Larissa Cohen 610 Farmington Avenue Hartford, CT 06105 July 8, 2012 William M.

Rubenstein, Commissioner Connecticut Department of Consumer Protection 165 Capitol Avenue Hartford, CT 06106 Dear Mr. Rubenstein: Asthma is a debilitating medical condition that affects many residents of Connecticut. The passage of Public Act No. 12-55 has made it possible to look into a new technique for treating and controlling asthma. The state of Connecticut Department of Public Health has been very progressive in designing treatment plans for its large population of asthmatic residents. Tetrahydrocannabinol is a potent anti-inflammatory that works remarkably well as a bronchodilator. Having more treatment options will help everyone in the struggle to control asthma symptoms. In accordance with the available research, statewide vision for asthma care, and Public Act No. 12-55, I propose to allow the palliative use of marijuana to treat asthma. Thank you for your time and consideration with this matter.

Respectfully,

Larissa Cohen Asthma Patient Resident of the State of Connecticut

Proposal to Allow the Palliative Use of Marijuana to Treat Asthma in the State of Connecticut
(2012)

Prepared for William M. Rubenstein, Commissioner Connecticut Department of Consumer Protection Hartford, Connecticut

by: Larissa Cohen Asthma Patient Resident of the State of Connecticut

July 8, 2012

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Table of Contents
page Letter of Transmittal.................................................................................................................................. ii Executive Summary.................................................................................................................................. iv Introduction................................................................................................................................................ 1 Overview........................................................................................................................................ 1 Connecticut State Law: Public Act 12-55...................................................................................... 1 Statement of Problem: Asthma in Connecticut.............................................................................. 1 Asthma: Measurements and Medications...................................................................................... 2 Proposed Plan.............................................................................................................................................3 Effectiveness of Marijuana for the Treatment of Asthma.............................................................. 3 Effect of Marijuana Smoke on Asthma.......................................................................................... 4 Different Ways to Consume Marijuana..........................................................................................5 Patient Freedom............................................................................................................................. 5 Ease of Implementation................................................................................................................. 6 Conclusion................................................................................................................................................. 6 Works Cited................................................................................................................................................7

Palliative Marijuana for Asthma in Connecticut iv

Executive Summary
Asthma is a public health issue in the state of Connecticut. There is a higher-than-average prevalence of asthma in Connecticut, and the state government spends millions of dollars each year on the treatment of asthma. There is plentiful evidence to support allowing patients to use marijuana to treat their asthma. Tetrahydrocannabinol is an anti-inflammatory and acts as a bronchodilator. If smoking marijuana triggers bronchoconstriction or irritation for a patient, there are other ways of preparing the plant that do not result in the inhalation of smoke. To utilize this plan, it is necessary for the Connecticut Department of Consumer Protection to adopt a regulation to add asthma to the list of debilitating conditions that qualify a person to use medical marijuana (in accordance with Pub L. 12-55, Section 14-c).

Palliative Marijuana for Asthma in Connecticut

Introduction
Overview The state of Connecticut has established a medical marijuana program that includes provisions about adding disorders to the list of debilitating medical conditions that qualify for the palliative use of marijuana. There is substantial evidence for the effectiveness of marijuana for treating asthma. It would be a positive step in addressing asthma in Asthma is a major public health issue in Connecticut, costing patients their livelihood and the government millions of dollars each year. qualifies for medical marijuana. Connecticut State Law: Public Act 12-55 Effective October 1, 2012, the state of Connecticut will implement Public Act No. 12-55, a statewide medical marijuana program. In order to qualify for a registration certificate, a patient must be diagnosed with a debilitating medical condition, defined specifically in Section 1-2 as (A) cancer, glaucoma, positive status for human immunodeficiency virus or acquired immune deficiency syndrome, Parkinson's disease, multiple sclerosis, damage to the nervous tissue of the spinal cord with objective neurological indication of intractable spasticity, epilepsy, cachexia, wasting syndrome, Crohn's disease, post-traumatic stress disorder, or (B) any medical condition, medical treatment or disease approved by the Department of Consumer Protection (1). Effective May 31, 2012, Section 14-c: The Commissioner of Consumer Protection shall adopt Connecticut to adopt a regulation that legally includes asthma as a debilitating medical condition that

regulations that will establish criteria for adding medical conditions, medical treatments or diseases to the list of debilitating medical conditions that qualify for the palliative use of marijuana, [and] add additional medical conditions, medical treatments or diseases to the list of debilitating medical conditions that qualify for the palliative use of marijuana as recommended by the board, among other things necessary for the implementation of the medical marijuana program (1). Statement of Problem: Asthma in Connecticut Asthma is a chronic malady of the respiratory system. It features a non-permanent, reversible impediment to breathing triggered hyper-sensitively by certain stimuli. It can be treated, but many

Palliative Marijuana for Asthma in Connecticut sufferers do not receive adequate treatment (2).

The state of Connecticut spends $47.3 million annually on hospitalization due to asthma. In the latest data available, the prevalence of both current and lifetime asthma among adults was higher in Connecticut than the United States as a whole. In 2002 alone, there were 49 deaths in Connecticut where asthma was defined as the underlying cause (2). The Collaborative Approach for Addressing Asthma in Connecticut (2009-2014) has set into motion several interventions for addressing this public health issue. These initiatives meet one or more of the following criteria: there is scientific evidence of their effectiveness, they follow NAEPP Guidelines, and/or they show potentially effective results that need further study (3). Also, in the Statewide Asthma Plan, put forward by the Collaborative Approach for Addressing Asthma in Connecticut, there is support for legislative change for healthcare coverage (4). Asthma: Measurements and Medications One of the characteristic symptoms of asthma is bronchospasm (sudden bronchoconstriction). Bronchoconstriction is a tightening of the smooth muscle around the bronchial tubes and lungs. This restricts air flow. The opposite of bronchoconstriction is bronchodilation, which is induced by medication. Figure 1 shows bronchoconstriction on the left side:

Figure 1 CT

Palliative Marijuana for Asthma in Connecticut Department of Public Health (5)

Pulmonary function testing provides ways to measure breathing. These are some variables that are measured: Airway resistance (RAW). Amount of resistance of airway during breathing, a function of pressure difference driving airflow and volumetric airflow. Higher resistance means it is harder to breathe. Airway conductance (GAW). The inverse of RAW. Higher conductance means it is easier to breathe. Thoracic gas volume (VTG). A measure of total lung capacity, based on functional residual capacity. Peak expiratory flow rate (PEFR). Maximum speed of breathing out. Forced expiratory flow rate in one second (FEV 1). Volume of air that can be forcefully blown out in one second (6). Inhaled short-acting bronchodilators force the muscles around the bronchial tubes to relax, quickly alleviating an asthma attack. Most of the short-acting bronchodilators on the market are 2-andrenergic receptor agonists, e.g., albuterol (7).

Proposed Plan
This plan is to establish asthma as a condition that qualifies for the palliative use of marijuana. Effectiveness of Marijuana for the Treatment of Asthma According to the United States Department of Health and Human Services, the most effective [medications] are those that attenuate the underlying inflammation characteristic of asthma (8). Marijuana works to relieve asthma symptoms primarily an anti-inflammatory mechanism of action. It reduces the inflammation of the smooth muscle around bronchial tubes associated with bronchospasm (9). As assessed in a literature review in the Archive of Internal Medicine, Eleven of twelve challenge studies found an association between short-term marijuana administration and bronchodilation (10).

Palliative Marijuana for Asthma in Connecticut

According to one study in the American Review of Respiratory Disease, natural marijuana has a systemically active bronchodilator effect in asthmatic patients beginning 1 hour and lasting as long as 4 hours after ingestion of the drug. Smoking marijuana produced a statistically significant increase in GAW and decreases in RAW in asthmatic subjects (11). Another study in the American Review of Respiratory Disease found also that, inhaled 9-Tetrahydrocannabinol causes a prompt, complete, and sustained reversal of [...] bronchospasm and correction of the associated hyperinflation. The findings were clear; the prompt return of specific GAW and VTG to pre-exercise values after smoked marijuana contrasts with the delayed recovery that followed placebo and saline, indicating the efficacy of inhaled 9-Tetrahydrocannabinol in the correction of exercise-induced asthma. (12). These findings were corroborated in a study in the New England Journal of Medicine, which tested the effect of marijuana smoke in non-asthmatic subjects. It found a 44% increase in GAW, a 38% decrease in RAW, and a 45% increase in PEFR (13). These findings are substantiated again by a study in the British Journal of Clinical Pharmacology that tested the bronchodilation effects of marijuana on asthmatic patients. It found that, all given doses of 1-Tetrahydrocannabinol caused bronchodilation, as reflected by increases in both PEFR and FEV 1. [] The maximum improvement was seen at approximately 60 minutes and was sustained for at least 3 hours (14). A study in Thorax: An International Journal of Respiratory Medicine, found that for asthmatic patients, [albuterol and 1-Tetrahydrocannabinol] were equally effective after one hour, and there is reason to hope that 1-Tetrahydrocannabinol has a longer duration of action than compounds which stimulate adrenoceptors. It determined that, by inhalation in humans 1-Tetrahydrocannabinol and [albuterol] are comparable in efficacy (15). Effect of Marijuana Smoke on Asthma Three of the above cited studies used smoking as the method of administration. This means that any potential bronchoconstrictive effects from smoking have been accounted for in these studies, and they still found profound bronchodilation across the board (11, 12, 13). Marihuana smoke, unlike cigarette

Palliative Marijuana for Asthma in Connecticut

smoke, causes bronchodilation rather than bronchoconstriction and, unlike opiates, does not cause central respiratory depression (13). However, it is likely that the particulate matter in the smoke may trigger bronchospasm in some asthmatic patients, so alternatives to smoking should be considered. Different Ways to Consume Marijuana There are ways other than smoking to effectively turn this plant into medicine. Other ways to administer marijuana include: Vaporizing. Marijuana must be heated (to 105C, 221F) to decarboxylate the naturally produced cannabinolic acids into the cannabinoids that humans have receptors for (16). 9Tetrahydrocannabinol vaporizes at 157C, 315F. This is lower than the flash point of the plant matter itself. Most vaporizers heat the material to 180-195C, 355-385F. Marijuana vapor is cooler and has less tar and particulate matter than smoke and is therefore less harsh and irritating than smoke (17). Edibles. Cannabinoids are soluble in lipids, but not water. Marijuana can be cooked into oil or butter for ingestion. This avoids the possibility of any throat irritation from inhaling heated plant matter, and the effect of the drug lasts longer than inhaled marijuana, making it more efficient (18). Many marijuana cookbooks have been published; there is a vast library of information for patients to learn how to cook with marijuana. An appropriate administration method could be determined in the same way as dosage, by doctors with their patients. It would be up to each doctor to assess their patient's individual needs and work with their patients to develop a treatment plan. Patient Freedom These new treatments would not replace conventional medication, but would give doctors and patients one more tool in the fight against asthma. Thirty percent of adults in Connecticut with current asthma are not using prescription medication to treat their asthma (CDC, 2008). Six percent of people in Connecticut do not have health insurance (2). According to section 16 of Public Law 12-55, health insurance will not be required to cover medical marijuana (1). Medical marijuana could work as a

Palliative Marijuana for Asthma in Connecticut

treatment option for the uninsured or the people who do not want to use prescription medications. The more options that are available, the more empowered patients will be to control their asthma. Ease of Implementation The only necessary action is the adoption of a regulation that adds asthma to the definition of debilitating medical condition. It would not require any additional resources from the state to implement this treatment plan as part of State Public Act No. 12-55.

Conclusion
Proposed is the adoption of a regulation to add asthma to the list of debilitating conditions that qualify a person to use medical marijuana, in accordance with Connecticut Public Act No. 12-55, Section 14(c). It would be a cost-efficient and effective treatment option for asthma among the residents of the state of Connecticut.

Palliative Marijuana for Asthma in Connecticut

Works Cited
(1) An Act Concerning the Palliative Use of Marijuana. Pub. L. 12-55. 31 May 2012. House Bill 5389. <http://www.cga.ct.gov/2012/ACT/PA/2012PA-00055-R00HB-05389-PA.htm>. (2) Connecticut. Department of Public Health. Asthma in Connecticut 2008: A Surveillance Report. 2008. <http://www.ct.gov/dph/lib/dph/hems/asthma/pdf/asthma_in_connecticut_2008_surveillance_report .pdf>. (3) Connecticut. Department of Public Health. Collaborative Approach for Addressing Asthma in Connecticut: 2009-2014. 2009. <http://www.ct.gov/dph/lib/dph/hems/asthma/pdf/102009_final_revised_state_plan.pdf>. (4) Connecticut. Department of Public Health, Statewide Asthma Task Force. Collaborative Approach for Addressing Asthma in Connecticut: Connecticut Statewide Asthma Plan. 2003. <http://www.ct.gov/dph/lib/dph/state_health_planning/dphplans/asthma_plan_2004.pdf>. (5) Why asthma makes it hard to breathe. Graphic. Connecticut Department of Public Health. <http://www.ct.gov/dph/lib/dph/hems/asthma/images/hard_to_breath.png>. (6) Gildea, Thomas R., and Kevin McCarthy. Cleveland Clinic: Disease Management Project. Pulmonary Function Testing. <http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/pulmonary/pulmonaryfunction-testing/>. (7) Connecticut. Department of Public Health. Common Asthma Medications. <http://www.ct.gov/dph/lib/dph/hems/asthma/pdf/pt._med_ed._sheet.pdf>. (8) United States. Department of Health and Human Services, National Institutes of Health, National Heart Lung and Blood Institute. Guidelines for the Diagnosis and Management of Asthma. 2007. <http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf>. (9) Lu, D., V.K. Vemuri, R.I. Duclos, Jr, and A. Makriyannis. "The cannabinergic system as a target for anti-inflammatory therapies." Current Topics in Medicinal Chemistry. 6.13 (2006): 1401-1426. <http://www.ncbi.nlm.nih.gov/pubmed/16918457>. (10) Tetrault, MD, Jeanette M., Kristina Crothers, MD, Brent A. Moore, PhD, Reena Mehra, MD, MS, John Concato, MD, MS, MPH, and David A. Fiellin, MD. "Effects of Marijuana Smoking on Pulmonary Function and Respiratory Complications: A Systematic Review." Archives of Internal

Palliative Marijuana for Asthma in Connecticut Medicine. 167.3 (2007): 221-228. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2720277/>.

(11) Tashkin, Donald P., Bertrand J. Shapiro, and Ira M. Frank. "Acute effects of smoked marijuana and oral delta-9-tetrahydrocannabinol on specific airway conductance in asthmatic subjects." American Review of Respiratory Disease. 109. (1974): 420-428. <http://www.ncbi.nlm.nih.gov/pubmed/4816823>. (12) Tashkin, Donald P., Bertrand J. Shapiro, Enoch Lee, and Charles E. Harper. "Effects of Smoked Marijuana in Experimentally Induced Asthma." American Review of Respiratory Disease. 112. (1975): 377-386. <http://www.ncbi.nlm.nih.gov/pubmed/1099949>. (13) Vachon, M.D., Louis, Muiris X. FitzGerald, M.D., Norman H. Solliday, M.D., Ira A. Gould, M.D., and Edward A. Gaensler, M.D. "Single-Dose Effect of Marihuana Smoke - Bronchial Dynamics and Respiratory-Center Sensitivity in Normal Subjects."New England Journal of Medicine. 288. (1973): 985-989. <http://www.nejm.org/action/showImage? doi=10.1056/NEJM197305102881902&iid=f002>. (14) Hartley, J.P.R., S.G Nogrady, A. Seaton, and J.D.P. Graham. "Bronchodilator Effect of delta-1Tetrahydrocannabinol." British Journal of Clinical Pharmacology. 5. (1978): 523-525. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1429361/pdf/brjclinpharm00292-0050.pdf>. (15) Williams, S.J., J.P. Hartley, and J.D. Graham. "Bronchodilator effect of delta-1tetrahydrocannabinol administered by aerosol to asthmatic patients." Thorax: An International Journal of Respiratory Medicine. 31.6 (1976): 720-723. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC470501/pdf/thorax00150-0100.pdf>. (16) Nelson, Robert A.. "Cannabinoid Chemistry." Hemp Husbandry. 2000. <http://www.rexresearch.com/hhusb/hh6thc.htm>. (17) Geiringer, Ph.D., Dale. "Marijuana Water Pipe and Vaporizer Study." Newsletter of the Multidisciplinary Association for Psychedelic Studies. 6.3 (2000). (18) Gottlieb, Adam. The Art and Science of Cooking with Cannabis. 3. Ronin, 1993. (19) Center For Disease Control's National Asthma Control Program, National Center for Environmental Health: Division of Environmental Hazards and Health Effects. Asthma in Connecticut. 2008. <http://www.cdc.gov/asthma/stateprofiles/Asthma_in_CT.pdf>.