The growth of medical marijuana

A legal minefield

Despite President Obama’s campaign assurances that he had no intention of interfering in state programs, and Attorney General Holder’s 2009 directive to deprioritize actions against dispensaries in medical marijuana states, there have been more than 270 Drug Enforcement Agency raids on medical marijuana providers since 2008.

Medical marijuana providers must navigate a legally ambiguous landscape in which their state laws support them but federal law considers them drug dealers. In some states, local municipalities may ban them from setting up dispensaries—California’s Supreme Court recently affirmed local governments’ right to exclude dispensaries—and US attorneys might target them using local police. Federal courts try them as drug dealers, not even permitting defendants to mention in evidence that medical marijuana is legal in their state. A bipartisan “Truth in trials” bill is currently before Congress that would permit compliance with state law to be mentioned in evidence.4

Fear of federal law is what kept many states from overseeing the production of medical marijuana themselves, or in some cases even issuing licenses to dispensaries. Many of the pioneering medical marijuana states instead permitted cardholders to grow their own, or to nominate “caregivers” to grow it on their behalf. It has proven an invitation to diversion. The caregiver system has been heavily abused in Oregon, where each caregiver might grow for up to six patients, and black market growers seek out patients on the internet for their cards. A common source of police tip offs is from patients who nominated a caregiver to grow for them but never received their marijuana since it was sold on the black market.5

Taming the Wild West

A clear trend is emerging toward more tightly regulated dispensary-based distribution systems. All of the most recent medical marijuana laws follow this model, as does the proposal now being floated in Florida. States that initially worked without licensed dispensaries, like Nevada, Arizona, and Oregon, are now setting them up. States that had a proliferation of unregulated dispensaries, like Michigan, Montana, and the original “Wild West” of medical marijuana, California, are now in the process of shutting many down.

“Everyone has become aware that lax state regulation tends to trigger federal intervention,” says Mason Tvert, communications director for the Marijuana Policy Project, a non-profit group advocating marijuana legalization.

Other amendments seek to regulate the process of certification by doctors, demanding, for example, that patient and certifying doctor have an existing therapeutic relationship. This aims at discouraging the sort of certification mills that have sprung up in Los Angeles and elsewhere, clinics with names such as Los Angeles’s “Recommendation Station.”

There is little doubt that the larger medical marijuana registries – California’s program numbers roughly 500 000 patients—include many who are not truly medical cases at all. But this fact alone has not been enough to turn the public against medical marijuana, since people in most of these states no longer support prosecution for recreational marijuana use anyway. And so the debate revolves around whether medical marijuana is increasing the overall rate of adolescent drug use, and whether it is increasing crime or traffic accidents. The weight of evidence appears to suggest it is not.6 7 8 9

Some evidence points to a substitution effect where marijuana replaces other drugs or alcohol. Stephen Lankenau of Drexel University has a grant from the National Institute on Drug Abuse to study the effects of medical marijuana use on other drug behavior among high risk, young adults in Los Angeles who have a history of prescription drug misuse. “While conducting unrelated research among young LA prescription drug misusers, we saw indicators that those with medical marijuana recommendations might actually be abusing other drugs somewhat less than pure recreational users,” says Lankenau. “It wasn’t a significant finding—it wasn’t what we were looking at in that study—but it led us to formulate hypotheses that formed the basis of this grant application. We’ve seen suggestions in research from the Netherlands that marijuana may help in “stepping off” other drugs such as prescription opiates.”

A case study: Arizona

Unlike most states, Arizona publishes demographic data on its medical marijuana cardholders. It is swiftly apparent that this is not a classic chronic disease population. Three-quarters are male, and the largest age group is 18-30. The diseases that featured in the campaign for legalization—like cancer, AIDS, multiple sclerosis—together account for less than 10% of patients certified for the program. More than 90% are certified for chronic pain.

“Chronic pain is the Trojan Horse,” says Will Humble, director of Arizona Health Services, who led the design of the state’s plan. “But it was mandated in the voters’ decision so we had to include it.

“Once the voters decided, we saw our role as to give them a true medical marijuana program, not a recreational marijuana program as some other states have. We haven’t succeeded completely, but when I compare us to Colorado next door, they have the same approximate population but about 120 000 cardholders compared to our roughly 38 000.”

Arizona might have kept enrollment lower still, says Humble, but for one other provision in the referendum. “The way the voter initiative read, it said that any physicians could sign a certification. Well, in Arizona there are four kinds of physician: MDs (doctors of medicine), DOs (doctor of osteopathy), homeopaths, and naturopaths. The vast majority of certifications in Arizona are coming from naturopaths although we have ten times as many MDs. Now, not all naturopaths are writing certifications, but a handful of them are clearly in the certification business.”

In fact, 95.5% of Arizona naturopaths certified no patients at all for marijuana in the program’s first year, and 98.5% of the state’s MDs also signed zero certifications. Just 24 health professionals—17 naturopaths, six MDs, and one osteopath—signed 73% of the year’s 28 977 certifications. Regulators call these high-volume certifiers the “frequent flyers.”

Arizona has 22 111 MDs eligible to write certifications, yet just six doctors wrote 61.6% of the profession’s total, 5279 out of 8574. Unsurprisingly, the 24 frequent flyers figure prominently among the 14 health professionals reported by Arizona to their respective state boards, the only sanction available to regulators. “The Naturopathic Board has actually taken a couple of cases to suspension,” says Humble. “And one MD had his license revoked—not just over pot though, he was also writing too many scrips [prescriptions] for oxy [oxycodone].”

Humble is seen by marijuana activists as one of the tougher regulators. But they might be surprised to hear his overall assessment of the program. “When you look at it from an overall public health perspective—deaths, hospitalizations—then prescription opiates are a far bigger problem, in terms of bodies in the street. In Arizona we’ve got more than a thousand deaths every year from opiates, which is more than car crashes. Now, I’m not advocating use of marijuana, I’m just saying, we don’t see the bodies in the street. The problem with prescription opiates in this country is a public health emergency, it’s a runaway train.”

The argument would fascinate a doctor from 1890, when medical marijuana was one of the most common active ingredients used in medicine the Western world, along with opium and alcohol. Cannabis indica, known as Indian hemp, was the subject of more than 100 research papers in the later 19th century, and few US citizens had not used it in patent or prescribed medicines, often at extremely high doses.

E Merck of Darmstadt was a leading early provider of the raw ingredient in Europe, while Burroughs, Wellcome and Co supplied the UK with cannabis. Squibb and Sons and Eli Lilly were among the US manufacturers to offer a range of cannabis products.10 Monographs often praised cannabis for its mildness and efficacy, but also bemoaned the lack of consistency in its strength and its short shelf life. It began to yield ground to opiates after 1880, especially since it would not work with the new hypodermic needles. The discovery of aspirin in 1899 struck the knockout blow to medicinal cannabis until in 1970 the Controlled Substances Act banned marijuana completely, putting it in Schedule 1, for drugs that have high abuse potential and no possible therapeutic value.

The American College of Physicians, the Institute of Medicine, and—since 2009—the American Medical Association have all called on the federal government to review the Schedule 1 listing, if only to facilitate research. None of these organizations either endorse medical marijuana or condemn it. All disapprove of smoking as a delivery mechanism, although the invention of vaporizers that burn cannabis without smoke or tar might allay that concern. None is impressed by the panacea like claims of marijuana enthusiasts, themselves so reminiscent of 19th century patent medicine claims. But the 1960s discovery of the endocannabinoid system has given scientific grounding to the claims of the 19th century doctors.

An oft cited Institute of Medicine (IOM) scientific review concluded: “The effects of cannabinoids on the symptoms studied are generally modest, and in most cases there are more effective medications. However, people vary in their responses to medications, and there will likely always be a subpopulation of patients who do not respond well to other medications . . . Marijuana is not a completely benign substance. It is a powerful drug with a variety of effects. However, except for the harms associated with smoking, the adverse effects of marijuana use are within the range of effects tolerated for other medications.”11

They are certainly within the range of harms that America is now tolerating from prescription opiates, whose use has exploded since the IOM published its 1999 review.

Writing in 1891 one of the last of countless doctors’ monographs on Cannabis indica, JB Mattison might have been speaking directly to us across the intervening century: “The young men are rarely prescribing it. To them I specially commend it. With the wish for speedy effect, it is so easy to use that modern mischief maker, hypodermic morphia, that they are prone to forget remote results of incautious opiate giving. Would that the wisdom which has come to their professional fathers through, it may be, a hapless experience might serve them to steer clear of narcotics shoals on which many a patient has gone awreck. Indian hemp is not here lauded as a specific. It will, at times fail. So do other drugs. But the many cases in which it acts well entitle it to a large and lasting confidence.”12