Suzanne Miller would not want to be called Princeton’s Marijuana Lady, but she would be proud to be known as Princeton’s Medical Marijuana Advocate. A clinical psychologist at Philadelphia’s Fox Chase Cancer Center, Miller has long dealt with the treatment options available not only to cancer patients but also to cancer survivors whose recovery regimens have permanently damaged parts of their nervous systems and bodies.
Though marijuana could not legally be prescribed for her patients until 2016, when medical marijuana was legalized in Pennsylvania, Miller had heard many comments from them about its beneficial effects in alleviating pain, depression, and anxiety. She was both impressed by and sympathetic to their stories, which she incorporates into her position as professor of cancer prevention and control and director of patient empowerment and decision making.
It was, therefore, without a second thought that in 2011 she agreed to join the board of a nonprofit foundation that would legally distribute medical marijuana in New Jersey. “It’s been a real learning curve, in many ways,” she says.
She was recruited by Pennington resident David Knowlton, the since-retired head of the West Windsor-based New Jersey Health Care Quality Institute. Miller, a Princeton area resident since she came here with her first husband in 1980, assumed that the dispensary would be located in the Princeton area.
Instead, the founding board learned, the dispensary — or Alternative Treatment Center (ATC), in government parlance — would be located in Egg Harbor Township, some 80 miles from Princeton. Though not pleased with that location, Miller and her fellow board members were committed to alleviating the suffering of many. “That feeling is embedded in our naming our dispensary the Compassionate Care Foundation,” she explains. The dispensary opened in October, 2013.
The Compassionate Care Foundation (CCF) is one of the original six dispensaries licensed under the New Jersey Compassionate Use Medical Marijuana Act, signed into law by Governor Jon Corzine on his last day in office in 2010. His successor, Chris Christie, opposed the law and in its implementation created an extremely strict medical marijuana program. That is set to change under the current governor, Phil Murphy.
For Miller the strict regulations began with a visit from the FBI. “The state required that all prospective board members be cleared by the FBI,” she says. “Agents came to my home and fingerprinted me. That was a new experience.”
Once they had an ATC approval and FBI clearance, the board had to finalize a detailed plan. While the board was small and well rounded, Miller says, “we were flying by the seats of our pants.” Besides Miller the board included Donald Parisi, the former state deputy attorney general for banking and insurance, and Charles Howard, a diagnostic radiologist retired from Princeton Radiology Associates.
In addition to the regulatory, administrative, and security hoops mandated by the state, the board had to decide what marijuana to grow and how to grow it. Each approved dispensary created its own plan, subject to state approval, and to this day each offers different products and marijuana strains — what gardeners would call cultivars or hybrids.
Marijuana was ubiquitous, Miller says, while she was growing up in the 1960s in Montreal, Quebec, where her father was a real estate investor and musician and her mother a professional model. That included McGill University, where Miller received her B.S. in psychology in 1972. Her asthma, she reports, prevented her from smoking it, but it appeared to make a lot of friends quite jolly. In England, however, where she received her Ph.D. in clinical psychology from the University of London in 1976, marijuana was not part of the curriculum or her social scene. She was aware that the name kush often appeared in various concoctions and terms such as shake and bud were common among marijuana users. These had come into being as part of the so-called street parlance long used in the marijuana underground. Though the street names remain in use today, none deal with the medicinal aspect of marijuana plants.
Most people do not realize what is encompassed within the broad term marijuana, which refers to members of the Cannabis genus. Even botanists aren’t quite sure what plants are in the genus. There is widespread but not total agreement that two species constitute the genus: indica and sativa. The two primary chemicals in these plants are known as THC and CBD. The former, dominant in indica, is potent as a mood enhancer and the latter, dominant in sativa, is said to be a pain inhibitor.
As with the grapes used in creating wine, growing conditions — light, soil, temperature — all affect the final product. And then there is the fact that the two cannabis species can be modified and combined beyond all original recognition. There are more than 100 what are called cannabinoids in a plant and all are needed, in some combination, to create a desired result (e.g., pain relief and anxiety reduction).
Hemp, for example is a sativa species rich in CBD and in which most if not all of the THC properties have been eliminated. This was probably a factor in the cultivation and sale of hemp plants with less than 0.3 percent THC being allowed under the 2018 Farm Bill. And that legality is why CBD oils and other hemp products are now being offered in stores.
Because of the great variety in cannabis strains, CCF only grows its plants from clones. This means that the plants are not grown from seed but from cuttings that are rooted. This method of propagation ensures that the resulting plants are exactly the same as the parent, something not possible from seed-grown plants.
Until recently, there was, as Miller and her fellow board members know, little recognized clinical or chemical research on the medical benefits of cannabis drug use since such exploration has long been difficult to pursue in the United States owing to its federal status as a controlled substance. And there is no one marijuana strain that addresses all medical needs.
Many of the highest quality studies on the effectiveness of marijuana have been done in Canada, where research faces fewer legal hurdles. Some rigorous clinical studies have not been encouraging for medical marijuana advocates.
The Alberta College of Family Physicians produced a report recently that summarizes the results of clinical trials and created guidelines for doctors to use in prescribing. Multiple studies showed medical marijuana, both of the inhaled variety and synthetic cannabinoid drugs, to be ineffective in treating chronic pain; pain from neuropathy, cancer, HIV neuropathy, and multiple sclerosis; and acute pain. Patients also experienced common side effects such as high blood pressure or hallucinations and paranoia.
But individual patient results can tell a different story. “We really are very patient centric,” Miller says, “so we’re constantly exploring strains that will work better for our patients and base that choice on patient feedback. That’s really the basis of medical marijuana research today. You can call in anecdotal; we prefer to call it clinical experience.”
While the state measures the THC and CBD content in every strain offered by the dispensaries, “it’s not because the strains are so different,” Miller explains, “but rather that the cultivation methods vary considerably.”
“This, we feel, is a problem associated with the legalization of recreational marijuana,” she says. “According to the National Institute on Drug Abuse, cannabis has changed and it is now possible to mass produce plants with potencies inconceivable when concerted monitoring efforts started 40 years ago. And because home grown conditions vary dramatically, the final marijuana product is basically an unknown — even though it might have the same name as many other offerings.”
Dr. Benjaman Gitterman, an internist with the Princeton Medical Group, echoes this finding. “I wouldn’t want young people to try recreational marijuana,” he says. “Not only because of the tremendous, unregulated variety in the product, but also because there is a significant amount of research that indicates it can harm the maturing brain.”
Dr. Gitterman has a different take on medical marijuana. “I think it cruel to not offer this to patients who have tried everything else and are still suffering,” he says, “especially when it appears that medical marijuana is not as addictive as opioids.”
With that belief, he convinced the Medical Group that he be approved by the state to allow patients to apply for medical marijuana (he is no longer accepting new patients). And he is not alone in certifying patients to receive medical marijuana — recent data indicates that Princeton has the state’s highest per capita of doctors approved to recommend this benefit.
Even with the expansion of medical marijuana benefits described below, the requirement that each patient receive a doctor’s approval remains. Such approval does not guarantee overnight access to medical marijuana. The doctor’s approval is sent to a state agency, and that agency then issues the card that allows an individual to obtain the drug.
It has now been more than six years since Miller joined the Compassionate Care Foundation, which has continued to grow as demand for medical marijuana increases rapidly. The board has expanded to include John Agos, executive vice president of the American Diabetes Association; Jon Martin, an attorney retired from Fox Rothschild; Donald Mazzella, COO and publisher at Information Strategies; and Rob Maroni, vice president for talent at the law firm Greenberg Taurig in Florham Park.
Since the CCF opened in 2013 it has served nearly 9,000 patients and distributed more than 3,000 pounds of marijuana. It has grown from serving 350 patients in 2013 to 4,200 in 2018. Last year CCF collected $4,905,560.61 in revenue — an increase from $3,499,533.86 in 2017 — and sold marijuana at an average of $365.29 per ounce for patients not qualifying for any discounts. (Groups who qualify for discounts can include those receiving government assistance, military veterans, seniors, and minors.)
These rapid growth numbers are not unique to CCF. All six of the state’s dispensaries have seen rapidly growing demand for their services. A biennial report issued in April by the state Department of Health’s Division of Medical Marijuana concluded that improved access was needed across the board, including a higher limit on how much marijuana patients are allowed per month, more dispensaries, and lower price points.
These findings led to new urgency at the state level to expand the medical marijuana program. Among states with a medical marijuana program, according to the report, the average population per dispensary is 102,029. In densely populated New Jersey, there are more than 1.5 million people per dispensary. The report also noted that less than half of the state is within a 30-minute drive of an ATC. The report concluded that roughly 90 dispensaries would be needed to properly serve the state’s population.
Already, Governor Murphy has used the 2010 New Jersey Compassionate Use of Medical Marijuana Act as the means of slowly expanding legal marijuana use. That act noted that “states are not required to enforce federal law or to prosecute people for engaging in activities prohibited by federal law.”
Last December he approved the addition of six for-profit Alternative Treatment Centers, including one in Ewing, again with the requirement that they be vertically integrated — that is that they grow, process, and sell marijuana. Due to required background checks, none have become operational yet.
Murphy markedly increased the legal number of conditions to be treated with medical marijuana in March, 2019, adding anxiety, migraines, Tourette’s syndrome, chronic pain related to musculoskeletal disorders, and chronic visceral pain to a list that already included ALS, multiple sclerosis, opioid use disorder, terminal cancer and other terminal illnesses with a prognosis under 12 months, and inflammatory bowel disease. There are also several conditional uses for diseases such as epilepsy and glaucoma in cases where traditional treatments have failed.
With the failure of recreational marijuana legalization in March, Murphy and the state legislature have engaged in what politely may be known as a pissing match. On June 3 the Division of Medical Marijuana in the Department of Health seized on the report’s conclusions by announcing that 108 requests for proposals for ATCs would be considered. That number has been revised downwards in light of more recent legislative developments.
That announcement from the Department of Health clashed with the work that the state legislature has been pursuing — legislation that started as an adjunct to the failed recreational marijuana legislation. A bill on the verge of passing several weeks ago was pulled amid concerns that Murphy would veto it. After numerous revisions, the bill was expected to be signed into law by Murphy after the state legislature approved it by a wide margin on June 20.
The new legislation reduces several onerous requirements, including a change from four annual doctors visits to recertify patients to one and a phase-out of the 6.625 percent sales tax on medical marijuana by 2022. Under the law, control of the program will pass from the Department of Health to a five-member Cannabis Regulatory Commission.
The law also increases the amount of marijuana patients are allowed to buy per month from two ounces to three, with no limit for those with terminal illnesses. The report found that in 2017 — the most recent for which these data are available — 27.71 percent of patients purchased the maximum monthly allotment in at least one month, and 8.62 percent purchased the maximum quantity in at least six months out of twelve.
Lawmakers hope that expanding access to medical marijuana will also help reduce prices, as the state report noted that “high prices are likely artificially suppressing demand among qualified patients.” Before discounts, the report said, the average price of marijuana at the ATCs was 8.44 percent higher than the average price of illegally sourced marijuana. At CCF the price was 6.34 percent higher. No health insurance plans cover medical marijuana, though roughly half of patients qualify for some discount.
But it is not just consumers who have concerns with cost. The original ATC licenses, like the one held by CCF, required that the centers operate as nonprofits, and they were not eligible to apply last year for new licenses as for-profits. As a nonprofit dealing with a substance still considered illegal by the federal government, the dispensaries could not rely on banks for funding and are charged exorbitant interest rates by private lenders. CCF is also not eligible to be considered a nonprofit by the federal government, meaning that the CCF pays taxes and is not eligible for certain deductions available to other small businesses.
A burden was lifted last May when CCF entered a management contract with Acreage Holdings, a cannabis investment firm backed by former Speaker of the House John Boehner, but CCF will face steep competition from new for-profit ATCs with easier access to funding.
In CCF’s annual report, issued earlier this year, board chair David Knowlton wrote that “the state is perhaps unintentionally creating a situation where for-profit investors actually harm existing nonprofits, which can only access funds through loans or donations. This doesn’t help anyone, especially not patients.”
While the idea of converting to a for-profit enterprise is a possible long-range plan for Miller and others involved in the Community Care Foundation, their commitment to patient care is also long range. This year Knowlton started a second nonprofit, the Cannabis Education and Research Institute (CERI).
In CCF’s annual report Knowlton explained that CERI “is committed to advancing unbiased, evidence-based research on the medical use of cannabis and to provide reliable information to consumers, clinicians, players and policymakers.”
Knowlton continued that “For CERI, for Compassionate Care Foundation, and for all of those associated with this patient-focused, policy-oriented approach to medical marijuana, the future holds great promise and excitement. All involved know there will be more obstacles to overcome. They also know that for patients, the benefits of medical marijuana cannot be overstated.”
As Miller says, “We have witnessed and dealt with incredible suffering and are committed to researching the means for alleviating it.”
For further information on the state’s medical marijuana program: www.nj.gov/health/medicinalmarijuana.
For more on the Compassionate Care Foundation: www.ccfnj.org.
Marijuana on the Calendar
There are several upcoming events related to medical Marijuana in New Jersey.
NJ Cannabis Insider hosts a summer meet-up on Wednesday, June 26, from 6 to 8 p.m. at JJ Bitting Brewing Company in Woodbridge. The event includes a Q&A with Kelly Crosson, vice president of the New Jersey Cannabis Industry Association, and Jeff Brown, assistant commissioner of the state Medicinal Marijuana Program. Tickets are $40; registration is required via njcannabisinsider.nj.com.
The Princeton Senior Resource Center hosts a seminar on the NJ Compassionate Use Medical Marijuana Act on Monday, July 15, at 1 p.m. at the Suzanne Patterson Building, 45 Stockton Street, Princeton. Ken Wolski, a registered nurse with more than 40 years of experience and the executive director and co-founder of the nonprofit Coalition for Medical Marijuana-New Jersey, discusses marijuana as it relates to the typical problems of aging. The event is free; registration is required at www.princetonsenior.org.