What happens to therapeutic cannabis if NH moves to legalize? | Health

A decade after New Hampshire lawmakers created a Therapeutic Cannabis Program (TCP) to serve the sickest of patients, a push to legalize recreational use here has some health advocates worried.

Nearly 14,000 New Hampshire patients are registered with the TCP, using cannabis to alleviate the pain, nausea, vomiting, seizures and other symptoms that accompany medical conditions such as cancer, AIDS, epilepsy, ALS and Hepatitis C.

Most TCP patients here are in their 50s and 60s, according to a 2022 data report on the program from the Department of Health and Human Services. A total of 118 patients last year were under 21, and 267 were in their 80s or 90s.

The youngest patient in the program was 1 year old; the oldest was 97.

Michael Holt, who has administered the TCP at the state Division of Public Health Services since its inception, said he hears from patients all the time about how cannabis has changed their lives.

“I believe that the program is helping patients have a better quality of life here in New Hampshire,” he said in an interview.

Those registered for the TCP are “truly patients,” not people looking to get high, Holt said.

“The fact that there’s only approximately 14,000 patients on the program in a state that has 1.3 million people is testimony to the fact that the folks that are choosing to be on the program have legitimate needs,” he said.

Lawmakers approved therapeutic cannabis for certain medical conditions in 2013. The first dispensaries — alternative treatment centers, or ATCs — opened three years later.

The law here requires “a true provider-patient relationship,” Holt said. Physicians do not write prescriptions for medical cannabis. Instead, patients must have their providers certify that they have one of 25 “qualifying” medical conditions, as well as certain symptoms, to apply for a card.

Over the years, lawmakers have expanded the program to include more conditions, and added some standalone conditions, notably chronic pain and PTSD.

By far, the leading reason patients apply for the program is chronic pain — 8,246 patients were registered with that condition this year.

Rounding out the top 10 medical conditions are PTSD, injuries, severe pain that has not responded to other treatments, cancer, spinal cord injury, multiple sclerosis, epilepsy, Crohn’s disease and traumatic brain injury.

A threat to access

On Thursday, Holt and Patricia Tilley, state director of public health, spoke before a legislative commission looking into state-controlled sales of recreational cannabis and cannabis products. The two DHHS officials asked lawmakers to protect the therapeutic program and its patients if they move forward with legalizing recreational use.

For the department, Tilley told the commission, three issues are paramount: “Patient safety, patient access and patient affordability.”

“We have 14,000 very sick people who use these products in this state,” she said. “We just want to make sure they’re available.”

The state-licensed, nonprofit Alternative Treatment Centers sell products that retail shops would not, including strains with low levels of THC and higher doses of CBD and other cannabinoids, high-potency products, and alternative forms such as suppositories, Holt said.

Holt stressed that educational counseling offered by ATC staff is a critical component, especially for first-time patients who have never used cannabis.

“Patients would say that the TCP and the ATCs are critical to their health and quality of life and they are worried about what adult-use legislation means to their continued access,” Holt said.

Some lawmakers seemed to push back against such concerns.

As Holt began his presentation, commission chairman Sen. Daryl Abbas interrupted to ask: “Why is there such a concern that the people receiving this alternative treatment would stop using the therapy products and switch to recreational?”

Some patients may prefer not to be in a state registry, pay the $50 registration fee and visit a doctor to get certified, Holt replied. And because insurance does not cover therapeutic cannabis, if there are cheaper alternatives, he said, “Patients will choose to self-medicate.”

Lives transformed

Holt called New Hampshire’s TCP “a maturing but vulnerable program.”

For one thing, he said, “We regulate a product that is federally illegal.” New Hampshire also is surrounded by states that have legalized recreational use, he said. “We know that access to cannabis, both therapeutic and recreational, oftentimes is easier and more affordable across our borders,” he said.

Other states that have legalized adult recreational use have seen sharp declines in enrollment in their therapeutic cannabis programs, Holt said. “It is expected that patients will leave the program if there’s legalization available in New Hampshire,” he said.

That could pose financial challenges for the state’s alternative treatment centers, which under current law are required to be not-for-profit.

Matt Simon, director of public and government relations at GraniteLeaf Cannabis (formerly Prime ATC), says it’s “imperative” for New Hampshire to maintain its therapeutic cannabis program.

“We’ve seen countless patients over the years whose lives have been transformed by access to therapeutic cannabis,” Simon said last week in an interview.

The educational support the ATCs provide to patients is key, said Simon, who previously was a lobbyist for the Marijuana Policy Project.

“One of the strengths of the program is that the ATCs all go out of their way to educate patients and help them figure out how to have the best possible experience with therapeutic cannabis,” said Simon, whose company has dispensaries in Merrimack and Chichester. “I don’t think people are getting that at the adult-use store across the border.”

“We see a portion of patients, many of whom have never tried cannabis before, or maybe smoked it in high school once or twice, and they’re afraid of it and don’t know where to start,” he said.

“Start low, go slow,” is the mantra for therapeutic use, Simon said. “You’re looking for what’s going to make you feel better,” he said.

Lawmakers here are looking at a “franchise” model for retail stores, licensed and regulated by the state liquor commission but run by franchisees.

At last week’s commission meeting, several lawmakers asked Holt to skip ahead in his planned presentation and address how the therapeutic program and retail market could “co-exist.”

Holt said the two models are fundamentally different. “In the therapeutic world, being high is an adverse side effect,” he said.

If the state adopts the franchise model for retail sales, Holt said lawmakers should consider allowing the ATCs to also operate retail outlets.

Tilley told the commission that if the state develops dual regulations for therapeutic and recreational uses, it would be important for the retail shops to adhere to the same rigorous independent lab testing the ATCs currently undergo.

Leveling the field

Simon from GraniteLeaf Cannabis said other states have allowed companies on the therapeutic side to also serve the recreational market, which could help the New Hampshire ATCs stay financially viable.

“From the ATCs’ perspective, if we’re able to get these franchisee licenses and able to sell cannabis to adults, maybe from one section of the store, and have separate counters for patients, this would enable us to weather the storm,” he said.

Barring the therapeutic cannabis companies from getting into the retail market if cannabis is legalized “would be a death sentence for the program and for the ATCs,” Simon said.

Lisa Withrow, an advanced practice registered nurse at Palliativity Medical Group in Bedford, has certified many patients for the TCP. When you look at the list of qualifying conditions and symptoms for the program, she said, “Those are my patients.”

Withrow, who serves on the Therapeutic Cannabis Medical Oversight Board, previously testified in favor of adding chronic pain and PTSD to the list of qualifying conditions.

Many of her patients previously relied on opioids to control their pain, she said. Cannabis has helped them reduce and in some cases eliminate those stronger medications entirely, she said.

Withrow said she supports making recreational use legal for adults. But she, too, is concerned that creating a retail market could restrict access to specialty products on which her patients depend.

The oversight board has worked hard to increase access for patients, and she worries that moving to recreational sales could decrease that access. In addition, she said, “There’s a concern that they’re going to focus on selling it cheap recreationally, so the medical patients are now going to pay more.”

She’s not opposed to having recreational and medical products sold in the same locations, Withrow said. “But there needs to be someone who can educate patients who come in, versus people coming in to use it recreationally,” she said.

Withrow also is concerned that recreational shops would not offer the same kind of discounts for low-income patients and those with disabilities, which currently are available at the nonprofit ATCs.

A change of thinking

Simon from GraniteLeaf Cannabis said it’s critical to protect TCP patients as the state moves to “adult-use” legalization.

“I see the experience that people have in a well-regulated market versus the experience they have when they’re fending for themselves in an unregulated market,” he said. “It’s really advantageous for patients to have something they can really trust.”

He’s talked with patients about the difference therapeutic cannabis has made in their lives — veterans with PTSD who say it helps them sleep, and cancer patients who find relief from the severe nausea caused by chemotherapy. “Even the doctors who were fighting this 10 years ago or even five years ago, they all admit there’s some therapeutic use to cannabis,” Simon said.

Still, seven years in, Bedford APRN Withrow said many physicians are reluctant to certify their patients for the program. She often gets patient referrals from health care providers whose employers bar them from certifying patients, she said.

“You have to understand: In medical school, we’re taught that cannabis is illicit … so we’re trained that our patients aren’t supposed to be using it,” she said.

But in her view, “As medical providers, it is our duty, it is our responsibility to know about cannabis, whether or not you want to be involved in certifying someone,” Withrow said. “Because you’re going to have patients who are using it, and you need to be able to at least counsel them on potential medicine interactions, and look for symptoms.”

The biggest misconception Withrow hears about therapeutic cannabis “is that people are using it for the high,” she said.

“But the patients coming to me, that’s not what they’re looking for,” she said. “In fact, they specifically don’t want that.”

“Almost every patient who comes in says, ‘I don’t want to be high.’”

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