Twice a month, Wendy Shoemaker visits a Windsor Heights shopping center to pick up something she believes has changed her life.
Her destination, a storefront with two-leaf plant images on the windows, is a dispensary that sells medical marijuana products. Next door is a Nepalese and Indian restaurant. Across the street is a B-Bop’s burger chain.
Shoemaker, 51, entered the dispensary on a recent November afternoon slowly, with the help of a cane. She sat on minimalist furniture, near computer screens set up to help customers with their purchases. The process, she said, can feel like visiting an Apple store.
Within minutes, Shoemaker walked out with capsules customized to address the pain she feels from a degenerative disease. The products — she sometimes buys cream and vapor — have helped her to quit the opioids she was previously prescribed, which in turn has allowed Shoemaker to work, drive and spend more time with her family.
“I’m alive again,” Shoemaker said.
Sunday is the first anniversary of Iowans being able to buy medical marijuana products in the state. On paper, things look promising: an expanding list of qualifying medical conditions under the program, 300 to 450 new patients each month, and more than $2 million in sales.
But as stakeholders mark the milestone, questions abound about the program’s future.
Officials from MedPharm Iowa, the leading medical marijuana manufacturer in the state, have warned that restrictions on the program will stagnate it. The company has lobbied Iowa lawmakers to increase the potency of available products, arguing that people with medical ailments need more relief. A bill that would have upped potency was rejected by the governor last spring, raising expectations that the debate will return in the 2020 legislative session.
MedPharm Iowa officials also say that adding qualifying medical conditions would increase program enrollment. While nearly 5,000 people have signed up — Iowa has 3.1 million residents — advocates believe many more could benefit from cannabis. Nearly half of current patients are from 50 to 70 years old.
“We are at a true inflection point,” said Lucas Nelson, general manager for MedPharm Iowa.
Another potential threat: the possibility that would-be medical marijuana users will bypass Iowa’s restrictions and cross the border to buy products in Illinois once its recreational marijuana law goes into effect Jan. 1.
Iowa’s Medical Cannabidiol Board, a state panel of physicians and law enforcement personnel that makes recommendations about the scope of the program, has acted cautiously on expanding it. Board members say their approach is appropriate, given the limited research about the medicinal benefits of marijuana or other related compounds.
“Their concern is the patient,” board chairman Mike McKelvey said of his physician colleagues. “They’re trying to be careful.”
‘We still do have a long way to go’
Several times a month, Nelson meets one or a group of Iowa lawmakers at the company’s manufacturing plant a few blocks from the state Capitol.
Nelson wants to dispel perceptions about the numerous marijuana plants inside. He shows the lawmakers temperature-controlled rooms with plants at various stages of readiness, and points to large machines that help crush and liquefy what will be distributed.
“Part of what we’re trying to showcase is that, whether it’s cultivation or our extraction or anything else over here in the facility, we’re doing everything based in science,” Nelson said.
MedPharm Iowa, which works with Des Moines-based Kemin Industries, was the first company licensed to manufacture medical marijuana in the state. It sells products at its two state-approved dispensaries, including the Windsor Heights location, where Shoemaker buys products. Iowa Relief, a subsidiary of New Jersey-based Acreage Holdings and the second licensed manufacturer in the state, began sales in August.
Nelson’s tours have increased in frequency since the bill to expand Iowa’s medical marijuana program died last session.
The bill would have lifted a 3% cap on how much THC is allowed in medical marijuana products made and sold in Iowa. THC is the psychoactive ingredient that in large enough quantities makes recreational marijuana users high. The legislation proposed a per-person limit of 25 grams of THC in a 90-day period.
The Republican-controlled Legislature approved the bill, but some lawmakers said they regretted their votes after realizing the medical cannabidiol board didn’t support the increase (it supports a lower purchase cap of 4.5 grams of THC in 90 days). A board member resigned, claiming some lawmakers misrepresented the board’s position when finalizing chamber votes.
Weeks later, Gov. Kim Reynolds vetoed the bill.
“The health and safety of Iowans is too important for us not to get this right,” the Republican governor said at the time.
Nelson is frustrated by the veto. He said MedPharm Iowa has invested about $15 million in Iowa’s medical marijuana program, which he believes is among the most restrictive in the country. Pennsylvania’s medical marijuana program, which has fewer restrictions, had sales top $500 million in its first two years. Sales in Arkansas, another state with fewer restrictions on its medical marijuana program, exceeded $6 million in its first three months.
In 33 states, the District of Columbia, Guam, Puerto Rico and the U.S. Virgin Islands, lawmakers have approved “comprehensive, publicly available medical marijuana/cannabis programs,” according to the National Conference of State Legislatures. Iowa is not among those states.
Instead, it is listed as a “low-THC/high CBD-cannabidiol” state, a reference to key molecules extracted from the marijuana plant.
“Look no further than the veto last legislative session to realize that we still do have a long way to go,” Nelson said.
‘It’s something new that we’re bringing to Iowa and patients’
State employee Owen Parker plans his work week around an Iowa map.
As program manager for Iowa’s medical marijuana program, Parker gives presentations to demystify the existing law. He explains which products are permitted (tablets, capsules, gels and ointments), and which ones are not (edibles and rolled cannabis cigarettes).
Parker estimates he’s given about 60 presentations to health care providers and other groups. His presentation, with its charts and figures, is up to 42 slides.
“It’s something new that we’re bringing to Iowa and patients,” Parker said. “The stakeholders need to have that information … how to navigate it, and what it really means.”
For Parker and other officials who oversee the administrative side of the program through the Iowa Department of Public Health, the behind-the-scenes work is proof that the state is serious about its medical marijuana program.
Sarah Reisetter, deputy director for the public health department, said staff worked nights and weekends to launch manufacturing and sales from scratch. Iowa’s medical marijuana law from 2014 allowed people diagnosed with a form of epilepsy to use oil. A 2017 update to the law expanded the number of products, along with the list of qualifying medical conditions (it now includes cancer, multiple sclerosis, seizures and other diagnoses).
“We have a lot of investment in this program,” Reisetter said.
But it’s the medical cannabidiol board, created in 2017, that has become a principal voice over the program’s future. Some marijuana supporters see the panel as a barrier.
Advocates for increasing potency have presented studies to the board showing marijuana’s medicinal benefits. McKelvey, the sole law enforcement official on the board, said the data is often limited.
“They’re using more anecdotal, small-sample-size research to say, ‘Yes, this is safe. This is effective,'” he said of some of the information.
The debate over medical marijuana benefits is playing out around the country. Marijuana is still a Schedule I substance under federal law, a classification that means it has no accepted medical use. Medical research on the drug is just now catching up.
The National Academies of Sciences, Engineering, and Medicine released a report in 2017 with nearly 100 conclusions related to the health effects of cannabis and cannabinoid use. The report included both limited and conclusive evidence of benefits, depending on the medical condition.
Separately, the U.S. Food and Drug Administration recently issued warnings to 15 companies they say were illegally selling cannabidiol products, and outlined “specific safety concerns related to CBD products, including potential liver injury, interactions with other drugs, drowsiness, diarrhea, and changes in mood.”
The board has cited limited data as the reason it’s been selective in adding medical conditions that qualify for the program, a process that involves public petitions. It rejected six of the 11 conditions considered in 2019.
The board approved corticobasal degeneration, a neurological disorder; severe intractable autism with self-injurious or aggressive behaviors; chronic pain; post-traumatic stress disorder, or PTSD; and intellectual disability with aggression and/or self-injury.
The Iowa Board of Medicine, a higher state authority, rejected chronic pain but approved the neurological disorder and autism condition. It will review PTSD and the intellectual disability condition in December.
McKelvey said the board, which supports other provisions of the 2019 medical marijuana bill designed to make the program more accessible, wants to collect more data about Iowa patients and their response to products.
“Our board, I think, is kind of on the medical side, or science,” he said. “They want to see how the patients are doing.”
Program in ‘danger of collapse’?
At a mid-November news conference on the first floor of the Iowa Capitol, Sen. Joe Bolkcom previewed the dynamics of the upcoming legislative session.
“Iowa’s medical cannabis program is in danger of collapse,” the Iowa City Democrat said.
Bolkcom’s concern: Illinois will start allowing the production and sale of recreational marijuana on Jan. 1.
Bolkcom thinks Illinois will compete for Iowa’s medical marijuana patients, who currently must have a qualifying medical condition, a doctor’s approval and a state card.
Federal law prohibits Iowans from buying marijuana products in Illinois and driving them across state lines. But Bolkcom doesn’t think that will dissuade Iowans who would save money by buying products in Illinois: The average cost per transaction for medical marijuana products in Iowa is $148.
“People are going to have access to cheaper, more effective cannabis products than are currently available here,” Bolkcom said.
In November, the medical cannabidiol board affirmed its recommendation of 4.5 grams of THC in a 90-day period. Whether the board compromises on dosage remains a key issue for the session. The panel has indicated support for health care practitioners to certify a patient for more THC if the patient and physician agree that the 4.5 grams is not enough. Nelson with MedPharm Iowa said that type of exemption could run into legal challenges.
Lawmakers like Bolkcom plan to introduce legislation to lift the cap, but passage will come down to Republicans like Rep. Steven Holt. The Denison lawmaker wants to follow the board’s recommendations.
Holt, who recently visited the MedPharm Iowa facility, hopes for consensus.
“The bottom line is we established a medical board specifically to try to take the politics out of this,” Holt said.
Bolkcom believes Iowa lawmakers shouldn’t rely solely on the board. He said Republican lawmakers have supported “Right to Try” legislation that effectively gives terminally ill patients treatment options that aren’t federally approved.
“At the end of the day, we should listen to sick, suffering Iowans about what they want,” Bolkcom said.
Reynolds, who toured MedPharm Iowa’s Des Moines plant a few days before Thanksgiving, suggested that the nascent medical marijuana program could evolve as more information is known.
“We’ll be working with the board, we’ll be talking to lawmakers, we’ll be talking to individuals that are impacted and using the product, and we’ll see where we land this next legislative session,” she said after the tour.
Her visit to the plant gives hope to people like Shoemaker, the MedPharm Iowa patient. Shoemaker said the board’s current recommendations will effectively limit the amount of products she can use. She worries it could lead her back to opioids.
“They’re taking away my freedom of feeling better,” she said. “… I don’t understand why.”