In August 2016, the Senate passed a bill allowing veterans access to medical marijuana. That same month, the Drug Enforcement Administration (DEA) ruled that marijuana would remain a Schedule l controlled substance, which declares that it has “no currently accepted medical use and a high potential for abuse.” This keeps the drug in the same category as heroin. Although progress is gradual, we continue to take two steps forward and one step backward in the process of legalizing medical marijuana.
Due to confusion, personal bias, and hidden agendas among politicians and regulatory agencies on the federal and state levels, mixed messages regarding medical marijuana are continuing. This ambiguity creates an atmosphere of insecurity among the public and the medical community that seeks to relieve their pain and suffering. The lack of accurate information regarding the appropriate use of this medicinal herb is significantly impeding progress in greater accessibility for those who can benefit most from it—chronic pain sufferers.
Rather than risk overwhelming you with too much information, I’ve structured this and the following two chapters in a format of frequently asked questions. By providing you with the most basic and necessary information for the safe and effective use of medical marijuana in this way, my intention is to instill a feeling of security and confidence in your capacity to care for yourself with MMJ (an often used acronym for medical marijuana). The truth is there are very few other options.
1. What is the difference between hemp and marijuana?
The shift from legal to illegal in 1937 illustrates the degree of confusion that existed, and still exists, between hemp and marijuana. They’re distinguished from each other based on their use. Both come from the same plant—Cannabis sativa. The term hemp commonly refers to the cannabis stalk and seed used in industry and commerce for textiles, foods, paper, body-care products, detergents, plastics, and building materials. The term marijuana refers to the cannabis flowers smoked or ingested for medicinal, recreational, or spiritual purposes.
2. Is medical marijuana legal in my state, and what are the restrictions?
The following information on the twenty-eight states as well as Washington, DC, that have some form of medical marijuana legalization was last updated in December 2016 by ProCon.org.
States with Medical Marijuana + Possession Limit |
|
Alaska |
1 oz. usable; 6 plants (3 mature, 3 immature) |
Arizona |
2.5 oz. usable; 12 plants |
Arkansas |
3 oz. usable per 14-day period |
California |
8 oz. usable; 6 mature or 12 immature plants |
Colorado |
2 oz. usable; 6 plants (3 mature, 3 immature) |
Connecticut |
2.5 oz. usable |
Delaware |
6 oz. usable |
Florida |
Amount to be determined |
Hawaii |
4 oz. usable; 7 plants |
Illinois |
2.5 oz. of usable cannabis per 14-day period |
Maine |
2.5 oz. usable; 6 plants |
Maryland |
30-day supply, amount to be determined |
Massachusetts |
60-day supply for personal medical use (10 oz.) |
Michigan |
2.5 oz. usable; 12 plants |
30-day supply of non-smokable marijuana |
|
Montana |
1 oz. usable; 4 plants (mature); 12 seedlings |
Nevada |
2.5 oz. usable; 12 plants |
New Hampshire |
2 oz. usable cannabis during a 10-day period |
New Jersey |
2 oz. usable |
New Mexico |
6 oz. usable; 16 plants (4 mature, 12 immature) |
New York |
30-day supply non-smokable marijuana |
North Dakota |
23 oz. per 14-day period |
Ohio |
Maximum of a 90-day supply, amount to be determined |
Oregon |
24 oz. usable; 24 plants (6 mature, 18 immature) |
Pennsylvania |
30-day supply |
Rhode Island |
2.5 oz. usable; 12 plants |
Vermont |
2 oz. usable; 9 plants (2 mature, 7 immature) |
Washington |
8 oz. usable; 6 plants |
Washington, DC |
2 oz. dried; limits on other forms to be determined |
As you can see, each state in which medical marijuana is legal has enacted its own set of laws to regulate this industry. The result has been a wide disparity between states that is both disturbing and, in some cases, astounding. For instance, the state of New Jersey, with a population of approximately 9 million, has 5 operating medical marijuana dispensaries in the entire state, while Colorado, with just over 5.5 million people, has 531 medical dispensaries. In the case of New Jersey, the will of the people has apparently been overruled by the politicians, whose primary allegiance appears to be to their benefactors. Not coincidentally, New Jersey is home to several of the world’s largest pharmaceutical companies.
Fortunately the Obama administration de-prioritized marijuana prosecutions at the federal level. Since then hundreds of businesses have opened throughout the country to cultivate, distribute, and sell medical cannabis. To learn more about the specific regulations in your state, google “medical marijuana laws and regulations [your state].”
3. What are the basic requirements common to all states?
A physician evaluation in order to obtain a medical marijuana license; a qualifying diagnosis (chronic pain is approved in almost all states); and the subsequent purchase of medical marijuana at a licensed medical dispensary or from a licensed caregiver.
4. What are the qualifying diagnoses for an MMJ license?
Other states differ slightly, but in Colorado, medical marijuana may be recommended for the following qualifying medical conditions or for a debilitating medical condition that produces one of the following:
• Severe pain
• Cachexia
• Cancer
• Glaucoma
• HIV or AIDS
• Persistent muscle spasms
• Seizures
• Severe nausea
Before you see a physician to obtain a recommendation for medical marijuana, it is important to know what the qualifying conditions are in your state. Fortunately for most of you, chronic pain qualifies in nearly every state. It is also helpful (and may be required in your state) to bring your medical records supporting the qualifying diagnosis to your initial appointment for the medical marijuana evaluation.
5. If marijuana is now completely legal in my state (i.e., “recreational marijuana”), why should I go to a medical marijuana dispensary instead of a recreational marijuana shop?
Medical marijuana dispensaries are far more likely to have stronger medicinal marijuana products than the recreational shops. This includes strains with a high content of CBD (cannabidiol), which is the strongest pain-relieving cannabinoid. The budtenders—i.e., the employees who assist you in choosing the appropriate marijuana product for your specific chronic pain condition—should be well informed and better trained than their recreational counterparts. The latter are more knowledgeable about the psychoactive products, since that is the intent of the majority of their customers. Sadly, however, a recent study has shown that many of the MMJ budtenders provide incorrect information to their customers. Medical marijuana in the dispensaries is also nearly always the less expensive of the two options, due to the high sales tax levied on recreational marijuana.
6. What is the physician’s role?
Physicians generally rely on scientific studies and standard-of-care protocols to guide their delivery of patient care. Since there are relatively few medical cannabis studies and most have not been widely disseminated in medical journals, the vast majority of the physicians who are willing to see patients for a medical marijuana evaluation know very little about maximizing the medicinal properties of cannabis. Many have also tended to have a negative view of medical marijuana as simply a legal means for people to get high.
However, in Colorado this is gradually changing. As more patients take the initiative and obtain MMJ without it being recommended by their primary care physician, an increasing number of doctors see patients who have suffered with chronic pain for years and have experienced a dramatic improvement with medical marijuana. At the same time, many of these patients have either reduced or eliminated their use of prescription drugs, especially opioids, benzodiazepines (for anxiety), antidepressants, and sleep aids. Even without the studies, these impressive results are hard to ignore.
In spite of the growing recognition of MMJ’s therapeutic benefits within the medical community of Colorado, a state that has created a model medical marijuana system, there is still a dearth of physicians who can knowledgeably advise their patients on how to best use this remarkable medicine. And if that’s the case in Colorado, I’m certain it is also true of every other state that has legalized medical marijuana. This book serves as a guide for the benefit of both medical marijuana patients and the doctors who recommend it.
In meeting the state’s requirements for medical marijuana evaluations, the role of the physician is to determine if the patient qualifies as a suitable candidate for using medical marijuana, and if he or she does, as the office visit is completed, the doctor signs a document issued by the Medical Marijuana Registry (or similar state agency) recommending this patient be permitted to use MMJ. (In Colorado, beginning in 2017, this process can be completed online and there is no paper document.) This is not a prescription for marijuana. Based on this signed document, the state then issues the patient a medical marijuana license. Known in Colorado as the “red card,” this permits the cardholder to purchase medical marijuana from a licensed medical dispensary.
The physician guidelines in Colorado for the initial evaluation process of a potential MMJ patient are similar to those for the initial office visit of patients in need of medical treatment other than medical marijuana. This includes an appropriate physical examination, an evaluation of medical and mental health history, as well as pertinent imaging and laboratory data. In many states, including Colorado, patients are required to renew their MMJ license annually.
While these guidelines make good sense from a conventional medical perspective, they do not take into account the relative safety of this medicinal herb, the time required to meet these new guidelines, the fact that most new MMJ patients are already under the care of a primary care physician or specialist, and more important, there is no mention of the need to educate medical marijuana patients on the safe and effective use of this new medicine.
As a cannabis clinician, I and hundreds of other physicians have not had the time to wait for the results of a sufficient number of studies that will take several years to scientifically prove marijuana is helpful for treating chronic pain, anxiety, insomnia, and many other medical problems. Our offices are filled with patients suffering a wide variety of debilitating chronic physical and emotional ailments. Although they are coming to us for the primary purpose of receiving a physician’s recommendation for legally obtaining medical marijuana, as health care providers it would be a formidable challenge to merely sign a document and not also instruct our patients on how to use MMJ most effectively for treating their specific condition.
As old patients return annually for a renewal of their MMJ license, or new patients return for a follow-up visit four to six weeks after their initial appointment, they become our teachers. Cannabis medicine is not taught in medical school, nor is it likely to be part of the standard medical curriculum anytime soon. Excellent training in this new sub-specialty of holistic medicine can only be obtained from our patients’ feedback, cannabis clinician colleagues, conscientious dispensary personnel, a modicum of studies, and through our personal experience with marijuana—medical, spiritual, and recreational.
During the thirty-minute consultations with my medical marijuana patients, I spend the bulk of our time together sharing with them all that I’ve learned from these various sources. In addition, I educate them on the most effective use of cannabis for treating their specific problem, advising renewing patients on improving their marijuana treatment program and, if any patients are interested, offering recommendations for holistically treating the underlying condition for which they’re using medical marijuana.
This book is essentially a comprehensive presentation of the information I would like to offer during consultations with my MMJ patients, if time permitted. The book allows you to digest the material in short segments and at a much more comfortable pace than can be provided in a short office visit.
I can fully appreciate the fact that when it comes to treating a serious health problem, most people prefer a one-on-one in-person consultation with their doctor. But if you’re unable to find a good physician within reasonable proximity to your home, through this book I can serve as your self-care guide. If you have questions that are not addressed in the book, you can email me at drrav@fullyalivemedicine.com. I may not be able to respond to every question, but responses to frequently asked questions not included in this book will appear on my website, www.fullyalivemedicine.com.
7. How can I find a good doctor?
Ideally you will find a doctor to perform your medical marijuana evaluation who also has expertise for advising you on how to best use the medicine. However, if a physician meeting that description does not exist in your area, you always have the option of using this book, while working with (or without) a local physician to complement it. However, you will need a physician at least to fulfill your state’s requirements for a medical marijuana license. These are my recommendations for finding a good doctor:
• Use word-of-mouth referral from someone you trust.
• Google “MMJ doctor [your city]”—here you will often find reviews and testimonials from patients.
• Go to www.abihm.org and click on Find an ABIHM Certified Physician. Here you will find the names and locations of more than three thousand holistic physicians (MDs and DOs) who have been certified by the American Board of Integrative Holistic Medicine (ABIHM). Botanical (herbal) medicine is one of the components of the core curriculum of integrative holistic medicine. ABIHM-certified doctors practicing in states with legalized medical marijuana would likely be a good choice for an MMJ evaluation as well as for treating your chronic pain condition holistically.
8. How long does it take to receive the MMJ license?
Once you have completed your visit to a physician and have mailed the signed (by the physician) document to the appropriate state agency, your next step is to obtain the medicine. In some states, including Colorado, if you are a new MMJ patient, you can take a copy of the signed physician document and a receipt from the post office verifying that it has been mailed (in lieu of the card) and visit a medical dispensary on the same day that you receive your physician evaluation.
If you are renewing your license, it can take from three to six weeks to receive your new card. I’d suggest you see a physician for the renewal evaluation at least a month prior to the expiration date. If you have not yet received your new card within a few days of that date, be sure you have a sufficient supply of medicine to meet your needs for the next three to four weeks.
Beginning in 2017 in Colorado, patients have had the option of having their physician certification completed online. They are still required to have an in-person appointment. But if they choose to (and most patients do), they can ask the physician to complete the certification online at the conclusion of their visit. Patients then fill out their information online, and can expect to receive their license within twenty-four to forty-eight hours.
9. After receiving my MMJ license, how do I obtain the medicine?
There are three ways in which medical marijuana patients can obtain their medicine, depending on the state in which they live—dispensaries, caregivers, and growing their own plants. Visiting a dispensary in close proximity to your home is the most convenient method (similar to visiting your local pharmacy), but there are some states in which this option is not available. You can easily find this information online by googling “medical marijuana laws [your state].”
10. What are the criteria for evaluating a dispensary?
To help determine the quality of the dispensary, I ask the following questions:
• Are their plants grown organically and free of pesticides? (Inhaling toxic pesticides can contribute to increased inflammation, thus causing more pain.)
• Have their plants and other products undergone microbiology testing (for bacteria and fungi) as well as analytical chemistry testing to accurately determine cannabinoid content (measured in milligrams—mg), as well as the percentage content of the cannabinoids? (This term will be explained in Chapter 3.)
• Do they have a broad selection of flower, with a variety of indica, sativa, and hybrid strains? How often, if at all, do they have high-CBD strains available for sale?
• How many of the nine different categories of delivery methods described in Chapter 4 do they have available? Most valuable to the chronic pain patient are: vaporizing high-CBD hybrids (e.g., Harlequin) and indicas; high-CBD, THCa, and THC-CBD-CBN tinctures; hybrid, indica, and high-CBD sublingual and swallowed tablets; high-CBD hash oils (CO2-extracted and dispensed in a syringe); hybrid and indica edibles; localized (Apothecanna Extra Strength Pain Creme, Mary’s Medicinals CBC) and generalized (CBD:THC/1:1 transdermal patch) topicals; fresh leaves for juicing (these are rarely available) or as an alternative, CBDa and THCa capsules or tinctures.
• If their selection of products is limited, will they accommodate your requests and order the specific products you’re looking for?
• How helpful and knowledgeable are the budtenders—i.e., dispensary employees—who interact with and advise their MMJ patient customers?
• How reasonable are their prices? Medical marijuana, with every type of delivery method, tends to be expensive. Prices can vary widely, but as with most other retail items, there are sales and other benefits offered to customers by individual outlets. Most dispensaries in Colorado, for example, offer lower prices to patients who register as a member of their dispensary.
By registering as a member, the patient allows the dispensary to grow the six plants that each MMJ patient is permitted by law in Colorado, thus creating a win-win situation. The higher the quality of the dispensary, the more patients will choose to become members. With additional members, the number of plants the dispensary can legally grow is increased, and it is able to provide a broader selection of products to its patients, hire better budtenders, and improve every aspect of its business. The selection of a specific dispensary does not preclude patients shopping elsewhere, but they will not be eligible for member prices there.
11. Who are caregivers?
Most of the states that have legalized medical marijuana have established a system that allows for people who qualify to use marijuana to choose another person to help them grow or acquire it, to sell it directly to the patient, or to advise them how to use it most effectively. These people are referred to as caregivers, which is defined as “someone who has agreed to assist with a patient’s medical use of marijuana.”
Caregivers are not required to have medical or health care qualifications, nor are they necessarily knowledgeable about the therapeutic use of marijuana. But they are generally less expensive than dispensaries. Typically the states with a dispensary system limit the number of patients an individual caregiver may have, so, depending on the state, he or she can help from one person to unlimited numbers of people.
12. What are the caregiver’s rights and protections?
After approval by the state Health Department, caregivers are entitled to manufacture or possess medical marijuana in order to provide that medicine to their patients. From then on both the patient and the caregiver are protected from state or local prosecution for possession or cultivation of marijuana, provided it is used for medical purposes and subject to the state’s guidelines for allowable quantities (in Colorado the law specifies no more than two ounces of a usable form of marijuana, and no more than six marijuana plants, with three or fewer being mature, flowering plants that are producing a usable form of marijuana).
Locating a competent medical marijuana caregiver can be a difficult task. In some states there are organizations associated with the regulatory agency overseeing medical marijuana that can assist you in finding a qualified caregiver.
13. Can I grow my own plants?
If you are unable to find a caregiver and there are no convenient dispensaries (or none at all), you are left with the option of growing your own plants. Some MMJ patients prefer this option in spite of the availability of dispensaries and caregivers.
Medical marijuana patients listed on the Colorado state registry have the right to grow up to six plants themselves. But as you can see from the “Possession Limit” in Table 2.1 above, this can vary widely depending on the state.I
14. How difficult is it to grow marijuana?
I have no expertise on this subject, nor have I ever grown marijuana, but I have heard repeatedly from multiple sources that it is a relatively easy plant to grow. If this is the option you’ve chosen, then your first step is to identify the specific strains that would be most helpful for treating your condition (you can identify some of these in Chapter 3 and in Part II). For steps two, three, and four—i.e., obtaining the seeds for those strains, the required equipment (for growing indoors), and instructions for growing and harvesting marijuana plants, you will need to search the Internet. There are a multitude of sources for this information.
I. Those patients who do not inhale and use only edibles, tinctures, cannabis oil, and topicals are able to obtain an extended plant count, since these methods of administration require more plants to produce.