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Two cases of “cannabis acute psychosis” following the administration of oral cannabis

Abstract

Background

Cannabis is the most commonly used illegal drug and its therapeutic aspects have a growing interest. Short-term psychotic reactions have been described but not clearly with synthetic oral THC, especially in occasional users.

Case presentations

We report two cases of healthy subjects who were occasional but regular cannabis users without psychiatric history who developed transient psychotic symptoms (depersonalization, paranoid feelings and derealisation) following oral administration of cannabis. In contrast to most other case reports where circumstances and blood concentrations are unknown, the two cases reported here happened under experimental conditions with all subjects negative for cannabis, opiates, amphetamines, cocaine, benzodiazepines and alcohol, and therefore the ingested dose, the time-events of effects on behavior and performance as well as the cannabinoid blood levels were documented.

Conclusion

While the oral route of administration achieves only limited blood concentrations, significant psychotic reactions may occur.

Background

As several countries in Europe have taken policies to decrease the penalties for cannabis possession, many people especially young persons have interpreted this move as giving support to consider cannabis as a benign drug [1].

However as stated by several reports cannabis is not a harmless substance and requires urgent attention considering public health issues such as car driving for example [2]. The relationship between Cannabis and acute psychosis is another important issue. In Pakistan and also India, Bhang, a beverage made from an infusion of cannabis leaves, and flowering tops combined with milk and nuts is reported to frequently induce psychotic manifestations among consumers [3]. Presenting symptoms include grandiosity, excitement, hostility, uncooperativeness, disorientation, hallucinatory behaviour and unusual thought content [3].

Recently five large-scale longitudinal studies and a systematic review have shown that cannabis use in adolescence is associated with a two-to threefold increase in the relative risk of later developing schizophrenia [4]. Furthermore short-term psychotic reactions, particularly in naive users have also been reported. Thomas [5] describes that one in seven people reported psychotic-like symptoms. Such reactions are usually acute, transient, self-limited however very unpleasant (“hearing voices, becoming convinced that someone is trying to harm you or that you are persecuted”) [6]. But cannabinoids are considered able to trigger long-lasting psychotic decompensations in predisposed individuals, which may in part account for the epidemiological association described between cannabis consumption and psychotic disorders [7, 8].

The therapeutic aspects of cannabis represent additional issues, as they are in constant development since several years. Synthetic THC (dronabinol) is available for restricted medical use in the USA since 1985. Nabilone, a synthetic THC analogue, is licensed in UK for the treatment of nausea and vomiting caused by chemotherapy unresponsive to usual anti-emetics. Clinical applications actually include nausea and vomiting, muscle spasticity in demyelinating diseases, loss of appetite in cancer and AIDS, pain, insomnia, asthma as well as other applications [9].

As these oral medications are becoming increasingly available, we think it is useful to report two cases of severe psychological sides effects, especially considering the lack of data in the literature on psychotic symptoms associated with oral synthetic or natural THC.

Case reports

We report two cases out of 8 healthy male volunteers who were included in a double blind crossover clinical study, approved by the ethics committee of the Department of Internal Medicine of the University of Lausanne. All subjects had to be occasional but regular cannabis users. Their urines were controlled to be negative for any drug of abuse (cannabis, opiates, amphetamines, cocaine, benzodiazepines) before each study period. The presence of ethanol was checked using a breathalyzer. All of them provided their written informed consent. This study was carried out to assess the effects of delta-9-tetrahydrocannabinol (THC) on psychomotor function and driving performance. It compared a medication containing 20 mg dronabinol (Marinol R ), and 2 hemp milk decoction containing either a medium (15.8 mg average dose determination) or a high dose of THC (45.7 mg) with matched placebos. The hemp plant fragments containing 1.5 % THC and 4.4 % THC-A were provided by Hiscia institute in Arlesheim, Switzerland. After administration, blood was sampled at regular intervals for cannabinoids determination by gas chromatography coupled with mass spectrometry (GC-MS-NCI). Clinical observations and 2 psychometric tests (roadsign recognition speed and accuracy on a tracking task) were also carried out. Furthermore, the subjects were asked to report their willingness to drive and the subjective effects on a VAS scale extending from 0 to 10 cm. The effects were assessed against placebo.

These 2 cases were withdrawn from the study because of adverse events. We consider them worth reporting for the following reasons: in contrast to most other case reports where circumstances and blood concentrations are not known, our two cases reported here happened under defined clinical setting: the ingested dose, the time-events of effects on behavior and performance as well as the cannabinoid blood levels are fully documented. In addition, the consumption of other psychotropic major drugs could be ruled out.

Case 1

The first subject was a 22-year-old medical student (weight: 65.3 kg, height: 1.82 m) and occasional cannabis smoker (about once per week). One hour after the administration of 20 mg of dronabinol, he started to laugh a lot and after 90 minutes, he manifested a severe anxiety with symptoms of derealisation and depersonalization. He reported “watching himself lying on the bed” and repeated several times the same questions at just a few minutes interval. Starting 2.5 hours after ingestion of dronabinol, and at the 4 hours and 5.5 hours post-ingestion series of tests, he was unable to perform the psychomotor tasks, despite reporting of weakening of symptoms approximately 165 minutes after their initiation. Before going to sleep (more than 10 hours after ingestion), he again felt a transient feeling of irrational anxiety and loosing the perception of his body. The next day he was well but a bit tired.

Figure 1 shows the evolution of his blood concentrations of cannabinoids after ingestion of 20 mg dronabinol. At the time of strong adverse effects, the blood levels of THC and 11-OH-THC reached a concentration of 1.8 and 5.2 ng/mL, respectively. The subject reported a strong feeling of intoxication (figure 2). He also evaluated that his driving capability was strongly impaired (figure 2).

Whole blood concentrations of THC, 11-OH-THC (actives metabolites) and THC-COOH (inactive metabolite) after oral intake of 20 mg dronabinol and of a hemp milk decoction containing traces of cannabinoids (placebo).

Subjective effects (feeling of intoxication or driving capability) after oral intake of 20 mg dronabinol. The subject reported no feeling of intoxication or of driving impairment after ingestion of the placebo.

Case 2

A 22-year-old student, also an occasional cannabis smoker (about twice a month), felt paranoid delusions with severe anxiety one hour after the administration of 16.5 mg of a THC decoction, and became suspicious during the experiment. He thought the investigators were concealing some problems. He was unable to perform the psychometric tests (roadsign recognition speed and accuracy on a tracking task) at the 1 hour and 2.5 hours post-ingestion series of tests. These effects persisted up to 4 hours after ingestion and weakened over the next 3 hours. The feeling was very unpleasant in comparison with that experienced after his usual smoking cannabis consumption.

On the next day, he was well, with no recurrence. The time-concentration curves for the major cannabinoids were similar to those observed after ingestion of 20 mg dronabinol. One hour after drinking the hemp decoction, the THC and 11-OH-THC blood levels were of 6.2 and 3.9 ng/mL, respectively. Similarly to the other volunteer, he also indicated a strong feeling of intoxication and a very important decrease in his self-reported capacity to drive (results not shown).

Conclusion

A temporary form of drug-induced psychotic reaction after administration of oral cannabis has occurred in these two cases. Cannabis psychosis is the term proposed in the literature [10]. In 1958, Ames [11] reported in an experimental design with 10 subjects psychological symptoms such as severe anxiety, panic attacks, paranoid delusions and depersonalization. Talbott [12] in 1969 described 12 soldiers in Vietnam who had disorientation and hallucinations after their first use of cannabis. In Germany, 19 cases of toxic psychosis were reported after hashish use [13] and in Calcutta, Chopra [14] described retrospectively 200 patients hospitalized after the ingestion of large dose of cannabis between 1963 and 1968. Other reports in different countries showed similar features after bhang ingestion [3, 15]. It usually results from taking large amount of the drug, generally in food or drink. The symptoms have some similarity with paranoid schizophrenia, which could raise the hypothesis that ” symptoms of schizophrenic illness might be caused by an abnormal over-activity of endogenous cannabinoid mechanism in the brain” (Iversen [10] citing Emrich [16]). However because of the poor quality of information on previous cannabis experience, cannabis dose intake, other drug consumption and previous psychiatric comorbidity, some commentators have criticized these case series [12, 17, 18]. Case-control studies have been conducted comparing people with cannabis psychosis with persons suffering from schizophrenia [19–21]. However the results were inconsistent due in part to the small sample size of these studies.

The originality of our two cases is that they were observed in an experimental setting, and therefore adds more evidence for the ability of oral cannabis to produce psychotic symptoms. In both our subjects, the effects appeared 1 hour to 1.5 hours after oral drug intake and lasted for 3 to 4 hours. Dronabinol (synthetic THC) is reported to have an onset of action at approximately 0.5 to 1 hour and peak effects between 2 and 4 hours. Psychoactive effects last 4 to 6 hours but the appetite stimulant effect may continue for 24 hours [22].

The issue of THC dose level is very important in terms of public health. A traditional cigarette of herbal cannabis in the 1960s and 1970s contained 1–3% THC: for a joint made of 750 mg of cannabis plant, the corresponding THC amount was 7 to 20 mg. However, the actual amount of cannabis taken up (i.e. the percent delivery to the respiratory tree) strongly depends on the smoking technique; it has been reported to reach approximately 50% [23]. Modern cigarettes (joint) based on intensive cannabis selection and improvement in plant cultivation contain 6 to 30% THC. Therefore, an average joint would correspond to 75 mg to 225 mg of THC! [22].

Through smoking, a 3.5% marijuana cigarette with about 900 mg plant materials can achieve plasma concentration in the range of 50 to 100 ng/ml. The maximum psychotropic effect or “high” occurs faster after smoking than by the oral route. Smoking is therefore the preferred route of cannabis administration for young users. Psychomotor function is considered to be obviously impaired above 10 ng/ml plasma THC for smoking cannabis. However in our two cases, the oral administration of cannabis produced circulating THC concentrations much lower than 10 ng/ml. We suggest several explanations for these differences. Firstly, the oral administration produces more active metabolite (11-OH-THC), which could more efficiently reach the effect site than THC. Secondly, as suggested by Chaudry [3], consuming oral cannabis may produce more potent, yet unknown psychotomimetic metabolites of THC. Thirdly, the slow absorption kinetics produces sustained plateau levels in the blood, which could influence the body and brain distribution. In a cocaine fatality, Giroud [24] found that THC and OH-THC were in higher concentration in brain than in blood.

Finally, Leweke [25] in a study including 17 healthy volunteers found also one case that suffered a two-hour episode of paranoid psychotic state following the administration of dronabinol with a lower dose than our study. Furthermore D’Souza [26] administrating intravenous THC to 22 healthy subjects in a double blind randomised clinical trial found a range of transient symptoms resembling those seen in endogenous psychosis. At last, it is important to differentiate these transient psychotic states with spontaneous resolution from the type of psychosis that persist beyond the persistence of drug in the brain, therefore probably indicating a worsening of an underlying pathologic problem.

In conclusion, doctors and users should be aware of the increasing availability of oral cannabis in “special” drinks or food as well as in medications under development. While the oral route of administration achieves only limited blood concentrations, significant psychotic reactions may occur. An increased incidence of psychotic episodes might be induced by this new trend and requires attention regarding this phenomenon in a public health perspective.

References

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Ramaekers JG, Berghaus G, Van Laar M, Drummer OH: Dose related risk of motor vehicle crashes after cannabis use. Drug Alcohol Depend. 2004, 73: 109-119. 10.1016/j.drugalcdep.2003.10.008.

Chaudry JM, Moss HB, Bashir A, Suliman T: Cannabis psychosis following bhang ingestion. British J Addiction. 1991, 86: 1075-1081.

Arseneault L, Cannon M, Witton J, Murray RM: Causal association between cannabis and psychosis: examination of the evidence. Br J Psychiatry. 2004, 184: 110-117. 10.1192/bjp.184.2.110.

Thomas H: A community survey of adverse effects of cannabis use. Drug Alcohol Depend. 1996, 42: 201-207. 10.1016/S0376-8716(96)01277-X.

Hall W: Cannabis and psychosis. Drug Alcohol Rev. 1998, 17: 433-444.

Johns A: Psychiatric effect of cannabis. Br J Psychiatry. 2001, 178: 116-122. 10.1192/bjp.178.2.116.

Van Os J, Bak M, Hanssen M, Bijl RV, de Graaf R, Verdoux H: Cannabis use and psychosis: a longitudinal population-based study. Am J Epidemiol. 2002, 156: 319-27. 10.1093/aje/kwf043.

Robson P: Therapeutic aspects of cannabis and cannabinoids. Br J Psychiatry. 2001, 178: 107-15. 10.1192/bjp.178.2.107.

Iversen L: Cannabis and the brain. Brain. 2003, 126: 1252-1270. 10.1093/brain/awg143.

Ames F: A clinical and metabolic study of acute intoxication with cannabis sativa and its role in the model psychoses. J Ment Sci. 1958, 104: 972-99.

Talbott JA, Teague JW: Marihuana psychosis: acute toxic psychosis associated with the use of cannabis derivatives. JAMA. 1969, 210: 299-302. 10.1001/jama.210.2.299.

Tennant FS, Groesbeck CJ: Psychiatric effects of hashish. Arch Gen Psychiatry. 1972, 27: 133-136.

Chopra GS, Smith JW: Psychotic reactions following cannabis use in East Indians. Arch Gen Psychiatry. 1974, 30: 24-27.

Wylie AS, Scott RTA, Burnett SJ: Psychosis due to “shunk”. BMJ. 1995, 311: 125-

Emrich HM, Leweke FM, Schneider U: Towards a cannabinoid hypothesis of schizophrenia: cognitive impairments due to dysregulation of the endogenous cannabinoid system. Pharmacol Biochem Behav. 1997, 56: 803-7. 10.1016/S0091-3057(96)00426-1.

Thornicroft G: Cannabis and psychosis: is there epidemiological evidence for association. Br J Psychiatry. 1990, 157: 25-33.

Gruber AJ, Pope HG: Cannabis psychotic disorder: does it exist?. Am J Addictions. 1994, 3: 72-83.

Thacore VR, Shukla SRP: Cannabis psychosis and paranoid schizophrenia. Arch Gen Psychiatry. 1976, 33: 383-386.

Rottamburg D, Robins AH, Ben-Arie O, Teggin A, Elk R: Cannabis-associated psychosis with hypomanic features. Lancet. 1982, 2: 1364-1366. 10.1016/S0140-6736(82)91270-3.

Imade AGT, Ebie JC: A retrospective study of symptom patterns of cannabis-induced psychosis. Acta Psychiatr Scand. 1991, 83: 134-136.

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Agurell S, Halldin M, Lindgren JE, Ohlsson A, Widman M, Gillespie H, Hollister L: Pharmacokinetics and metabolism of delta-9-tetrahydrocannabinol and other cannabinoids with emphasis on man. Pharmacol Rev. 1986, 38: 21-43.

Giroud C, Michaud K, Sporkert F, Eap C, Augsburger M, Cardinal P, Mangin P: A fatal overdose of cocaine associated with coingestion of marijuana, buprenorphine, and fluoxetine. Body fluids and tissue distribution of cocaine and its metabolites determined by hydrophilic interaction chromatography-mass spectrometry (HILIC-MS). J Anal Toxicol. 2004, 28: 464-474.

Leweke FM, Schneider U, Thies M, Munte TF, Emrich HM: Effects of synthetic D9-tetrahydrocannabinol on binocular depth inversion of natural and artificial objects in man. Psychopharmacology. 1999, 142: 230-235. 10.1007/s002130050884.

D’Souza DC, Perry E, MacDougall L, Ammerman Y, Cooper T, Wu YT, Braley G, Gueorguieva R, Krystal JH: The psychotomimetic effects of intravenous delta-9-tetrahydrocannabinol in healthy individuals: implications for psychosis. Neuropsychopharmacology. 2004, 29: 1558-72. 10.1038/sj.npp.1300496.

Pre-publication history

The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-244X/5/17/prepub

Acknowledgements

the financial support of the Swiss Federal Office of Public Health is warmly acknowledged (contract 02.001036 to LTCF/IUML). Mr Jérôme Tinguely is thanked for preparing the placebo capsules. Dr Frank Sporkert is strongly acknowledged for fruitful discussion.

Written consent was obtained from the patients for publication of study

Author information

Affiliations

Unité de Médecine du Trafic, Institut Universitaire de Médecine Légale (IUML), 1005, Lausanne, Switzerland

Bernard Favrat & Marie Pin

Laboratoire de Toxicologie et Chimie Forensiques (LTCF), Institut Universitaire de Médecine Légale (IUML), Rue du Bugnon 21, 1005, Lausanne, Switzerland

Annick Ménétrey, Marc Augsburger, Patrice Mangin & Christian Giroud

Division de pharmacologie et toxicologie cliniques, CHUV, 1011, Lausanne, Switzerland

Laura E Rothuizen, Monique Appenzeller & Thierry Buclin

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Cannabis is the most commonly used illegal drug and its therapeutic aspects have a growing interest. Short-term psychotic reactions have been described but not clearly with synthetic oral THC, especially in occasional users. We report two cases of healthy subjects who were occasional but regular cannabis users without psychiatric history who developed transient psychotic symptoms (depersonalization, paranoid feelings and derealisation) following oral administration of cannabis. In contrast to most other case reports where circumstances and blood concentrations are unknown, the two cases reported here happened under experimental conditions with all subjects negative for cannabis, opiates, amphetamines, cocaine, benzodiazepines and alcohol, and therefore the ingested dose, the time-events of effects on behavior and performance as well as the cannabinoid blood levels were documented. While the oral route of administration achieves only limited blood concentrations, significant psychotic reactions may occur.

Illegal Cannabis is Unconstitutional: Hiller PC Takes Landmark Case to Supreme Court

Publié le 8 Oct 2020

Washington v Barr, the biggest cannabis case in recent history to decide the federal legality of the plant and Controlled Substances Act, goes before SCOTUS

Bill of rights, we the people with wooden gavel and American flag.

“Cannabis is nature’s most effective treating product and we’ve criminalized it,” says attorney Michael Hiller. “The racism and deprivation of liberty and life is awful.”

On Friday October 9, 2020, Hiller and his team will bring one of the country’s most groundbreaking cannabis legalization cases before the Supreme Court. Washington v Barr confronts the destructive racism, inequality, and senseless endangerment of life that the War on Drugs has only reinforced since the 1970s. It is the biggest cannabis case in recent history to decide the plant’s federal legality, and comes as adult-use legislation stands on the ballot for five states this November. (As of October 2020, 38 states and U.S. territories have legalized cannabis use in at least a medical capacity, though it remains federally illegal.)

Washington v. Barr centers on the idea that the Controlled Substances Act (CSA) of 1970, which designates cannabis as a Schedule I drug with “no proven medical uses” – alongside substances such as heroin and mescaline – is unconstitutional and violates the First Amendment rights of medical marijuana patients. First filed in September 2017, the class-action suit features five key plaintiffs: NFL legend and cannabis entrepreneur Marvin Washington; U.S. Army Specialist Jose Belen; 14-year-old legalization advocate Alexis Bortell; 9-year-old Jagger Cotte; and the Cannabis Cultural Association, a nonprofit organization dedicated to creating opportunities for representation and advancement for people of color in the cannabis industry. Particular attention has been given to the fact that Belen, Bortell, and Cotte are medical patients whose cannabis treatments keep them alive, and who are hampered by federal restrictions on cannabis that prevent them from travel by air and other basic rights. They live in fear that their medicine may be taken from them at any point, or that the government may arrest them or their families simply for seeking out the only effective treatment for their chronic conditions.

Additionally, Hiller and his team argue that the current federal laws against cannabis overwhelmingly penalize people of color, as former aides to President Richard Nixon have admitted that the CSA and War on Drugs were established to subjugate Black Americans. The criminalization of cannabis has deepened and intensified an already-entrenched systemic racism to the point that people of color today are three-and-a-half to four times likely to be arrested, prosecuted, and convicted for cannabis-related charges than white Americans, even though white people and people of color use cannabis in equal proportions.

Honeysuckle has followed the developing case since September 2017, when the plaintiffs named the Department of Justice (DOJ), the Drug Enforcement Agency (DEA), and then-United States Attorney General Jeff Sessions as defendants. Much was made at the time of Sessions’s extreme bias toward criminalizing cannabis users, and that while in office he rescinded the Cole Memo, an Obama-era piece of legislation protecting the rights of states that legalized marijuana. In February 2018, Hiller and his team presented the case at the U.S. District Court of the Southern District of New York, where Judge Alvin Hellerstein declared a disappointing ruling that the plaintiffs had “failed to exhaust their administrative remedies” to alter cannabis’s legal status, and recommended that future efforts to decriminalize cannabis should be pursued through legislation rather than through the courts. However, Judge Hellerstein offered some hope when he stated on the record that the use of medical marijuana saved the lives of Bortell and Cotte. Shortly afterward, co-counsel Joseph Bondy, David Holland, and attorney Lauren Rudick of Hiller PC all concurred that an appeal directly to the Second Circuit Court would be the next most effective step. On May 30, 2019, the Second Circuit delivered a written opinion testifying to the “transformative effects of cannabis” based on the evidence presented by Hiller and Co, and urged the DEA to “act promptly” to review the plaintiffs’ claims. After some delays and attempts by the federal government to dismiss the case, by July 2020 the plaintiffs formally filed an appeal to argue the case before the Supreme Court.

Should the Supreme Court decide in favor of the plaintiffs, Washington v Barr would have a far-reaching effect on national cannabis legislation. According to Hiller’s team, it is the greatest opportunity to federally legalize cannabis and eliminate the hardships caused by massive confusion in the law. The case also has tremendous support in the form of amicus briefs from Congressional Representatives Earl Blumenauer (D-OR), Barbara Lee (D-CA), Jamie Raskin (D-MD), and Tulsi Gabbard (D-HI), as well as from advocacy groups including the National Organization for Reform of Marijuana Laws (NORML), the International Cannabis Bar Association, the National Cannabis Industry Association, the Last Prisoner Project, the Minority Cannabis Business Association, and Americans for Safe Access.

Honeysuckle caught up with lead counsel Michael Hiller for a few updates on the case and his thoughts on why this decision has such an impact on American lives now and for generations to come.

HONEYSUCKLE MAGAZINE: Given the DEA’s refusal and stated inability to reschedule or reclassify cannabis as anything below Schedule II, and Congress’s failure to date to remedy this through legislation, the Supreme Court is now our best and only option to end cannabis prohibition. Why has this administrative back-and-forth continued so consistently since the 1970s?

MICHAEL HILLER: According to the DEA and the DC Circuit, there’s this international convention called the 1961 Single Convention Treaty, which prohibits signatories to that treaty from decriminalizing, among other substances, cannabis. The DEA and the DC Circuit have concluded that the only reclassification for cannabis consistent with that treaty would be to reschedule it under Schedule II. That’s a huge problem. But before we get into what problems that creates, let’s now unpack what that means: The way it works in our country is the Constitution is the supreme law of the land, and there’s legislations and treaties underneath that. So what they’re saying is that because the treaty is in existence, it prohibits any executive or agency like the DEA from overruling it. The bottom line is that if the Second Circuit is telling me that the only way my clients can obtain relief is to go to the DEA, when the DEA cannot give the relief I’m asking for, it’s a futile process. Essentially, they have resigned us to a procedure that they know must fail.

The DC Circuit and DEA will not reclassify cannabis as any level below Schedule II. Our clients would not benefit from reclassification under Schedule II. They would suffer, and in fact, America would suffer… What happens if you go to Schedule II? Any medical or other protocol pertaining to cannabis must go through [Federal Drug Administration] FDA guidelines. That means three phases of clinical trials under FDA guidelines. Why are there no trials for Schedule I? Because Schedule I presupposes that you can’t use cannabis for any medical purpose or any purpose whatsoever, for that matter. The minute cannabis is reclassified as Schedule II or below, when it is still on the CSA, every single cannabis company in the country is out of business because they cannot sell any of the medications or substances for purposes not approved by the FDA. Every cannabis physician in the United States is committing a crime the minute that position dispenses or recommends cannabis. Every patient is violating the law—it’s an absolute disaster.

Now, we explained this to the Second Circuit. The DEA takes the position that all they can do is reschedule cannabis, so if we file a petition with the DEA, the most they can give us is to reclassify it as Schedule II—which means if we “win,” each one of our clients would be immediately divested of the opportunity to take medical cannabis. Our corporate plaintiffs wouldn’t be able to engage in any manufacture or distribution.

If we were to “win” before the DEA, that would be a catastrophic loss for not just our clients, but for any medical cannabis patient in the United States and it would resign them to the black market. Because those people do need their medications and they’re going to get them from the black market. The black market has significant risk, so we told the Second Circuit we were not going to go to the DEA… The only way for us to succeed on these issues is to go through the court system.

HONEYSUCKLE: Why is it so important to go through the court system, and why has the DEA refused to acknowledge cannabis’s proven medical uses?

HILLER: I believe that the Second Circuit [assumed] that the DEA would acknowledge what the rest of the country already knows to be [true]. To be on Schedule I, the substance must, among other things, have no accepted medical use in the United States and is so dangerous it cannot be used unless under strict, legal supervision. Those are two out of the three requirements. 70% of American jurisdictions permit the use of cannabis in the treatment of patients. How could anyone legitimately dispute that it has safe and effective accepted medical use?

I genuinely believe that the Second Circuit thought that the DEA would declassify cannabis altogether. But we’ve since learned the DEA won’t do that, can’t do that, because of the decisions they have been making since 1977 when they first ruled the single convention treaty [prohibited] them from descheduling cannabis…

To me, what the DEA could have been doing, and should be doing, is disregard the single convention treaty. But they won’t. And because they won’t, we have no choice but to go to court—some have suggested that we should let this go through the legislative process and let Congress make the change. I think it’s really important that your readers understand why that is simply not an option. The courts are the last defense against Congressional overreach. The courts are the guardians of our constitutional rights. Therefore, the notion that we should be looking to Congress to correct a wrong that they previously committed by classifying cannabis under Schedule I and that the courts punting on that issue, is antithetical to the framework of our constitution. The courts are supposed to be the ones to say “Hey, Congress, you have overstepped.” So, the first and most important aspect of this, is that the courts should not be abdicating their responsibility to protect the constitutional rights of those patients who desperately need cannabis to live.

The second most important thing is that even if the courts didn’t have that role, and they clearly do, there is no way Congress is going to fix this without judicial intervention. And let me tell you why. Today, 93% of Americans support legalized cannabis for medical purposes… You can’t get 93% of Americans to agree on anything, and yet 93% of Americans support medical cannabis—still Congress can’t pass the legislation. That tells you that the legislative process on this issue does not work and will not work. Because when you have that many Americans agreeing on something, and you still can’t Congress to pass the law, that means there is some sort of interruption of legislation that precludes completion.

HONEYSUCKLE: What roles do other actors play in this situation?

HILLER: In this case, Big Pharma is not going to let Congress deschedule cannabis. Why? Because [Big Pharma companies] need to keep America on [their] medications, not on cannabis. So, they are pumping millions of dollars into the coffers of the members of Congress to prevent them from voting their consciences… Mitch McConnell will not allow [this issue] to come to a vote. The House of Representatives passed substantial regulatory changes and legislative changes in the last session, but it doesn’t matter because Mitch McConnell won’t let it happen. So that’s one problem. The other problem is the tobacco industry. They don’t want people smoking joints and vaping, or taking edibles–they want people smoking their product; cigarettes.

Now, maybe someday, Big Pharma and the tobacco industry will change their perspectives. But my instinct is, [that will only happen] when they have done the necessary legwork to take from the “Mom and Pop” cannabis industry, that which rightfully belongs to them, namely: the business. Someday, Big Pharma and Big Tobacco may allow cannabis to be marketed and distributed through the “Mom and Pop” organizations and the small businesses that currently distribute cannabis in the United States. But until that happens, they won’t let Congress [pass the legislature]. And my clients can’t wait that long. Alexis Bortell is 14 years old. She has to get her health insurance renewed this year when she turns 15. She can’t go on a military base because she can’t take her medical cannabis with her. I have clients who… need their relief.

HONEYSUCKLE: Why have cannabis patients become second-class citizens in the United States?

HILLER: They can’t do the things that most people can do. For example, anyone who needs to bring their medical cannabis with them cannot go on federal land, which represents 28% of the United States today. So Alexis Bortell has never been to a national park. She was invited in 2017 to speak to members of Congress. She couldn’t go. She wants to go to a high school near her house. Instead, she has to travel 90 minutes because the schools closest to her won’t accept her as a student because they will not allow medical cannabis on the campuses. So people like Alexis Bortell are literally second-class citizens. They don’t enjoy the same rights that you and I do. Why should they have to wait? For kids like Alexis–why should they be subjected to the sense of otherness that plagues young boys and girls every day?

When Alexis’s class was invited to go to Washington D.C. in April 2020, every kid in her class was able to sign up for that trip except her. She’s constantly being placed in a position of being “other.” I don’t know if you ever met Alexis, but she’s one of the most impressive young women I’ve ever met–she’s amazing and she should not have to go through that. She should be able to live her life and grow up the same way you did. They should all have the right to grow up in a society that accepts them for who they are, not the medication they take…

The district court also said something else which was really strange: there is no fundamental constitutional right to treat with a medication that can save your life. Why I find that so bizarre is that in a case called Cruzan v Director, Missouri Department of Health, the Supreme Court actually ruled that you have a fundamental constitutional right to end your life with medication, if you want to. So what the district court is apparently saying is, “You have a constitutional right to end your life, but not to perpetuate it; not to extend it.” That to me makes absolutely no sense whatsoever.

HONEYSUCKLE: In your view, is criminalizing medical cannabis an infringement of the Due Process Clause of the Fifth Amendment?

HILLER: Under the Due Process Clause of the Fifth Amendment, the federal government cannot deprive you of life, liberty, or property without due process. Over the years, the terms Life and Liberty have been understood in the broader context. It’s not just procedural due process… The courts have recognized that the concepts of liberty and life are more transcendent. They recognize that when, for example, the federal government prohibits a person from treating with a life-saving medication, the federal government is literally depriving you of your life without due process. For example, in the same way people who treat [with] medical cannabis aren’t allowed to go into federal land or get on a plane or go on federal rail, because that’s federally regulated. Alexis Bortell can’t go to her parents’ military base because that’s federally regulated, or she can’t go to school because the school accepts federal funds and doesn’t want to lose their sponsorship. That is a deprivation of their liberty… the right to travel, the right to [medically] treat, the right to get an education. Liberty’s much more expansive than just being restrained. It can also mean the restraints of not being able to go to school. You have a fundamental right to attend school, because the courts have recognized that it is fundamentally necessary to be able to earn a living wage, and to have a career, and eventually to own property. So, if you can’t go to school because you can’t treat with medication that the federal government irrationally determines should be illegal, they are depriving individuals of their liberty interests without the process of a trial.

HONEYSUCKLE: How do you think the operational anomaly between federal and state regulators has contributed to our national confusion surrounding the cannabis issue?

HILLER: [The ambiguity of state and federal dichotomy] is a big issue and one that’s very relevant to our petition to the Supreme Court. If you go to the U.S. Supreme Court, it’s not enough to show that you’re right. SCOTUS first and foremost wants to determine if there’s ambiguity in the law…

Under federal law, cannabis is illegal; under these 38 state and territorial jurisdictions it’s legal. But what about, for example, colleges? At the University of Maryland, there’s a graduate program [in] cannabis science… In medical schools, doctors are taught how to treat patients with cannabis. Lawyers can take cannabis law in school. Lawyers like myself can advise cannabis businesses on how to generate more business and navigate the regulatory landscape. We have those facts, and yet every medical school that teaches a doctor how to [treat] patients with cannabis is technically aiding and abetting the commission of a federal crime. Every university that teaches cannabis undergraduate or graduate school courses is teaching people how to commit crimes. There’s a university in [Oakland, California], Oaksterdam—an entire university dedicated to teaching people how to (according to the federal government) commit a crime. And then of course there’s the fact that the United States has its own domestic and international cannabis patents, and has been licensing those patents all over the world. The United States government has something called the Investigational New Drug Program, pursuant to which it subsidizes a growth operation in the University of Mississippi and distributes up to 9 pounds of joints per year to cannabis patients all over the country to see whether or not it works—since 1976! The Department of Treasury has… a guidance which tells banks and other lending institutions how to do business with cannabis companies. They are advising banks and lending institutions how to commit crimes, because when they’re giving money to a cannabis company, they are aiding and abetting the commission of a federal crime.

Now, how can we as Americans know what is legal and what is not? It literally is an ungodly mess of conflicting laws and regulations that seem to point in different directions… We need the U.S. Supreme Court to step into the breach and provide clarity where the federal government has been unable to do so.

HONEYSUCKLE: How does this case relate to larger movements we are seeing against systemic racism – i.e., Black Lives Matter, anti-police brutality demonstrations, social justice movements against institutional oppression, and others?

HILLER: This is one of the most important aspects of this fight for me. I see the criminalization of cannabis as part of a larger struggle by African-Americans and persons of color against an establishment that is rooted in racism. The criminalization of cannabis in 1970 was specifically created for the purpose of subjugating persons of color and those who were against the Vietnam War… [two top members] from the Nixon Administration, John Ehrlichman and H.R. Haldeman, admitted it… Nixon thought that persons of color were his enemies but he couldn’t make it illegal to be Black. So what he did was he tried to find something that he thought that Black Americans use and criminalize it—and that’s why cannabis is illegal today… There is overwhelming evidence of this. It’s really undeniable. As disgusting as it is going to sound, Nixon was remarkably effective.

Cannabis has become the pretext to subjugate persons of color. The consequences of America’s racist drug war against Black America have been profound and deeply tragic. Once a person is convicted of a drug crime, a drug felony, they can’t vote in most states. They can’t get a lot of jobs. They can’t sit on a jury. They can’t file applications for student loans. It is a life-wreaking experience…

We are seeing today in 2020 the same deeply-rooted racism that was responsible for the enactment of the Controlled Substances Act of 1970. 50 years later, we’re still fighting the same fight. I want to do everything I can to take this part of the arsenal that has been used against Black Americans and throw out the trash. I’m not going to be able to eliminate racism through this lawsuit, but I can take one of the methods, one the tools, that the federal government has used historically (and even to this day) and take it away from them. If I can I will.

There is a tie-in between what I just described to you and the Constitution. Under the Fourteenth Amendment, every American is entitled to equal protection under the law. The Fourteenth Amendment as written applies to the states—but there’s this old case called Bolling v Sharpe which says that the Equal Protection Clause of the Fourteenth Amendment is understood to be an outgrowth of the protections afforded by the Due Process Clause of the Fifth Amendment. What the courts have said is, “The federal government is obligated to provide equal protection. The federal government cannot deprive people of equal protection.” That is the law.

Every time a person of color is treated differently under the Controlled Substances Act, and that’s every day, it constitutes a violation of the Equal Protection Clause. In my view, it violates the Civil Rights Act as well. So, if we can declassify cannabis and remove it from the schedule by obtaining a declaration that it is unconstitutional, that would essentially void the law—and if it’s voided, all of those criminal convictions, I hope, can be vacated. All of those lives that have been destroyed can go on a pathway towards restoration. That, to me, is so important to what we’re doing; it’s one of the reasons why when we took this case on pro bono.

What kind of society would we have if we could take this tool out of their arsenal? It wouldn’t resolve all racism… Racism is so important to those in charge that they’re willing to fire on American citizens to perpetuate it. We have to take the wall of racism down brick by brick. This [case] is one brick.

Stay tuned for updates on the case as it goes to the Supreme Court and follow Hiller PC (@hillerpc) on Instagram for more details.

Washington v Barr, the biggest cannabis case in recent history to decide the federal legality of the plant and Controlled Substances Act, goes before SCOTUS