A calamitous mix-up at a Portland marijuana bottling plant apparently originated with a single employee who confused two similar buckets with nearly identical identification numbers, according to a state investigative report.
The report does not specify, though, whether manufacturer Curaleaf had any quality control measures in place to catch such mistakes, and state investigators withheld some key details of their findings.
Nevertheless, the report – obtained by The Oregonian/OregonLive through a public records request – is the first direct account of how Curaleaf confused bottles of marijuana drops with those containing CBD, a wellness product that doesn’t have psychoactive properties.
Following Curaleaf’s blunder, at least a dozen people who thought they were taking benign CBD drops reporting becoming ill after ingesting jumbo doses of THC, the psychoactive ingredient in marijuana.
At least five customers reported going to the emergency room after taking the mislabeled drops; two said they were driving when they were incapacitated by an unexpected marijuana high.
Curaleaf maintains that it complied with state safety requirements, but in a statement this week acknowledged its responsibility in the incident and described several new safety procedures. Among other reforms, Curaleaf said it now tests samples before selling its products.
“The health and safety of our patients and customers remains our number one priority and we feel confident about the changes made to ensure this doesn’t happen again,” the company said.
Curaleaf sells both the CBD and THC products under the Select brand name. Oregon regulators recalled the products last summer following a customer complaint and quickly concluded that Curaleaf had mislabeled several hundred bottles. Consumers purchased at least 523.
Massachusetts-based Curaleaf, one of the nation’s largest recreational marijuana companies, now faces a 70-day suspension from Oregon regulators and a record, $200,000 fine. Curaleaf plans to contest the penalties before an administrative law judge.
The mishap represents the first big test of how the Oregon Liquor & Cannabis Commission handles consumer safety and how it applies its regulatory standards.
The commission declined to discuss its investigation before the penalty phase is complete. It also refused to release Curaleaf’s account of what went wrong, citing a broad exception to public records law written into Oregon’s marijuana statutes.
“The legal cannabis industry is young. The rules regulating it will continue to evolve,” the commission said in a statement. “When a licensee doesn’t do what they’re supposed to, our rules spell out the consequences.”
In 2016, Portland-based Cura Cannabis agreed to pay a $110,000 “dishonest conduct” penalty to Oregon regulators for falsely claiming that more than 186,000 Select-brand vapes contained 100% marijuana. Shortly after that, Curaleaf closed a $400 million, all-stock deal to buy Cura and the Select brand.
The latest mistake took place last June 1 in Portland, according to the report, but it didn’t come to regulators’ attention until September. That’s after an Idaho man ingested Select drops labeled as CBD, which he had purchased in Oregon. He reported alarming symptoms while driving home from a camping trip, nearly wrecking his motor home. The man spent hours in an emergency room before learning he had THC in his system and deducing the source of his ailment.
The cannabis commission began investigating immediately but it took nearly two weeks before regulators obtained a sample of the drops from the Idaho man and found they did indeed contain THC. Regulators issued the recall the same day they received and tested the sample, Sept. 21.
Here’s what Oregon investigators say went wrong:
Curaleaf kept THC and CBD in two buckets stored in a caged area inside the company’s Portland manufacturing facility. The buckets had different colored lids but were otherwise similar and were stored next to one another on a shelf, according to investigative records.
Each bucket had a small identification number written on a blue tag and affixed to the handle with a rubber band. The identification numbers on the two buckets were one digit apart from one another.
On June 1 last year, Curaleaf instructed an employee named Liam Drain to bottle both the CBD wellness drops and the THC drops, the ones with psychoactive ingredients. Curaleaf provided investigators with a video of his activities beginning around 6:30 a.m., near the beginning of his 10-hour shift.
The cannabis commission declined to release a copy of the video but the report describes Drain’s actions in some detail. He moved in and out of the cage where Curaleaf stored the two buckets, consulting a whiteboard in the bottling area that had his instructions for the day.
After about 20 minutes, Drain removed the identification tag from the bucket containing THC, evidently to see it more clearly, and leaves it on a table. It appears he confused the two buckets after that and proceeded to put the THC into bottles labeled for CBD.
Bottling took all day. The report doesn’t show how CBD ended up in bottles labeled for THC, but it was apparently a consequence of the initial mistake.
Curaleaf’s explanation for the mix-up is redacted from the publicly available report, but it appears the company believes Drain confused the two buckets. Drain acknowledged to state investigators that might be what happened.
“He stated it would not be normal for him to have two (ID) tags in his hands at once but admitted he may have,” the report said, “and it’s possible he did accidently switch the tags.”
The report does not say whether Drain kept his job after the incident. He could not be reached for comment.
The report doesn’t say whether anyone supervised Drain’s work or checked it once it was complete. It doesn’t say whether Curaleaf did any testing of its bottles to ensure they contained ingredients identified on the labels.
Curaleaf reiterated this week that the incident resulted from “human error.” And, for the first time, it described changes made to prevent such mix-ups in the future.
“New protocols include extensive color coding of product ingredients aligned to THC and CBD percentage, and a new sealed and serialized tamper proof tagging system,” Curaleaf said. The company said it retains samples from each batch and has an independent lab test additional samples “to verify product compliance before anything is sold.”
Curaleaf said “staffing changes were made as soon as the error was identified. Following internal review, one team member was reassigned to a role without direct responsibility for product quality and one employee left the company.”
The company has settled 10 lawsuits stemming from the tainted CBD. At least one remains pending.
“There were mistakes. There could have been a tragic outcome. But we need to use it to educate,” said Joy Waite-Cusic, professor at Oregon State University’s Department of Food Science and Technology. Waite-Cusic has studied food safety extensively and reviewed the cannabis commission’s investigatory report at the request of The Oregonian/OregonLive.
Recreational marijuana has been legal in Oregon since 2016 but the industry and its regulators are just starting to implement safety practices and policies that are common among food manufacturers, she said.
Food manufacturers process allergens and potentially hazardous ingredients separately so there’s less possibility for confusion, according to Waite-Cusic. And she said they use distinctly different ID numbers to clearly differentiate them.
“These are pretty basic practices. Should (Curaleaf) have better inventory management practices? Sure they should,” Waite-Cusic said. “Is it a regulatory requirement? No.”
Curaleaf’s sloppiness should be an occasion for marijuana businesses and government regulators to reflect on how they operate, she said.
“It hurts the whole industry when these things happen,” Waite-Cusic said. “Does the industry take the lead in tightening this up, or does the regulator take the lead?”
— Mike Rogoway | mrogoway@oregonian.com | Twitter: @rogoway | 503-294-7699
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