A study published in the Journal of the American Medical Association (JAMA) found that recreational and medical marijuana legalization does not lead to increased youth consumption. In fact, researchers found that legalization actually leads to lower youth consumption rates.
The study found that in states where recreational marijuana had been legal for two years or more, there was an associated decrease in marijuana use.
According to researchers, “medical marijuana law (MML) adoption was associated with a 6% decrease in the odds of current marijuana use and a 7% decrease in the odds of frequent marijuana use.”
The study further concluded that “estimates of the association between the opening of the first recreational dispensary and marijuana use were qualitatively similar” Meaning, that there’s a clear link between the first marijuana dispensaries opening and a decrease in teen use.
The overall association between legal recreational marijuana and marijuana use among adolescents was “statistically indistinguishable from zero.”
Critics of marijuana legalization often cite concerns about increased youth marijuana use in support of prohibition or more restrictive cannabis laws.
Researchers analyzed data compiled from the Youth Risk Behavior Survey from 1993 to 2017 in ten medical or adult-use states.
The JAMA results are consistent with other studies on youth marijuana use after legalization. Earlier this year, a federal study by the U.S. Department of Education’s National Center for Education Statistics (CNES) found that states that have legalized adult-use marijuana did not see an increase in either youth marijuana use or availability.
A study published in JAMA Pediatrics in 2019 produced the same findings.
“Consistent with the results of previous researchers, there was no evidence that the legalization of medical marijuana encourages marijuana use among youth. Moreover, the estimates reported…that marijuana use among youth may actually decline after legalization for recreational purposes.”
Additionally, data from the U.S. Centers for Disease Control and Prevention reported that the number of adolescents admitted to drug treatment programs for marijuana-related issues has fallen in states with legal adult-use marijuana.
New hemp-derived CBD regulations in Colorado
The Colorado Department of Public Health and Environment (CDPHE) has finalized state testing requirements for hemp. The new regulations take effect on October 1 and include all hemp-derived goods intended for human consumption, including hemp-infused CBD products.
“We don’t want to burden the industry,” Jeff Lawrence, CDPHE director of environmental health and sustainability, told Westword. “But what we’ve learned is that there are things in hemp products that we obviously need to be considerate of. Since the inception of hemp, Colorado has been a leader in this industry. This will provide some better guidance.”
Testing will screen for things like pesticides, heavy metals, and residual solvents.
Hemp-infused products like foods, drinks, nutritional supplements, cosmetics, and pet products will be subject to the new testing requirements. Industrial hemp products like textiles, fuel, and building materials, are excluded from the testing requirements. Hemp-derived smokable products, including those with modified cannabinoids like Delta-8 THC, are also excluded from the new regulations.
“Ultimately, this is a public-health issue. In 2018, when, statutorily, these products were allowed, we said it would be treated like every other food and dietary supplement requirement,” Lawrence said.
DEA-approved medical marijuana research facility coming to Denver
A Denver-based marijuana research and cultivation firm received approval from the Drug Enforcement Agency (DEA) to begin federally-approved medical marijuana studies.
The research license will allow MedPharm to study all of the molecules known to be made by the cannabis plant—more than 400 so far. The company will also be studying the interaction between phytocannabinoids and different brain cells.
“Access to the diversity of chemicals produced by cannabis has never been greater, and we are excited to unlock the medical potential of these compounds,” said Dr. Tyrell Towle, MedPharm’s director of chemistry and research.
Although MedPharm is licensed to grow medical marijuana for research purposes at the city and state levels, they’re still waiting on the DEA to approve federal licensing. That means that the company won’t be using its own marijuana for research. Currently, the University of Mississippi is the only federally licensed medical marijuana research supplier.
Colorado Cannabis Business Office focuses on social equity
Governor Jared Polis announced the creation of a new office aimed at supporting cannabis businesses and promoting social equity.
The Cannabis Business Office (CBO) was created as part of a bill passed earlier this year. $4 million was set aside for the program for the 2022-’23 fiscal year from the state Marijuana Tax Cash Fund.
According to the CBO, the office will:
- Provide loans to social equity licensees for seed capital and ongoing business expenses;
- Offer grants to social equity licensees to support innovation and job creation and organizations that support marijuana businesses to be used to support innovation and job creation of social equity licensees; and
- Support cannabis business owners with technical assistance, prioritizing social equity licensees who have been awarded a loan or grant through the program.
“This office will offer tools like technical help and improve access to money for businesses. Where the federal government has fallen behind, Colorado will lead. Colorado is, and always has been, the best place to live, work, grow and sell cannabis,” Polis said in a press release.
Surgeon General supports marijuana decriminalization
During an interview with CNN, US Surgeon General Vivek Murthy, MD, said that he thinks it’s time to stop incarcerating people for marijuana.
“When it comes to decriminalization, I don’t think that there is value to individuals or to society to lock people up for marijuana use. I don’t think that serves anybody well.”
Murthy was commenting on new draft legislation to repeal federal marijuana prohibition introduced by Senate Majority Leader Chuck Schumer (D-NY) last week.
“In terms of our approach to marijuana, I worry when we don’t let science guide our process and policymaking and as Surgeon General that’s my role, is to work with policymakers who work with members in the community and the general public to help people understand what science tells us and where you gaps, to help fill those gaps with research and with honest inquiry.”
MMJ patient sues Governor Polis over new medical marijuana regulations
In June, Colorado Governor Jared Polis signed House Bill 1317, which added a host of new restrictions to the state’s medical-marijuana program.
Under the new law, physicians must prescribe a THC dosage amount and method of consumption and refer the patient for medical and mental health reviews. In addition, all medical marijuana purchases must be entered into a new tracking system, and patients are limited as to the amount of medical marijuana concentrate they can purchase.
Proponents of House Bill 1317 said the legislation was aimed at curbing youth use of marijuana concentrates.
“The reality is that it’s too easy for Colorado’s youth to access high-potency marijuana when they shouldn’t be able to, and we don’t have the full picture of how these products impact the developing brain,” Garnett said at the bill signing. “This law will help educate consumers about high-potency cannabis, and it will advance critical research that will give us a better understanding of how high-potency products impact developing brains,” said House Speaker Alec Garnett, who introduced the legislation.
However, medical marijuana advocates feel that the new law adds unnecessary hurdles for patients and physicians.
Benjamin Wann, a nineteen-year-old medical marijuana patient who uses cannabis to treat seizures, is suing the governor over the new restrictions. Wann and his parents, Amber and Brad, say that the governor and legislators failed to include the medical marijuana community in their policymaking.
“Polis didn’t have a conversation with us. We reached out, and had a rally in front of his office after it passed. I don’t know of anyone in the community who he had a conversation with, especially those of us who just passed that other bill,” Brad told Westword.
The Wann family was with the governor on May 6 as he signed a bill into law that expanded medical marijuana access to underage patients in public schools.
“We’ve seen a roller-coaster effect over the years with Benjamin having seizures. People keep saying [marijuana] is so bad for the developing brain, and here’s Benjamin, and we’ve literally seen him flourish and grow from it,” Amber said.
Denver receives first marijuana delivery application
In April, the Denver City Council passed a bill to (finally) allow marijuana delivery and consumption lounges in the city. Now, the City of Denver has received its first application for a marijuana delivery permit.
“We are kind of accustomed to getting everything delivered. Our groceries, our medicine, our clothing, our basic needs. So now this is just one thing we can deliver and provide that type of service,” said Dooba owner Karina Cohen.
The same restrictions that apply to purchasing cannabis in a dispensary will apply to the new delivery service. Cannabis delivery will only be available to a residential address to a person with a valid ID. Purchases will be limited to one ounce of flower, 8 grams of concentrate, or edibles containing 800 milligrams of THC.
Colorado’s Speaker of the House, Alec Garnett (D-Denver), has introduced legislation that would create more stringent rules for medical marijuana patients and marijuana concentrates.
House Bill 1317 would require a review of a patient’s mental health history before a physician could recommend medical marijuana. That recommendation would have to include a prescribed THC potency level and daily dosage.
Additionally, a new state tracking system would monitor medical marijuana patient’s purchases.
Instead of being packaged and sold by the gram, marijuana concentrates, aka dabs, would be packaged in single doses no larger than 0.1 grams. Medical purchases of cannabis concentrates would be limited to 8 grams per day for patients 21 years and older. Medical marijuana patients between the ages of 18 and 20 would be limited to purchasing 2 grams of concentrate per day.
It’s not clear what data is driving the lawmaker’s desire to regulate marijuana concentrates and medical cannabis further. There has been an uptick in marijuana concentrate usage among teenagers from 2017 to 2019, but overall, marijuana usage rates in Colorado have remained flat in Colorado since legalization. Additionally, enrollment for Colorado’s medical marijuana program has fallen in recent years. It’s uncertain what impact the new legislation would have on patient access or the medical marijuana program as a whole.
“We have been at the table for months to produce a balanced policy measure, and we very much appreciate that the conversation has shifted to a more evidence-based approach to cannabis regulation,” according to a joint statement from the Marijuana Industry Group and Colorado Leads. “The cannabis industry has always supported youth prevention efforts and strict regulations that keep marijuana out of the hands of teenagers. That’s why we support an even more robust tracking system that limits the amount of medical marijuana concentrate 18- to 20-year-olds can purchase, as well as other provisions that make it harder for teenagers to obtain marijuana illegally.”
The new state system proposed under HB 1317 tracking the purchasing data of medical marijuana patients has raised both privacy concerns and fears about how that data could be used against minority communities.
Hashim Coats, executive director of Black Brown and Red Badged, a coalition of Black and Brown cannabis business owners, told Westword:
“The current draft legislation has serious racial bias implications and racial blind spots, particularly in the areas that address data collection and research,” he says. “We are supportive of some important provisions of this bill, [but] we are unfortunately still incredibly concerned about the racial tone-deafness and exclusion of Black voices from the discussion, which any legislation of this nature should include, and that the bill at this point has yet to strike the right balance.”
HB 1317 will have its first hearing in the House Public & Behavioral Health & Human Services Committee on May 18.
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In 2018, voters in Missouri were in favor of legalizing medical marijuana, passing Amendment 2 with 65 percent approval. It was a watershed moment for a state that had traditionally opposed marijuana use. The amendment to the state constitution allows doctors to prescribe medical cannabis for ten qualifying medical conditions and patients can cultivate up to six plants.
Medical marijuana sales are just starting to ramp up in Missouri. During the first week of 2021, the state saw the first sales of edible marijuana products. Plus, there’s the possibility that voters could weigh in on legal recreational marijuana as early as 2022.
Oklahoma became the 30th state to legalize medical marijuana in 2018. Like Missouri, Oklahoma generally opposed marijuana legalization—in 2016 they joined Nebraska in an attempt to sue Colorado over legal weed. However, in 2018, public opinion had shifted enough that a medical marijuana initiative passed with a 57% to 43% margin.
In 2020, medical marijuana was booming in Oklahoma. Residents bought a record amount of medical marijuana, increasing tax collections by more than 25%. The Oklahoma Tax Commission received $9.8 million in state taxes in April.
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It has been a slow start for medical marijuana in Missouri. In 2018, voters approved Amendment 2, allowing doctors to prescribe medical cannabis for qualifying medical conditions.
Since then, not a whole lot has happened. 372 Missouri-based medical marijuana businesses have received licenses from the state, but only 43 have received approval to operate as of December 31 of last year. Twenty-two approvals have gone to retail medical marijuana dispensaries, while 13 approvals have been granted to cannabis cultivation centers. More than 700 potential marijuana businesses that didn’t receive licenses have active appeals.
In a bit of good news for medical marijuana patients in the state, edible marijuana products went on sale for the first time in Missouri during the first week of 2021. While production is expected to be slow until more cultivation centers and retail dispensaries are licensed, it’s still a step forward for medical cannabis in Missouri.
Another first for Missouri is the Republican state lawmaker who wants to legalize recreational marijuana.
“We spend more time and more law enforcement resources going after marijuana smokers than all the other drugs combined,” said Rep. Shamed Dogan (R). “Ten percent of the arrest in the state of Missouri right now are from marijuana possession.”
Dogan hopes legalization will bring more revenue to the state and eliminate the black market.
“I think alcohol prohibition taught us that trying to prohibit something this way, the way we’ve gone about marijuana prohibition, it backfires,” Dogan said.
Dogan plans to introduce a constitutional amendment, House Joint Resolution 30, during the 2021 legislative session. If lawmakers approve the amendment, residents could vote on legal recreational marijuana as early as 2022.
Dogan’s legislation doesn’t directly address racial inequity, but he does support clearing previous marijuana convictions.
“And it automatically lets out of prison anybody that is still serving a prison term for marijuana-only offenses and then expunges from your record if you have a non-violent marijuana offense,” Dogan said. “If you are currently incarcerated [for more than] a marijuana offense, so if you have a marijuana offense, but you also committed a robbery, you don’t get out.
It was a historic night for marijuana legalization in the U.S. four states voted to legalize recreational marijuana, and two states legalized medical marijuana.
Arizonans overwhelmingly voted to pass Proposition 207, legalizing adult-use marijuana. Adults 21 years and older can possess and consume up to one ounce of marijuana. Adults can grow six cannabis plants at home or no more than 12 plants in a house with more than one adult.
Arizona’s Department of Health Services will begin accepting applications for recreational dispensaries in January. It will begin issuing licenses within 60 days–so expect the first recreational sales to kick off in March.
Arizonans with a prior marijuana conviction can petition to have the record expunged as of July 12, 2021. Finally, a 16% excise tax will be added to recreational marijuana sales to fund public programs.
The Garden State will be cultivating a new crop thanks to voters who approved Question 1 on the ballot, legalizing recreational cannabis. Adults 21 and older will be able to purchase and possess legal cannabis, subject to rules and regulations that will be overseen by the state’s Cannabis Regulatory Commission, which already oversees New Jersey’s medical marijuana program. Recreational marijuana sales will be subject to a 6.625% sales tax.
In 2019, legislation that would have legalized adult-use cannabis in New Jersey was pulled from a vote in the state legislature after failing to secure enough support from lawmakers.
Montana had not one but two ballot measures to legalize recreational marijuana, both of which were approved by voters.
Initiative 190 legalized the sale and possession of up to an ounce of cannabis and the cultivation of up to four cannabis plants and four cannabis seedlings at home. Recreational marijuana sales will be subject to a 20% tax.
Constitutional Initiative 118 amended the state constitution to allow the Legislature to set the age for adults permitted to possess and consume marijuana to 21 years and older.
New Approach Montana, the group who backed both ballot measures, estimates that legal adult-use marijuana sales will generate $48 million in tax revenue for the state by 2025.
“Our research has always shown that a majority of Montanans support legalization, and now voters will have the opportunity to enact that policy, which will create jobs and generate new revenue for our state,” said Pepper Petersen, campaign spokesman for the group.
South Dakota is the first state where voters simultaneously approved legalizing both medical and recreational marijuana.
Voters passed Measure 26 legalizing medical marijuana for people with qualifying conditions with 69% of the vote.
Amendment A passed with the approval of 52% of voters, allowing adults 21 and older to possess up to an ounce of cannabis and allowing the cultivation of up to three marijuana plants. The South Dakota Department of Revenue will issue licenses for manufacturers, testing facilities, and retailers. Sales tax on recreational sales will be 15%.
Marijuana possession will remain illegal in South Dakota until July 1, 2021.
Mississippians have said ‘yes’ to medical marijuana by approving Ballot Initiative 65.
The Mississippi Department of Health is required to hammer out the rules and regulations for a medical marijuana program by July 1, 2021. Mississippians will be able to apply for a medical marijuana card for 22 qualifying conditions, including cancer, chronic pain, and post-traumatic stress disorder (PTSD).
Each medical marijuana patient will be allowed to possess up to 2.5 ounces of cannabis per 14-day period. Home cultivation of marijuana is prohibited.
Cannabis sales during coronavirus shutdowns haven’t been the same in every state, with newer cannabis markets seeming to fair better than established markets that depend on tourism.
Despite a statewide stay-at-home order issued on March 23, Washington state saw record-breaking cannabis sales in April. Recreational marijuana sales increased 20% compared to April 2019, generating $106 million. Adult-use cannabis sales in Washington during March amounted to $99 million.
According to Marijuana Business Daily, Washington is a good test state to see if cannabis is “recession-proof” because it has a relatively mature market that generates a higher portion of sales from locals.
States like Colorado generate a higher amount of cannabis sales from tourists, so even with the leveling off of sales in the state in recent years, Colorado should expect to see a dip in cannabis revenue.
“Estimates prepared for the Department of Revenue suggest that tourists accounted for 7 to 9 percent of marijuana consumption in Colorado between 2014 and 2017,” according to a state budgeting report.
Adult-use cannabis sales in Colorado during April 2020 generated $91 million, a 16% decrease as compared to the same time in 2019
While California saw a modest gain in cannabis sales in April, monthly sales growth was less than before the pandemic. In March, Californians bought $276 million in recreational cannabis, an increase of 53% compared to March 2019. In April, sales equaled $248 million, an increase of only 17%.
With travel all but grounded during the pandemic, Nevada’s cannabis businesses have been hit hard by the lack of tourism. Adult-use cannabis sales fell 26% in the state, earning $38 million in sales in April, down from $54 million in March. According to Will Adler, Director of the Sierra Cannabis Coalition, 80% of recreational and medical marijuana sales in Nevada are generated from tourists.
Illinois’ adult-use cannabis market launched in January, with a record-setting $39.2 million in sales. April’s adult-use marijuana sales didn’t top January’s numbers, but they were still higher than average. In April, Illinois sold nearly $37.3 million in recreational cannabis, $2.6 million more than was sold in March.
In Oklahoma, residents bought a record amount of medical marijuana, increasing tax collections by more than 25%. The Oklahoma Tax Commission received $9.8 million in state taxes in April. By comparison, the state generated $7.8 million in medical marijuana tax revenue in March. According to The Oklahoman, medical marijuana dispensaries sold $61.4 million worth of medical cannabis in April or nearly $217 per licensed patient.
Bud Scott, executive director of the Oklahoma Cannabis Industry Association, credits people staying home with the increase in medical marijuana sales.
“With the stay-home order in place, and medical marijuana dispensaries being categorized as essential health services, Oklahoma patients were afforded the ability to take their medicine on a more regular basis and sample a broader range of available medicines,” Scott said.
Cannabis users looking for relief from stress and anxiety could account for increases in marijuana sales that don’t rely on tourism.
“I’ve probably medicated more these past few months. You’ve got people staying home and getting stimulus checks, and what are they spending it on? Things that help keep them calm and collected,” Keith Wiley, owner of Native Brothers Dispensary, told The Oklahoman.
Higher Education: Colorado State University-Pueblo offers cannabis major
Starting this fall, CSU-Pueblo will offer a bachelor of science in cannabis biology and chemistry.
The degree program will offer students two tracks–a natural products track focused on biology or an analytical track that focuses on chemistry. Students will have to complete general biology and chemistry courses in addition to nine proposed cannabis courses to complete their degree.
This is Colorado’s first cannabis degree program, and one of the first cannabis degree programs in the country. Northern Michigan University and Minot State University in North Dakota offer bachelor programs in medicinal plant chemistry.
“We have been working on this particular degree program for over a year now, and the chemistry department and the biology department have put together a program that really emphasizes the science of cannabis,” said David Lehmpuhl, dean of the College of Science and Mathematics at CSU-Pueblo.
The Colorado Commission on Higher Education approved the program earlier this month. According to Lehmpuhl, there are plans to create more cannabis-related degree programs at universities in the state.
“We anticipate this is the first of several cannabis-related degrees and certifications that will be developed by Colorado institutions of higher education in the near-term,” Lehmpuhl said.
“It’s a challenge in a way because cannabis has both positive and negative connotations. We want to make sure that we are viewed as being not pro or anti-cannabis, but just looking at the science behind it,” Lehmpuhl said.
“To those of us who are scientists, this is really exciting.”
Kentucky gives medical marijuana another try
A bill to legalize medical marijuana passed in Kentucky’s House Judiciary Committee for the second year in a row. House Bill 136 would legalize medical marijuana and allow doctors to prescribe it. Qualifying medical conditions have not yet been spelled out but would be determined by a panel of eight doctors, four public advocates, and a pharmacist.
The bill passed in the House committee last year, but failed to receive a full floor vote. The bill is expected to pass in the House but faces an uphill battle in the Senate.
Senate President Robert Stivers (R-Manchester) said that he hadn’t seen sufficient research into medical marijuana, but there’s a “narrow path” to passing the bill in the Senate.
“It’s a balancing test of do the goods outweigh the bads,” Stivers said. “And we just haven’t had anything done on that.”
Advocates of the bill say that medical marijuana is a better alternative to addictive opioids.
“If House Bill 136, medical cannabis, were to pass in the Commonwealth of Kentucky, I would not be a criminal,” said Eric Crawford, who spoke before lawmakers. “I would not have to live in fear. I would not have to lay awake at night worrying about law enforcement coming to my home. I would not have to stress about going to jail, or losing my home, work or freedom.” Crawford has been in a wheelchair since being involved in a car accident in 1994.
If the bill were to pass in both the state House and Senate, it would create one of the more restrictive medical marijuana laws in the country. Smoking marijuana would be illegal, although flower would be available for other uses. Colorful packaging and gummies would be prohibited. Even THC may be a no-go under the bill, something that would be decided on at a later date by the Kentucky Cabinet of Health and Family Services.
90 percent of Kentuckians support legalizing medical marijuana, according to a recent poll by the Foundation for a Healthy Kentucky. That’s up from 78 percent support in 2012.
States with medical marijuana have fewer workers’ compensation claims
A new study found that in states with legal medical marijuana, there was a 6.7 percent decline in workers’ compensation claims. Medical marijuana “can allow workers to better manage symptoms associated with workplace injuries and illnesses and, in turn, reduce need for workers’ compensation,” according to the study.
Researchers from the University of Cincinnati Ash Blue College and Temple University analyzed data from the Census Bureau’s Annual Social and Economic Supplement to the Current Population Survey. The data spanned from 1990-2013 and included survey interviews from 150,000 U.S. residents 15 and older.
“We think there is a lot of overlap between conditions for which medical marijuana can be used in managing symptoms and the types of illnesses that lead people to file workers’ compensation claims,” said study co-author, Catherine Maclean, an associate professor in the economics department at Temple University.
When workers did file claims, they were for shorter periods of time, on average, after medical cannabis was legalized.
“Our findings add to the small, but growing, literature on the effects of MMLs (medical marijuana laws) on labor market outcomes. On net, the available findings suggest that MML passage may increase work capacity among older adults, reduce work absences, improve workplace safety, and reduce WC (workers’ compensation) claiming and the pain and suffering associated with workplace injuries.”
Thailand’s first full-time medical marijuana clinic opened in Bangkok this month. Thailand is the first Southeast Asian country to allow medical marijuana, though cannabis has not been legalized, and there are harsh penalties for recreational use.
The Ministry of Public Health anticipates between 200 to 300 patient visits daily, and nearly 2,200 patients have registered for treatment with medical marijuana. On its first day, the clinic gave away free cannabis oil to nearly 400 people. Patients who visit the clinic will receive two weeks of free care.
Thailand has approved 38 medical conditions for treatment with medical marijuana, including Parkinson’s, epilepsy, Multiple Sclerosis, and cancer. In the future, Thailand may expand its medical marijuana policy to include allowing patients to cultivate up to six plants at home.
Chad Tribble, one of the co-founders of Mountain High Suckers who recently visited Thailand to speak and attend the Elevating Cannabis Expo 2019, told the Bangkok Post about the wide range of uses and products that can be derived from cannabis.
“You can infuse the oils, the cannabis compounds into a lotion which delivers the medicine through your skin instead of smoking or eating it. You can probably feed animals such as elephants with the by-product from the plant as well.”
Thailand already has about 25 cannabis clinics, but access to them is limited to hospitals, and they’re only open part-time.
“This is a pilot clinic, because we cannot produce enough doctors with expertise in cannabis,” said the country’s public health minister Anutin Charnvirakul.
Until at least 2024, only Thai companies will be licensed to cultivate the plant. Tribble sees huge potential in Thailand for CBD and cannabis businesses in the coming years.
“Thailand is a great prospect for foreign companies to be able to work with Thai companies to offer products for people to use medically,” Tribble said.
Despite Thailand’s current harsh drug laws, and recent 180 on medical, the country has a long history with cannabis. Before its ban in the 1930s, cannabis was used for clothing and other fabrics, as well as food. A Thai boat noodle soup called kuaytiaw reua used cannabis as a spice.
“It is vital to remember that cannabis is one of the 50 Fundamental Herbs of Chinese Medicine and dates back 4000 years in Asia,” Dr. Jenelle Kim, Founder & Chief Formulator of JBK Wellness Labs, told Forbes. “Beginning thousands of years ago, the healing properties of cannabis were used to help balance a variety of conditions–from calming the mind and body, balancing digestive disorders, easing pain and fatigue, among others.”