BILL ANALYSIS                                                                                                                                                                                                    



                                                                     AB 258


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          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; 








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             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.












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          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  








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            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.








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               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  








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               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  








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               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


















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