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How Do You Spell Releaf?

Part 2 You can now buy medical cannabis in Utah. Just don’t spark it up.

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Now that Utah has a medical cannabis program (for its rollicking timeline, see City Weekly's "Get on the Canna-bus," published April 22), it should be easy for anyone to sign up and start smoking, right? Wrong. There are plenty more steps and hoops to jump through before you're able to even visit a pharmacy.

As many City Weekly readers likely know, two of our neighboring states—Colorado and Nevada—have had recreational cannabis programs running for years (on top of their decades-old medical cannabis systems), almost certainly capturing millions of tax dollars from Utahns and residents of other restrictive nearby states.

Soon, Colorado and Nevada will be joined by most of the rest of our neighbors: Arizona voters approved a referendum creating a recreational system in November 2020 and were able to start making purchases this January, and the New Mexico Legislature passed a law in March 2021 creating a recreational program scheduled to be up-and-running within the next year.

Of course, by the letter of the law, this availability currently means little for most Utahns, as it's still a state and federal crime to transport cannabis across state lines.

Despite this, Utah medical cardholders can use a loophole approved by the Legislature extending their ability to travel to neighboring states and bring back cannabis—either around 4 ounces of flower, or other products with no more than 20 grams of THC (total, not each)—without worrying about legal ramifications from the state until June 1, when it expires for good. (Cardholders utilizing the loophole are limited to once every 28 days.)

On the legalization front, Wyoming could be next; Republicans in two state House committees voted to send bills that would have legalized recreational cannabis to the full House of Representatives, but legislative leaders eventually let the bills die without coming to a full vote. Idaho, one of the 14 states with no medical program whatsoever, seems to be on shakier ground. There, in direct response to a voter referendum for a medical program that activists are hoping to place on the state's 2022 ballot, Republican lawmakers recently nearly passed a bill that would have created a constitutional amendment forever outlawing cannabis—recreational or medical—in the state. (A separate bill still working its way through the Legislature would create a medical program.)

At this juncture, access to medicinal and recreational weed remains up to the states, and because you, dear reader, have chosen to reside in Utah, you already know that elected officials here are nervous about implementation and just can't resist making it complicated for those who are already suffering.

Thus, like buying booze in Utah, there will be odd requirements and untested regulations just waiting to trip us all up. But breathe easy. City Weekly's "Releaf" guide should make accessing the Utah's forbidden medicine slightly less fraught.

Cannabis for beginners
If you're a little late to game on this whole weed thing—maybe for religious or cultural reasons, or maybe it just hasn't been your thing—not to worry. Cannabis is a plant that has been used by societies around the world for centuries, the flowers of which can be dried and smoked, or made into a variety of other substances.

There are two main categories of cannabis: sativa and indica. Generally, the rule of thumb is that sativa strains produce lighter and more energetic effects, while indica strains are calming—though this isn't a hard-and-fast rule, and there are plenty of strains that are hybrids between the two. There are other parts of the flower—organic compounds called terpenes or terpenoids (which are terpenes in their dried form)—that produce the flavor and smell associated with cannabis.

How much should I take?
If you're participating in the medical cannabis program, you should have access to a medical professional and a cannabis pharmacist that you can talk through your specific needs with; as with any substance, the effects of cannabis can vary widely by product and by person. However, the biggest rule to follow for anyone new to cannabis is to start slow. Take a little at a time and give it some time to work, as opposed to wolfing an entire brownie down if the first few bites don't do anything in the first 10 minutes.

Different products will also produce different effects. Cannabis flower that is vaped or smoked, or cannabis oil or concentrates that are vaped, will produce almost instant effects—though, depending on strain, those effects may be different. Products that have to be ingested, such as edibles or tinctures, can take anywhere from 30 minutes to a couple hours to kick in, depending on your weight and metabolism, how much you've had to eat that day, and the dosage and strain you're taking. And topicals generally only work where they are applied on the body, and don't produce (many) psychoactive effects.

Where can I buy medical cannabis?
There are 14 pharmacies (the state's term for dispensaries) that have received licenses from the Department of Health, but just eight of those have opened their doors as of press time. (Two more are scheduled to open within the next week, according to the state.) To purchase at any of these pharmacies, you have to first register with each individual business and go through a short consultation with one of their pharmacists (even if you've already registered with another pharmacy). Then, finally, you are able to walk through pharmacy doors, or put in a delivery order.

Offerings vary by pharmacy, but generally, patients are able to purchase flower (the green buds most commonly associate with cannabis and are meant to be vaped—smoking it is technically against the law), cannabis oil cartridges or other concentrates, capsules, gummies, topicals (like balms or lotions), or tinctures (liquid drops). Prices also vary, but an eighth of an ounce of flower—the amount that most pharmacies typically offer in a single container—can range from $30 to over $60.

The pharmacies that are now open are concentrated in northern Utah along the Interstate 15 corridor, which has caused access issues for patients who live outside of the state's population centers. Some pharmacies now offer delivery to most parts of the state, for additional delivery fees. Some patient advocates have criticized the relatively low amount of pharmacy licenses issued, placement of the existing pharmacies and delayed timelines for pharmacies outside of the I-15 corridor as being critical bars to access for many would-be participants in the system.

The state now says that the rest of its six licensees—including two in Southern Utah—will be open by summer, and the Legislature passed a bill requiring a 15th license to be issued to a pharmacy in an unspecified rural location. Rich Oborn, director of the state's Center for Medical Cannabis, told KUTV Channel 2 earlier this month he hopes to issue the license, with the help of an outside expert, by the middle of the year.

One of the two pharmacies set to open in coming days, Pure UT, was originally licensed to open in Vernal—at population 10,000, the largest municipality in rural northeastern Utah—but sought and received approval from the Department of Health to relocate to the fast-growing Utah County community of Payson, where it will be one of four pharmacies in quick succession along I-15 in that county. Jordan Lams, founder and CEO of Pure UT's parent company Moxie, wrote in an email that Pure is "pleased that, after much consideration, the DOH agreed with our suggestion that the location in Payson would be able to ultimately provide a greater public health benefit."

Oborn told City Weekly that the pharmacy showed it could serve more patients in Payson, which was the main consideration the state made. The fact that, unlike cultivators, the law allows the state to issue additional pharmacy licenses on top of the initial 14 was also a factor—because there was nothing preventing the state from issuing a new one if data showed it needed to—as was the lower count of cardholders in rural areas. He also said that some Native tribes in the state had expressed interest in opening pharmacies on tribal land, which the law allows them to do through an easier process than other companies are subjected to, which may have helped solve the rural access issue, but no tribes have announced any plans to move forward with their own medical cannabis operations.

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How do I get a medical card?
It's a considerably more complicated process in Utah than in many other states with medical programs, though the Legislature made some efforts to improve certain aspects of that in this year's session. Here are the steps you need to take:

➜ Be sick in the 'right' way
The first requirement you must meet is having the misfortune of being diagnosed with one of the qualifying conditions laid out in the state law: HIV/AIDS, Alzheimer's, ALS, cancer, cachexia (also known as Wasting Syndrome), "persistent" nausea, Crohn's disease or ulcerative colitis, epilepsy or debilitating seizures, MS or persistent muscle spasms, PTSD, autism, a terminal illness, a condition requiring hospice care, rare diseases that meet specific requirements and can't be managed with conventional medicine, or chronic pain that can't be managed with conventional medicine.

If you don't have one of these conditions—or if you're under 21, or the parent/guardian of someone under 21—you can still apply for a medical card through the Compassionate Use Board, a body within the Utah Department of Health created solely to process such applications. The CUB has denied just three of the 215 applications it's received since the program launched last year, according to a report published by the state last month.

There is a separate body that exists to, among other things, make recommendations about new conditions to add to the law—the Cannabinoid Product Board—but it has yet to do so. A bill that would have added opioid use disorder as a qualifying condition, which the CPB opposed, went nowhere during this year's legislative session.

➜ Find a 'qualified' provider
Then, you need to determine which medical provider to see. Broadly, you have two options: a Qualified Medical Provider (QMP) or most other medical professionals. QMPs are doctors, physicians assistants and nurses registered with the state medical cannabis program who are required to undergo extra training and have the ability to write between 275 and 600 recommendations. As of March 2021, Utah had 628 active QMPs. The Utah Department of Health's Center for Medical Cannabis provides a list of most of the registered QMPs on its website.

The Legislature created your other option in the most recent legislative session, when it passed a bill allowing essentially any licensed medical provider in the state to write up to 15 recommendations for medical cards without registering as a QMP. This option allows you to potentially use your general physician or another provider you already know and feel comfortable with—the visits for whom may be covered by insurance, which does not cover most QMP visits (see insurance section).

(Both of the largest medical providers in the state, Intermountain Healthcare and University of Utah Health, allow their medical professionals to write recommendations and/or become QMPs, if they so choose.)

So, to see either a QMP or your regular doctor is a question that requires some research on your end. Does your general physician support you taking medical cannabis, or the concept of medical cannabis at all? If they do, and they aren't a QMP, have they hit their 15-patient cap? If they are a QMP, have they hit their patient cap?

(These patient caps, for both QMPs and other medical providers, are not common among other state medical cannabis systems and are opposed by some patient advocates. The QMP system has also been criticized by advocates and medical professionals for encouraging some QMPs to act as "card mills," charging patients high rates not covered by insurance while providing little actual medical information, according to a January report by the Utah Investigative Journalism Project and Park Record.)

➜ Apply with the state and register with a pharmacy
Once your medical professional ascertains that you do indeed have the qualifying condition, they issue a recommendation to the state through its Electronic Verification System, which you also have to create an account with. You also have to pay the $15 application fee. The state will respond to all applicants who don't have to undergo further review (see below) within 15 days.

Once you've been approved, you can begin the process of registering with pharmacies so you can actually buy cannabis products.

➜ Get tested for adverse effects
However, you're not out of the woods yet. The state requires you to get some basic tests done within 90 days of issuing your card and have your QMP analyze the results to make sure you're not having any adverse effects. If you are, your card will most likely not be renewed. If you're not, you still need to go through a renewal process, which comes with a $5 fee. Six months later, and every six months after that, you'll be due for another renewal, the fee for which goes back up to $15.

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What does the product cost, and will insurance cover it?
That depends entirely on you, your needs and your tolerance.

If you just need the occasional hit from a vape pen for temporary pain, you probably don't need to buy much. If you're a daily vaper (or secret smoker) of flower, $30 to $60 an eighth adds up pretty quickly. You should consult with your medical provider and the pharmacist on staff at the pharmacy you purchase from before making your first purchase, or if you have any questions after that point.

And no, health insurers will not cover your direct costs. A representative for SelectHealth, Intermountain Healthcare's insurance provider, said, "We continually evaluate our benefits to ensure that our members can access cost effective and safe treatment options across the spectrum of health-care needs. At this time, we do not offer coverage for medical cannabis. We only cover FDA-approved prescription drugs, and our coverage excludes herbal medications, most over-the counter medications, and most vitamins or supplements. The FDA has not approved medical cannabis to treat any disease or condition and classifies it as a Schedule 1 drug. In addition, some of the government-sponsored plans we administer, including Medicare and Medicaid, do not allow medical cannabis to be covered."

The vast majority of, if not all, major insurance providers take a similar stance.

Officials in some states, like Florida and New York, have proposed requiring insurers to cover at least some costs, and at least one insurer in Canada offers robust coverage, but no plan in Utah currently offers any coverage. The high prices are preventing many patients and even some advocates who pushed for medical legalization from using the program, said Christine Stenquist, the founder of Together for Responsible Use and Cannabis Education (TRUCE). "At the end of the day, I need to know that patients can get quality medication at an affordable price," she said. "And that is not what this program is. It is designed for the elite. It is not designed for me, I can't afford this program."

Ultimately, "the only thing that would really move the needle on pricing is rescheduling cannabis," according to Narith Panh, the chief strategy officer of Dragonfly Wellness—something that Oborn echoed. Dragonfly is one of Utah's three "vertically integrated" cannabis companies, meaning it holds both cultivation and pharmacy licenses. "Rescheduling" refers to removing cannabis from Schedule I of the federal Controlled Substances Act, which classifies cannabis along with heroin as being addictive with no medical value.

But there may be some help for those in financial need. At the recent Utah Canna Fest, the Utah Patients Coalition launched an initiative to help low-income patients cover some of the costs, according to a Fox 13 report. UPC—a political action committee borne out of one of the organizations that supported the original Prop 2 referendum and then worked with legislative and LDS leaders on the "compromise bill" that eventually passed—will provide subsidies to patients who are able to demonstrate their financial need. Applications are accepted on its website.

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How likely is it that cannabis will be rescheduled?
Being categorized as a Schedule I or II drug subjects cannabis businesses to a provision of the U.S. tax code that prevents businesses that "traffic" in these substances from deducting business expenses from gross income, as essentially all other businesses can. (The Reagan-era provision was originally intended for actual drug traffickers.) This can leave some businesses with effective income tax rates as high as 70 percent. After taxes and expenses, Panh wrote in an email, "As a business, you are forced to choose between charging the patient more to make up for your taxes, or if you are Dragonfly, you make the conscious decision to only make a 5% margin on your business."

An array of powerful legislative leaders, including Senate Majority Leader Chuck Schumer, D-NY, have voiced support for full recreational legalization. During a recent press conference, White House Press Secretary Jen Psaki said that President Joe Biden supports rescheduling cannabis to Schedule II, which would relax most of the prohibitions around its medical use and research, and federally legalize medical—but not recreational—cannabis. However, Schedule II drugs are still subject to many of the same banking and tax restrictions that Schedule I drugs are. Additionally, some in the cannabis industry have voiced concerns around being categorized as Schedule II, which would open the industry up to FDA regulation. The Drug Policy Alliance's official position is in support of descheduling cannabis entirely.

Can Latter-day Saints be prescribed medical MJ?
Yes. In July 2020, the church issued a new section in its General Handbook for members on medical cannabis, which laid out its position: it's in support of medical use, and against recreational use. Regardless of whether or not they can use medical cannabis, they certainly are: LDS stronghold Utah County, which rejected Proposition 2 in 2018, is now home to both the most cardholders and most pharmacy licensees. (Whether that's because Latter-day Saints really like weed more or, as patient advocate Stenquist surmises, most Salt Lake County residents have a "traditional source" that's significantly cheaper than the medical program is up to you to decide.)

Is cannabis being tested for other uses?
Despite barriers such as still being listed as a Schedule I controlled substance by the DEA, studies on different potential medical uses for cannabis are being conducted at universities and private labs around the world, with new research being published every month. Locally, psychiatric researchers at the University of Utah in Salt Lake City have been using brain imaging to learn how cannabinoids affect the brain, while agricultural researchers at Utah State University in Logan have been studying how to get optimal growth out of hemp plants using hydroponics.

Why buy Utah medical cannabis if it's easier/cheaper to purchase in nearby states?
Ultimately, between easy access in neighboring states, a complicated application process and high prices for products, a potential Utah medical cannabis cardholder could be forgiven for asking why it's worth it to participate in Utah's program at all. That's a fair question, Oborn, director of the state's Center for Medical Cannabis, said, but it doesn't take into consideration the patient protections built into Utah's program. The testing that the state's products undergo at independent lab facilities is far beyond what most other states require, he said—recreational or medical. "There's some additional cost involved in sending products to independent labs," he said, "but a higher degree of trust in the products you can buy." Because of the testing procedures, "If you compare our products to one in Nevada, it's like apples and oranges." The benefit of having trained and licensed pharmacists at each pharmacy is also something not offered in most other states, he said.

For more information on Utah's Medical Cannabis program, visit these websites:
medicalcannabis.utah.gov | utahpatients.org | truceutah.org | utahmarijuana.org

Sam Stecklow is a journalist and editor based in Salt Lake City.