Podcast

Marijuana and opioids mixed with politics could be hot button issues at the Statehouse in 2018. We dive deeper with State Representative John Forbes and the Director of the Iowa Department of Public Health Gerd Clabaugh on this edition of Iowa Press.

Funding for Iowa Press was provided by Friends, the Iowa Public Television Foundation. The Associated General Contractors of Iowa, the public's partner in building Iowa's highway, bridge and municipal utility infrastructure. I'm a dad. I am a mom. I'm a kid. I'm a kid at heart. I'm a banker. I'm an Iowa banker. No matter who you are there is an Iowa banker who is ready to help you get where you want to go. Iowa Bankers, allowing you to discover the genuine difference of Iowa banks.

(music)

For decades, Iowa Press has brought you politicians and newsmakers from across Iowa and beyond. Now celebrating more than 40 years of broadcast excellence on statewide Iowa Public Television, this is the Friday, December 22 edition of Iowa Press. Here is David Yepsen.

Yepsen: When the Iowa legislature paved the way for medical marijuana critics still cried foul. Proponents of cannabis for medical use complained Iowa still had a large number of issues to resolve regarding production and implementation. And another problem legislators may confront a national crisis over opioid abuse hitting home here in the Heartland. Two men tackling those issues and many more are Urbandale pharmacist and democratic State Representative John Forbes and Gerd Clabaugh, the Director of Iowa's Department of Public Health. Gentlemen, welcome to Iowa Press. Good to have you with us. Thank you for being here.

Yepsen: Across the table, James Lynch of the Cedar Rapids Gazette and Kay Henderson, News Director for Radio Iowa.

Henderson: Dr. Clabaugh, people who have chronic epilepsy have been able to obtain cannabis oil over the past few years, they had a legal right to have it in Iowa. Now a whole host of other conditions may be treated with cannabis oil grown here. How soon, let's say someone with multiple sclerosis has a prescription for it, might that person be able to obtain it?

Clabaugh: The law that was passed by Representative Forbes and legislators requires that there be a drug available, a medication available by December 1, 2018. And so we have been working through, as the agency that was delegated the task of putting the structure into place, we have been working through the process to actually achieve that goal. And so just within the last two weeks we have identified the manufacturer that will be manufacturing and producing the product and soon we'll be into the work related to identifying the dispensaries and the locations so that we can achieve that December 1, 2018 goal.

Henderson: Representative Forbes, as you have been watching this process, is it playing out as you had anticipated?

Forbes: Well, it is a pretty aggressive schedule. When we passed that legislation back in April we knew that the timeframe that we were putting in place was going to be aggressive. But we knew also that Iowans were really calling for us to get a medical cannabis bill out of the legislature. So I think I have a lot of confidence in the department that they can come forward and bring out the program on the scheduled times we have put forth in this bill.

Lynch: Director Clabaugh, it's sort of a nuts and bolts question here, why only one license, grant one license, you could have granted another, so there's really only one manufacturer at this time?

Clabaugh: The law allows two, up to two, and part of our application process allowed, it asked for companies or organizations to file with us a notice of intent to apply. So we had an early indication about who and how many applications we might receive. And in that part of the process we received nine letters, so we expected we could see certainly not more than nine, but could see up to nine. And the applications came in and we had one. We certainly were disappointed with that because we know the law allows up to two and we think there is some benefit to having multiple manufacturers. And so after the process was complete we went back and we informally asked some of the companies that submitted letters but didn't apply why that was and there was just a variety of responses. There was some discussion about the timelines being tight in some cases, there were fees that were projected in the applications and some felt they were too high, others made no mention of that at all. And then of course there are other states who are also doing this work as well and so companies I think are making some determination about which states they want to apply for and we heard that some companies applied in other states and didn't apply in Iowa. So it's a variety of reasons.

Lynch: Representative Forbes, as Director Clabaugh mentioned, there is a license fee. I think it runs from like $150,000 to $200,000. Is that going to cover the cost of this program or will we still need tax money to support medical cannabis here in Iowa?

Forbes: It will start to cover the program but we didn't have time to get a fiscal note put together before we passed this legislation in April, which we should have. But I'm hearing numbers of around half a million to a million dollars to run this program effectively here in the state of Iowa. And one of the things we want to try to avoid doing is pricing ourselves out of the market by overburdening companies that are going to get into this business by a bunch of fees because when we do that we're going to also have, they're going to have to pass those costs back on to consumers who are going to purchase medical cannabis here in the state. So from the perspective of the state I'd like to be able to see some type of an appropriation this coming year to cover some of the costs of putting together this program for the Department of Public Health.

Lynch: What is the estimate right now in terms of how many people are likely to participate?

Clabaugh: It's hard to know that number. About the best we can do is use other states as a guide, but even then the programs differ so substantially from state to state, it's hard to know what that right number or what the expected number might be. I think earlier in the year when the legislature was debating the topic there was some focus on Minnesota and I think at the time there was around 6,000 cardholders in Minnesota. Of course it's a bigger state, but being nearby I think there was some landing on that number as a possibility. At the end of the day this is really about the relationship between a patient and their health care provider and the experiences that the patient is having as it relates to the health issues and the judgment of those two individuals as it relates to whether or not this is a medication that can make a difference for an individual.

Henderson: Representative Forbes, there were those who were disappointed at the limitations on the list of potential conditions for which you can obtain a prescription for medical marijuana. Do you anticipate the 2018 legislature expanding that list to perhaps include post-traumatic stress disorder or other conditions?

Forbes: The bill that we passed this year really only covers about ten to twelve different medical conditions and we left I think a lot of them off that are very, would have a lot of benefits to Iowans, certainly pain control, PTSD is one and even rheumatoid arthritis, which are very debilitating diseases. So I think that we have a medical advisory committee in place now that will make recommendations to the legislature on medical conditions. Realistically I think without the program really being up and running I would be very, it would be very hard to see us expanding that this year, but hopefully after it is up and running we can see how it's going and then we can look at expansion.

Henderson: Director Clabaugh, you have been meeting with this medical advisory board. Do you anticipate that they will make recommendations for action on the program in 2018?

Clabaugh: They have a report that they will be filing before January 1st and the basics of that report are done. Because they're just getting up and running they really haven't had an opportunity to talk much at all about expansion. They're still providing us with some really excellent advice as it relates to operationalizing the program. They have really dug in, they're spending full day meetings focusing on what is a very complicated topic and really using their medical expertise to help us understand that. So I wouldn't anticipate any recommendations in the short run about expansion.

Yepsen: Representative, is one of the problems with expansion not only that the program is new, but there's a lot of political concerns about we're legalizing marijuana, this is a gateway drug, is this going to be a gateway into something else? How do you feel about the politics of that? Is it a heavy lift in the legislature?

Forbes: It was a heavy lift in the legislature this year. We talked about it at the beginning and it took us to the last hours of the legislature this year to pass a bill. And so I know there were a lot of House republicans that were very nervous about a medical cannabis bill thinking that is the gateway to legalizing medical marijuana or medical cannabis or the whole plant here in the state of Iowa, just like Colorado. As a pharmacist I see the benefit from the medical side. I do not see the legislature at this point in time working or looking at any type of passage of a bill similar to what Colorado has done.

Yepsen: And what has been Colorado's experience? Is it going to work some day for Iowa? You said not this session.

Forbes: No, I personally don't have a desire to go down that path. I have friends and pharmacists who work in Colorado and I've heard some of the stories that it's just not, society is not accepting it very well, it is causing a lot of people to go homeless because housing costs have gone up so much in the state because a lot of people are moving there because they can access cannabis. So I think Iowa, I prefer to just stay down the path of the medical cannabis route and make sure we have a quality program that serves all Iowans.

Yepsen: What about, Director, what about that issue in terms of the public health? Would it be a good idea for Iowa to go down the path that Colorado has gone down? Or are there too many health concerns for us to go that direction?

Clabaugh: We're going to look to our medical advisory board to give us some input on all of those things and provide that feedback to Representative Forbes and his colleagues and the Iowa Board of Medicine as well. Our focus is really on ensuring that the product that is available is really, it's consistent and it's high quality, and those are the public health aspects that we're really focusing our effort on. And then with our partners at the Department of Public Safety certainly relating on those issues in the legislation that relate to the public safety issues as well.

Yepsen: But you don't have an opinion then about whether or not we ought to go down the recreational path as a director of the department? You care, for example, about issues like alcoholism. Why wouldn't you care about whether or not this is going to be a gateway drug in Iowa?

Clabaugh: Sure, well and it's true that marijuana is a high use drug among our youth and adults and so that is something we are certainly concerned about. But I think as it relates to those issues about expanded use that is certainly something that I think Representative Forbes and the legislature will have something to say about.

Henderson: Director Clabaugh, many of the people who suffer from the dozen or so conditions for which they can now get a prescription and medical marijuana after December 1st of next year are too ill to work. What is their option as opposed to paying out of pocket? Will insurance, will private insurance cover this as a medical treatment? Will Medicaid, will Medicare cover it? What are the options?

Clabaugh: Access is our primary focus. There is a financial aspect to access that you're talking about. Our focus right now is on manufacturing, points of sale access with dispensaries identified. I'm not aware that there are insurance programs that will cover the product at this point in time. Representative Forbes mentioned earlier the sensitivity to price and certainly that is an aspect of this making it affordable and so we want to find that right balance so that we don't price consumers out of the market.

Henderson: So who sets the price?

Clabaugh: Well right now that will be done by the manufacturer. So as a part of their application process they described to us their manufacturing process, their expertise, where they locate and then they gave us some idea about the forms as well as the prices that they would anticipate charging for those medications.

Lynch: As we head down this path is there sort of a Jeff Sessions cloud looming here if the U.S. Attorney General cracks down on the use of medical cannabis? He doesn't seem very favorably disposed to that. What happens to the program?

Clabaugh: Yeah, it's a good question and we're continually trying to understand the thinking at the federal level on this particular topic. Our understanding is really the Interstate commerce issue is really kind of the fundamental problem or the concern that the federal government has as it relates to this issue and that they provided latitude to states, again, as the legislation has outlined, to do things within our borders to make access to this --

Yepsen: Excuse me, what about in the legislature, as James says, is there a Jeff Sessions cloud over this issue? What is the Attorney General going to do? And how does that affect the public policy you have to make?

Forbes: Well, it is a concern. I mean, we are violating federal law with a cannabis bill here in the state of Iowa. Cannabis is a schedule I which is considered an illegal product here in the United States, it is also considered not safe. Many people think differently, especially on the medical side. So we're going to monitor this very closely and keep track of what is going on in Washington, D.C. but knowing that if they do put the hammer down it's going to affect 30 plus states here in this country and there are literally hundreds of thousands of patients right now in the United States that are being treated with cannabis and having very positive outcomes.

Henderson: Director Clabaugh, let us switch gears and talk about the opioid crisis. Can you give us a sense of why Iowa is not having the level of crisis that we're seeing in states like Ohio?

Clabaugh: Yeah, it's a very good question. I think there could be a number of answers to that. We certainly do see the level of prescription available of opioids from the provider community, we just haven't had the unfortunate death rate that we've seen in other states and we hope to avoid that. We have been benefited by federal dollars coming into the state and some of those dollars will focus on prevention and we will continue to focus on prevention as well and our substance abuse division is working on that particular topic.

Henderson: Give us a sense of how many prescriptions, either one of you, for opioids are floating around out in Iowa on an annual basis.

Forbes: I think the latest report from the Board of Pharmacy there was millions of doses of hydrocodone being dispensed here in our state and I don't know the exact numbers but it is in the millions when it comes to actual tablet doses that are dispensed. But it is a huge problem in our state, as Director Clabaugh recommended, that we do not have the death as seen on the eastern part of the country. But we, last year I think we lost about 180 Iowans due to opioid abuse and overtaking of drugs and also heroin. So we need to address this problem.

Lynch: Representative Forbes, as a pharmacist and a legislator, I wonder what your thoughts are on requiring all prescribers to participate in the prescription monitoring registry, including doctors as they write prescriptions, have to register or record those?

Forbes: Right now we have a system in place called PMP or Prescription Monitoring Program and right now only about 40% to 45% of prescribers here in the state of Iowa utilize it. That number should be up around 80% to 90%. We had legislation this past session that would have not required them to use the program but it would require them to sign up and have a user name and password. That bill died out in session so we're going to come back again this session with another piece of legislation that will address this and get prescribers at least using the system to make sure that people aren't gaming the system when they go to the doctor to ask for medication to treat certain kinds of pain conditions or coming to pharmacies with false prescriptions that we can hopefully identify and then stop that prescription from being filled.

Henderson: So what is the push back here? You have a registry for buying Claritin at the pharmacy. Why is this such a tough pill for people to swallow, if you will?

Forbes: Well, I think the medical society feels it is sorting of putting a mandate on their practices. Most professions don't like mandates and so they looked at this as being something forced on them. The other issue with the medical profession was the system we had in place or have in place now, it's somewhat cumbersome to use. But the Board of Pharmacy right now is working on a new system that hopefully will be up and running somewhere around April 1st of next year that we'll be able to access and make it much more user friendly for both physicians and pharmacists to use.

Yepsen: Representative, government regulations tend to follow problems. We can say we don't have a big problem in Iowa but unless you're the loved one or a friend of one of those 180 people you think we have a problem. Have doctors not stepped up to the plate here? Are they handing out too many pills? Are pharmacists, people in your profession, not doing their job? There's some reason why we have a problem, it sounds like the doctors, from what you say, don't want to be held accountable for their practice. If they weren't giving out so many pills we wouldn't have this problem.

Forbes: Well, doctors, like I say, they are getting more and more educated now on opioid prescribing here in the state of Iowa. That is a push not only in Iowa but nationwide, but we need to put in place, and there is some talk about putting in dispensing limits for opioid medications here in the state of Iowa, especially for patients who are an acute, they go into the doctor and they have a shoulder injury, they don't need to be on an opioid for a month or two, seven days is probably adequate.

Yepsen: Now here's the flip side to my question, you hear some health care providers, doctors who will say there are people out there who need these drugs who are not getting them like they should because we're getting so paranoid about looking like we're handing out a lot of pills and so we don't give them to people in hospice, for example, who need them. What do you say to that?

Forbes: Well, we need to put in place also for people chronic medical conditions that need chronic pain treatment. And I have had many patients in my pharmacy bring that up to me. They are very concerned that they're going to be cut off on their monthly opioid doses and many of these patients have been taking them for years and are very well controlled on their pain. They're not handing them out to their friends, neighbors, and so we need to make sure that we don't overlegislate and put people at risk who need these medications to actually function on a daily basis.

Yepsen: Director Clabaugh, what about those two questions? Is it your perspective that physicians are handing out too many? Is there a danger that some people won't get them that need them?

Clabaugh: I think for a number of years the prevailing training and education that was provided to health care providers, to prescribers particularly has been to focus on pain management. There have been some financial incentives in the insurance system to help providers focus on pain management and now I think we're perhaps overprescribed in that way. And I think Representative Forbes is exactly right, I hear from physicians I talk to about the reverse being true, that we overcorrect in the direction to take away from folks who are in need and are also well managed. And so I think that has got to be one of the tensions here in the public policy discussion is how do we find the right balance.

Lynch: What are the solutions from a public health perspective? In the past week I've heard stories, a librarian talking about people shooting up in the library bathrooms, in park bathrooms, 180 deaths last year and law enforcement says it's probably going to be over 200 this year in Iowa, deaths in Iowa. So what are the solutions here? Do we need more programs? More beds? More funding? All of the above?

Clabaugh: I think we focus on community and individual resiliency. These are coping strategies that people have and so our focus in the department on prevention has got to be a key component of that outreach, working with community based organizations, early interventions, availability and access to naloxone, but really thinking about it at a community level what we can do to educate and help people become more resilient and have coping strategies that are more productive than what we're seeing.

Yepsen: Representative, what is your answer to that question?

Forbes: Well, in my practice here in Urbandale I had two patients of mine die this year since May from opioid overdose. One was a heroin overdose, this individual thought he was getting heroin, he got Carfentanil and he died within an hour, shuts his respirations down and they die. The other individual was a chronic user of opioids but unfortunately a friend or a relative gave him methadone liquid and this individual took that, taking too much not knowing how to dose it, and died. So it is a huge issue here in the state of Iowa.

Yepsen: What is the most important thing, Representative, do you think people in Iowa should know, we've got just a minute left here, should know about this issue and how we deal with it?

Forbes: Well, it's an issue and the big thing it boils down to is funding for programs here in the state of Iowa. The Governor came out with her four points at a conference I attended about a month or two ago, great points, but the issue we have we can talk about it but unless we put the money into the program to help people, medication assisted treatment programs, they're very effective but if we don't have the funding for it, it's not going to happen. People are going to continue to get back in the system and reuse heroin and opioids over and over again.

Henderson: Mr. Clabaugh, we've been talking about policy prescriptions in the legislative realm, stuff is happening in the court system. The makers of these drugs are getting sued. Will that happen more quickly to limit prescribing than what happens in the legislative arena?

Clabaugh: I think with a complicated topic like this all of those things will contribute, the education at our agency, the Pharmacy Board, the Board of Medicine is putting forward will help providers understand how to better control what they're doing in terms of the prescribing part of that. We also need to equip people just to have better strategies in terms of their coping strategies, understanding how they can better deal with stress in their lives as well. I'm sure that the court actions you talk about will also have some impact as well.

Henderson: We have just a short time left. The coalition of nineteen groups including the American Heart Association, the Lung Association, the Cancer Society are suggesting that the tax on cigarettes and other tobacco products be raised to give your agency more money to deal with obesity and mental health system in addition to tobacco cessation. Is that an initiative that you as the department director support?

Yepsen: Less than a minute.

Clabaugh: Yeah, certainly as an administrator I'm going to tell you there are always needs for resources, we can always make an investment in resources. It really comes down to the question I think for the policy makers who make those decisions about the taxes.

Henderson: So what's the answer, Representative?

Forbes: Well, I have always been against cigarette smoking so whenever we can put a tax on something that will hopefully reduce the usage, especially on cigarettes, I'm in favor of that.

Yepsen: Do you think that that's likely to happen in an election year?

Forbes: Probably not this coming session, no, but I think we'll have some discussion on that.

Yepsen: We have to leave it there. Thank you both for being with us today, appreciate it. And thank you for joining our latest edition of Iowa Press. We'll be back next week with another edition. Pollster Ann Selzer joins us for a conversation on voter opinions and trends here in Iowa and beyond. Iowa Press at our regular times, Friday night at 7:30 and Sunday at Noon on our main IPTV channel with a rebroadcast on our .3 World channel Saturday morning at 8:30. For all of us here at Iowa Public Television, I'm David Yepsen. Thanks for joining us today.

(music)

(music)

(music)

Funding for Iowa Press was provided by Friends, the Iowa Public Television Foundation. The Associated General Contractors of Iowa, the public's partner in building Iowa's highway, bridge and municipal utility infrastructure. I'm a dad. I am a mom. I'm a kid. I'm a kid at heart. I'm a banker. I'm an Iowa banker. No matter who you are there is an Iowa banker who is ready to help you get where you want to go. Iowa Bankers, allowing you to discover the genuine difference of Iowa banks.