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7.1 Brief history of reform

7.1.1 In 1996 the state of California passed the Compassionate Use Act, (Health and Safety Code 1132.5). "To ensure that seriously ill Californians have the right to obtain and use marijuana for medical purposes where the medical use has been recommended by a physician". This had been proposed by petition of over 20,000 people, and passed with 56% of the state vote, in a referendum known as Proposition 215, or The Medical Use of Marijuana Initiative. The state of Arizona passed a similar law at the same time.

7.1.2 The code provides that State possession and cultivation laws "shall not apply to a patient, or a patient"s primary care giver, who possesses or cultivates marijuana for the personal medical purposes of the patient, upon the written or oral recommendation or approval of a physician".

7.1.3 The law is specifically about raw herbal cannabis (marijuana). It does not appear to apply to THC or other extracts or synthetics. (dronabinol is available on prescription). Permitting cultivation potentially removed the problems of obtaining supplies. Permitting the assistance of a "primary caregiver" was an essential element, allowing access to the drug for people too sick to grow or obtain it, or who lived in inconvenient locations such as nursing homes.

7.1.4 Among members of Cannabis Buyers Clubs, the most common reasons given for medical use included anorexia, nausea, vomiting, insomnia, depression, anxiety/panic attacks, arthritis and other pain relief, AIDS related illnesses, muscle spasm, and harm reduction (reducing or controlling other drug or alcohol abuse).

7.1.5 Briefings to District Attorneys, police, and doctors suggested that a doctor must have approved the marijuana use, but need not have issued a formal written prescription. The amount must be appropriate to the patients medical needs - possession for sale, and sale, remain crimes in any circumstance. In Californian law, possession of under 28.5 grams (1oz) is usually deemed to be for personal use, and dealt with by a written citation and confiscation, which would still apply in all non- medical cases.

7.1.6 Codes of practice were produced in several areas for police, doctors, and care givers. In February 1997 the State Attorney General (who campaigned against the Proposition) issued detailed guidelines for law enforcement officials, on enforcing laws against marijuana in the light of the changes. This suggested that suspects claiming medical necessity would have to be:

i/ California residents who were seriously ill,

ii/ had been examined by a doctor, who had determined that their health would benefit from marijuana use,

iii/ should not be engaged in conduct that endangers others, such as driving a car,

iv/ should not be involved in any diversion for non-medical purposes, such as furnishing to friends or using strictly for recreation, and

v/ should not possess or grow more than needed for personal medical use. - It was suggested that one plant would produce one pound of marijuana, or 1,000 "joints", and that therefore "one can argue that two or more plants would be cultivation of more than necessary for personal medical use." Alternatively, possession of more than 28.5 grams might be more than personally medically necessary.

vi/ If a suspect claimed to be a primary caregiver they must have been specifically designated by the patient, in advance, and have specific knowledge of the doctor"s recommendation.

7.1.7 Some police forces issued medical marijuana user photo-ID cards to patients after checking their doctors recommendations, to avoid them having to prove their case repeatedly.

7.1.8 Also in February, the San Francisco Department of Public Health issued guidelines for dispensing medical marijuana, including standard forms for doctors" recommendations and nominating "primary care-givers", and a code of practice for dispensing centres, mostly concerned with very careful record-keeping.

7.1.9 In July 1998 Oakland City Council adopted a limit of 24oz (1 1/2lb or 680g), or 100 plants, on the amount of marijuana to be allowed for medicinal use by any one patient. This was based on the amount needed for 3 months supply (a typical growth cycle), by patients in receipt of medicinal marijuana in the wake of the Randall case (see below), smoking 10 pure cannabis cigarettes per day each containing 0.9g of cannabis with 2% THC.


7.2 U.S. Government and medical marijuana

7.2.1 The US Federal government opposed Proposition 215 before and after it was voted into law, arguing that it was against national and international law to allow possession or cultivation of cannabis for any purpose. This opinion has been challenged in the US courts on several grounds, and is currently being disputed. It seems very likely that in the long term Federal law will override the State legislation, and the Compassionate Use Act will be overturned.

7.2.2 All uses of cannabis were effectively banned in the USA from 1937, under the Marijuana Tax Act. The Controlled Substances Act 1972 is similar in outline to British drug control laws; it places cannabis and its derivatives in Schedule I, among the drugs which "have no accepted medical use in the United States and have a high abuse potential". There are five schedules, substances in the lowest can be distributed without a prescription but only by a pharmacist.

7.2.3 There have been occasional attempts and recommendations to re-introduce the medical use of marijuana, e.g. California Research Advisory Panel 1970, compassionate Investigative New Drug status until 1991, numerous local and federal court cases. In 1977, a glaucoma sufferer, Robert Randall, was acquitted of growing cannabis plants, on appeal, on the defence of medical necessity. He successfully petitioned the federal government to provide him with legal marijuana to preserve his eyesight. He was eventually entered on a research project, and was provided with a regular supply of government-grown, ready-rolled, neat marijuana "joints" of a standardised strength from the National Institute on Drug Abuse"s research centre. He is still smoking them regularly to this day. Several other individuals later obtained supplies from the government, for various ailments, in each case after long court cases and negotiations. The requirement in general was to prove medical needs which could not satisfactorily be met by other drugs, or by synthetic cannabinoids. The Randall case established a precedent that herbal cannabis, smoked, could be more effective in treating some conditions than extracts or cannabinoids.

7.2.4 The same ready-made "joints" were available to suitably qualified researchers in the US from the early 1970"s on. The synthetic cannabinoid Marinol (dronabinol) was made available for research and a limited range of prescriptions in 1985. Other cannabinoids have been available for research through NIDA. In 1988, the Drug Enforcement Administration's chief administrative law judge recommended reclassifying marijuana so that it could be prescribed, but no action was taken.


7.3 Distributing medical cannabis - Buyers Clubs

7.3.1 The validity of sales by non-profit clubs, often co-operatives, acting as "primary care givers" or cannabis dispensaries, was unclear in the law. Several were shut, and some re-opened, in legal actions in the early months after the Act was passed. In March 1997 the Superior Court in San Francisco ruled that such a club could be legal, if members had each designated the club as primary care giver, it was non-profit, each person treated had a doctors recommendation, and they kept detailed records of what was dispensed to whom. This was overturned on appeal by Federal authorities, and at the end of May 1998 several clubs were closed down by court orders. Others have shut voluntarily pending legal appeals. At the same time the State Attorney General has brought another case that the clubs do not qualify as "primary care givers" under the Act.

7.3.2 Some of the cannabis buyers clubs had existed before the law was passed, and played a large part in the campaign for Proposition 215. Several were linked with existing AIDS and cancer-victim activist groups. There were over 30 such clubs in early 1998, the largest with over 9,000 members. Many people who were too sick to obtain or grow their own claimed that the clubs were their only potential source of marijuana. Cannabis was grown by club members, and sold in small amounts to other members, without profit, as smokeable marijuana, powdered in capsules, tea, or cookies, usually but not always for the patient to take away.

7.3.3 Two ethnographers had a Drug Policy Foundation research grant to analyse 12,000 intake forms from one buyers club, with the goal of determining the distribution of disease categories and demographic characteristics of members. However, the club was raided in March 1996, temporarily shut down, and the records remain sealed. Instead, the researchers investigated the way members used the club, and the impact of its closing, by interviews and observations. Respondents reported highly positive health benefits from marijuana itself, and even greater benefits from the social aspects of the clubs, which they described as providing important emotional support groups, of therapeutic value to the sick and terminally ill.

7.3.4 The position of individuals or their care-givers who can provide their own medical marijuana, remains unclear: They are not breaking California laws at present, but they are breaking Federal law.

7.3.5 A document released by the California Medical Association in January 1998 invoked the Federal law and told physicians in the state to steer clear of prescribing marijuana. The federal "Drugs Czar" had suggested publicly that they might lose their licences to prescribe common drugs if they co-operated with proposition 215.

7.3.6 In late May 1998, the Mayor, City Supervisors, District Attorney and Public Health Director of San Francisco were proposing a new bill to establish a model for the distribution of marijuana to medically ill patients, who would no longer be able to obtain supplies when the clubs were banned . They felt that without the co- operation of most doctors, or the club distribution network, the law would be almost impossible to implement, even if it was legitimate under federal law. At one point it was seriously suggested by these officials that the City and County public health service should grow and distribute the marijuana, or make arrangements with existing medical clinics to do so. Another suggestion was that police could provide confiscated marijuana to qualified patients.

7.3.7 At the same time, police, prosecutors and lawmakers from all over California met in Sacramento to consider strategies for fully implementing Proposition 215. They concluded that it would be impossible without the co-operation of the federal government, which they were very unlikely to get. Federal agency representatives did not attend.

7.3.8 Many of the participants, including the California Medical Association, concluded that a necessary first step would be to persuade the federal government to reclassify marijuana from Schedule I to Schedule II. A Schedule II designation would allow physicians to directly prescribe marijuana to patients, removing the need for private dispensaries.


7.4 Problems and benefits of the Californian model

7.4.1 The fact that Proposition 215 got on the ballot at all, and was then passed by 56% of the vote, indicates a wide public acceptance of the use of marijuana for medical purposes. It is an issue in this year"s local elections for Governor, State Attorney-General, and Mayor of San Francisco, with most candidates supporting some level of medical use, even when they are hostile to this particular way of providing it. In Oregon a similar referendum has qualified for the ballot, in Nevada a similar petition failed to achieve the required number of signatures in two small rural districts.

7.4.2 The Act supports medical use of herbal cannabis (marijuana). It does not affect the possibility of using derivatives or synthetic cannabinoids if they are appropriate. This recognises that marijuana is by far more easily available, already being used illegally in some cases, and cheaper. There is extensive anecdotal evidence that it is more effective in some illnesses. The effects of marijuana are undoubtedly different from those of any single derivative and there seems no reason to doubt the views expressed by individual patients that smoked cannabis is more effective and easier to control. Similar control might be achieved by inhalers or other routes using synthetic or extracted cannabinoids.

7.4.3 The Act supports cultivation for personal medical use. This is the most obvious way to provide cannabis, a common plant which can be grown easily almost anywhere. It avoids patients having to add to the criminal economy, and is cheaper for them. However, it provides uncertain doses of a complex drug with variable effects. This could be mitigated in monitored, larger scale, or collective production: fine quality control on plant products, though perhaps not to pharmacologists" standards, is well established in the food, beverage and tobacco industries.

7.4.4 "Primary care givers" were authorised to possess or grow cannabis for others" personal medical use. This made access to the drug possible for people too sick to grow or go out and get their own, or who lived where home cultivation was impractical, such as in hospices.

7.4.5 Methods of certifying and monitoring medical use were put in place. Police and prosecutors" responses to the legal change were devised. No doubt they will be extensively tested in the local courts.

7.4.6 Only small numbers of patients have the wherewithal, patience, and knowledge to regularly grow enough of their own cannabis plants, of the right quality, for their medical needs. In some cases pollen or moulds might exacerbate medical problems. Buying from the illegal market offers risks of arrest, (though not prosecution), lack of availability when needed, and of poor quality and prices. Distribution from police seizures, or cultivation and distribution by medical services, have been suggested but met legal, political, moral and practical difficulties.

7.4.7 The co-operative Buyers Clubs offered one workable method of producing and distributing enough marijuana for medical needs, without a surplus available for diversion. They could also have been used for quality and dosage control. Their legal position was at best ambiguous. Their development was ad hoc and in some cases illegal. As well as extreme hostility by Federal and some State law officials, they were damaged by personality politics and, especially, by over enthusiastic promotion by some advocates of legal marijuana. Nevertheless, the clubs were so successful that the State authorities have had to consider taking over their role now that they have been shut down.

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