BILL ANALYSIS Ó AB 258 Page 1 Date of Hearing: April 7, 2015 ASSEMBLY COMMITTEE ON HEALTH Bonta, Chair AB 258 (Levine) - As Amended March 25, 2015 SUBJECT: Organ transplants: medical marijuana: qualified patients. SUMMARY: Prohibits a potential recipient of an organ transplant from being denied based solely on their use of medical marijuana (MM). Specifically, this bill: 1)Prohibits a hospital, physician and surgeon, procurement organization, or other person from denying the recipient of an anatomical gift based solely on a potential recipient's status as a patient whose physician has recommended MM, or based solely on a positive test for the use of MM. 2)Allows for an exception to the provisions in 1) if the patient's use of MM, based on a case-by-case evaluation by a physician or surgeon, has been found to be medically significant to the provision of the anatomical gift. 3)Applies the provisions in 1) above to each part of the organ transplant process, including, but not limited to: a) The referral from a primary care provider to a specialist; AB 258 Page 2 b) The referral from a specialist to a transplant center; c) The evaluation of the patient for the transplant by the transplant center; and, d) The consideration of the patient for placement on the official waiting list. 4)Requires the court to accord priority on its calendar and handle expeditiously any action brought to seek any remedy authorized by law for purposes of enforcing compliance with this section. EXISTING LAW: 1)The Compassionate Use Act, enacted by the approval of Proposition 215 at the November 6, 1996 statewide general election established the right of patients and their primary caregivers to obtain and use MM, as recommended by a physician, in the treatment of cancer, anorexia, AIDS, chronic pain, spasticity, glaucoma, arthritis, migraine, or any other illness for which MM provides relief. 2)The Uniform Anatomical Gift Act regulates the making and distribution of organ donations. FISCAL EFFECT: None. AB 258 Page 3 COMMENTS: 1)PURPOSE OF THIS BILL. According to the author, arcane public health policies treat medical cannabis patients as drug abusers and as a result, too often, patients are denied a life-saving organ transplant solely because they are recommended medical cannabis. The author notes that many of these patients have died after being dropped from the list, and many more are in jeopardy right now and contends that this bill will save lives by ensuring medical cannabis patients are not discriminated against in the organ transplant process. 2)BACKGROUND. The Organ Procurement and Transplantation Network (OPTN) is a unique public-private partnership that links all professionals involved in the United States donation and transplantation system. The United Network for Organ Sharing (UNOS) serves as the OPTN under contract with the Health Resources and Services Administration of the U.S. Department of Health and Human Services. UNOS is a private, non-profit organization. Currently, every transplant hospital program and organ procurement organization in the United States is an OPTN member. Membership means that their transplant programs are certified by UNOS, and that they play an active role in forming the policies that govern the transplant community. In California there are 21 transplant centers (hospitals) and four Organ Procurement Organizations (OPOs), organizations authorized by the Centers for Medicare and Medicaid Services to procure organs for transplantation. Each individual hospital comes up with their own policies regarding how they evaluate a patient to determine whether or not they are eligible to receive an organ transplant. UNOS develops the policies to determine how available organs are distributed among eligible patients waiting for a transplant. According to OPTN there are currently 123,288 people in the United States waiting for a life-saving organ transplant, and AB 258 Page 4 every 10 minutes another person is added to that list. According to the UNOS, approximately 23,000 Californians are on the waiting list for an organ transplant. a) Substance use vs. abuse. A 2011 study published in the University of Michigan Journal of Law Reform, "Transplant Candidates and Substance Use: Adopting Rational Health Policy for Resource Allocation," notes that the autonomy OPOs and hospitals have in determining selection criteria for transplant recipients has led to striking differences in selection tactics with regard to individuals who present issues of substance use and abuse, and one of the greatest areas of regulation that lacks medical and policy foundation is medicinal marijuana use and cigarette smoking. The evidence of cigarette smoking harm is clear. According to the World Health Organization tobacco use causes 8.8% of deaths worldwide and kills more than 430,000 U.S. citizens each year - more than alcohol, cocaine, heroin, homicide, suicide, car accidents, fire, and AIDS combined. According to a 2008 study of substance abuse policies for liver transplant candidates, those who smoke cigarettes are much more readily accepted by liver transplant centers than those who use marijuana, even though marijuana has been found to have beneficial health care uses, including relieving pain and curbing nausea. b) The effect of MM on organ transplant recipients. A 2009 study published in the American Journal of Transplantation, "Marijuana Use in Potential Liver Transplant Candidates", notes that tetrahydrocannabinol, commonly known as THC, the active component in marijuana, may contribute to the development of various liver diseases and could exacerbate liver disease, however the study also notes that cannabinoids have been shown to help regulate immune system functions, and anti-inflammatory properties, potentially reducing the risk of rejection. The study finds that overall, the survival of marijuana users with chronic liver disease who present for transplant evaluation is not significantly different from marijuana non-users, and from those findings, the study concludes that marijuana users are not systematically exposed to excess risk of mortality. AB 258 Page 5 However, a 2011 article in the American Journal of Hospice & Palliative Medicine, "Medical Marijuana and Organ Transplantation: Drug of Abuse, or Medical Necessity?" examined the case of a patient at a state-funded hospital, in a state where MM is legal, who was disqualified as a transplant recipient for his use of MM, even though it was recommended by his primary care physician. The patient subsequently died. The authors of the article concluded that this case shows the need for more research on the medical use of marijuana and for states that have made marijuana legal to examine how the laws affect the policies for state-funded hospitals. According to the California Hospital Association, policies regarding the criteria for medicinal marijuana use and organ transplants vary at each institution. The eligibility to receive an organ depends upon the type of transplant in question and often includes active alcohol and drug abuse as a disqualifier for candidacy. Some institutions allow patients with a history of alcohol or substance abuse dependency to be given the opportunity to re-apply for transplantation after documented compliance with conditions such as abstinence, attending substance abuse treatment, and demonstrating negative drug tests. Many institutions make exceptions to their illicit substance use policies for MM when lawfully recommended by a physician for medical purposes prior to evaluation. However, some institutions make the distinction between smoking medicinal marijuana and ingesting medicinal marijuana due to the risk of the mold aspergillus, which can grow on cannabis products and when smoked can lead to fatal infections for those with compromised immune systems. The California Medical Association passed a resolution in December 2014 urging transplant programs to clearly indicate their policies on the use of cannabis to waiting list candidates prior to evaluation of candidacy and AB 258 Page 6 opposing blanket restrictions of potential organ transplant donors and recipients based solely on reported or detected marijuana use. Currently six other states provide legal medical cannabis patients the protections proposed in this bill: Arizona, Delaware, Illinois, Minnesota, New Hampshire, and Washington. 3)SUPPORT. Americans for Safe Access (ASA), the sponsors of the measure state that this bill will extend the same protections to legal medical cannabis patients that already exist under California law for patients with mental and physical disabilities. ASA also notes that some clinical research shows that medical cannabis and compounds in medical cannabis have beneficial immune-suppressive and anti-inflammatory effects. ASA estimates that there are approximately 1,150 Californians that are at risk for being denied an organ transplant due to their cannabis use. Health, Education & Legal Patients' Rights (HELPR) notes it has been 18 years since the Compassionate Use Act was passed, however our medical industry and the state Legislature have not kept up with the current times and protecting those rights for the patients that use medical cannabis. HELPR contends that cannabis patients should no longer be discriminated against. 4)PREVIOUS LEGISLATION.a) a) AB 1689 (Lieber and Berryhill), Chapter 629, Statutes of 2007, specifies, among other things, that the eligibility of a patient on the organ transplant waiting list shall not by determined by his or her physical or mental disability. b) SB 108 (Speier), Chapter 740, Statutes of 2001, creates the Organ and Tissue Donor Registry in the California AB 258 Page 7 Health and Human Services Agency and required the Department of Motor Vehicles to provide information and a standardized form to applicants for drivers' licenses and identification cards who wish to become organ donors. REGISTERED SUPPORT / OPPOSITION: Support Americans for Safe Access (sponsor) California Cannabis Industry Association California Chapter of the National Organization for the Reform of Marijuana Laws Crusaders for Patients' Rights Emerald Growers Association Health, Education & Legal Patients' Rights Legal Services for Prisoners with Children Marijuana Policy Project Two individuals Opposition None on file. Analysis Prepared by: Lara Flynn / HEALTH / (916) 319-2097 AB 258 Page 8