Center for Mississippi Health Policy

Mississippi Ballot Initiative 2020

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Currently, 33 states have legalized medical marijuana, Mississippi has added a ballot measure for public vote on the legalization of medical marijuana in 2020. As recently as 2015 over half the US has expressed the opinion that both recreational and medical marijuana should be legal.

Medical Marijuana Programs (MMPs)
MMPs are publicly regulated programs where individuals with a medically certified condition can use marijuana as medical treatment.

Medical Marijuana as a Policy

Public opinion has shifted in recent years to find marijuana more acceptable, but the medical evidence of its effectiveness as a treatment is mixed. Medical Marijuana Programs (MMPs) allow physicians to certify the existence of a state qualifying medical condition for a specific patient. MMPs do not allow providers to prescribe or distribute marijuana for medical use; only certified dispensaries can distribute medical marijuana.

AMA Position Statement on Marijuana As Medical Treatment
Believes that scientifically valid and wellcontrolled clinical trials conducted under federal investigational new drug applications are necessary to assess the safety and effectiveness of cannabis products for medical use. Hospitals and health systems are encouraged to: (a) not recommend patient use of non-FDA approved cannabis or cannabis derived products within healthcare facilities until such time as federal laws or regulations permit its use; and (b) educate medical staffs on cannabis use, effects and cannabis withdrawal syndrome.

A recent report from the National Academy of Science, Engineering, and Medicine suggested that conclusive or substantial evidence exists for the use of cannabis, or marijuana, as an effective treatment for chemotherapy-induced nausea, and chronic pain. Moderate evidence was found that marijuana is effective for improving short-term sleep outcomes. Limited evidence exists for effectiveness of increasing appetite among HIV patients, improving clinically measured spasticity, improving anxiety symptoms, symptoms of Tourette syndrome, and improving anxiety symptoms of post-traumatic stress disorder (PTSD). Limited evidence was found to show marijuana was ineffective at treating conditions such as glaucoma, dementia,
and depression. Moderate evidence exists of no statistical association between marijuana use and incidence of lung, head, and neck cancers. Evidence does exist that marijuana may entail acute cognitive and memory impairment, elevated risk of motor-vehicle accidents, risk of dependency, and asthma. Those who use marijuana frequently are at the most risk for the potential negatives of use.

Federal & State Marijuana Legality

THE COLE MEMO
The Cole memo “deprioritized” marijuana prosecution, however in 2018 the Cole memo was rescinded. The recension of the Cole memo created a lack of clarity but has not substantially impacted state decisions to create MMPs.

THE ROHRBACHER-FARR AMENDMENT
Congress has maintained the Rohrbacher-Farr amendment which bars the use of federal funds to prosecute medical marijuana cases.

CURRENT MISSISSIPPI LAW
Marijuana is classified as “decriminalized” meaning that possession of marijuana up to 30 grams is punishable only by a fine of $100-250.

HARPER GRACE’S LAW MISS. CODE ANN. §41-29-136
Mississippi has legislatively approved research and treatment using marijuana
extract, oil, or resin containing no more than .5% THC for debilitating epileptic condition. This legislation is considered a limited-access medial marijuana program and is not a comprehensive MMP.

In a systematic review and meta-analysis conducted at the School of Social and Community Medicine at the University of Bristol (UK), researchers examined 79 medical trials including both FDA approved and non-FDA approved marijuana treatments, and moderate-quality evidence was found to support the use of cannabinoids, the active chemical in marijuana, for the treatment of chronic pain. Low-quality evidence suggests that cannabinoids improved nausea and vomiting due to chemotherapy, weight gain in HIV infection, sleep disorders, and Tourette syndrome. There was an association between cannabinoids and an increased risk of short-term adverse events such as dizziness, dry mouth, fatigue, euphoria, vomiting, disorientation, drowsiness, confusion, loss of balance, and hallucination.

With increased public support and the only medical evidence being relatively split, the initial emergence of MMPs was not primarily a health intervention but rather a policy intervention that impacts the public’s health. However, as more evidence becomes available research has emerged to support marijuana as a valid medical treatment worthy of policy consideration.

Common Policy Questions

Will MMPs increase child use of marijuana?

A recent systematic review and meta-analysis conducted by researchers in the department of Epidemiology and Psychiatry at Columbia University found no significant association between MMPs and child marijuana use prevalence. However, there is evidence that MMPs may be associated with an increased risk in accidental consumption of marijuana among young children. Adolescent marijuana use and overall risky behavior has remained unchanged after enacting MMP legislation.

CANNABIS USE DISORDER (CUD)

• Defined as a problematic pattern of marijuana use leading to clinically significant impairment or distress manifested by symptoms such as spending a lot of time obtaining, using, or recovering from use; decline in fulfilling major obligations at home, school, or work; and craving, tolerance, and/or withdrawal.
• CUD effects approximately 1.5% of the US population and has been cited as an important issue for states to be aware of with MMPs.
• From 2002-2016 CUD decreased among adolescents by 27%.
• Dosage based on THC content has been difficult to establish. Associations have been found between frequent marijuana use and the development of CUD.

Do MMPs reduce opioid use and addiction?

The impact of MMPs on opioid use disorder is mixed and currently inconclusive. At least two studies showed a connection between MMPs and a reduction in prescription pain treatments. However, a recent study attempted to replicate these findings and found little evidence of an association between MMPs and nonmedical prescription opioid use or opioid use disorder.

Marijuana & Mental Health
One study in Colorado found a fivefold higher prevalence of mental health diagnoses in marijuana-associated ED visits.

Do MMPs increase the chance of marijuana addiction?

Research has indicated that higher levels of Tetrahydrocannabinol (THC) and chronic marijuana use have been linked with certain psychiatric conditions, including the risk of developing cannabis use disorder (CUD), or marijuana addiction.

Would increased potency of marijuana-associated MMPs create additional issues?

Although no state laws directly regulate THC content of marijuana, an indicator of potency, at least some research indicates that the potency of marijuana seized on the black market in states with MMPs has been shown to be between half a percent and one percent higher on average after program implementation.

Tetrahydrocannabinol (THC)
The chemical responsible for most of marijuana’s psychological effects.

Are MMPs associated with increased emergency department (ED) visits?

The evidence on whether MMPs increase ED visits is mixed. Some studies suggest that there could be an increase in ED visits of as much as seven percent and some studies suggest that there is no significant increase in outpatient visits or overnight hospital admissions.

Do MMPs increase illegal drug use, crime, or impact public safety?

Research involving MMPs and increases in crime are mixed. Some studies suggest possible increases in marijuana-related arrests associated with MMPs of between 15-20%. Other studies suggest that crime related to geographic location of marijuana dispensaries is unrelated to violent crime and property crime.

Though data on these programs is limited, research has indicated that MMP
participants report improvement in overall health status, specifically reductions in levels of risky alcohol consumption, and illegal drug use. However, research has linked marijuana to increased risk for motor vehicle accidents and accidents in general.

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STATES WITH A COMPREHENSIVE MMP

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Mississippi’s Ballot Initiative

A certified ballot initiative to legalize medical marijuana will appear on Mississippi’s 2020 ballot. The Mississippi State Department of Health (MSDH) will be the agency responsible for the entirety of the preparation and rollout of the state’s MMP if the ballot measure passes. Any subsequent changes to the ballot measure would have to come from another ballot measure and cannot be directly modified through state statute.

MISSISSIPPI BALLOT INITIATIVE

The Ballot Would:

• Amend the state constitution (state legislation would not be able to modify the provisions of the ballot if approved by popular vote).
• Create an MMP under the sole supervision of the Mississippi State Department of Health (MSDH).
• Allow for physicians with an unrestricted license to certify that patients have one of the outlined debilitating medical conditions.
• Allow for qualified patients to receive up to 2.5 ounces of marijuana every 14 days.
• MSDH will be responsible for:
  • Issuing rules and regulations covering the MMP
  • Tracking and labelling of the medical marijuana
  • Qualifications for the safe and secure processing by medical marijuana treatment centers
  • Placing restrictions on advertising and marketing
  • Setting standards for testing facilities
  • Use of medical marijuana in assisted living, hospice, and nursing homes
  • Reciprocal agreements with other states for patients registered in MMPs
  • Qualifications of and limitations on caregivers and officers, owners, operators, employees, contractors, and agents of treatment centers
  • Issuance of medical marijuana identification cards, implementation/operation of a statewide database system
  • Enforcement of established rules and regulations

The Ballot Would Not:

• Restrict the number of licensed medical marijuana treatment centers.
• Set Medical Marijuana Prices.
• Allow a medical marijuana treatment facility to be located within 500 feet of a pre-existing school, church, or licensed child-care center. Otherwise, no zoning ordinance, regulation, or provisions of municipality or county code can be any more restrictive than those applicable to retail pharmacies of other lawful commercial business.

Deadlines & Benchmarks

• MSDH has until July 1, 2021 to adopt final rules and regulations.
• MSDH shall begin issuing identification cards and treatment center licenses no later than August 15, 2021.
• MSDH may set up an advisory committee to assist in the creation and promulgation of the rules and regulations, which is a common aspect of other state MMPs.
• MSDH may request $2.5 million from the State Treasury as a special loan to be repaid from funds generated by the MMP.
• MSDH may assess up to the equivalent of the state’s sales tax to the final sale of all medical marijuana.
• All revenue generated from the MMP is set to help pay for the cost of the MMP and any money left over will go to a state special fund to be used by the department without prior appropriation by the state legislature.
• All records of qualified patients are to be confidential and exempt from the Mississippi Public Records Act.
• Ballot measure must receive 40% of the total number of votes cast in the election to pass.

Figure 2: How Medical Marijuana Would Be Obtained In Mississippi As A Result Of The Initiative.

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DEBILITATING MEDICAL CONDITIONS AS LISTED ON THE BALLOT

• Cancer
• Epilepsy or other seizures
• Parkinson’s disease
• Huntington’s disease
• Muscular dystrophy
• Multiple sclerosis
• Cachexia
• Post-traumatic stress disorder
• HIV / AIDS
• Chronic or debilitating pain
• Amyotrophic lateral sclerosis
• Glaucoma
• Agitation of dementias
• Crohn’s disease
• Ulcerative colitis
• Sickle-cell anemia
• Autism with aggressive or self-injurious behaviors
• Pain refractory to appropriate opioid management
• Spinal cord disease or severe injury
• Intractable nausea and severe muscle spasticity

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Discussion

With support of MMPs gaining states are having to prepare for the possibility of medical marijuana becoming legal. There are many concerns regarding medical marijuana, but there is also evidence of its positive medical effects as a treatment. As public opinion changes policy changes as well. The ballot initiative proposed for 2020 is not a foregone conclusion, but the State must also be prepared for the possibility of its passage.

MMPs Revenue Range
Revenue generation for MMPs ranges from $406 million in states like Arizona that has had its program since 2008 to $17.4 million in states like Florida that passed their MMP via a ballot measure in 2016.

An important difference between using a ballot measure creating an amendment to the State’s Constitution and passing legislation to create a MMP is that the legislature cannot change or modify the ballot measure. The legislature would be able to create laws that could affect the state’s MMP, but the rules and regulations controlling the implementation of the program will be left up to the State Department of Health. While the ballot measure gives a lot of latitude to the MSDH to create program rules and regulations, this puts a lot of strain on one agency. However, MSDH can seek help by creating a committee to establish the rules and regulations.

An additional consideration is that there is some uncertainty as to how MSDH would work with other state agencies to provide services. Ideally, MSDH would work with other state agencies such as the State Department of Agriculture to help with the certification of cultivators, or with the Department of Revenue to collect sales tax on marijuana sales. Colorado’s MMP works through ten state agencies to accomplish a sustainable and reliable system. The state legislature could clarify interagency cooperation through legislation.

Ballot Measure & Contracting
If passed, the ballot measure would become an amendment to the State Constitution and trump state law. The ballot measure specifically states that all contracts related to the operation of medical marijuana treatment centers shall be enforceable.

If the ballot measure passes, MSDH would be responsible for issuing rules and regulations, but also aspects of quality control, safety, and regulatory enforcement. Currently, MSDH does not provide any of the services required under the ballot measure. If the ballot measure passes, a significant strain will be placed on MSDH. However, most states have relied on their departments of health to roll out and manage their MMPs. While some states have had challenges related to added strain to state agencies, functioning programs do exist and provide treatment to patients deemed to be in need.

The MMP ballot measure is set to be on the State ballot for elections in 2020 and cannot be modified. The State Department of Health and other agencies must consider what sort of structure needs to be in place to prepare for the possible creation of a MMP.

Sources

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