to go if they have questions,” Nelson said.

State officials identified 13 health care practitioners who only certified patients for the program via telemedicine, according to data provided to the Des Moines Register. In all, 1,920 providers prescribed medical marijuana as of last year.

State lawmakers consider proposals to grow medical marijuana program

At the State Capitol, the Iowa Senate is considering legislation that would expand the type of products that could be purchased through the state’s medical marijuana program and increase the number of dispensaries.

A three-member Senate subcommittee unanimously agreed Feb. 14 to advance Senate Study Bill 1113, which would add inhalable cannabis, including “vaporizable dried raw cannabis,” to the products that can be purchased by participants in the program. Under current law, patients can buy tablets, capsules, liquids, tinctures, ointments and gels.

The legislation would also authorize up to 10 medical marijuana dispensaries, doubling the current number allowed under current law.

The Iowa Cannabidiol Board had recommended the state license more dispensaries in a December report to the Iowa Legislature, stating lawmakers should “provide Iowans with greater geographical access to medical cannabidiol products.”

Currently, the state’s dispensaries are in Windsor Heights, Council Bluffs, Sioux City, Waterloo and Iowa City.

Stephen Gruber-Miller contributed to this report.

Michaela Ramm covers health care for the Des Moines Register. She can be reached at mramm@registermedia.com, at (319) 339-7354 or on Twitter at @Michaela_Ramm.

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